Care Coordination and Resilience

by Stefani Daniels, Managing Partner
Published on Aug 14, 2017

CareOregon, the state’s largest Medicaid managed care plan, established their Health Resilience Program to provide trauma-informed care management for Medicaid and dually eligible Medicare-Medicaid beneficiaries with complex health and psychosocial needs. The program is designed to address the bio-psychosocial needs of this high risk/high cost population using a strengths-based, trauma-informed approach to advance client-identified health goals.

CareOregon is a not-for-profit Managed Medicaid health plan based in Portland, OR.  They quickly recognized that just 10% of the members accounted for over half of the plan's spending and leaders knew they had to find a new way to reduce costs for those high-risk members without compromising care. Using a trauma-informed approach, CareOregon launched its community care coordination program using Health Resilience Specialists (HRS).The HRSs spend their time in the community with their patients and are able to bring the patients' real story back to the primary care physicians so that the doctors know the barriers to good care and can make adjustments to the patients' treatment plan.

The program was so successful when it launched, that CareOregon now has 30 HRSs embedded into 26 primary care practices, patient centered medical homes and community clinics.  Each HRS coordinates care for roughly 60 patients each year and they address the psychosocial determinants affecting health including housing, food or transportation needs to improve medical outcomes. According to a study published by the Center for Outcomes Research & Education at Providence Health & Services, the program has boosted primary care visits, reduced unnecessary ED visits and hospitalizations, and generated $1.65M in annual savings.    

Health Resilience Specialists are master’s level ‘engagement specialists’ tasked with developing meaningful partnerships with the high-acuity/high-cost patients to enable wellness and stability in their lives. This approach not only reduces the total cost of care but enhances patient experience and outcomes. The HRSs are trauma-informed; that is,  they understand the prevalence and pervasive impact of chronic, overwhelming stress on the lives of the people they serve and build interventions from a collaborative, strengths-based approach, appreciating the resilience of traumatized patients. CareOregon’s six programmatic principles of trauma-informed care include: reducing barriers; providing client-centered care; increasing transparency; taking time and building trust; avoiding judgement and labels; and providing care in a community-based setting.