Community Engagement and Health Systems
Overview
The purpose of the Community Health Development Team is to develop productive local partnerships with community-based organizations, healthcare systems, local governments, OHP Members, Tribes and other local entities who address Social Determinants of Health and Health Equity in order to facilitate locally-driven health system transformation.
Community Health Development
Function
The Community Health Development Team serve as consultants who facilitate locally-driven solutions through knowledgeable technical assistance to EOCCO communities with the goals of:
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Fulfilling section K of the CCO 2.0 contract
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Facilitating community engagement with LCACs and the RCAC
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Facilitating population health assessments and identification of priorities
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Assist with the fulfillment of CCO 2.0 vision of better health outcomes, improved systems of care, and cost efficiencies via health integration, planning for behavioral health need & integration, social determinants of health, and DEI
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Working with Tribal Partners
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Administer and oversee special programs and projects (in compliance with Section H and M):
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Behavioral and physical health integration
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Frontier Veggie RX
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Rental Assistance
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Children’s Health Coordination
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Tele-behavioral health
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Local board and community work
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Health research partnerships
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Contribute to EOCCO governance
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Primary Care Practice Transformation
GOBHI provides on-site practice facilitation to assist primary care clinicians and staff in practice transformation efforts with the intent to enhance health care delivery and population management in alignment with the Oregon Health Authority’s Patient Centered Primary Care Home Program (PCPCH). Change strategy outreach through county specific PCPCH learning collaboratives include the following topics: workflow redesign, using data (incentive metrics) for quality improvement, and measuring patient satisfaction and access to care.
Behavioral Health & Mental Health Integration
The integration of behavioral health and mental health into schools, primary care clinics, and community settings is critical to health behavior change and CCO success. Better collaboration and integration between physical health and mental/behavioral health agencies is essential for increased health outcomes and continuity of care. Key functions include monitoring contracts between primary care practices with full integration of mental/behavioral health services on a per member/month basis, strategies for the community-wide reduction of opioid prescriptions, medication-assisted therapies, and facilitating the need for “pain schools.”
Data Analytics
GOBHI provides analysis of data to community groups, clinics, boards and others with the intent to enhance the understanding of data for informed decision making. Key functions include the analysis of claims data to identify costly and “at-risk” patients, practice management data reviews, gaps in preventive health services to OHP members and descriptions of utilization and spending patterns for physical, oral and mental health. Field Team members are also available to assist primary care and community mental health programs with the implementation of Premanage and Arcadia software.
Public Health Integration
The goal of public health integration is to strengthen the relationship between the CCOs and public health agencies that focus on population-based community services.
Special Projects
GOBHI is housed with leaders and innovators who are proud to respond to the needs of local communities when opportunities become available. Field staff members are able and willing to support and/or submit requests for grant funding that aligns with the mission of GOBHI and the CCO communities we serve, such as the HRSA Telebehavioral Health Grant, connecting members to their treatment via a secure mobile teleconferencing platform, and providing a self-support and recovery-focused mobile app.