JEFFERSON REGIONAL HEALTH ALLIANCE

Programs: I. Advanced care planning:2013 outputs included: public forum lecture series shared information with 1,500 attendees; a volunteer speakers bureau that reached 2,548 people; small group advance care planning facilitation that reached over 140 people; a successful completion of a palliative care nurse model for outpatient advance care planning in the primary care setting; the distribution of 7,000 educational brochures; advance care planning for over 100 physicians including tools and resources for supporting their practice changes; stronger relationships established with all regional hospitals resulting in one hospital system adopting a system-wide palliative care strategy. Increased public awareness and engagement created through the use of multiple media forums (web, radio, television, newspaper). Completed a grant to provide administrators and care givers at three local nursing home facilities with advance care planning facilitation skills. Ii. Mental health and primary care integration:2013 outputs included: received $103,000 funding for opioid prescribers group (opg) pilot for implementation of new chronic pain guideline into primary care settings. Developed printed version of guidelines, resources, and tools, and created a flow sheet for distribution. Developed website. Refined logic model and created work plan for implementation pilot. Developed provider, consumer, and data subcommittees. Selected providence doctors group as the first location of pilot and began initial clinic assessment, agreements, and education for the pilot clinic. Developed data plan with pilot clinic. Hired contractors for implementing the pilot project. Created mous as needed for implementation. Redesigned pilot budget to reflect initial learning and opportunities for success. Iii. Jefferson health information exchange (jhie):2013 outputs included: jhie spun off to have its own non-profit status. Began implementation phase in 15 difference clinics with more than 150 clinicians. Over the next five months, the implementation phase grew to include over 300 clinicians and over 27 clinics. Vetted, hired, trained, and housed program manager and implementation specialist for staffing and technical support for implementation phase. Developed user groups for peer support and implementation follow up. Began partnership meetings with proposed new funders of jhie to engage both financial and user support. Formed full board with 3 county representation, cco representation, clinical providers, and behavioral health representation. Secured funding for phase 2 implementation. Met with oha and state hit staff to discuss alignment with and support of state in jhie. Shifted from 3 hospital-based contracts with hie vendor to one jhie contract. Iv. Health care reform:cco 2013 outputs included: invited ccos to participate in jefferson health information exchange, choosing options honoring options, complex care project, and opioid guideline pilots. Invited ccos to participate in jrha meetings as presenters with oha director bruce goldberg. Recruited cco participation in jrha as ex-officio board members. Care oregon pilot 2013 outputs included: held daily community health worker (chw)-client meetings and connections. Held monthly staffing meetings with outreach chw from other programs to develop cross-organizational relationships, learned and leveraged community resources, supported chw learning and growth, brainstormed and refined care plans, and identified systems barriers to care and larger systems issues. Held monthly systems meetings to develop and refine the pilot and its operations, identified systems challenges and opportunities, supported multi-agency relationships and cross-system effectiveness, developed logic model and best practices for community-wide practices, began to analyze existing community resources. Fully integrated the complex care project into two fqhcs. The pilot project saved $92,062 over six months for the 12 trial patients. V. Jrha administration:2013 outputs included day long retreat with the council members and guests representing 30 individuals and health related organizations; reaffirmed the mission and strategies of jrha during the retreat; created a contribution guideline for board members and ex-officio members; created a new leadership position, ex-officio which allows the expanded thinking capacity of jrha while limiting the number of voting members needed for quorum. Elected new council mix of community stakeholders; elected new executive board with two founding members acting as emeritus for committee; hired and supervised pt temp administrative assistant and two consultants for the opg project; supervised three interns from three different educational programs for opg and jrha administrative. Completed the project coordinator consultant position of in third quarter of the year; increased executive committee leadership engagement meetings to monthly commitment.