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CareOregon's Community Care Program |
Oregon |
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CareOregon is a Medicaid health services organization operating within HealthShare - a Medicaid Coordinated Care Organization (CCO). In 2011, CareOregon developed the Community Care Program, a model that embeds community outreach workers into primary care and specialty practices as a means of enhancing their "high touch" interactions with super-utilizers. The Interdisciplinary Community Care Teams provide multidisciplinary support to high-utilizing patients to help them build health literacy, address psychosocial needs and overcome barriers to health. Patients are identified using claims data, real-time event notification and care team referrals. Research is conducted to determine if these high-utilizers' hospital admissions were preventable and might have been mitigated by extra supportive outreach or care coordination. The Community Care Program includes the Health Resilience Program, the Central City Concern Health Improvement Project, the Tri-County 911 Service Coordination Program, New Directions and The Skin Care Clinic at Bud Clark Commons. |
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Partner Organizations |
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Target Population |
Adults with 6 or more ER visits or 1 non-obstetric inpatient hospital admission within the last year |
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Care Team |
Community outreach or social workers, in addition to primary care physicians, specialists and other healthcare providers as needed |
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Timeframe |
2011 - present |
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Results/ Studies |
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Funding |
Grant |
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Resources |
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