Coordinated Care Model Summit - Nov. 17, 2015

Highlighting Outcomes and Promoting Excellence

Summit Materials

• Agenda
• Oregon's health system transformation (handout)

Plenary Sessions

• Plenary speaker bios
• Achieving Results: Voices from the Frontline - Maggie Polson, Jennifer Johnstun, Tracy Muday
• Moving Upstream: Connecting with the Community to Improve Health
• Walking Together on a Path of Transformation - Soma Stout
• Eastern Oregon CCO's Upstream Initiatives to Improve Health - Megan Lee Gomeza
• John Wetten Elementary School "Healthy Kids" video - Wendy Wilson
• Health Commons Grant: A Community-Wide Partnership to Improve Health - David Labby

Breakout Sessions

1A: Behavioral Health Integration

• Improving Severe and Persistent Mental Illness Outcomes in Behavioral Health Homes - Tina Busby
• The Tipping Point of Physical and Behavioral Health Integration in Medical Homes - Lynnea Lindsey-Pengelly
• Primary Care Psychiatric Integration - James Phelps
• Integration Inside and Outside Primary Care to Reduce Emergency Room Visits and Improve Health Outcomes - Shelly Uhrig

1B: Improving Health through Community Engagement

• Using a Community-Inclusive Framework to Identify and Address Health Disparities - Sandra Clark
• A Population-Health Approach to Meeting the Needs of Transition Age Youth - Meg Pitman
• Building a Collective Impact to Address Social Determinants of Health - Kim Whitley

1C: Improving the Patient Experience of Care

• Rapid-cycle Improvement for Team-Based Care - Jim Connolly
• Use of Patient Experience of Care Data to Drive Improvements - Colleen Reuland

1D: Using Technology to Improve Health

• Session overview - Susan Otter
• Emergency Department Information Exchange (EDIE)/PreManage - Susan Kirchoff
• Project ECHO - Mark Lovgren
• Jefferson Health Information Exchange - Coco Yackley and Gina Bianco

2A: Empowering Patients to Take Charge of Their Health

• Session overview - Oliver Droppers
• Using Software to Track Outcomes of a Pain Management Member Wellness Program - Laura Fisk
• Environment, Social Connectedness and Trauma-informed Coaching to Improve Engagement and Outcomes for Wellness Programs - Heidi Hill
• Interventions to Encourage Effective Weight Managmeent and Increase Participation in Living Well Self-Management Programs - Jeanine Stice

2B: Reducing Health Disparities Using Traditional Health Workers

• Using Non-emergent Medical Transportation and Community Health Workers to Improve Access to Care for Vulnerable Populations in Rural Areas - Diane Barr
• Warriors of Wellness: A Multicultural Collaborative of Community Health Workers - video
• Outcomes of Creating a Peer-delivered Services System of Care in the Community - Ally Linfoot
• Providing Culturally and Linguistically Appropriate Services to Reduce Health Inequity and Improve Access to Care - Lynska Villiarimo

2C: Complex Care

• Novel Interventions in Children's Health Care to Bend the Curve in Pediatrics - Michael Harris
• Using Health Plan Incentives to Engage High Utilizers - Tracey Smith
• Community Emergency Medical Service Program to Improve Health Outcomes for Medically Vulnerable Populations - Tami Tigner

2D: Oral Health Integration

• Oregon Children's Dental Health Initiative - Melissa Durham Freeman
• Evaluating the Effectiveness of New Delivery and Payment Systems for Improving Dental Care and Oral Health - Sharity Ludwig
• The Virtual Dental Home: An Innovative and Cost-Effective System for Providing Dental Care - Linda Mann

3B: Trauma-Informed Care

• Mental Health Court - Stacy Brubaker
• Screening for Parental Adverse Childhood Experiences in Primary Care Pediatrics to Prevent Toxic Stress Transmission to Children - R.J. Gillespie
• ACEs and Trauma Informed Care: Health Care Education Efforts - Teri Petterson

3C: Opioids

• OHA Opioid Guide for CCOs - Katrina Hedberg
• Reducing Opioid Overdose, Misuse and Dependency: A Guide for CCOs - OHA Handout
• A Primary Care Approach to Reduce Opiate Overdose Deaths - Lydia Anne Bartholow
• An Alternative Pain Clinic Model - Claire Ranit
• A Collaborative Approach to Improve Outcomes for Complex Chronic Non-cancer Pain - Jim Shames

3D: Social Determinants of Health

• Impacting the Social Determinants of Health at Oregon's Community Health Centers - Alicia Atalla-Mei
• Social Determinants of Health video (coming soon) - Oregon Primary Care Association
• Improving Health through Supportive Housing - Kevin Campbell
• Improving Health with Food Insecurity Screening and Intervention - Lynn Knox
• Food Insecurity Screening - Oregon Food Bank Handout

