July 1, 2013 (Portland) — When Oregon Health Plan members leave the hospital, the health care team at Eastern Oregon Coordinated Care Organization has a single goal: making sure people – especially those who are frequently in the emergency department and hospital – have what they need to get well sooner and stay well longer.
"That's a key outcome of coordinating care," said Laurie Schilperoort, R.N., supervisor of care coordination for Moda Health, which is part of the CCO. "What we are doing is re-admission prevention."
"Patients feel more in control of their health. It helps them know there are people out there who really care." ~ Laurie Schilperoort, R.N.
Schilperoort convenes a care conference with mental health, physical health and other service providers to craft post-hospital plans for patients. For example, the state Adult Persons with Disabilities program could provide a home caregiver to assist with meals, showering and home cleaning. Greater Oregon Behavioral Health, Inc. might arrange for mental health counseling. A nurse from the patient's primary care provider would make sure the patient has follow-up visits as needed.
"Patients feel more in control of their health. It helps them know there are people out there who really care," Schilperoort said.
Before the CCO formed, this type of coordination wouldn't have been possible, according to Toni Olin, a registered nurse and certified case manager. She is the Healthcare Services Manager at Moda Health.
"We might have made suggestions about what a patient needed after being discharged, but there was no way we could have put all the services in place without working with all of the partners and providers in the CCO," said Olin. "This is exactly how health care is supposed to work."