MEDFORD, Ore. —This month, Jackson Care Connect, a nonprofit Coordinated Care Organization (CCO) providing care for Oregon Health Plan (Medicaid) members in Jackson County, celebrates its fifth birthday. In 2012, the state started a new model of health care aimed at providing more comprehensive and locally focused care to Medicaid members. Now, five years into that change, Jackson Care Connect boasts increased and improved care for its members, and partnerships that are improving the health of members and the community in Jackson County.
The CCO model combines physical, mental and dental health under a single umbrella. It also focuses on involving the whole community in improving health care. Jackson Care Connect works not only with its provider network, but also with families, schools, agencies, non-profit organizations and community members to support the health of its members and the whole community. Research shows only 10 percent of total wellness is related to a person’s visits to the doctor. The rest is related to social determinants such as housing, nutrition, exercise, genetics and environment. For that reason, Jackson Care Connect works with members from a holistic perspective.
Transition leads to successes
Jackson Care Connect counts the health care expansion under the Affordable Care Act as a key part of community health improvement. This expansion doubled the number of members, improved access to people who didn’t have care before, and increased the number of Jackson Care Connect members who have a patient-centered medical home, meaning they have a primary health care home that is focused on the patient, with a team approach to care.
Director of Clinical Integration Anne Alftine says, “The ACA provided the opportunity for this community-led and community-based network of providers—combined with an innovative approach to health care—to come up with solutions.”
“We’ve also benefited locally from the support of CareOregon, which has served members in our county for more than 20 years,” says Jackson Care Connect Executive Director Jennifer Lind. “They helped form Jackson Care Connect and continue to support us financially, administratively and educationally, while understanding that decision making and operations is at the local level through our own board directors, Community Advisory Council and Clinical Advisory Panel.”
Because CCOs focus on local input, the community has had a direct impact on the way health care is changing. Lind says, “we have identified a lot of the needs based on feedback from our providers and members.”
- Reducing overuse of emergency departments, in partnership with Mercy Flights and local hospital staffs
- Supporting members’ weight loss, fitness and nutrition goals through deep partnerships with the local YMCAs
- Supporting holistic ways to help at-risk families through the Family Nurturing Center’s Farm & Food Program
- Integrating Behavioral Health services into primary care clinics
Lind says, “Health care is local. It really only makes sense to do it in this way.”
Jackson Care Connect Medical Director Matt Hough, a physician at Southern Oregon Pediatrics, says, “Jackson Care Connect has really changed the relationship between provider and plan. It’s a much more collaborative plan.”
Hough says that the CCO model has gotten medical providers and ancillary service organizations to communicate more openly. Having options to direct patients to, such as weight loss programs at the YMCA, has added more tools to providers’ toolboxes, offering tangible approaches to complex problems.
He says, “to a large extent, it’s never been more exciting to be practicing medicine in the primary care setting than it has been in the last five years.”
As health care continues to change, Jackson Care Connect will continue to serve its members and strive to meet the triple aim of improving patient care, improving the health of the population and reducing medical costs by focusing on preventive care. Lind says, “Medicaid has always been an important payer in this valley, and always will be. Now we have the right model to make the adjustments that are needed.”
Lind and Alftine say the next priorities include helping members navigate the health care system efficiently, and continuing to stabilize and strengthen the behavioral health network.
Jackson Care Connect also will look for ways to provide stability for health care providers who care for Medicaid patients, through reliable payout models, and financial support for addressing measures that are correlated to improved patient health, including blood pressure control, colorectal cancer screening, breast cancer screenings, and adolescent well care visits, depression screening and others.
Hough’s practice implemented a new depression screening, for example, and because of that process, ended up better identifying problems in patients. He says “we added a behavioral health specialist in the office, and Jackson Care Connect provided the seed money to try it out. It never would have been possible otherwise.”
Hough says the screening has resulted in better, more comprehensive care for the patients and families.
Jackson Care Connect will continue to be part of helping address complex community issues. Homelessness and lack of housing, for example, have health implications for individuals and the community. The organization also is working toward a better understanding of health inequities, knowing that different segments of the population experience different outcomes.
Lind says, “these are issues where it’s important we knit together with the community to help find solutions.”