Poster Session

Clinical Innovation Fellows

• Oregon Council of Clinical Innovators: Clinical Innovation Fellows Program - Oregon Health Authority
• Non-Emergent Medical Transportation and Community Health Workers - Diane Barr, Cascade Health Alliance
• Diabetes Management in a Community Mental Health Setting - Renee Boak, Cascadia Behavioral Healthcare/FamilyCare
• Addressing Nicotine Dependence - Marilyn Carter, Adapt/Umpqua Health Alliance
• Behavioral Health Medical Home: Payment Reform Project - Carla Gerber, PeaceHealth/Trillium Community Health Plan
• Assessment of Parental ACEs in Pediatrics - R.J. Gillespie, The Children's Clinic/Oregon Pediatric Improvement Partnership
• Developing an Alternative Payment Strategy for the Tri-County 911 Service Coordination Program - Alison Goldstein, Multnomah County/FamilyCare/Health Share of Oregon
• Integration of Behavioral Health and Primary Care - Lisa Howe, Harney District Hospital Family Care Clinic
• Assessing and Addressing Clinician Burnout and Engagement in Work - Safina Koreishi, Columbia Pacific CCO
• Maternal Medical Homes - Lindsey Manfrin, Yamhill County Public Health/Yamhill CCO
• The Virtual Dental Home, Polk County - Linda Mann, Capitol Dental Care/OHSU/University of the Pacific
• Medication Therapy Management Service for the North Coast of Oregon - Julie Owens, Providence Seaside Hospital
• Creating a Model of Care for Pregnant Women with Substance Use Disorders - Karla Pearcy-Marston, Providence Milwaukie Family Medicine Clinic
• Persistent Pain Education Program - Andrew Roof, Mid-Columbia Medical Center
• Community Health Programs for All - Trish Styer, Jackson Care Connect
• Integrated Team Based Care - Kimberly Swanson, St. Charles Health System

Open Call

• Alternative Payment Models - AllCare CCO
• Alzheimer's Care via Telemedicine for Oregon - OHSU Layton Center for Aging and Alzheimer's Disease
• Behavioral Health Home Learning Collaborative - Oregon Rural Practice-based Research Network, OHSU; Oregon Health Authority
• Care Coordination for Children and Youth with Special Health Care Needs - Oregon Pediatric Improvement Partnership
• Clubhouse Model: Transforming Mental Health Care - Compass House, Jackson County Mental Health
• Connecting the Dots for Health - Jackson Care Connect, La Clinica, Asante, Providence Health Systems
• Discontinued Hospital Medications after Hospital Discharge - Central City Concern, CareOregon
• Exploring the Intersection between Housing and Health - Center for Outcomes Research and Education, Enterprise Community Partners
• I-CAN: Building Academic, Community and Health Networks in Underserved Communities in Oregon - Oregon Health and Science University
• Integration of Primary Care into Behavioral Health - Central City Concern Old Town Clinic, Old Town Recovery Center
• Jefferson Health Information Exchange: Integrating Health Care in Oregon for Better Care and Value - Jefferson Health Information Exchange
• The Medical-Legal Partnership of Oregon: Impacting Health through Legal Services - Health Share of Oregon
• Meeting the Health Care Needs of the Recently Incarcerated - Oregon Health Authority, Multnomah County Health Department, Department of Community Justice
• Nutrition in Primary Care: Integrating Dietetic Interns into the Patient-Centered Medical Home - Oregon State University, FamilyCare
• One Key Question - Oregon Foundation for Reproductive Health
• Promoting Healthy Lifecourse Development through Home Visiting - Oregon Health Authority
• Shared Care Planning - OHSU Oregon Center for Children and Youth with Special Health Needs; Coos, Deschutes, Harney and Marion County Public Health Departments
• Tele-dermatology in Primary Care - Yamhill Community Care Organization
• Virtual Residential - Kairos, Jackson County Mental Health
• Wellness Hub Approach to School Health in Rural Oregon - Umatilla County Public Health, InterMountain Education District
• Yamhill CCO and Early Learning - Yamhill Community Care Organization

Partner Events

Pathways to Health Equity: Success Means Getting There Together

• Conference materials

Health and Early Learning Forum

• Forum agenda
• Forum speaker bios
• Overview: health system and early learning system transformation
• World Café project packet (project summaries)
• World Café instructions
• Regional conversations worksheet
• Building an Early Learning Nation One Community at a Time (keynote slides) - Sondra Samuels
• Plenary sessions and keynote address (video)

Event documents can be provided upon request in an alternate format for individuals with disabilities or in a language other than English for people with limited English skills. To request event documents in another format or language, please contact the Transformation Center.

Thank you to our generous partners!

 

Previous Coordinated Care Model Summits

• December 3-4, 2014 - Oregon’s Coordinated Care Model: Inspiring Health System Innovation
• December 5, 2013 - Transformation in Action