From Insight to Impact, Strengthening Population Health

Follow Blog

As the health needs of Oregon communities evolve, Community Health Centers (CHCs), are increasingly called upon to lead efforts to improve population health, address access, and deliver high-quality, patient-centered care. Achieving this requires more than clinical expertise—it demands strong infrastructure, robust data systems, continuous quality improvement, and a culture of collaboration.

To illustrate OPCA’s strategy in strengthening population health through CHC engagement and analytics, I sat down with my colleagues on the Data and Programs teams to learn of initiatives and services available to members.

Conversation about the Data Platform & QI
Updated on 11/26/25

To start our conversation, I asked my colleagues to share a little about themselves:

Simon Parker-Shames, Data Strategy Director

“For the past 15 years, I’ve worked closely with CHCs and currently support OPCA’s Data Team in collecting data to support the mission of Oregon’s health centers.”

Ada Catanzarite, Quality Improvement Sr. Manager

“I’m on the Programs team, and support health centers with quality improvement efforts with a focus on metrics, systems, and processes.”

Carla Jones, Network Director

“As Network Director, I bring over 25 years of broad healthcare experience—including leading a public entity Community Health Center.”

What is VisualizOR (the Data Platform)?

Response from: Carla Jones, Network Director, IntegratOR

It’s one of the primary services that IntegratOR provides to the health safety net. Through VisualizOR, our clinically integrated network has established and continues to promote a centralized Population Health Management (PHM) data platform to support community health center members of IntegratOR. The goal of the PHM data platform is to improve health outcomes through data-informed care delivery, reduce administrative and reporting costs by consolidating data infrastructure, and create a unified population health data resource to support statewide initiatives and advocacy.

The platform serves as shared infrastructure for collecting, aggregating, analyzing, and reporting health data to support value-based care, care coordination, and quality improvement initiatives. In addition to robust analytic capabilities, VisualizOR uses AI to identify patients who are ideal candidates for case management based on demographics, disease history, and geographic data. Generative AI is used to assist providers and care managers in developing care plans and conducting care planning work.

What led to the development of VisualizOR?

Response from: Simon Parker-Shames, Senior Data Strategy Director, Oregon Primary Care Association

“There’s tremendous value in integrating health center data into one container. We understand that a data platform is advantageous in gaining insight into the individual and collective performance of health centers on quality metrics, risk, cost, and attribution. These insights then inform health centers’ decisions in improving patient health outcomes. This particular iteration emerged from the formation of the Clinically Integrated Network, specifically the Oregon Network of Community Health Centers (The Network) in 2020. One of our early priorities was to create a data platform that supports Value-Based Care initiatives. The Network embarked on a 2-year process, during which we considered a “build-it-ourselves” model. However, the committee ultimately interviewed a range of vendors, bringing in six to present their ideas, and designated Arcadia as the leading contender.

Despite numerous Statewide data initiatives that have ingested FQHC data in my career—at least eight, which I can name off the top of my head—this is the first time that FQHCs themselves have selected and directed the development of a data initiative. FQHCs chose the features, evaluated the options, selected a vendor, and continue to oversee the implementation and direction of the data platform. This is a historic accomplishment! While our initial focus is on creating a stable foundation for succeeding in Value-Based Pay work, our long-term vision is to integrate EHR data from all FQHCs and Look-Alikes in Oregon into this data system and expand to other programs, such as APCM, from these same features.”

How does VisualizOR illustrate the impact of Oregon health centers in providing vital health services?

Response from: Simon Parker-Shames, Senior Data Strategy Director, Oregon Primary Care Association

“The Data Platform has three key features in helping advance population health. First and foremost, it consolidates claims, EHR, and other data from 15 health centers into a common dataset to illustrate the whole picture of the patient and the community. This insight allows us to incorporate not only the demographic and social data that health centers collect, but also the costs, risks, and utilization that occur within and outside the clinic walls. The ability to pull patient-level details from this platform enables us to present a stronger case for the impact of health centers on the lives of tens to hundreds of thousands of patients across Oregon, in terms of quality and cost-effectiveness. This level of detail and immediacy is not possible to pull from UDS or one-off manual requests for information.

