Linkedin-in Facebook-f
Donate

The following projects are funded through the COHQA & our Grant Program. Made possible through generous donations from COIPA providers and clinics. One purpose of these projects is to share any lessons learned with other healthcare practitioners. If you are interested in accessing the reports and data from a particular project, please email info@cohqa.org.

2024 Projects

Caring Connections Older Adults In-person Isolation Program Expansion
The Council on Aging of Central Oregon’s (CoA) current volunteer service model, called Caring Connections, provides seniors with regular telephone calls to create meaningful social connections, provide safety checks, and support family caregivers. The program is expanding to in-person visits and events to facilitate deeper friendships between the volunteers and their participant match and provide opportunities for transportation and chore assistance. By creating a variety of additional touch points, CoA will enhance the accessibility of the program, ensure access to the full social service resources they offer across Central Oregon, and meaningfully address isolation and loneliness. The program is undergoing significant expansion requiring additional volunteer recruitment and training, a new intern program, additional staff time and robust data collection and client tracking.
Peer to Peer Mentorship Program for People Experiencing a Disability
Destination Rehab is a nonprofit community-led provider whose goal is to develop a peer-to-peer mentorship program for people with neurological disabilities to reduce their fear of engaging in the community or in a rehabilitative program that addresses their mental, emotional and physical wellbeing. Funds will be used to support this mentorship cohort learning model to improve quality of life, reduce potential health costs associated with a neurological disability, and improve awareness of and knowledge about safe spaces and support. The target audience are Central Oregon residents who experience a neurological disability and have been historically underserved and marginalized.
Expanding Access to Quality Mental Health Services for Children & Families Impacted by Trauma
Through long-term professional mentorship, Friends of the Children – Central Oregon (Friends-CO) empowers children and families facing the greatest vulnerabilities with the relationships, resources, and resilience to overcome barriers, heal from trauma, and reach their fullest potential. Their project aims to build capacity to fill mental health service gaps across the Central Oregon community. They plan to meet the mental wellness needs of those they serve by training their Professional Mentors (called “Friends”) and direct service staff members as Qualified Mental Health Associates (QMHA). Offered through the Mental Health & Addiction Certification Board of Oregon, QMHA certification, alongside clinical supervision and ongoing psychoeducation workshops through Juniper Mountain Counseling, will equip their “Friends” with an advanced understanding of mental health issues and diagnoses, enhancing their ability to provide targeted mental wellness supports through weekly therapeutic mentoring activities and increasing their ability to facilitate referrals to clinical interventions when necessary.
Rural Expansion: Mobile Child Abuse Medical Clinic
KIDS Center, a medical model Child Advocacy Center (CAC), is located in Bend, Oregon and is responsible for providing child abuse medical examinations and assessments, structured forensic interviews, family advocacy, and therapy services to children and families impacted by abuse in Deschutes, Crook, Jefferson, Harney, Sherman, and Wheeler Counties. Currently, children and their caregivers from outlying rural areas of this region who need these services must travel to our Bend clinic, despite multiple barriers that create significant challenges (i.e. extended travel time and poor weather conditions) to accessing services, adding additional stress during an already difficult and traumatic time. By purchasing a mobile clinic, KIDS Center aims to ensure all children in need of child abuse evaluations can be seen in a timely and trauma-informed manner by removing barriers and creating equitable delivery of these essential, legally mandated services.
TBreaking Barriers to Health: Care & Connect Mobile Dental Clinics Serving Members of the Confederated Tribes of Warm Springs
In response to self-identified significant need for additional oral healthcare support among tribal members of the Confederated Tribes of Warm Springs, Medical Teams will deploy their Care & Connect mobile dental clinics to provide free oral health care services to children, youths, and adult tribal members living on the Warm Springs Reservation. In addition to providing dental clinics on the reservation in partnership with the Confederated Tribes of Warm Springs, Medical Teams will also provide mobile dental care clinics in nearby Madras, to provide free oral healthcare for tribal members living or attending high school in Madras. Their overall goal is to provide free urgent and restorative oral healthcare, referrals, and insurance navigation services to 175 tribal members before March 31, 2025. As a COHQA 2024 grantee, they will be able to serve 80 members out of the total 175.
Community Connector Program for Serious Illness Care
The Community Connector Program for Serious Illness Care will address social isolation and loneliness among residents living with or supporting someone with chronic or serious illness. The model promotes spaces where trained Traditional Health Workers (THWs) and community members offer compassionate support, help individuals identify their strengths, and assist in connecting them to available resources. By expanding their social circle and nurturing meaningful relationships, the project strives to improve both the quality of life and health outcomes for its participants.

