Welcome to the Health Commons Grant blog. This communication tool is meant to provide high level updates on the activities of the many teams working together to create a regional system of care to better serve the Medicaid population in the tri-county area.

February 22, 2013 Collaborative

The first Health Commons Grant Learning Collaborative was held on February 22, 2013 with more than 130 people in attendance. Through a variety of facilitated conversations, a poster session and small group discussions, the following objectives were achieved:

  • Create overall shared understanding about the grant
  • Get burning questions answers
  • Networking across organizations and teams
  • Convene cross functional groups to problem solve operational workflow issues

An additional objective of this and future learning collaboratives is to empower conversations within partner organization on approach to implement grant interventions via lessons learned.

Content from the meeting can be found here.

Building a complete, whole-person, patient-centered care experience (2-19-13)

The Health Commons Project was originally conceived as five connected but separate projects.  These projects no longer feel entirely separate.  The project leads continue to meet weekly in an Intersections Group to discuss strategies for building a complete, whole-person, patient-centered care experience and to reduce inefficiencies and duplication of care.  These meetings have produced a deeper understanding across all interventions in terms of what each project’s strengths are and how the leads can help each other through the growth process.  The team has drafted workflow and swimlane diagrams to document a patient’s path through the grant projects, and has used those diagrams to identify touchpoints and roles.  The process has been helpful in ensuring that no one duplicates work, and the process has highlighted potential gaps in care.  The entire team agrees that the Intersections Group meetings have been invaluable in enabling leads and outreach workers to identify “who’s on point”—that is, when a patient might benefit from more than one Commons Project intervention, what team would best take the lead in coordinating care.  The Intersections Group work will also help primary care partners (who might be interacting with four or five interventions) to understand what to expect from each individual intervention.

The Intersections Group has been critical to locating potential gaps in care—that is, opportunities for us to enhance our ability to provide a connected care experience and to reduce readmissions and hospitalizations.  A recent Intersections meeting led us to ask questions such as:

As part of the primary care workflow of Standard Hospital Transitions, the primary care team will make post-discharge calls to patients.  If they cannot get ahold of them by phone, what should they do?  Also, should this process be different if the patient has an ICCT worker assigned to them?

What is the best referral pathway from C-train to an ICCT worker? Should it involve someone in the primary care clinic team, or should it go directly to the ICCT worker and bypass the normal pathway to primary care?

These questions highlight opportunities for us to improve our work, and provide focus and content for Learning Collaboratives.


IT innovation (2-19-13)

A central challenge to a CCO system is the limitation around the sharing of patient data.  The Health Commons Project is a set of interventions that could potentially touch all providers in the region, yet without a logical method for data-sharing providers might never be aware that an intervention has touched their patients.  Similarly, because many of the Health Commons Grant interventions are targeted at high-utilizing patients, it is important to track patient utilization across the community—yet as of now, different providers across the community are not linked.

As a solution, the Health Commons Project is developing PopIntel, a regional care coordination registry.  PopIntel allows the interventions to be informed of patients who are suitable for the program, keep track of the patients who are enrolled, record patient touches and care plans, and collect program data.  A version of PopIntel is already in use by the ICCT workers.

We have been hard at work on several next steps.  First, PopIntel must be customized to serve the needs of all the Health Commons Project interventions.  During the past three months, the PopIntel development team has been working with project leads to customize elements of PopIntel in order to ensure that the system will be useful and efficient.  Second, PopIntel must be built for an external secure web server.  The current version is accessible only by CareOregon employees; the next version will be web-based so that outreach workers from all partner organizations can use it and so that it can be used in the community as well as at a desk.  This development is in process; specifications for ensuring that the next version will be fully HIPAA-compliant were completed in November. 

By January, CareOregon outreach workers will be using the external version of PopIntel.  By March, we expect to add non-CareOregon users.  PopIntel and its improved, customized functionality is a crucial piece of our self-monitoring system, providing data on each program and allowing us to track progress. 

Debra Read, who has been leading the development of PopIntel, describes this as “invisible work.”  It is work that goes on behind the scenes. Its products, if they are crafted well, will never be noticed by the patient because technology will not intrude on the patient experience.  Nevertheless, despite the “invisibility” of the work, this homegrown system is the only means we have of tracking our population across providers and of mapping overlap between interventions.  The CCO structure aims to integrate all partners, including physicians, health plans, public health, and the safety net, and as Ms. Read puts it, “Integration doesn’t happen without technology.”


