Umpqua Health Alliance Umpqua Community Health Center Extended Care Clinic

1. Umpqua Health Alliance Umpqua Community Health Center Extended Care Clinic Integrated clinic for patients with complex health and addiction issues

2. OHP Client Oral Health Physical Health Mental Health Addictions TX • Assessment • Diagnosis • Treatment Plan (EBP) • Pre-set rate per service • Monitor / Update • Assessment • Diagnosis • Treatment Plan (EBP) • Pre-set rate per service • Monitor / Update • Assessment • Diagnosis • Treatment Plan (EBP) • Pre-set rate per service • Monitor / Update • Assessment • Diagnosis • Treatment Plan (EBP) • Pre-set rate per service • Monitor / Update

3. CCO created a culture which allowed providers to bring these local activities into the next generation of integration Why This Why Now?

4. Current Conditions Douglas County is ranked thirty-one (31) out of thirty-three (33) counties for poor health outcomes in a National study • Intergenerational issues of at risk behaviors which impact health: • Smoking • Substance abuse • Poor diet • High poverty rates High rate of chronic diseases – Poor personal health care (disease management) People with chronic health conditions and mental illnesses on average die 25 years younger than counterparts Limited access to health care Overuse of ER due, in part, to waiting until health issues escalate, limited access to care, poor personal health care, etc Fragmented health care systems limits implementation of evidence based practices and increases health risks Above conditions drive health care cost

7. Prevalence Rate (per 1,000 Eligible - 2011 – OHP)

9. Improve Health System, Improve Health Outcomes, Lower Costs At High Risk - Chronic Disease Chronic Disease All OHP Clients Early Assessment & Identification of High Risk For Chronic Disease Coordinated case management – Reduce likelihood become chronic Coordinated case management – Reduce high end costs

10. At High Risk - Chronic Disease Chronic Disease All OHP Clients Early Assessment & Identification of High Risk For Chronic Disease Coordinated case management – reduce likelihood become chronic Coordinated case management – Reduce high end costs

11. At High Risk - Chronic Disease Chronic Disease All OHP Clients Early Assessment & Identification of High Risk For Chronic Disease Coordinated case management – reduce likelihood become chronic Coordinated case management – Reduce high end costs

12. At High Risk - Chronic Disease Chronic Disease All OHP Clients Early Assessment & Identification of High Risk For Chronic Disease Coordinated case management – reduce likelihood become chronic Coordinated case management – Reduce high end costs REALLY? Savings = reinvestment into system – incentive, etc.

13. Cost Impact Sample – Using Diabetes for Douglas County: Number of Persons: 9,300 Number of Deaths: 531 Costs: $42.6M If you can prevent 4.67% of people from getting Diabetes: If you can prevent 20% of people from getting Diabetes: 437 Number Prevented: 1,860 32 121 Lives Saved: Financial Cost Savings: $2 M $8.52 M

14. Cost Impact Sample – Using Diabetes for Douglas County: The risk of Type 2 Diabetes can be reduced by 50-70% by control of obesity And by 30-50% by increasing physical activity $8.52 Million Question: What is the likelihood of preventing 5%, 10%, 20% of population from getting Diabetes? If you can prevent 4.67% of people from getting Diabetes: If you can prevent 20% of people from getting Diabetes: Number Prevented: 437 1,860 Lives Saved: 32 121 Financial Cost Savings: $2 M $8.52 M

15. Personal impact cannot be quantified • Can apply model to other chronic diseases – Each has risk factors which increase the likelihood of illness: • Heart Disease and Stroke Prevention: • No tobacco • Physically active • Healthy weight • Healthy food choices • Preventing / controlling high blood pressure • 12 – 13 point reduction in average systolic blood pressure over 4 years reduces heart disease risk by 21%, stroke risk by 37% • Cancer Prevention: • No tobacco • Limiting alcohol • Limited exposure to ultraviolet rays • Diet rich in fruits and vegetables • Maintaining a health weight • Being physically active • Seeking regular medical care

16. PCP Addictions Mental Health Oral Health

17. Health Integration System Family Behavioral Health Mental Health Spiritual Community Patients Providers Dental Health Peers Physical Health Neighborhood Health

18. What do you think about health integration? “How would a patient with chronic health conditions, mental health issues and substance abuse problems receive effective treatment through an integrated system of care in Douglas County?”

19. Purpose Statement - The team (health, mental health and substance abuse treatment) provides prevention and integrated health care (physical, mental health and substance abuse treatment) for OHP members with or at risk of chronic conditions in order to improve health outcomes and reduce costs.

20. Target Population Focus

21. What model? • Best serve complicated patients? • One from around Oregon • Nationally recognized • What will be built ---

22. Patient Advocate Medical Case Manager (Nurse) Nurse Clinic Manager MH Case Manager Psychiatric Nurse Practitioner Behavioral Specialist Receptionist Medical Assistant Doctor RX Coordinator

23. What do you want for these patients – “survey responses”: • I am involved in – help direct my health care (engaged) • I have easier access to care • One stop care – each team member is understanding and helpful • I am part of the team & feel empowered to help myself • I am heard – listened to – my input matters • I receive better health care through each team member • I am better able to manage my health • I learned to take charge of “my health” • I feel better • I would refer family / friends to the clinic • I took skills learned about managing my health needs and applied them to other parts of my life…

24. Who does what….

25. Day 1 – Develop the model… • Start with the “empty chair” – • How might they feel that day • How to get to the “want” list? – who will do what • Engagement – goal setting • Referral • Meeting them • Screening • Clinic education • Meeting the team • Information sharing • Scheduling • Daily huddle • Weekly review meetings

26. What are we doing right? • Build relationships - bring people to the table • Focus on processes • Start with something that can be fixed • Keep momentum and don’t get stuck • Bring it back to the patient and quality of care • Optimize productiveness of meetings – set goals, use a facilitator, have food…. • Always find the Win Win • Respect the expertise of the team • Allow for a paradigm shift

27. Changes in Oregon Health Plan Federal Accountable Act Coordinated Care Organizations Healthcare Coordination & Integration Dual Eligibility Metrics / Performance Measures Community Advisory Councils Global Budgets For All Primary Care Health Homes