2015 Accomplishments:
Transparent, Collaborative, Consensus-Based Policy
Development in Support of the Coordinated Care
Model
Executive Director: Ben Hoyne, MA, MBA
Policy Coordinator: Sara Love, ND
Executive Summary
Thank you for your interest in the work of CCO Oregon. 2015 has been a watershed year in the history of CCO Oregon.
As many of you know, CCO Oregon has been holding conferences for several years, originally focused on broad-based
coordinated care policy, but more recently began taking deep dives into specific subject matters.
Over the past two years, CCO Oregon has begun convening groups of subject matter experts to develop agreements,
principles, and policy in a transparent, collaborative, and consensus-based manner. In 2014, these workgroups focused
on Dental Integration as well as Integrated Primary Care Behavioral Health. The accomplishments of those two groups
have led to profound agreements in support of the Triple Aim.
For the first time, Dental Care Organizations and Coordinated Care Organizations have found a collaborative space to
work together collectively for a common goal of reducing administrative burden. The Integrated Behavioral Health
Alliance of Oregon, the CCO Oregon workgroup working on Primary Care Behavioral Health, created recommended
minimum standards for behavioral health integration that provides CCOs, Providers, and Clinics a concise framework
necessary to improve behavioral health care in the Patient-Centered Primary Care Home.
In 2015, CCO Oregon convened an additional two workgroups. Our pharmacy workgroup brings together Pharmacy
Directors from throughout the state. With the majority of CCOs represented on this group, from all corners of Oregon,
we are able to host dialogue that encompasses challenges and view points that affect most every Oregonian. We look
forward to additional collaboration and policy development in 2016.
Finally, our Social Determinants of Health workgroup brings experts in Food Insecurity, Housing, Safety Net Clinics, and
more, together to find solutions to one of the most critical aspects to ones health, the conditions outside their health
care. They have found agreement on integrating Social Determinants of Health into the CCO Transformation Plans.
The work of each workgroup is filtered up through our Policy Committee and ultimately our Board of Directors. CCO
Oregon’s Policy Committee is comprised of workgroup chairs and CCO leaders. Participating CCO’s have agreed to
incorporate the policies, practices, and principles into their work in support of coordinated care.
As a non-profit organization, a Board of Directors governs CCO Oregon. CCO Oregon strives to have broad
representation on its Board, similar to that of a CCO, as such it has allocated 8 of its Board Seats to specific fields of
expertise. CCO Oregon’s Board of Directors strives to be representative of Oregon’s diverse geography, cultures, and
professions.
We are thrilled with the policy development accomplishments in 2015 and look forward to additional groups and
accomplishments in 2016. Thank you to CCO Oregon members for making this work possible and thank you to all that
participated. We look forward to continued partnership with all of you and welcome additional participation from
Oregon’s Coordinated Care community.
Board of
Directors
Policy
Committee
Dental
Integrated
Behavioral
Health Alliance
of Oregon
Pharmacy
Social
Determinants
of Health
2015 Board of Directors
Behavioral Health
Dr. Brian Sandoval, Yakima Valley Farm Workers Clinic
Coordinated Care Organization (CCO)
Martin Taylor, CareOregon, 2015 Policy Committee Chair
Kim Whitley, InterCommunity Health Network CCO
Consumer
Alberto Moreno, Oregon Latino Health Coalition
Dental
Matthew Sinnott, Willamette Dental
Hospital
Andy Davidson, Oregon Association of Hospitals & Health Systems, 2015 Governance Committee Chair
Practicing Provider
Dr. Rick Kincade, PeaceHealth
Primary Care
John Duke, Outside In, Oregon Primary Care Association
At Large
Jack Dempsey, Oregon Nurses Association
Dr. Robin Henderson, St. Charles Health System, 2015 Board Chair
Jeremy Vandehey, Kaiser Permanente (Resigned from Board of Directors, September 2015)
Please note that organizations are listed for reference only. Board Members represent only themselves, not any
organizations.
2015 Policy Committee
The CCO Oregon Policy Committee is comprised of workgroup chairs and CCO Oregon stakeholders. The Policy
Committee reviews the principle statements and other work product drafted by the workgroups. The committee also
facilitates discussion between the workgroups and the Board of Directors for the creation of CCO Oregon Principle
Statements. Members on the Policy Committee must represent CCO Oregon member organizations.