Partnering with primary care (2-19-13)

Primary care in Oregon is facing massive changes.  In addition to legislation around the Patient-Centered Medical Home and the introduction of the CCO model, primary care clinics are facing higher client rosters and changes in Medicaid reimbursement.

The Commons Project interventions were originally conceived of as a way to take some pressure off of primary care.  Many of the interventions inject new workers into the system to take on some of the region’s most challenging Medicaid patients—we thought this would make things easier on primary care.  Coming at the problem from this perspective, we thought it would be easier on primary care clinics if we designed the interventions outside of primary care and offered them as an enhancement.

As the Health Commons Project launched, we realized that our care coordination interventions such as ITT, ICCT and CTraIn would take more collaboration with primary care than we had anticipated, and we are working to find the best model for that partnership.  ICCT has sought the input of primary care clinics during the interviewing and hiring process for outreach workers.  The ICCT team has also recognized that many primary care doctors might need the information that is documented in Popintel, and the team is working with our IT team to create simple paths for data sharing.  The ED Guides project has also identified a need for primary care partnership:  When helping patients in the emergency department find the most appropriate site for them to receive care, it helps to have open appointments at safety net clinics.  The ED guides program has been working closely with primary care clinics to negotiate those appointment slots so that a patient with an urgent but not emergent need can be seen at a primary care clinic.


Hiring and training a new workforce (2-19-13)

The Health Commons Project hired 16.57 FTE new workers in Quarter 2, including 2 project managers, 5.5 Qualified Mental Health Specialists for the ITT project, 5 outreach workers for the ICCT project, and 1.7 FTE transitional care nurses for the CTraIn intervention. Health Commons Project workers have been hired by 9 different employers for work at 19 different locations.

Hiring for these new positions was a pleasant challenge.  Many applicants were interested in the positions because of the opportunity to generate positive outcomes and to make a difference.  We also had a high level of interest because the positions are new—nothing like this has been done in the region before.  However, because these are new roles in a new system we had to be careful to select for the qualities that would set each new employee up for success.  We looked for candidates who were prepared to step into a health care culture that is in a state of chaos and change, who could adapt to new cultures and new languages, and who exhibited cultural sophistication and maturity. 

Whenever possible, the grant projects hired using a cross-system hiring panel.  Many of these positions cross health care sites and disciplines, and so primary care clinics, behavioral health partners, and public health departments were invited to give feedback.

Training for these new staff must be highly customized.  This new staff will provide a linked system of care coordination across the region and across providers.  They come from different backgrounds and are hired for multidisciplinary positions.  For example, we aren’t just hiring social workers as outreach workers—we’re also hiring mental health specialists, community advocates, and people who have worked in customer service.  As a result, each new employee comes to the table with a different set of valuable skills, and the project leads must design a method of filling in the gaps, rather than providing a simple orientation to a new worksite.  Training has included an orientation to technological tools, an introduction to Motivational Interviewing techniques and Trauma-Informed Care, training in how to handle insurance, and training in how to facilitate connections across the region.


Advocating for system-wide change (2-19-13)

We have been hard at work to find ways to measure our progress and to make improvements to each individual intervention that will enable us to better serve our community.  At the same time, an important key to our success will be our ability to advocate for system-wide change that affects our ability to serve our patients.   For instance, we know that we can improve our ability to identify patients who could benefit from an ICCT outreach worker or an ITT worker.  We know we can improve our workflow, we know that we can increase the ability of a worker to build rapport or to act as a coach.  We know that we can do some things to increase the graduation rate for these programs.  But there is only so much we can do within the intervention.  Some ICCT or ITT patients are facing homelessness or addiction, and we know that there is not enough capacity within the region to address those problems.  The Health Commons Grant Oversight Team provides a forum to bear witness to these challenges and to brainstorm upstream solutions—it also connects the interventions to leaders who can implement system-wide change.  One goal for our data management and self-monitoring system, which includes the learning system, is to communicate lessons to those community leaders who can make a system-wide difference.


Engagement tools and learning system in development (2-19-13)

A key piece of the learning system is our community-wide communications strategy.  During Quarter 2 we hosted a webinar introducing the community to the grant projects.  Invitations were extended to executives and project partners as well as patients, physicians, and local media representatives.  This webinar served as an introduction to grant activities and will foster a dialogue with the regional community about grant activities so that we can learn from our stakeholders. 

