1. Support clinics in strengthening core attributes of the medical home (teams, integration, leadership, data, process improvement, panel management) and health center operations (19 requirements).
a. By May 2016, OPCA will host advanced team based care and panel management learning sessions.
b. By December 2016, OPCA will host an Integration Summit – Integrating Oral and Behavioral Health into Primary Care.
2. Support clinics in providing customer focused, integrated and well-coordinated care, including enhanced access by drawing on technology, alternative interactions, walk in clinics, new role types and other advanced care strategies.
a. By June 2016, OPCA will create a multidisciplinary team to explore OPCA’s support in advanced access.
b. By May 2016, 50% of clinics in APCM will have defined a new role/function as part of their expanded team composition.
3. Advance policy to support comprehensive, integrated and well-coordinated primary care.
a. Work in coalition to pass at least on policy at the state level to increase access to affordable coverage in 2016 (such as premium support for COFA or Basic Health Plan blueprint).
b. Work in coalition to strengthen policymaker support for passing a policy in 2017 to extend affordable coverage to all OR children.
4. Streamline and enhance peer learning within the network (best practices, site visits, peer network gatherings).
a.By December 31, 2016, OPCA will host up to three Peer Centered gatherings with at least 60% of clinics represented at each event.
5. Working with the Community/Site Development Workgroup, communities and other partners, address Oregon health care access gaps.
a.By December 2016, OPCA will convene 4 meetings with the Community Site Development (CSD) work group to develop a needs assessment framework and plan to share access gaps around the state.
III. By 2017, Oregon CHCs are known to be highly effective and valued organizations in the community.
6. Assist clinics in creating a culture and patient centered practice that leads to high levels of staff engagement and positive patient experience.
a. By December 2016, thirty percent of CHCs will participate in the staff engagement or patient experience learning collaborative. Of these, at least 75% will create a goal statement about how staff engagement and/or patient experience support their own patient-centered culture.
7. Lead and support the emergence and spread of advanced and innovative models of primary care (APCM, optimal team based care, connections to the health neighborhood) that will lead to higher quality and reduction in total cost of care and inappropriate utilization.
a. By July 2016, APCM leaders will convene around a shared APCM dashboard to discuss program progress and accountability.
8. Refine the components of the value equation for CHCs, reflecting both the common value of the network and unique strengths in each community.
a. By June 2016, refine the definition of value for CHCs and develop principles for participating in Value Based Payment.
b. By December 2016, start collecting data to populate the value definition for at least 5 CHCs, including total cost/utilization data.
9. Engage all CHCs in transparently sharing metrics and best practices throughout the network with a focus on clinical transformation that constantly improves CHC value.
a. By the second Peer Network Session, OPCA will have 50% of clinics agreeing to share value data (e.g. UDS cost data) transparently.
b. Host one training regarding best and innovative practices in data sharing with clinic staff and include non-FQHC and non-medical organizations by October 2016. Of participants, at least 50% will engage in a follow up call to share implementation lessons.
10. Lead the state and national evolution of payment and its connection to CHC-defined value, preventing or addressing adverse fiscal and health outcome consequences.
a. By December 2016, develop a strategy with NACHC to have payers pay for interventions or adjust payment to account for SDoH barriers.
b. By December 2016, participate in 1115 waiver and 1332 waiver discussions in Oregon to support CHC efforts to continue to improve their value.
11. Assist clinics in maximizing patient centered care through data management strategies (segmentation, focus on sub population disparities) which lead
to a greater understanding of patient and population issues.
a. 100% of APCM clinics will have an identified “subpopulation” that is experiencing poor health outcomes and has an associated psychosocial or economic barrier by August 2016 for intervention.
12. Influence and address alignment of state and national evolution of quality, access and utilization metrics on behalf of CHCs.
a. By March 2016, investigate measurement strategies among other state PCAs.
b. By October 2016, OPCA will establish a process to create at least one state and one nationally focused strategy to align metrics.
13. Define a balanced dashboard of value indicators, embed data and quality improvement efforts in all peer networks.
a. By June 2016, develop a dashboard prototype, informed by multiple stakeholders (EDs, MDs, DDs, Behavioral Health) and share at Fall 2016 peer network gathering.
14. Support clinics in improving best practices for access to, analyses, use and communication of data.
a. By July 2016, assess each center’s data and quality improvement capabilities and develop a strategy to provide individual and network TA based on those needs.
b. Offer a training on dashboard creation for clinic data/QI staff, including how to use data, access, sharing and communication with staff by December 2016.
15. Work with CCOs, state, regional and/or national healthcare and non-healthcare partners to explore new and innovative ways of paying for and improving health outcomes through addressing SDoH barriers.
a. By December 2016, work with a coalition to require CCOs to develop plans or show progress in addressing at least one SDoH barrier.
b. By November 2016, Metrics and Scoring Committee technical advisory group has developed specifications for a food insecurity metric.
c. Share incorporation of PRAPARE in care model development and segmentation at two national forums by December 2016.
16. Work with state and national partners to promote public policy that addresses the SDoH.
a. By September 2016, develop a policy framework around SDoH.
b. By March 2016, engage in statewide efforts to pass policy to increase the availability of affordable housing.
17. Support CHC leadership engagement in community partnerships to advance the health of the populations they serve. (traditional, non-traditional, policy makers, opinion leaders).
a. Provide at least 2 trainings through peer networks and APCM on developing community partnerships by October 2016.
18. Bring together early adopter leaders across state and country who are naturally drawn to experimentation.
a. By September 2016, host a gathering with leading health equity thinkers to further our understanding of best steps to enhance equity while preparing for new payment strategies.
b. Create follow up opportunities for early adopters to sustain interaction and dialogue.