Participating Policy Committee Members:
Chair: Martin Taylor, Director of Public Policy and Community Relations, CareOregon
Vice Chair: Sean Jessup, Director of Medicaid Programs, Moda, EOCCO
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Marian Blankenship, Director of Government Relations, PacificSource
Jim Carlough, President/CEO, Yamhill CCO
Jack Dempsey, Lobbyist, Oregon Nurses Association
John Duke, MBA, Clinic Director, Outside In, Oregon Primary Care Association; Chair- Social Determinants of
Health Workgroup
Erin Fair Taylor, JD, MPH, Executive Director CCO Partnership and Development, Jackson Care Connect and
Columbia Pacific CCO
Lindsey Hopper, JD, MPH, Executive Director, Central Oregon Health Council (Resigned from Policy Committee,
July 2015)
Robin Moody, MPH, Senior Director of Policy Development, OAHHS
Henry O’Keeffe, JD, In House Council, GOBHI
Brian Sandoval, PsyD, Primary Care Behavioral Health Manager, Yakima Valley Farm Workers Clinic; ChairPrimary Care Behavioral Health Workgroup
Matthew Sinnott, MHA, Director of Government Affairs and Contract Management, Willamette Dental; ChairDental Workgroup
Jim Slater, PharmD, Director of Pharmacy, CareOregon; Chair- Pharmacy Workgroup
Jeremy Vandehey, JD, Kaiser Permanente (Resigned from Policy Committee, September 2015)
Mark Whitaker, MD, Senior Medical Director, Providence Health Plan
Kim Whitley, MPA, Chief Operating Officer, IHN-CCO
Dental
The CCO Oregon Dental Workgroup created a bank of quality metrics with the goal of aligning metrics in service level
agreements (SLAs) between CCOs and DCOs. Currently, DCOs have different SLAs across multiple CCOs. This disjointed
approach creates an administrative burden as DCOs must focus on a variety of metrics that may not be aligned across
CCOs. The body of work was developed by expert consensus with participation including dental professionals, CCO
administrators, and other stakeholders.
The quality metrics were created thoughtfully with the Triple Aim in mind while focusing on relevance and feasibility for
both CCOs and DCOs. Since CCOs may not have a dental professional on staff the bank of quality metrics is designed to
ease the implementation and operational burdens while aligning SLAs for more robust and expansive health outcome
analysis.
CCOs would have the flexibility to create SLAs utilizing metrics that are relevant to their membership. DCOs would be
able to focus on quality metrics that are based in patient care and outcomes and aligned with other SLAs and reduce
costs.
Participating Dental Workgroup Members:
Chair: Matthew Sinnott, MHA, Director of Government Affairs and Contract Management, Willamette Dental
Gary Allen, DMD, Dental Director, Advantage Dental
Teri Barichello, DMD, Vice President & Chief Dental Officer, ODS
Christina Swartz Bodamer, Managing Director Public and Professional Affairs, Oregon Dental Association
Doreen Crail, Director, Dental Services, Moda Health
Tony Finch, Executive Director, Oregon Oral Health Coalition
Alyssa Franzen, DMD, Dental Director, CareOregon
Sean Jessup, Director of Medicaid Programs, Moda Health/EOCCO
Deborah Loy, Executive Director of Government Programs, Capitol Dental
Sharity Ludwig, EPDH, Director of Community Programs, Advantage Dental
Monica Martinez, JD, CCO Contract Administrator, CareOregon (Columbia Pacific CCO and Jackson Care Connect CCO)
Shanie Mason, MPH, CHES, CCO Dental Portfolio Manager, CareOregon
Mike Shirtcliff, DMD, President/CEO, Advantage Dental
Heather Simmons, MPH, Dental Services Program Manager, Government Programs, PacificSource
Eryn Womack, Dental Program Coordinator, IHN-CCO
CCO-DCO Quality Measure Set
CCO Oregon concepts developed by expert consensus—December 2015
Specifications available on CCO Oregon website and by request
Quality Measure Core Set:
 Percentage of adults who received at least one dental service
 Percentage of children who received at least one dental service
 Percentage of children who received at least one preventative dental service
 Percentage of pregnant women who received at least one preventative dental service
 Percentage of children who presented to emergency department for caries-related reasons and
received timely follow up with dental provider
 Percentage of adults who presented to emergency department for non-traumatic dental related
reasons and received timely follow up with dental provider
 Utilization of CAHPS Dental Plan Survey Questions
Quality Measure A La Carte Set:
 Percentage of patients with moderate to high risk of caries who received at least one topical fluoride
treatment
 Percentage of patients identified as tobacco users who received at least one oral health evaluation
 Percentage of pregnant women who received at least one comprehensive dental exam while pregnant
and received fluoride treatment
 Percentage of children and adults who received at least one oral health evaluation
 Percentage of patients identified as diabetic who received at least one oral health evaluation or
comprehensive periodontal exam
 Percentage of patients with a history of treated periodontitis who received periodontal maintenance
 Number of pediatric emergency department visits for caries-related reasons per 100,000 member
months
Integrated Behavioral Health Alliance of Oregon
This document establishes a structure for behavioral health integration as a fundamental component of the patient
centered primary care home (PCPCH). It is a clear description of behavioral health integration in PCPCHs. It uses
integration models supported by research and national consensus. CCOs and other stakeholders can reference this
framework when determining what resources are necessary in the system to ensure integrated service delivery for all
Oregonians. This framework also could be used to support the development of statewide benchmarks for integration
success and could likewise inform policy decisions.