2023 Projects

Community Resource Specialist Outreach Program
Diversability Inc. and the PEDAL Clinic will collaborate to ensure patients and their families access and utilize community resources. Clinic professionals will refer patients and their families to Diversability Inc. who will provide a certified Community Health Worker (CHW) from their DiversabilityVillage Program, educated and trained through the Central Oregon Community College (COCC) Public Health Program. The CHW, known as a Community Resource Specialist (CRS), will meet with patients and their families to establish Action Plans using SMART goals and will follow up regularly with patients and their families to identify and eliminate barriers to access and utilization of resources.
Integrated Perinatal Mental Health Project
This funding supports the development of an integrated perinatal mental health care program within ECWG. The project will be led by a psychologist and the current ECWG Clinical Director. The funds will ensure there are appropriate personnel and technology in place to apply an evidence based, nationally recognized framework for perinatal mental health (PMH) care to develop the program. The project will result in sustainable PMH programming and improved care outcomes for patients and their families and have positive impact at a clinic and regional level.
Integrated Health Coach/Nutritionist + PCP Targeted Approach
This pilot program integrates a certified health coach/nutritionist into primary care visits. Based on a successful model used at the Cleveland Clinic’s Center for Functional Medicine, this pilot provides patients in-depth care focused on lifestyle/behavior and nutrition to achieve health and healing.
Conference on Executive Function for Educators and Medical Professionals
Funds will go to support the Special Education Department at the High Desert ESD bring nationally-renowned speaker, Sarah Ward, to Central Oregon on October 25, 2023. This conference will present multiple strategies for special educators and medical professionals who specialize in evaluating and treating a wide range of speech-language and cognitive issues for young children, school-age children, adolescents, college-age, students and adults.
Tobacco Cessation Program
The Liberation Pathways Tobacco Cessation Program combines the power of the indigenous perspective, particularly as it pertains to Tobacco’s history, and will bring indigenous methodologies for addiction treatment as well as evidence-based therapeutic models (EMDR, IFS, Motivational Interviewing, DBT) and holistic approaches such as acupuncture, herbalism, and nutrition to support participants in their journey to cessation. Funding will go toward creating a program to be led by a licensed professional counselor/certified addiction drug counselor, and other practitioners/facilitators offering various specialties, utilizing a 3-day retreat format followed by three months of weekly, online support for maintenance. Participants will shift their relationship with Tobacco (nicotine products) through engagement in a holistic approach that includes evidence-based therapeutic practices, indigenous modalities for healing, acupuncture, breathwork, nutrition, and psychoeducation.
School Dental Services Program
OCH’s School Dental Services Program is a leader in Oregon in school-based oral health programs. This funding expands their efforts by including a Community Health Worker to the program to help with oral health education, oral care coordination and referrals to oral healthcare providers as needed. The addition of a CHW will help expand the program to additional students and age ranges including summer school, high school, community college and add new geographic areas. The CHW will also be able to support the program’s expansion to additional preventative healthcare services in schools, such as vision screenings, and help with data collection and program analysis.
Health Within Reach II: Diabetes Education with Oral Health and Healthy Food Supports for Low-Income Latinx Patients
This program expands the COHQA supported “Health Within Reach” pilot into a second year. The pilot provided dental care, diabetes education, and supports for healthy choices for uninsured diabetic patients. “Health Within Reach II” will build on this success to offer a more flexible, economically efficient model. This year VIM will contract with a dental hygienist to come into our clinic for cleanings, x-rays, and treatment recommendations so that volunteer dentists in the community can quickly provide services. VIM will continue to provide diabetes education, food cards for healthy meal choices, and depression screening as part of the project.

