July 18, 2013
July 18, 2013 – A new pilot program in the Portland Metro area called the Community Care Connection (c3) Network has resulted in significant improvement in health care outcomes for high-risk patients insured by the Oregon Medical Insurance Pool (OMIP), as measured by a substantial reduction in both emergency room visits and hospitalizations. The project has engaged nearly 200 patients so far. The agencies involved are excited about the initial successes of the model and its potential for improving health outcomes for challenging and underserved populations, according to Project Access NOW executive director Linda Nilsen-Solares. While everyone agrees that improving public health is a priority for many important reasons, there is a lot of dialogue around how to do it. Resources are limited and funders, as well as the public, demand a plan that we can afford but that also yields measurable positive results. One of the biggest challenges is reconciling the need for an effective system, which requires streamlining and standardization, with the reality that health improvement and behavior change on the individual level are more attainable when the care is personalized. Project Access NOW, Familias en Accion and Impact NW have been working together over the last eight months to create a system of patient navigation that allows communitybased organizations to interact with individuals in a personal way while at the same time demonstrating positive outcomes at the systemic level. Project Access NOW, Familias en Accion and Impact NW have developed, built and implemented the Community Care Connection (c3) Network to create a local version of Pathways Community HUB, a nationally recognized model promoted by the Agency for Healthcare Research and Quality (AHRQ). The Pathways model utilizes patient navigators, who are knowledgeable advocates and problem solvers that create community-based individual engagement. Navigators find clients most in need of support and use VistaLogic’s Clara™ technology framework to connect them to the health and social services they need to achieve health and well being, and then measure the outcomes of those efforts. Funders define the outcomes they will pay for, and navigators are paid based on their client’s successful connection to quality services and, ultimately, improved health outcomes. The current project focused on OMIP members with high rates of emergency room visits and inpatient stays as well as members with complex, chronic health conditions. Recognizing that many factors such as safe, affordable housing, reliable transportation, and access to healthy foods are as important as taking medications properly, patient navigators partner with health care providers to support people trying manage their health conditions. Navigators also help clients understand their health insurance coverage, effectively utilize the benefits available to them and connect to the health care providers best able to serve them. The c3 Network’s configuration of ClaraTM went live with the Pathways module in mid-June, which sets the stage for program replication and expansion. This important milestone in the OMIP Pathways development was accomplished by a strong collaboration that included VistaLogic, Familias en Accion, Impact NW and Project Access NOW. Even in this short time, notable program accomplishments for clients representing the highest cost and utilization of emergency room and inpatient services:
- 70% annual reduction of emergency department visits (based on eight months of data.)
- 87% annual reduction of inpatient hospitalization days (based on eight months of data.)
- Increased education and health literacy by empowering individuals to maximize their health insurance benefits and navigate through the healthcare system.
- People served by the program experience improved health and wellbeing. Navigators have received many notes from clients expressing gratitude for their improved health and support. One client said, “Thank you for all your help and everything you have done for me. I thank God that you came into my life when you did and helped me to find help. Thank you from the bottom of my heart.”