This document overviews the following topics:
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Integrated behavioral health services and staffing model
Behavioral Health Clinician access parameters
Interpersonal and individual professional practices for delivering integrated care
Organization-level professional practices that support integrated care
Protocols for engaging patients in integrated care
Participating IBHAO Workgroup Members:
Chair: Brian Sandoval, PsyD, Primary Care Behavioral Health Manager, Yakima Valley Farm Workers Clinic
Co-Chair: Julie Oyemaja, PsyD, Behavioral Health Manager, Multnomah County Health Department
Diane Bocking-Byrd, MBA, LPC, Behavioral Health Supervisor, CareOregon
Vanessa Casillas, PsyD, Clinical Director of Behavioral Health Integration, Providence Health and Services
Dawn Creach, MS, Program Manager Medical Home Innovation, Children’s Health Alliance
Robin Henderson, PsyD, Chief Behavioral Health Officer, Vice President Strategic Integration, St. Charles Health System
Joe Hromco, PhD, Vice President Operations, Western Psychological and Counseling Services
Andrew Huff, LPC, Behavioral Health Innovation Specialist, CareOregon
Lexy Kliewer, LCSW, Program Director, Lifeworks NW
Lynnea Lindsey-Pengelly, PhD, MSCP, Medical Services Director, Trillium Behavioral Health
Doug Luther, MD, Senior Medical Director, CareOregon
John Muench, MD, MPH, Associate Professor, Oregon Health and Science University
Laura Nissen, PhD, LMSW, CADCII, Dean and Professor, Portland State University, School of Social Work
Mary Peterson, PhD, Department Chair & Professor, George Fox University
Jim Phelps, MD, Director of Mood Disorder Program, Samaritan Health Services
Dan Reece, LCSW, Consultant, Transformation Center, Oregon Health Authority
Barb Seatter, MS, Executive Director, Mid-Columbia Center for Living
Lisa Sprague, MD, Clinical Lead Provider, Multnomah County
Elizabeth Waddell, PhD, Senior Study Director, Oregon Rural Practice-Based Research Network
Recommended Minimum Standards for Patient-Centered Primary Care Homes (PCPCH) Providing Integrated Health Care
CCO Oregon concepts developed by expert consensus—November 2015
Minimum Standard*
Integrated behavioral health services are provided as part
of routine care at the PCPCH including licensed Behavioral
Health Clinician(s) (BHC) delivering an array of services onsite. BHC as defined in ORS 414.025.
Specifications
BHC(s) provides care at the PCPCH with a ratio of 1 FTE BHC for every 6 FTE of Primary Care
Clinicians (PCC). For example, a practice with 4 FTE PCC would need to have .67 FTE of a BHC
(approximately 26.5 hours/week).
For rural practices with behavioral health clinician shortages, integrated services may be
provided virtually as long as other standards are met.
Integrated BHC provides a broad array of comprehensive
BHC services should be applicable to the PCPCH patient population served, including care for:
evidence-based behavioral health services.
mental illness, substance use disorders, health behaviors that contribute to chronic illness,
life stressors and crises, developmental risks and conditions, stress-related physical
symptoms, preventive care, and ineffective patterns of health care utilization per ORS
414.025.
Integrated BHC provides same-day open access behavioral
Same-day open access services include warm hand-offs, brief assessments and interventions
health services.
for patient and families, consultations to primary care clinicians and other care team
members, and participation in pre-visit planning and daily huddles. Same-day open access
services are provided in real-time at the point of care when behavioral health issues are
identified at the PCPCH.
On average, at least half of the BHC’s hours at the practice each week must be available for
same-day open access services.
Primary care clinicians, staff, and BHC utilize shared medical Primary care clinicians, staff, and BHC document clinically relevant patient information in the
records and have a mechanism in place for collaborative
same medical record system and participate in collaborative treatment planning and cocare planning and co-management of patients.
management via case conferences, consults, pre-visit planning and/or daily huddles.
BHC is an integrated part of the primary care team.
