An Innovative Community Collaborative

Central Oregon Complex Care Strategy – Centered Around the Patient 2 Imagine if Rebecca was at the center of multi-faceted coordinated care: Comprehensive 60 minute evaluation – meeting with physician, care manager, and behavioral health specialist Action Plan in her own words – identifying what steps she would take first, and how she would manage in coordination with his responsibilities of his mother Followup call/ from her dedicated care manager to check in on medications, blood sugars and follow-up appointments Nutritionist in the same place as her doctor, co-located with her care manager and behavioral health specialist Emotional support from her health care team Original slide from Renaissance Health 2 Pharmacy Management Team-based Care Customized Comprehensive Eval Shared Action Plan Transitions of Care Specialist Coordination Proactive, between visit care Virtual Visits Nutrition Counseling Multi-faceted Approach Community Collaborative Actionable data in the hands of caregivers Patient Education Socio-behavioral Risk Modification Patient

Complex Care Planning Process Ensuring community trust and engagement in the care partnership is critical

From Conception to Reality: the Basics

First Order: Getting These Right Original slide from Renaissance Health

Care Model Elements Original slide from Renaissance Health

Contact Information 7 Ken House, Mosaic Medical Kate Wells, PacificSource