In addition to the webinar, we also refined the project website (www.healthcommonsgrant.org).  The project website is our platform from which we can send monthly updates.  The update tracks the progress of the entire grant team as well as the progress of the individual interventions in relation to key tasks identified in the operational plan.  The update is disseminated through email and is also archived on the Health Commons Project website; a dashboard tracking progress towards quality and cost targets will also be updated monthly.  We also introduced a blog to the website.  These formats allow the grant team to communicate frequently and consistently with stakeholders, and to introduce a level of transparency that builds trust among partners.

In addition, the ICCT team has built an initial version of a learning system at the intervention level.  The team incorporates multidisciplinary case review into this system, allowing outreach workers to meet weekly in a group, along with providers, to problem-solve system-level and patient-level challenges.  Data from PopIntel are fed into the case review sessions, allowing supervisors to see how each outreach worker is progressing through their caseloads and to track the progress of each patient through the program.  This system will be expanded project-wide with the first learning collaborative being held in February.


Usind data to improve the project (2-19-13)

Over the past quarter, the Health Commons team has further developed PopIntel, a homegrown community-wide care coordination registry that is key to our work.  PopIntel was under development for the ICCT intervention prior to the grant award and is being expanded to suit the needs of the broader project.  It has become our IT solution for organizing and strategizing for patient outreach as well as an invaluable tool for measuring our progress.

Self-Monitoring Case Study:  Popintel data has been used in conjunction with claims data and hospital census data to test new casefinding methods.  The success of our care management interventions depends on our ability to find patients who could benefit from our services; these are not services that patients will seek on their own.  So it is particularly important that we improve our ability to identify new cases. 

Previously, in the ICCT intervention, historical claims data was used to identify high-acuity, high-utilizing patients who might benefit from the program.  But claims data is old news; the ICCT team wanted to explore strategies for finding these patients before claims data is reported.  The team’s triage coordinator in testing the feasibility of using hospital and ED census data to identify patients who are currently at the hospital to see if ICCT workers can connect with the patient at the moment that they are seeking care, instead of later—when the claim has already gone through.  Early results are positive and we expect that this data will lead to more timely outreach on the part of ICCT workers, including more hospital visits.

Building a self monitoring plan (2-19-13)


The evaluation team is fully staffed and has created a comprehensive plan for collecting data to measure performance and to inject feedback into the learning system to catalyze process improvement.  The team began data collection in September, monitoring patients served under the ICCT intervention. 

While the grant-wide evaluation plan has been set for some time, some work remains to be done in identifying how the evaluation team can best serve the individual interventions.  Over the last quarter, the evaluation team has worked to identify the key metrics each intervention will need in order to assess project progress.  The Evaluation Team met often with each of the project leads to think carefully about what numbers the leads need to see each month in order to understand how to improve their projects.  Project leads also brainstormed with the evaluation team to identify sources of data and to sketch out reporting schedules that would not be burdensome but would still provide timely feedback for process improvement.

A significant piece of the self-monitoring plan includes qualitative interviews with individuals who interact with the project at all levels—from executives to community partners to patients.  During Quarter 2 the interview guide was drafted and the team created an analysis plan to organize qualitative data collected during these interviews.  Consent forms were also drafted.  We expect to obtain IRB approval for these data collection efforts in January.


ICCT expanded rapidly in last quarter of 2012 (2-19-13)

 The ICCT intervention expanded rapidly over Quarter 2 to include 7 new hires, including 5 OWs at 5 clinics.  By Spring 2013, there will be 15 ICCT workers in the field with patients.  In addition to hiring outreach workers, CareOregon hired a supervisor and a Data and Triage Coordinator to help the ICCT workers streamline the process of identifying appropriate new clients and reaching out in a timely manner.  This Coordinator has also begun to support coordination between C-Train and ICCT by acting as a single point-of-contact for C-Train staff with regards to shared clients.  As part of ongoing learning, ICCT staff attended trainings on Motivational Interviewing and Trauma-Informed Care.  ICCT project team also completed mapping project workflows, as part of the work of the Intersections Group.

In December the ICCT Steering Committee was launched, and will be chaired by Rebecca Ramsay of CareOregon.  A charter was formed and membership includes leadership representation from all clinics, organizations, and sites of care where outreach workers have been hired or deployed.  This group got off to a great start and has identified 6-8 high-priority areas to address and standardize over the next few months.  This Steering Committee will meet monthly for 90 minutes.