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Our team recently had the pleasure of conducting a site visit with a PCPCH that exemplifies what it means to meet patients where they are with continuous, team-based, high-quality care. Housecall Providers is a nationally-recognized nonprofit in-home medical organization that has served the Portland metro area for nearly three decades. Housecall Providers’ mission centers on delivering in-home medical care to under-resourced and marginalized Oregonians.
 PCP Natalya Balanetskaya, FNP sharing a laugh with patient, George
Meeting patients where they are with home-based care:
The 2,500+ patients that Housecall Providers serves annually include several distinct at-risk populations such as homebound elderly individuals striving to maintain their independence, those with severe disabilities, middle-aged patients grappling with advanced illnesses along with associated behavioral health and housing challenges, and those nearing the end of their lives. Delivering care within the homes of these patients meets PCPCH Standard 1.G - Alternative Access and allows Housecall Providers' healthcare providers to practice more effective medicine as they gain insight into the full spectrum of their patients' lives including living conditions, functional status, and the quality of care they receive. Patients, in turn, benefit from a wide array of services and advantages offered by the program.
Offering continuous, team-based care:
Housecall Providers uses an award-winning interdisciplinary team-based approach (provider, care coordinator, social worker, and nurse) to meet PCPCH Standard 4.B - Personal Clinician Continuity and bring knowledge, experience, and wisdom to both patients and healthcare partners. This model improves health outcomes, creates cost savings, and enhances the satisfaction of the entire care team.
 AAHCM's first-ever Housecall Interdisciplinary Team of the Year: (left to right) Ashley Schumacher, Gillian Beck van Heemstra, Crystal Delatorre and Cheryl Zechmann
Another feature of Housecall Providers’ model that our site visit team felt reflected the spirit of PCPCH Core Attribute 4 - Continuity was their comprehensive continuum of care which includes primary care, palliative care, and hospice care which are seamlessly adapted to the evolving needs and desires of their patients over time. Primary care patients have access to proactive palliative care if their conditions progress, and in the final months of life the hospice team can step in without necessitating a disruptive transition to a new healthcare provider. This smooth transition of care is appreciated not only by patients and families but also by the practice’s community partners.
Improving care quality through risk stratification:
One final dimension of Housecall Providers’ care model that impressed our site visit team was the risk stratification tool that their primary care team utilizes to build trust and lay the foundation for a long-term relationship with their patients. This tool meets PCPCH Standard 5.A - Population and Data Management by assisting the team in identifying the medical and psychosocial needs of the patient and thereby which care team members need to be involved in their care.
“In the face of today's evolving healthcare landscape, Housecall Providers' mission to enhance lives by bringing health care directly to the doorstep of those in need has never been more vital. Our unwavering commitment revolves around the goal of making in-home medicine more sustainable, with the aim of ensuring that homebound adults and individuals dealing with serious illnesses can access care that improves their quality of life.”
- Pam Miner, MD, Chief Medical Officer
 Patient, Gloria (center) surrounded by her family and care team members from Housecall Providers
Oregon Health Authority (OHA) is currently recruiting members to serve on the Oregon Health Policy Board’s Health Care Workforce Committee which will contribute to Oregon’s efforts to expand and diversify its health care workforce. OHA is looking especially for members with lived experience in the health care system, cross-cultural experience, and experience addressing health equity. People who live in Central or Eastern Oregon are especially encouraged to apply, as are people with familiarity in behavioral health, allied health, and medicine.
The Oregon Health Care Workforce Committee meets approximately every other month to hear reports, consider current events in the health care sector regarding workforce, and help make recommendations to the Oregon Health Policy Board, OHA, and the Legislature. Committee members commit to either a three-year term or (for non-voting student members) a one-year term. The Primary Care Office is accepting nominations to the Committee through the close of business Friday, December 1, 2022. Click here to apply.
Everyone has a right to know about and participate in Oregon Health Authority (OHA) Committees. If you need this information in an alternate format (such as Braille, large print, audio, video or other formats) or in another language, or would like to request interpretation service, please contact Jessica Malstrom at Jessica.Malstrom@oha.oregon.gov or you can call 541-975-3759.
Thursday November 16, 10:00 am
The Primary Care Development Corporation (PCDC) is hosting a free webinar on maternal mental health that will address the most common complication of pregnancy and childbirth. Experts Adrienne Griffen (Executive Director of Maternal Mental Health Leadership Alliance) and Joan King (Senior Consultant with the National Council for Mental Wellbeing) will share their experiences advocating for and implementing perinatal integration through collaboration. Join this session and gain critical insight into addressing the maternal mental health needs of individuals. Click here to register.
Effective January 1, 2023, Oregon implemented the full Early and Periodic Screening, Diagnosis and Treatment benefit (EPSDT) for children and youth until their 21st birthday. This means that both the Open Card program and coordinated care organizations (CCOs) must cover any medically necessary and medically appropriate services (and dentally appropriate, for dental services) for enrolled children and youth. |
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OHA has issued an updated EPSDT Provider Guide and Frequently Asked Questions that reflect changes to the Medicaid Management Information System (MMIS) related to EPSDT. OHA is also hosting an informational session on Monday December 4 (12-1 pm) for clinicians and practice managers serving children and youth who are OHP members, with a focus on Open Card providers. Please note there are no changes in EPSDT coverage requirements since the last session, only clarifications as well as process updates for Open Card providers. Click here to register. Please contact Tom Cogswell (thomas.cogswell@oha.oregon.gov) if you need an accommodation to fully participate in this webinar.
Additional information may be found at: www.oregon.gov/EPSDT, including:
Café Connect:
The OHA Transformation Center, in partnership with the Oregon Rural Practice-based Research Network, will be hosting a Cafe Connect series to support implementation of the CCO Social Determinants of Health (SDOH) Social Needs Screening and Referral Incentive Metric. Café Connect events are an opportunity to hear from experts and allow for CCOs, CBOs, and
providers to engage in dialogue to strengthen partnerships and support successful metric implementation. Click here for additional information including session dates (next one on Wednesday January 23) and topics for each session.
SDOH-HE Program:
ORPRN is currently recruiting clinics in Oregon to participate in the Social Determinants of Health and Health Equity Population Approaches to Chronic Disease Prevention program (SDOH-HE). The program supports clinics in collecting and using social needs data to inform clinical decision-making and develop population-based approaches to prevent and manage chronic diseases. Participating clinics will receive one-on-one technical assistance including EHR specialist support, analysis of the social needs screening and referral process, and support for developing and implementing a small quality improvement intervention of the clinic’s choosing. Please reach out to Sara Wild (wilsa@ohsu.edu) if you have questions or if this program is of interest!
Questions?
We are here to help! Contact us at PCPCH@oha.oregon.gov
About the Patient-Centered Primary Care Home Program
Patient-Centered Primary Care Homes (PCPCHs) are health care practices that have been recognized by the Oregon Health Authority (OHA) for their commitment to providing high quality, patient-centered care.The PCPCH Program administers the application, recognition, and verification process for practices applying to become Patient-Centered Primary Care Homes.The program is also working with partners across Oregon to support adoption of the primary care home model. For more information visit www.PrimaryCareHome.oregon.gov.
The mission of the PCPCH Program is to be a trusted partner in primary care, collaborating with stakeholders to set the standard for transformative, whole-person, and evidence-based care.
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