2022 Projects

Tele-behavioral Health Project
The Tele-Behavioral Health Project will enable La Pine Community Health Center (LCHC) to meet the increasing demand for behavioral health services, enable behavioral health patients to have greater access to services and provide a way to facilitate patient continuity of care. Finding a Behavioral Health Consultant (BHC) anywhere is a challenge currently since the demand far exceeds the supply, but this is an almost impossible-to-fill position in rural areas such La Pine, Gilchrist, and Christmas Valley. By having the tools needed to support a virtual BHC who can conduct all visits remotely (including facilitating warm hand-offs which are person-to-person within LCHC), this project will create a reach for patients that live in these remote communities.

Treehouse Therapies Professional Development Program
In 2021, like many other health care organizations, Treehouse Therapies experienced significantly increased turnover largely due to provider burnout. Many organizations have tried to address turnover and burnout by providing workplace incentives such as more time off, flexible work schedules, increased pay, or bonuses. Such incentives do not address the root cause of the burnout in a sustainable, long term way. This funding will address the provider burnout and overwhelm issue with an intentional, staff-wide, curated professional development program that includes mindset and leadership training through The Arbinger Institute. The Arbinger Institute has a 40 year record of successfully helping organizations, and the people who work for them, to shift from an inward mindset to an outward mindset. Studies show that organizations that focus on this kind of mindset change are four times more likely to succeed in organizational-change efforts than companies that focus only on changing behaviors. This outward mindset shift has been shown to significantly reduce burnout by increasing self-awareness, personal accountability, collaboration and communication, improving problem solving skills, and decreasing workplace conflict. Following this training, health care organizations have reported increased revenue, decreased staff turnover, and improved quality of care.

Dermatology Virtual Care Pilot
This funding will support the development of a virtual consulting path for dermatological conditions to improve access to care for those patients who are underserved in central Oregon. Locally, patients wait on average 60 days to see a dermatologist. Together, OCHIN, Dr. Wisco at Dermatology Health Specialists, and the LaPine Community Health Center will conduct a pilot virtual care (including electronic consulting) project that establishes a pathway through a health care software system used by over 54% of provider settings in the US, namely Epic Systems. This virtual care project would provide community clinic systems in the region a direct connection with specialists to improve access to dermatology and empower primary care providers. The approach could potentially be scaled to address many common conditions and improve access to specialty care across the county.
Veteran Counseling
THE SHIELD works to eliminate barriers to accessing mental health services for veterans. Their process consists of a network of trauma-informed, culturally competent mental health providers ready offer an appointment to veterans within 5 days. As a trusted, collaborative community resource that receives referrals from partners like the Central Oregon Veterans Council, Central Oregon Suicide Prevention Alliance, St. Charles, and Central Oregon Veteran’s Ranch, we are pleased our funding will offer our veterans 100 hours of free counseling through THE SHIELD.
Contingency Management Pilot
Medication Supported Recovery has historically been underfunded and stigmatized, both in the recovery communities and by medical providers. With increasing access to medications, the landscape has improved, however stigma and miseducation on the disease of addiction remains an obstacle to recovery. At a time when both opiate overdoses and alcohol related deaths are at an all-time high, improving engagement and access meets a critical community healthcare need. Funding provided by this grant would be utilized to implement contingency management at BestCare’s MSR clinics in Deschutes, Jefferson and Crook county, with the intent of improving patient engagement. The goal is to assist patients in achieving long term stability.
Autism Evaluation Pilot
Historically families have had to navigate the evaluation process required in both the education and the healthcare systems separately. In addition, the evaluation process has been identified by families as being incredibly stressful and confusing. The impact of this funding would be to create a collaborative system between the High Desert ESD’s Early Intervention/Early Childhood Special Education Program and our local health care system. This collaboration will improve early identification of high-risk special education children and their access to community services and educational supports. This project follows the model set up by OHSU’s Oregon ECHO Network’s ACCESS Project. ACCESS stands for Assuring Comprehensive Care through Enhanced Service Systems for Children with Autism Spectrum Disorders (ASDs) and other Development Disabilities. The primary goal of the ACCESS Project is to establish a single, valid and timely process in the local community to determine both educational eligibility for autism services and a medical diagnosis for children up to age five.
Health Within Reach: Diabetes Education with Oral Health and Healthy Food Supports for Low-Income Latinx Patients
For low-income, diabetic, Latinx patients served by VIM, oral health is substantially untreated. In fact, individual interviews with 150 VIM patients showed that 40% had trouble eating or sleeping due to dental pain. The issue is most pronounced for diabetic patients. VIM will pilot a dental health program for patients who participate in our diabetes education program. Patients will work weekly with our two volunteer certified diabetes educators and/or our staff RN diabetes care coordinator. At week four, patients will be eligible to begin dental care including evaluation & X-rays, cleaning or deep cleaning, and gum disease treatment.
Training to increase therapy services for children/families
Over the last two years, JMC had a dramatic (150%) increase in demand for mental health counseling services for children and families. Juniper Mountain Counseling is developing a comprehensive Child & Family Mental Health Program to coincide with the opening of a new facility in Fall 2022 to meet that demand. This program will specifically and effectively address this need through the expertise of a better trained team of clinicians who will be skilled in utilizing well researched and evidence-based practices in mental health. This funding will support expanding training requirements for our clinicians, and make strategic purchases for age and program appropriate therapeutic materials.

