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AN EVOLVING SUCCESS STORY

The Community Health Workers (CHWs) Program is a vital part of the patient-centered model within the Trillium Coordinated Care Organization. By assisting high-needs patients and connecting them with necessary health resources, CHWs aim to bridge healthcare gaps and improve overall member health. They visit community members to build trust, address health barriers, and enhance communication with healthcare providers. Ongoing training and collaboration among teams ensure a unified approach to patient care, laying the foundation for future expansions and improvements in service delivery.

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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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