Second, it has long been the case that health centers reduce the total cost of care by preventing expensive downstream utilization of hospital and specialty care in our communities. The combination of Value-Based Pay contracts and our Data Platform is allowing us to demonstrate the impact of health centers as drivers of cost reduction to payers, stakeholders, and decision-makers. In turn, we can negotiate better contracts and regulations that reward health centers for the impact of their work.

Lastly, we are using the Data Platform to drive improvement in operational, quality, and financial outcomes within our ACO and Network Clinical Quality Committee. We are learning there are health centers that have a lot to teach their colleagues, who may not be aware of their performance. OPCA highlights top-performing health centers in the Quality Improvement Collective and provides them with an opportunity to share best practices with fellow health centers.

Through The Network, we are beginning to see pathways and analyses that point the way to a healthier future in Oregon.”

Please summarize quality improvement initiatives led by the association to ensure FQHCs are leaders in health care transformation.

Response from: Ada Catanzarite, Quality Improvement Manager, Oregon Primary Care Association

“The Quality Improvement Collective (QIC) is a group of quality improvement personnel, including community health workers, operations staff, clinical leaders, and others. So, anyone invested in increasing positive patient health outcomes. QIC offers monthly and quarterly webinars, focusing on priority metrics that are either UDS measures or CCO incentive measures, to identify areas of the greatest impact. Participating health centers submit performance data through The Network’s Data Platform, which includes priority measures such as chronic health conditions, cancer screening, and linkages to care. In addition to these measures, the state prioritized and invested in measuring the social needs of patients. As part of QIC, health centers are identifying ways to address social needs and improve positive health outcomes.

During the webinars, the group collectively reviews their performance and discusses whether they’re meeting, exceeding, or reaching the national benchmark. In each metric, top-performing health centers are encouraged to share their best practices, explaining the processes and systems utilized with their colleagues. Also, subject matter experts are invited to present resources and answer questions. Information sharing is a key aspect of QIC, as sharing best practices allows the group to examine structures for quality improvement. So, any tools within the quality improvement toolkit, whether that is from failed practices or innovative approaches to addressing patient engagement. We’re really trying to support each other.

As part of the Accountable Care Organization (ACO), there is the Quality Payment Program. The idea is that if you can prove you’re providing care effectively and efficiently, hence saving the system money, the ACO will share those savings with you. That’s an opportunity for a health center to become more financially secure and potentially reinvest in underfunded aspects of health care delivery, such as traditional health care workers. The Quality Payment Program is driven by investment in the Data Platform, where members in the ACO share their data, enabling us to stratify and segment the data in ways that drive improvement. There is also a Clinical Quality Committee within the ACO. The intention behind the committee is to deliver better health care and improved health outcomes while reducing costs.”

How does sharing evidence-based practices improve the quality of care and patient health outcomes?

Response from: Ada Catanzarite, Quality Improvement Manager, Oregon Primary Care Association

“When QIC reviews the collective data, OPCA facilitates conversations with health centers to understand patients’ needs better. We are breaking down the data by all these metrics and posing questions: Who’s bearing the burden of disease disproportionately to other members of the community? How do we close those gaps in care to reduce burden? How can we create an intervention that provides more resources to invest in those relationships, ultimately bringing people into the clinic? By exploring these questions, we’re assessing the nuances and complexities that go into addressing health care access, demonstrating that Oregon’s health centers are trusted providers of care.

These insights inform various programs, projects, and initiatives led by OPCA, such as the Advanced Care Learning Collaborative (ACLC). Overall, quality improvement serves as a catalyst for transforming primary care in health centers.”

In summary, OPCA remains deeply committed to strengthening the capacity of Oregon’s Community Health Centers through meaningful engagement, strategic use of data and analytics, and collaborative programming that advances community-driven, community-centered care.

Central to this work is the Oregon Network of Community Health Centers—a Clinically Integrated Network (CIN) built by and for Oregon’s FQHCs and the communities they serve. The Network offers a sustainable, long-term solution for enhancing advanced access to care and supporting the financial and clinical success of CHCs. Through collective bargaining power, shared quality improvement resources, centralized services, and a unified voice in value-based care, members of the Network are empowered to improve outcomes, reduce costs, and remain committed to their mission. To learn more about the Network and the Data Platform, contact Carla Jones, Network Director, at cjones@orpca.org.