2021 Projects

Warm Springs Clinic
Treehouse Therapies partnered with the Confederated Tribes of Warm Springs and the Central Oregon Disabilities Support Network (CODSN) to open a therapeutic clinic and directly serve children with specialized needs who live in the Warm Springs community and the surrounding areas. Before this initiative, there were no such services in that community and families needed to drive to Redmond and Bend to access therapy for their children. Coupled with insurance and financial limitations, often these children had to forgo therapy. The funding went towards paying physical, occupational, and behavioral therapists from Treehouse to be based out of a new clinic in the Warm Springs Early Childhood Education Center to reduce the barriers to accessing high quality care for children in Warm Springs.

Pilot effort to improve services for older adult patients in the Gorge
This pilot was a collaborative effort in Hood River and Wasco Counties that served medically frail older adult patients, with a commitment to increasing services to Latinx and Indigenous patients with evidence-based, in-home patient-centered and integrated primary care and advocacy support. Based on the GRACE Team Care model developed by Indiana University School of Medicine, the pilot for this region is spearheaded by the Older Adult Working Group of the Clinical Advisory Panel for the Columbia Gorge Health Council. Funding went to support adaptation of GRACE protocols to the local context as well as training and technical assistance for participating clinics and pilot staff.
Patient Nutritional Intake Monitoring
This project is a collaboration between researchers at Oregon State University-Cascades, St. Charles Health System’s Nutrition and Diabetes Manager, and the Central Oregon Health Council (COHC) to bring together multiple disciplines to address a long standing issue in healthcare delivery that affects diabetic patients and patients at risk for malnutrition. Currently, the method of tracking nutritional intake in an inpatient setting is subjective, unreliable and gathered depending on the capacity of the care team. The researchers from OSU bring expertise from the fields of Computer Science, Food & Beverage, Business Administration, and Mechanical Engineering to enhance and test a prototype that uses image recognition technology, machine learning, artificial intelligence (AI), and cloud-computing resources to track and quantify nutritional intake in an inpatient setting to provide an accurate data point for care teams to make proactive care decisions. The funding goes toward compensating OSU student workers to assist the research team in training the computer vision model and testing the model in a live test environment. Once this phase is completed, the OSU team will work in partnership with the St. Charles Nutrition and Diabetes Manager for full-scale testing and implementation at the St. Charles Redmond hospital. You can hear more from the team here: https://media.oregonstate.edu/media/t/1_ydzipj9w
Veteran Counseling
THE SHIELD works to eliminate barriers to accessing mental health services for veterans. Their process consists of a network of trauma-informed, culturally competent mental health providers ready offer an appointment to veterans within 5 days. As a trusted, collaborative community resource that receives referrals from partners like the Central Oregon Veterans Council, Central Oregon Suicide Prevention Alliance, St. Charles, and Central Oregon Veteran’s Ranch, we are pleased our funding will offer our veterans 100 hours of free counseling through THE SHIELD.
Cultivating Compassionate Care in Central Oregon
The Peaceful Presence is a non-profit that works to reimagine the way communities talk about, plan for and experience serious illness and the end-of-life. Evidence shows that the rate of advance care directive completion in the general population is around 30% of adults; in the unhoused and BIPOC populations it is even lower. This project was an initiative to improve proactive planning for serious illness and end-of-life care for marginalized, vulnerable and unhoused populations in Central Oregon. Peaceful Presence envisions a community where every individual has the planning, support, and care to die where and how they prefer.
Improving Perinatal Care Coordination Across Oregon
Central Oregon’s Perinatal Care Coordination (PCC) is a community-developed and public health-led program to assist pregnant and postpartum individuals in Central Oregon access health insurance, prenatal care, nutritional services, and other referrals with ease and dignity. The PCC program was developed by Deschutes County perinatal care coordinators and implemented in 2016 in response to Central Oregon’s worsening maternal health and birth outcomes. The program now serves approximately 60% of all pregnant persons in Central Oregon, mostly low-income and vulnerable populations. In March 2021, Oregon Health Authority’s Healthier Together featured PCC as a promising model and intervention for improving maternal health and birth outcomes across Oregon. This funding will help create a comprehensive handbook to assist other communities with establishing a similar program, as well as to establish an evaluation methodology to continuously measure the effects of the program.

