The Eastern Oregon Care Coordination Project

December 9, 2015   |  Tags: Blog   |  Tags: Care Coordination , Eastern Oregon , Rural , ORPRN , Training
Maggie McLain McDonnell

On October 9th clinicians, staff and patients from four primary care practices in Hermiston and Pendleton joined the Oregon Rural Practice-based Research Network (ORPRN) for a day-long Eastern Oregon Care Coordination (EOCC) summit at the Pendleton Convention Center. Participants identified local care coordination needs and explored best practices for managing referrals, transitions of care and medications in their practices. Hannah Rosenberg, MSc, Program Coordinator of Boston Children’s Hospital and Manager of the National Center for Care Coordination Technical Assistance, presented evidence supporting care coordination, which Dr. Richard Antonelli defines as the “space between” provider visits and hospital stays.  

The summit was modeled after the Boot Camp Translation (BCT) method developed by Colorado's High Plans Research Network Community Advisory Council. BCT is a community-based participatory intervention designed to engage participants and build consensus (Norman, et al, 2013), (Griswold, et al, 2013). Throughout the day, ORPRN facilitators engaged participants to share their ideas, concerns and suggestions for successfully meeting care coordination needs in the region. Participants commented on the power of patients and practice staff sharing their views; the value of networking with other practices; and the opportunity to learn about new tools and resources.

For the next six months, EOCC practices will receive three practice facilitation visits from Angela Combe, ORPRN’s Practice Enhancement Research Coordinator (PERC) based in La Grande, to support EOCC practices as they work on improving care coordination in their clinics. A recent systematic review shows that practices that receive practice facilitation are 2.76 times more likely to adopt evidence-based guidelines and incorporate them into organizational processes (Baskerville, et al, 2012).  

The summit, along with two weeks of encounter-level data collection on care coordination activities in October 2015 and April 2016, will inform the final project deliverables which include a  community resource guide and final project report that will describe the scope, costs, and value of care coordination in the county. Participants will have the opportunity to review and provide comments on the final report.


Simple Tools to Increase Patient Satisfaction with the Referral Process: practical tips for organizing your referral management process

Reducing Avoidable Emergency Department Visits: A Guide for Primary Care: simple, actionable suggestions that primary care practices can implement to reduce ER visits

Care Coordination Measurement Tool: encounter-level care coordination tracking tool that is available for no cost and can be adapted for both pediatric and adult settings.

Pediatric Care Coordination Curriculum: curriculum developed to support family-centered care. The curriculum is available for no cost and can be adapted for both pediatric and adult settings.

Maggie McLain McDonnell earned a Master's degree in Public Health and Bachelor of Business Administration degree from The George Washington University in Washington, DC.  Prior to joining ORPRN, she was curriculum development manager for OHSU's employee wellness program and research coordinator for the Pregnancy Exercise & Nutrition study. In her role with ORPRN, she serves as the project manager for the Eastern Oregon Care Coordination project. She is particularly interested in preventive care and wellness in primary care to improve health outcomes and reduce costs.