Primary care clinicians, staff, and BHC utilize shared physical space and the BHC participates
in practice activities such as team meetings, daily huddles, pre-visit planning, and quality
improvement projects.
PCPCH utilizes a population-based approach to delivering
PCPCH utilizes universal behavioral health screening, care coordination, and panel
and coordinating integrated behavioral health services.
management to monitor the behavioral health needs and outcomes of the PCPCH patient
population. PCPCH utilizes written protocols for referrals to appropriate specialist(s) and
hospitalization if clinically indicated.
The integrated team includes psychiatric consultative
PCPCH identifies the psychiatric care needs of their population, determines viable psychiatric
resources.
consultation strategies and provider options, and develops a care model hat includes these
services.
* Adapted from AHRQ Professional Practices in Behavioral Health and Primary Care Integration 2015 http://integrationacademy.ahrq.gov/
Pharmacy
The Pharmacy Workgroup was created in 2015 and approved the following purpose statement: The CCO Oregon
Pharmacy Workgroup convenes to create thoughtful recommendations for the advancement of quality metrics,
promotion of best practices, and to collaborate on innovative solutions to pharmacy challenges impacting achievement
of the Triple Aim.
Participating Pharmacy Workgroup Members:
Chair: Jim Slater- Director of Pharmacy, CareOregon
Co-chair: Kerrie Fowler, Pharmacy Director, Umpqua Health Alliance
Kimberly Blood, Pharmacist, Willamette Valley Community Health
Amy Burns, Pharmacy Director, AllCare
Jennifer Johnstun, Director of Clinical Operations, Primary Health of Josephine County
Kristel Jordan, Clinical Pharmacy Supervisor, IHN-CCO
Caryn Mickelson, Pharmacy Director, Western Oregon Advanced Health CCO
Tina Patel, Pharmacist, PacificSource
Clinton Smith, Interim Director of Pharmacy Services, PacificSource
Robin Traver, Clinical Program Manager of Government Programs, Moda/EOCCO
Social Determinants of Health
The Social Determinants of Health workgroup was created in 2015 in response to CCO Oregon member feedback at the
2014 Annual Meeting. The group crafted the following purpose statement: To create recommendations to advance
policy, funding, and other efforts to mitigate the negative effects of social determinants of the health of Oregonians.
Principle statement:
CCO Oregon acknowledges that there is a relationship between interventions addressing social determinants of health
and an individual's quality of life, health outcomes and the cost of care. We encourage the Oregon Health Authority to
request individual CCOs submit a transformation plan, timeline, and accountability measures focused on the integration
of social determinants of health to further health transformation in Oregon.
Participating Social Determinants of Health Workgroup Members:
Chair: John Duke, MBA Clinic Director, Outside In, Oregon Primary Care Association
Matthew Carlson, PhD, Portland State University
Rose Englert, Senior Business Leader, Community Health Innovation Programs, CareOregon
Craig Hostetler, Executive Director, Oregon Primary Care Association
Howard Klink, Principle Consultant, Housing with Services
Lynn Knox, State Clinical Outreach and Training Coordinator, Oregon Food Bank
Lola White, PsyD, Behavioral Health Consultant, Yakima Valley Farm Workers Clinic
Kim Whitley, MPA, Chief Operating Officer, IHN-CCO
2015 CCO Oregon Members
CCO Oregon's membership network is comprised of healthcare leaders and coordinated care stakeholders.
The following companies and organizations make our operations possible.
Partners:
CareOregon
GOBHI
InterCommunity Health Network CCO
Kaiser Permanente
Moda Health
Novo Nordisk
Oregon Association of Hospitals and Health Systems
Oregon Health & Science University
PacificSource
PeaceHealth
Providence Health Plan
St. Charles Health System
Sustaining:
Advantage Dental
Astellas
Oregon Nurses Association
PH Tech
Willamette Dental
Supporting:
Albertina Kerr Centers
Central Oregon Health Council CCO
Columbia Gorge Health Council CCO
Columbia Pacific CCO
Eastern Oregon CCO
Housing with Services
Indivior
Jackson Care Connect CCO
Medline
Netsmart
Oregon Academy of Family Physicians
Oregon Association of Naturopathic Physicians
Oregon Dental Association
Oregon Dental Service (ODS)
Oregon Food Bank
Oregon Latino Health Coalition
Oregon Medical Association
Oregon Primary Care Association
Oregon Psychological Association
Portland State University School of Social Work
Qualifacts
Tri-County Behavioral Health Providers Association
Urban League of Portland
Vibra Specialty Hospital
Yakima Valley Farm Workers Clinic
Yamhill CCO