2020 Projects

Enhanced recovery pathway for hip fractures
This project supported the development and implementation of an ERAC for hip fractures, focusing on early pre- and peri-operative anesthesia to reduce time to surgery, opioid use, and length of stay, and improve recovery time.
Population-based data analysis and clinical decision support for low-income patients
This project provided support for VIM to continue transition to the Epic EMR (purchase supported in 2019), focusing on training, workflow development and implementation, and developing data reporting capabilities. VIM’s transition to Epic aims to enhance implementation of care standards and best practices utilized by high-quality private sector providers, but not often found in free and reduced-price clinics.
Diabetes Nurse Coordinator – Year 2 Expansion of services to target patients with uncontrolled diabetes and depression
Funding partially supported a second year of the Diabetes Nurse Coordinator grant awarded by COHQA in 2019. The program demonstrated success in 2019 and seeks to expand, specifically targeting patients with dual diagnosis of uncontrolled diabetes and depression.
Increasing Same Day Care Access for Pediatrics & Adolescents
This project supported the startup and implementation costs for PCPCH certification, as well as an increase in clinic capacity, and expansion of telehealth care delivery capabilities to enhance access to care.
The Provider Capacity Enhancement Project
This project supported the purchase and implement the Dragon One voice recognition system to reduce charting time; aiming to improve provider satisfaction and retention, reduce burnout, and increase time with patients.
Improving Perinatal Care Coordination Across Oregon
Central Oregon’s Perinatal Care Coordination (PCC) is a community-developed and public health-led program to assist pregnant and postpartum individuals in Central Oregon access health insurance, prenatal care, nutritional services, and other referrals with ease and dignity. The PCC program was developed by Deschutes County perinatal care coordinators and implemented in 2016 in response to Central Oregon’s worsening maternal health and birth outcomes. The program now serves approximately 60% of all pregnant persons in Central Oregon, mostly low-income and vulnerable populations. In March 2021, Oregon Health Authority’s Healthier Together featured PCC as a promising model and intervention for improving maternal health and birth outcomes across Oregon. This funding will help create a comprehensive handbook to assist other communities with establishing a similar program, as well as to establish an evaluation methodology to continuously measure the effects of the program.
Back On Your Feet Clinic for Displaced Patients
This project was a partnership with St. Charles and Bethlehem Inn, to provide a free quarterly foot care clinic to displaced patients. The goal was to provide foot care kits and foot health education, perform screenings, and provide clinical evaluation and follow-up where needed.
Metabolic parameters as a function of shift work changes in sheriff’s deputies
The Deschutes County Sherriff’s office will be slowing their shift rotation scheduling, providing a natural experiment to measure the impact of increased time for circadian resetting on metabolic health. Assessment of metabolic impact of shift work and variations in scheduling is lacking in the literature, and this project could produce new learnings.

