Better Together: Care Coordination Efforts Enhance Patient Care
by Rebecca Ramsay, MPH, Manager of Program Development, Care Coordination Unit

Meet Our Staff

Health Care guides, from left (standing): Donita Smith, Anita Peterson, Keara Rodela, Heidilyn Safe, Christina Gordon, Taombi Luckett and Sherrie Taylor. Seated are, from left: Margaret Wheelhouse, Brenda Gonzalez and Yelena Levchenkova

CareOregon RNs, from left: Marcia Taylor, Consuelo Vazquez, Sheryl Sherman, Debbie Root, and Connie Burroughs. Terri Schwarz is seated, in the foreground.

Behavioral Health coordinators, from left: Buck Clarke, Dora Montgomery, and Kylie Street. Photos by: Eleanor Gorman

The care coordination unit at CareOregon is changing and growing.  In fact, if a day goes by without some sort of change, it only means that the next change is just around the corner!  Fortunately, we are also learning that change usually results in improvement.

Care coordination revolves around our unique model of complex care case management.  Within this model, our goal is to proactively identify our members who are at greatest risk for poor outcomes, and to provide assistance to them before they experience a health crisis.  We use a variety of methods to identify these members including an innovative predictive modeling software program created at Johns Hopkins University.  This program utilizes a combination of claims history and clinical diagnoses to stratify our members and identify those at highest risk for future utilization of health care resources.  We are also offering our highest risk CareOregon Advantage (dual-eligible) members the opportunity to have an RN come to their homes and conduct a home health assessment to identify areas where we might be able to provide assistance.

The health care system in the United States is primarily reactive – a person becomes sick, and the health care provider(s) attempts to fix them. CareOregon has long recognized that this is an inefficient and often ineffective approach. We believe that by encouraging interdisciplinary collaboration, care coordination, and disease self-management support, we can improve the quality of our members’ lives, improve their health outcomes, and reduce utilization of our limited resources. Ultimately, we can reduce costs and better meet the needs of our members.

The concept we are pioneering is team-based population management.  Right now, it involves creating Care Support teams comprised of a lead RN, three or four Health Care Guides, and a Behavioral Health specialist.  Each team is assigned a population of members based on primary care clinics.  The team is then responsible for identifying those members of their assigned population who would benefit (using the health status, access to care, and resource utilization perspectives) from our services. A significant benefit of our population-based team approach is that each Care Support team has the opportunity to become familiar with the subset of PCPs to which their population of members is assigned.  It is our hope that this familiarity and consistency will foster the collaborative model we desire.  A primary goal of our program is to provide assistance to the providers that are caring for our members by supporting the plan of care that has already been established.  Sometimes that assistance comes in the form of information that we can share with providers; sometimes it involves establishing a therapeutic relationship with the member in order to enhance their motivation for self-management. 

The Health Care Guide is often the member’s first introduction to the team. Our Health Care Guides conduct a comprehensive telephonic clinical assessment on our high risk members.  This questionnaire is a 360 degree assessment of the member, and includes questions related to specific chronic diseases, ability to complete activities of daily living, depression, substance abuse, socioeconomic barriers, environmental and social support barriers, and relationships with medical providers. We are presently working out a system to provide our PCPs with this very valuable information about their patients.  From there, the member might interact with the RN or social worker depending on the particular needs of the member.  Our staff members collaborate daily with a variety of outside providers including the member’s PCP, specialists, family members, case workers, mental health providers, disability specialists, and other care givers.  Our goal is to promote the “Medical Home” concept by providing care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally competent (say that five times fast!). 

With the introduction of our CareOregon Advantage program, there are some exciting partnerships that the care coordination unit has successfully developed.  CareOregon has retained Pacificare Behavioral Health, Inc. to provide behavioral health administrative services for our CareOregon Advantage members. This means that PBHI will take on the utilization management activities, networking and provision of care management services for dual-eligible members who have outpatient and inpatient behavioral health needs.  The exciting news related to this partnership is that, in the words of our very own Kylie Street, Behavioral Health program coordinator, we will be able to encourage "joyous rapport" with the behavioral health therapists who are providing care for our CareOregon Advantage members.