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

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

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

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

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

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

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

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

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

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 Oral Health Mental HealthAddictions

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

18. “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?” What do you think about health integration?

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. Low Risk OHP Members (Provide episodic treatment (members only needing short-term or one time treatment and screening / assessment to identify high risk members) High Risk – Early Identification and Intervention (Prevention) Chronic Disease – Coordinated Intervention 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 Healthcare Coordination & Integration Coordinated Care Organizations Dual Eligibility Global Budgets For All Primary Care Health Homes Metrics / Performance Measures Community Advisory Councils