2019 Projects

Moving further upstream: nurse-led palliative care in the home setting
For the last several years, Partners in Care has pursued a grant-funded model of embedding palliative care nurses in several primary care clinics. This model, although highly impactful for patients, was financially unsustainable. This project allows PiC to launch a new palliative care pilot program, based on RN home visits for a targeted population of patients: those believed to be in their last two years of life, patients deemed at high risk for crisis, those requiring medical goal clarification or support, and those requiring better symptom management related to serious illness.
Diabetes Nurse Coordinator
Partial support for a new RN coordinator focused on Summit BMC’s diabetic patients. Diabetes is a complex disease process that requires close monitoring, patient education and frequent communication in order to reduce complications and keep costs contained. Improving diabetes care is a major focus of the health care community in Central Oregon.
Chronic Pain & Addiction Patient-Caregiver Training
The project supports a health educator and clinical social worker to provide education, training, and support for caregivers of chronic pain and addiction patients. Specifically, the caregivers received education related to adherence principles of MAT can positively impact treatment of chronic pain and addiction for patients and their families. This project demonstrated the impact of a psychoeducational intervention delivered to both patients and caregivers to improve adherence to buprenorphine MAT in patients diagnosed with complex chronic pain and opioid use disorder.
Patient Pain and Opioid Use Outcomes Post Laparoscopic Cholecystectomy
Study of a proposed approach to implementing the Grade A recommendation to aspirate the pneumoperitoneum after cholecystectomy in practice. Studies of this intervention generally leave gas decompression drains in for at least 24 hours, which is difficult to implement in an outpatient practice. This project studied impact of a 1-2 hour drain on post-surgical outcomes and opioid use.

Computer hardware for EMR upgrade
This project provided support to VIM to upgrade their EMR and significantly increase their ability to provide and coordinate care for impoverished and uninsured patients of Central Oregon. VIM is now able to implement care standards and best practices utilized by high-quality private sector providers, but not often found in free and reduced-price clinics.

Clinical pharmacy consultant
Partial support for a clinical pharmacist FTE to be added to Summit’s primary care team. The clinical pharmacist supported providers by providing 1) formulary, cost, and authorization considerations, 2) recommendations for step therapy for diabetes, hypertension, asthma, and other chronic conditions, 3) substitutions for high-risk interactions or contraindications. They also provided patient education and outreach with the intent of maximizing adherence, safety, and outcomes.
Improving check-in experience and patient comfort
This project funded the implementation of a digital check-in process, with iPads linked to the clinics EMR. While COHQA generally does not provide grant funds for the purchase of needed clinic equipment (outside of special cases like Volunteers in Medicine), the proposed measures could generate data of interest to the healthcare community.

2018 Projects

Naloxone Rescue for Opioid Overdose Prevention
The purpose of this project was to educate community stakeholders on the availability of intra-nasal naloxone medication to prevent fatal opioid overdoses, provide direct one-on-one instruction on how to administer naloxone, train other provider groups in the Gorge on how to develop naloxone programs within their organizations, and disseminate best program practices.
Goldilocks’ Clean Slate
This was the second phase of Goldilocks’ Clean Slate, a pre-charge diversion program for drug possession offenders that connects eligible individuals with health care instead of entering them into the criminal justice system. Offenders were connected to primary care, as well as substance abuse and mental health care services. PCPs completed compliance assessments at the beginning and end of 12 months of care to determine progress toward health and sobriety.
RN Training to Implement Diabetes Pathway
Supports the implementation of Mosaic’s organization-wide Diabetes Pathway. Mosaic sent 10 RN care coordinators through the Diabetes Educator Level 1 course. This course certifies RNs to adjust medications, treat and monitor complications, council patients on lifestyle modifications. This project also supports the development and production of patient education and self-management materials.
Mobile Medical Care for the Underserved
Supports the development of an independent mobile medical clinic, intended to bring care directly to the most vulnerable, such as those living in homeless camps and shelters, or those who cannot easily get to a clinic for mental health reasons. Hearthside will also partnered with regional clinics to provide mobile care for those with mobility issues, mobility issues, childcare difficulties, or transportation access.
Managing Weight Regain After Bariatric Surgery
A study designed to assess the impact of close follow-up on health outcomes/weight regain. Currently, OHP only covers visits at 6 weeks, 3 months, 6 months, and 1 year post-surgery. This study created a control group (standard OHP follow-up) and a treatment group with bi-monthly visits for 24 months and assess variations in outcomes.
COAPP Event and Connection Resources
Funding went to defray start-up and development costs for COAPP as an organization to support and provide continuing medical education for advanced practice providers in the region.

