By Rebecca Ramsey, BSN, MPH, Director – Community Care, CareOregon
For years, CareOregon— a non-profit health plan serving the healthcare needs of low-income Oregonians—used more traditional means (telephonic case management predominantly) to reach our population. However, there was a segment that we were unable to engage with optimally or even at all. To expand our reach to underserved portions of our population, we built a partnership with our primary care network that was designed to implement primary care home team-based models within our safety net network.
With these limited, but incredibly important, experiences, we improved chronic disease management and access to preventive care; built more data driven process; brought behavioral health consultants on the team; and expanded our capacity to reach different populations. However, we still didn’t quite get there – the high cost and very complex patients remained elusive.
At the same time as this partnership was reaching our sixth year, managed care plans were experiencing significant cuts. We knew we had to do more with less. To accomplish this, we had to take chances and try something completely different.
So, a medical director and I performed a few site visits of similar organizations that seemed to be thriving in the changing culture and reaching high cost patients. These places had more experience performing community-based outreach to their most vulnerable members/patients and we wanted to learn more.
Through these visits, we spent time with mobile outreach teams that were conducting home visits and talked with leaders and administrators.
The whole trip was one long eureka moment. The minute we were back, we knew we needed to partner in a different way with our primary care network and develop a different model of care management, which would really be a new vulnerable population strategy.
The strategy revolved around helping the primary care teams in clinics with high cost members expand their team to include a new workforce that had the ability to work outside the clinic walls and meet patients where they lived and where they were struggling.
We began the plan with data – we looked through tons and tons of claims data to identify members who were frequently admitted to the Emergency Department and/or Hospital, and we began this new work with two clinics that had a high proportion of these members.
We identified a cohort of members in these two clinics and did chart reviews, talked with providers and made home visits to interview them – all of which supported our conclusion that we needed to reach these folks via different means. We found that these patients were going to the clinic, but there was so much psychosocial risk in their daily lives that couldn’t be managed within an office setting—and this was certainly impacting their health.
We then recruited two outreach workers to go out into the community and work with high-risk patients. We hired individuals with amazing engagement skills, social justice understanding, compassion, exceptional interpersonal skills and extensive knowledge of vulnerable populations.
Somewhat surprisingly, our first two hires ended up being masters-level social workers who really liked the innovative idea of integrating their work right into primary care and doing community outreach. While they were health plan employees, they were embedded in the clinics – but they could also liaise back with us.
We called our new staff Community Outreach Workers and they immediately began to engage with a small panel of high-cost, very complex individuals. Specifically, they conducted care planning and individual outreach that was completely client-centered—meeting with individuals in shelters, homes, emergency departments, hospitals, etc.
They worked intentionally and methodically with each patient to identify what their barriers to health were. They found that there were mild cognitive impairments, developmental disabilities, health literacy issues, housing instability, childhood trauma, posttraumatic stress disorder, anxiety, depression, addiction, etc. It was what we were expecting but at a far larger magnitude.
After the interventions began, we saw hospital and emergency department utilization decrease. Of course, the providers were happy. But they also noticed that patients would interact differently during their visits and seemed more engaged and receptive within the clinic’s walls.
The pilot lasted about nine months and the results were great. We had clinics lining up to participate in the next round. At about the same time, the Centers for Medicare and Medicaid Services announced the innovation awards (Center for Medicare and Medicaid Innovation) and our community decided to apply for one, which we received. Our plan was to do what our clinics were clamoring for: to expand the community outreach worker model along with four other interwoven programs to create a cross continuum safety net for this population.
The last aspect of our success that shouldn’t be overlooked: our model relies on principles of trauma informed care**. We were blown away by how prevalent the experience of childhood and lifetime trauma was in our patients. We feel far more informed now and primary care is shifting the culture with this understanding. Within our local community, people are now paying attention in a new way at the root causes for these members poor health.
Currently, we have 17 community outreach workers, now known as Health Resilience Specialists, in 17 clinics and we are seeing 34 percent declines in hospital and emergency department utilization. We’re in the process of developing a control group to obtain more specific results. If the results hold, we could see savings of between $3.7 and $7.4 million per year. At the current scale, the program costs us $2.5 million per year.
As far as I know, this is the first time that, as a health plan, we have partnered with our networks in such a collaborative way. For many years, payers tried to run these programs for members at high risk—with limited results. What we learned is that we have to collaborate intensively with the entire continuum of care. I think the reason we’re seeing astounding results is because of the partnership and because the staff are integrated.
**TFAH/Editor’s note on trauma informed care: The most common social risk factor in CareOregon’s target population is trauma, which clearly strained interpersonal relationships, made self-care difficult and lead to misunderstood behavior patterns. To truly reach this population, CareOregon first sought to understand trauma and the ramifications of experiencing traumatic events. CareOregon then implemented a nationally recognized, evidence-based Trauma Informed Care model called the Sanctuary Model™. Staff and clinics were encouraged to avoid being hierarchical and to motivate patients so they had a stake in their own care. In practice, trauma-informed principles influenced each member and provider interaction.