News

Contact: Maria Ramirez

Through the new gap care project, Cascade Health Alliance (CHA) continues a strong partnership with Oregon Mobile Healthcare (OMH) to offer in-home follow-up service for people recently discharged from the hospital to reduce emergency room visits and hospital readmissions.

"It's a way for us to work with doctors in the community to help people with serious health problems to overcome them," said CHA's Medical Director Dr. Jim Calvert.

CHA serves Klamath County as a coordinated care organization, managing Oregon Health Plan benefits, the state Medicaid program, for 18,000 members. Through its affiliate company ATRIO Health Plans, this new program will also impact Medicare Advantage plan holders served in conjunction with CHA.

CHA and OMH have worked together for several years on various projects and initiatives, including offering free flu shots to health fair attendees. This newest project represents a continued collaboration between CHA's Case Management Director Diane Barr and OMH Program Director Chad Partington.

Over the summer, Barr graduated from the prestigious Clinical Innovation Fellows program, organized through the Oregon Health Authority Transformation Center. The fellowship is focused on leadership, quality improvement and methods for spreading innovation expertise across the health care delivery system.

For her fellowship project in the 2015-2016 cohort, Barr worked to expand the Non-Emergent Medical Transportation and Community Health Care Worker Program, including reaching out to the rural communities of Sprague River, Beatty, Bly, Chiloquin, Merrill, and Malin to offer health screenings and to "take health care to them."

Partington is currently participating in the fellowship program as part of the 2016-2017 cohort. This care gap program is both his fellowship project and an extension of Barr's original project.

Upon discharge from the hospital, many patients are given instructions to follow up with their primary care provider, or doctor, to continue care. For some patients, it may be difficult to schedule an appointment, or travel to their doctor's office, particularly for people who live in outlying communities.

The national bounce-back rate to hospitals ranges from 48 hours to seven days, Partington said. This program allows Partington and his team to reach out to discharged individuals to help them figure out new or changed medications, and to offer some interventions to reduce the bounce-back rate.

OMH will work with primary care providers to report concerns and determine appropriate care. The team will also share all information about these follow-up visits with the patients' doctors and with CHA to make sure all health care providers have the most current information about their patients' health. This boosts the coordination of care, benefitting both providers and members.

As part of the program, OMH staff, including Partington, who is an Emergency Medical Technician (EMT), will provide medical assessments, medication management, physical therapy education, and review discharge instructions with patients to make sure they understand what steps to follow at home. OMH can also perform IV hydration, lab draws, nebulizer treatments, and wound care if a patient needs that care.

"Our philosophy is that we're really focused on outcomes," Partington said, adding that the OMH crew can act as an extension of the primary care team that can make house calls and perform in-home social and environmental assessments, and then help connect people to the services they need most, including socials, behavioral, dental, and home health services.

Partington and his team can meet people at their level, and are able to establish a trust and rapport with patients, Barr said.

This type of intervention helps reduce health care costs, creates healthier outcomes for patients, and avoids potential health catastrophes, Barr said. "I really think that it fills a huge need in our community," Barr said. Innovative programs like this gap care partnership can help people in the community achieve better health and a better life, she said.

George Olson, the Chief Operations Officer of Klamath Health Partnership, Inc. which operates Klamath Open Door Family Practice, said the idea behind the program is "phenomenal." Patients at the Klamath Health Partnership clinics could be impacted by the gap care program.

The new program allows medical professionals to go to patients, rather than patients needing to go see a medical professional, Olson said. That helps remove barriers to health for patients, especially for the people that potentially need access to health care the most.

"It ends up being a great collaboration between our team and the Oregon Mobile team through CHA to really impact the health of the community," Olson said. "I think that we have to be partners with our customers and our community."

Molly Jespersen, the Director of the Outpatient Care Management Program through Sky Lakes Medical Center, said OMH is a valuable community partner, helping everyone get the care they need.

"By working collaboratively with the patient's health care team, Oregon Mobile Healthcare helps to ensure that people who may not otherwise be able to access health care, who are often the most vulnerable and underserved, can get the care they need," Jespersen said.

The gap care project also has the added benefit of helping CHA meet quality metrics measured by the Oregon Health Authority. In addition to the discharge checks, OMH can also deliver FIT tests for colorectal cancer screening, and provide Hemoglobin A1c (HbA1c) testing for diabetes.

Dr. Grant Niskanen, the Vice President of Medical Affairs at Sky Lakes Medical Center, sees CHA's partnership with OMH as an important opportunity to successfully meet the Oregon Health Authority incentive metrics.

"This will help us expand our work to patients that can't get to the doctor to receive this preventative care and screenings," Niskanen said.

This project offers ample opportunities for expansion in the future, and encourages positive health outcomes for CHA members.

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