2016 Projects

First Year of COHQA Foundation Projects & Official Grant Program

Pilot project using Extension for Community Healthcare Outcomes project (ECHO) telemedicine model to educate and support PCPs in diagnosing and treating common dermatology conditions and identifying those that truly need specialty care.

Random split-sample study attempting to decrease hospitalizations and ED visits among patients with COPD by preemptively calling treatment group patients 2x/month to assess presence of early warning signs for an exacerbation event and, if present, scheduling a priority office visit.

The pilot of a structured system of phone follow-up and monitoring using existing Health Information Systems to improve medication adherence & disease control in patients newly initiated on DMARDs and biologic agents in RA patients.

Supported the purchase of 40 test kits to assess whether dust mites are a major allergen in Central Oregon, with the hypothesis that they are not common and therefore thousands of dollars in testing and treatments among allergic individuals could be saved.

Assessment of utilization & cost incurred by OHP patients with biliary dyskinesia or cholelithiasis denied cholecystectomy approval. Condition-related claims data for these patients collected & assessed for 12 months following denial, or until cholecystectomy was performed.

Building on 2016 CHE grant to initiate team-based care for diabetes. Year two sought to integrate a diabetic educator, CHW, and pharmacist into the primary care home, including EMR access. Focus was on medication education/adherence (and communication with PCP), and outreach for patients not meeting BP & A1c targets.

Supported a radiology RN navigator to track and coordinate care for oncology patients with newly diagnosed cancer, those with significant or incidental findings, or those needing follow-up imaging. Navigator coordinated with patient, PCP, and specialists to ensure appropriate follow-up care.

Year 2 funding for the diabetes Expanded Access and Outreach program, supported expanded specialty care presence & access in Madras & Prineville, focused on population health management approach.

Funded a project manager to develop & implement a Heart Failure Medical Home to establish interdisciplinary team-based care for heart failure patients.

Supported a palliative care RN to embed at regional primary care clinics to guide patients’ pain treatment, treatment choices, care coordination, emotional, social & spiritual support, and help navigating the health care system.

