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CareOregon and Central City Concern—“inextricably intertwined”

Posted on Jul 1, 2019 @ 7:00 AM
CareOregon and Central City Concern—“inextricably intertwined”
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In a shared office just off Portland’s West Burnside Street in Central City Concern’s Old Town Clinic, the Ambulatory Intensive Care Unit — aka “the Summit Team” — considers the challenges that lie ahead today.

There is the patient who is bruised and cut from a fall from a wheelchair. She believes herself to be royalty. She’s on medication for her mental illness, and her residential facility wants her to have an escort for medical appointments. Should the Summit Team arrange for the escort?

There is the patient with monthly income of $200–$300, who was convinced by a salesman to buy a life insurance policy with premiums near $200 per month. Should the Summit Team find free or pro bono legal help? Maybe contact the State Insurance Commissioner?

Then there is the young patient who has end-stage renal disease. Are his care needs complex enough for the Summit Team to take on?

These are the kinds of questions that the 10-member team asks when taking on the clinic’s most medically complex patients, including social and economic challenges that their make healing difficult.

The clinic serves a large population of homeless people, and at times, these challenges can appear unsurmountable.

With support from CareOregon, which insures most Old Town patients, the Summit Team has accepted the challenges.

The partnership between the Old Town Clinic, a Federally Qualified Health Center, and CareOregon is lengthy, deep and critical to the creation of the team, and to the clinic itself.

“Frankly, inextricably intertwined,” says Central City CEO Rachel Solotaroff, MD.

CareOregon provided startup funding for the Summit Team, but how the team structure and operating methodology is a direct result of a much earlier CareOregon initiative that changed how Central City Concern organizes its medical operations at the Old Town Clinic, and beyond.

Twelve years ago, Old Town Clinic was one of five organizations that participated in CareOregon’s Primary Care Renewal, the pilot project that introduced the medical home model to Oregon. In a medical home, the physician is not a solo act, but rather one member of a team that focuses collectively on its panels of patients, proactively considering each patient’s needs before they even come in for an appointment.

“Because of that primary care home model there are so many other innovations that have been made possible,” Dr. Solotaroff says. “There was an emergency department utilization pilot that we did with CareOregon that we showed some dramatic decreases in that area of utilization. The behavioral health integration work has advanced treatment for opioid use disorder. None of this would be possible if we hadn’t spent those 10 years working on that strong foundation of the medical home.

“We have actually taken those ideas and tried to apply them to other parts of the organization, like utilizing team-based care in our mental health and in our addictions programs, so it has just had a lot of leverage, a lot of legs.”

Additionally, with CareOregon’s support Central City Concern has adopted other innovations in the provider-health plan relationship that have given life to better ways of providing care. And that’s particularly important for a patient population that includes a high percentage of homeless people, and, before the Affordable Care Act, with a high percentage of uninsured.

“The traditional ways that you get paid for primary care, which is by turning out visits, weren’t going to apply with this population,” Dr. Solotaroff says. “We worked with CareOregon to figure out more of an incentive-based model so that we can have more flexibility in caring for the population.”

Flexibility for things like visits while patients are in the hospital; home visits; longer, more integrated appointments; more care by phone or after-hours; and using provider types that might not traditionally be billable in a primary care setting.

The Summit Team, for example, includes two social workers, a health coordinator, two care coordinators, a nurse, two physicians, a pharmacist, a research assistant and a team manager.

“Twenty percent of folks in our patient population, maybe more, are kind of churning through the system outside of these walls, whether that is in hospital systems, criminal justice systems, substance use treatment, detox settings, or caught in a cycle of homelessness,” says Meg Devoe, MD, one of the Summit Team physicians. “There are all of these other complex systems that our patients interact with. And when you take a population that has chronic medical illness that is unstable, that gets super chaotic really fast. They are often getting care elsewhere, care that is often really fragmented.”

Old Town Clinic believes the Summit Team application of the primary care medical home model to this population is the only one of its kind. Based on their own experiences day to day, the team expects good results from an OHSU study of the team when the data is published later this year.

The Summit Team and its support from CareOregon is one example of the “CareOregon Effect:” how the relationship between the health plan and its community partners has far-reaching, positive outcomes beyond the initial collaborative project, far beyond a typical provider-payer relationship. At Old Town clinic, it also extends to behavioral health integration and emergency department utilization projects (to decrease patient use of emergency rooms for non-emergency care). Additionally, CareOregon and Old Town are collaborating on community health outreach to engage clients who are not yet receiving care, and on quality-based payment models for improvements in preventive screenings and diabetes care. The teamwork extends to the Housing is Health initiative, with CareOregon joining with other health care organizations to provide $21.5 million for the construction of three major affordable housing projects under Central City Concern’s leadership. And even to using the medical home model to manage the social services that will be a part of the Blackburn Building, opening in mid-2019.

“CareOregon is special and will always be special,” Dr. Solotaroff says. “All that CareOregon does is to figure out the best way to take care of a vulnerable Medicaid population.

“You know, I would say ‘we’ rather than ‘they,’ because I feel myself as part of CareOregon, as we have done it together for 25 years.”

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