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AN EVOLVING SUCCESS STORY

THE INTEGRATION OF COMMUNITY HEALTH WORKERS INTO CARE COORDINATION:. AN EVOLVING SUCCESS STORY . Why do we have a Community Health Workers Program???. The Program is part of the patient-centered, team-focused concept that is the basis for the Coordinated Care Organization

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AN EVOLVING SUCCESS STORY

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  1. THE INTEGRATION OF COMMUNITY HEALTH WORKERS INTO CARE COORDINATION: AN EVOLVING SUCCESS STORY

  2. Whydo we have a Community Health Workers Program??? • The Program is part of the patient-centered, team-focused concept that is the basis for the Coordinated Care Organization • To assist the member’s network of providers: -Improve overall health -Work directly with high-needs patients -Fill in gap of needs not met elsewhere Trillium CCO Board-10-13-2013

  3. Whoare the Community Health Workers??? • Originally, contracted through Lane United CareConnect (LUCC); which is part of the Trillium Coordinated Care Organization • Dedicated people with a desire to help improve healthcare in Lane County • Specially trained to provide a unique service to the Medicaid, Medicare, & dual-eligible members of our CCO community Trillium CCO Board-10-13-2013

  4. Lane United CareConnect (LUCC) Community Health Workers Trillium CCO Board-10-13-2013

  5. What Do Trillium Community Health Workers Do? 1) Visit member in their homes or community to build trust & identify goals 2) Address barriers to health 3) Connect members to their PCPCH/PCP and, when needed, behavioral health or specialty care practitioners 4) Help members to navigate health care, social services & other support systems Trillium CCO Board-10-13-2013

  6. What Do Trillium Community Health Workers Do?(continued) 5) Assist in improved communication between practitioners & members 6) Chronic disease management; promote health literacy & link to educational resources 7) Support member to comply w/ prescribed medications & treatment recommendations 8) Link to transportation resources Trillium CCO Board-10-13-2013

  7. Trillium CCO Board-10-13-2013

  8. Trillium Community Health Care Model External Provider makes referral of patient to Trillium Care Coordination. Provider/TCHP identifies patient as having complex needs. • Internal • Hot Spot List • Risk Stratification • Hospital Readmissions • CC/UM Identification referrals • Trillium Care Coordination triages patient referral to determine if CHW is needed. • Trillium Care Coordination Team identified to work with CHW and patient • Trillium Care Coordination Team meets every 2 weeks with CHWs • Ongoing training • Complex Case Review • Updates on patients referred • Continued ongoing communication Trillium CCO Board-10-13-2013

  9. Trillium Behavioral Health, Medical, and CHW Care Coordination Team Meeting Trillium CCO Board-10-13-2013

  10. So What’s Next ??? • Development and deployment of community-wide consistency with THW education and scope of practice • Brought six CHWs in-house at Trillium, Oct. 1st • Expansion of Perinatal Program to include greater integration of CHWs • Involvement of CHWs with “Hot-spotter” lists • Involvement of CHWs in Readmissions Program • Integration of CHWs in ED usage reduction Trillium CCO Board-10-13-2013

  11. What Questions Might You Have? Trillium CCO Board-10-13-2013

  12. …AND IN CONCLUSION THANK YOU FOR YOUR TIME AND ATTENTION Dr. Holly Jo L. Hodgesand Dr. Michael Reaves, Medical Director Trillium 541-431-1950 Trillium CCO Board-10-13-2013

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