2015

COIPA Funded Projects

Walk with a Doc
BMC offered weekly walks on Tuesday mornings led by providers for the community to improve health knowledge, encourage activity and build community. Winter walks had 2-3 participants per walk, and spring/summer/fall had 3-8. They added a Thursday evening option in the summer as well. Over the course of the year they had 50 walks, led by five physicians from the family medicine department and one specialist. The most consistent participants were from the community (as opposed to BMC staff), which indicates that the COIPA-funded advertising through newspapers and radio reached community members. BMC measured outcomes via a questionnaire sent to 16 participants (10 responses). Six people said they were more active since participating in the Walk With a Doc program. Four people said their activity level was unchanged. No one said their activity level declined since participating. Eight people said they felt better informed about health issues since participating and two people said they were about the same. Seven people felt more empowered to ask about and discuss health-related issues. One person reported that they were able to lower the number of medications they took. Providers who led walks reported strong satisfaction from the opportunity to connect with patients in a different environment.
Empowering Pain Patients through Alternative Therapies
Deschutes Rim recruited 32 patients into the acupuncture treatment program (which also included massage and yoga options), 23 of whom completed the full recommended course of treatment. Most represented diagnoses were lumbosacral pain (10) and osteoarthritis (6). Additional diagnoses included rheumatoid arth, other back pain, myalgia, and neuropathy. A survey was conducted among those who completed treatment, with 11 responses (41%). 6 reported an improvement in functional status and none reported a decrease. 9 reported improvement in ability to cope with pain and 1 reported decreased coping ability.
Patient Nutritional Intake Monitoring
The addition of a new PA travelling to Madras and Prineville helped to expand access to diabetic care for rural patients without private insurance. Access in Prineville and increased in 2016, with a 40% increase in the number of patients seen in Prineville and an 80% increase in Madras (over 2015 numbers). This expanded access has led to an improvement in A1c measurements, with average A1c for patients across both areas decreasing from 8.9% to 8.0% over the course of the year.
Telemedicine for Complex Patient Management
This pilot study demonstrated that direct-to-consumer telemedicine for complex pain management is clinically and logistically viable. 46 visits were completed, and both patients and providers reported very high levels of satisfaction with the program. Only one patient reported that they preferred a physical visit. Phone contact between patients and MAs increased, as did use of email for patient questions. There was, however, a high rate of no-shows for telemedicine appointments as patients had a greater tendency to forget. This was mitigated by altering patient selection to include those on Suboxone and low-dose opioid therapy that had a significant distance to travel. Patient education as the project went on also improved rates and reduced failures due to tech problems.
Palliative Care Program
In 2015, Partners in Care performed 506 palliative care consultations (207 initial and 299 follow-up). Most of these (145) were referrals from BMC oncology, where project lead Dr. Blechman was partially embedded. Of the 506 palliative consults, 176 patients reported pain of 4 or more (1-10) during a palliative consultation visit. At the end of care, 81% of patients reported that their pain improved, 12% of patients reported the same score, and 7% of patients reported pain had not improved. 121 patients reported a dyspnea score of 4 or more (1-10) during a palliative consultation. At the end of care for the other 64 patients, 63% of the patients reported symptom improvement, 24% reported no improvement, and 14% reported their dyspnea was the same. 8 were not seen for follow-up. Advanced care planning was discussed at 94% of visits, and POLSTs were completed by the end of 89% of visits (20% already had POLST in place at time of palliative consultation). Patient satisfaction was measured via an optional follow-up survey, with 48 respondents. Patient satisfaction was extremely high on all survey items.
EMR Implementation
Madras successfully implemented the Athena Health EMR system in fall of 2016. They report that they are now nearly back to full visit productivity. The 16 tablet computers purchased with this grant are being effectively used by providers in exam rooms, and the wireless and firewall upgrades are functioning as desired. Madras is currently working with Shiela Stewart to implement effective QIM measure workflows using the new system.
Transforming Pain Management with Primary Care
Mosaic requested and was granted a 4-month no-cost extension, due to an unforeseen delay in the credentialing and contracting process for the two movement instructors/massage therapists. The process has now been completed for both, and the multidisciplinary persistent pain pilot in Prineville was launched November 1st. Using the now-standardized process for credentialing alternative therapy practitioners, they will launch a similar pilot project in Bend in February 2017. Final reports on these two projects will be delivered to COIPA in May 2017.

2014

COIPA Funded Projects

Support of Patient-Centered Medical Home Activities
This project provided staffing support for patient-centered medical home activities. Including patient outreach for preventive care and patient education in a rural, single provider practice.

Medical Evaluation in Behavioral Health Setting
LCHC partnered with Deschutes County Behavioral Health (DCBH) to screen DCBH patients for acute medical concerns. For patients requiring medical evaluation, care was coordinated with LCHC to provide same-day appointments.
Rheumatology: Clinical Decision Support for Primary Care Providers
Partnership between rheumatologist and Columbia Gorge Family Medicine to introduce and use clinical decision support instrument to reduce diagnostic complexity. Effectiveness of this tool was then evaluated with assistance from OHSU/Office of Rural Health.
Initiating Group Visits for Diabetics
Initiated group visits for patients newly diagnosed with diabetes or pre-diabetes in a rural FQHC.
Behavioral Health Integration
A study designed to assess the impact of close follow-up on health outcomes/weight regain. Currently, OHP only covers visits at 6 weeks, 3 months, 6 months, and 1 year post-surgery. This study created a control group (standard OHP follow-up) and a treatment group with bi-monthly visits for 24 months and assess variations in outcomes.
Certified Health Coaches
This project certified clinic staff as clinical health coaches through the Iowa Chronic Care Consortium to provide intensive management for high-risk patients to reduce unnecessary hospitalizations and ER visits.
Empowering Patients to Improve Care for Type 2 Diabetes
Project identified high-risk diabetic patients seen within the last year, utilized a team of care coordinators to ensure risk factors are monitored, implemented a Diabetic Medical Home template to capture and track key assessments and merge EMR with a primary care group for a more efficient and collaborative patient care model.
Scroll to Top