Oregon’s Community–Clinical Partnerships Tackle Chronic Diseases

March 10, 2017   |  Tags: Blog   |  Tags: Eastern Oregon , FQHC , Community Health Workers , Medicare , Medicaid
Tracy Carver, MPA

Read the complete blog post and join the discussion on community-clinical partnerships at HealthInsight.org

Cardiovascular diseases, pre-diabetes and diabetes are at a record high. According to the CDC, cardiovascular diseases are the leading cause of death in the United States. Nearly one in 10 Americans has diabetes, and without intervention, this number will likely continue to grow. More than one-third of American adults have pre-diabetes, an estimated nine out of 10 don't know they have it. The good news is many risk factors for these conditions can be prevented or managed with lifestyle changes between visits to the doctor. Success, in many cases, depends as much on lifestyle as it does on quality care.

Throughout my career, I've worked with community-based partners across Oregon to increase access to self-management education (which is proven to help patients better manage their chronic conditions) and improve systems that support patient activation. Although these models are evidence-based, they often rely on tenuous grant-based funding and volunteer commitment. These community programs are doing amazing work and they are changing lives. They are also laying a foundation that ultimately could bend the cost curve for the health care system.

Three exciting models in Oregon rely on community-clinical partnership, using traditional health workers to help patients navigate the health system and access appropriate self-management education and needed social services.

  • Through a partnership with Kaiser Permanente Northwest, Familias en Accion employs community health workers and health navigators using a Pathways to Health model to help ensure that patients receive culturally sensitive support and the tools they need to become activated partners in their care. Their newly released implementation guide has details on how to replicate this program.
  • Asian Health & Service Center's (AHSC) Asian Wellness Connection program, a three-year pilot, is a partnership of AHSC, two Portland area federally qualified health centers and Portland State University. Together they're building an integrated medical home model in which patients receive culturally specific assistance with care coordination, navigating wraparound services and chronic disease prevention and management education.
  • In rural eastern Oregon, Good Shepherd Medical Center's ConneXions program is using community health workers to bridge geographic and cultural divides by helping patients navigate the health care system and by providing support and education in the communities where they live.

In January, the Centers for Medicare and Medicaid Services (CMS) began reimbursing for Medicare beneficiaries to complete the Diabetes Prevention Program (DPP), marking the first time Medicare has paid for preventive services for beneficiaries with pre-diabetes. Since many organizations that provide the DPP are nonclinical, this shift will likely open the door for other new and innovative clinical-community partnerships. CMS also incorporated direct incentives for providers in the new Quality Payment Program to reward referrals to community-based education and other support services. HealthInsight can help organizations navigate these opportunities and test new ways of improving care.

Similarly, Oregon's Medicaid program is beginning to test payment models using flex funds to facilitate member access to Stanford University's evidence-based self-management education programs and the DPP. These value-based payment reforms will help to drive much-needed conversations about how to invest long-term in population health and how to scale up and spread the most promising models.

Tracy Carver, MPA, has worked with HealthInsight Oregon (formerly Acumentra Health) since 2011. Currently, she manages the Centers for Medicare & Medicaid Services (CMS) Everyone with Diabetes Counts initiative and the Integrating Evidence-based Self-Management Education into Patient Care Special Innovation Project in Oregon. She also manages HealthInsight Oregon’s integrated physician office team and is a leader for companywide physician office integration design and operations. Previously, Tracy served as a quality improvement specialist focused on medication safety initiatives. Before joining HealthInsight, Tracy worked for the Oregon Health Authority coordinating initiatives focused on community-based approaches to self-management, health literacy, disparities and reducing the burden of chronic disease. She has more than nine years of experience leading innovative quality improvement and population health initiatives. She holds a Master of Public Administration degree from Portland State University.