The InCK Model cooperative funding from CMS/CMMI consists of up to $16M distributed over seven years, including a pre-implementation period (Years 1-2; 2020-21) and implementation period (Years 3-7; 2022-2026). A subset of funding ($300K) in years 5-7 of the performance period is contingent on performance against a set of measures.
Oregon's InCK Model Service Area & Population
Target population: All Medicaid and CHIP beneficiaries from birth to age 21 (~88,235) in Crook, Deschutes, Jefferson, Marion and Polk Counties
The Oregon InCK Model aims to achieve its goals through the following strategies:
Early identification of children and youth with multiple physical, behavioral or other health-related needs. The Oregon Model uses system-level data on children’s health complexity and child-level strength and needs assessments to identify priority populations who have higher needs for care coordination.
Integrated care coordination and case management across physical health, behavioral health, and other local service providers, including those focused on addressing the social determinants of health. Funds will be used to provide training and dissemination of best practices in care coordination and community-based services with a focus on culturally and linguistically responsive care. OPIP leads these training and technical assistance efforts for local partners.
Health information exchange across service providers and the expertise of regional service integration coordinators will be utilized to support care coordination for children with health complexity and their families.
Development and implementation of alternative payment models (APMs) will align payment with care quality and accountability for improved child health outcomes.
Oregon’s InCK Model includes a strong focus on health equity and the reduction of racial and ethnic health disparities and is developing community-based strategies to ensure the voices of those most impacted by health inequities are central in the development and implementation of the Oregon InCK Model.
InCK Model Participants and Roles
State Medicaid Agency – Oregon Health Authority (OHA): OHA supports the InCK Model implementation by providing population-level data and analytic support for the InCK target region; informing data sharing arrangements and infrastructure; aligning the Model with state child health policy priorities, ensuring engagement with child-focused state agencies, and developing a pediatric APM with CCO partners and consultants. OHA is accountable for the target population enrolled in Fee-For-Service Medicaid and is also responsible for overall project management and reporting (financial and performance) to CMS/CMMI. OHA’s sister agency, Oregon Department of Human Services (ODHS), has dedicated staff time to ensure partnership and coordination in InCK planning and implementation. This position provides child and family system subject matter expertise, fosters alignment in ODHS and InCK initiatives and acts as an ODHS contact point for coordination efforts across ODHS program areas that play a role in InCK. ODHS’ Office of Reporting, Research, Analytics and Implementation (ORRAI) and Integrated Client Services Data Warehouse (ICS) provide support on the data components of the InCK Model by linking healthcare claims with ODHS data sources and other system-level data and provide subject matter expertise and support of data analysis.
Lead Organization – Oregon Pediatric Improvement Partnership (OPIP):
OPIP helps to inform InCK Model development through facilitating, convening and supporting local community partners and the regional Partnership Councils. OPIP will provide funds to local organizations to support region-specific System Navigator positions and is also responsible for training and dissemination of best practices related to care coordination for children with health complexity. For more on OPIP’s role with InCK, please visit
Coordinated Care Organizations are critical partners for implementing InCK Model activities and achieving InCK Model goals. CCO roles include but are not limited to: participation on the regional Partnership Councils; collaboration and coordination on the InCK stratification plan and data exchange; determining appropriate leveraging of local health information exchange resources; developing and applying APMs for the InCK Model; and applying best match care coordination for Medicaid/CHIP members identified through the stratification model. In our InCK Model region, PacificSource Community Solutions holds the CCO contracts and is instrumental in implementation of the Model.
Region-Specific Partnership Councils
are convened regularly in each of Oregon’s InCK sub-regions (Central Oregon and Marion County and Polk County)to provide input on the development, priorities and implementation of the InCK Model in their region.
The Partnership Council includes “core child service” representatives outlined below and other organizations that address factors that impact child health and health care use. OPIP develops and facilitates the Partnership Councils to build on regional structures and partnerships already in place.
CMS Innovation Center, Integrated Care for Kids Model
Communities most impacted by health inequities and youth and parents will be specifically engaged to participate in the development and implementation of Oregon’s InCK Model, building on existing relationships and supported by the development of Parent, Young Adult and Youth Advisory Groups and intentional community engagement focused on promoting health equity. OHA’s Office of Tribal Affairs provides guidance around engagement of Oregon’s Federally Recognized Tribes.
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