Highlighted Project: The Health Commons Project

Testing innovations in Medicaid

The 2012 Health Commons Project brought an opportunity to test ideas for improving care and controlling costs in Medicaid with Oregon’s largest Coordinated Care Organization. Funded by the Center for Medicare and Medicaid Innovation, the Health Commons Project was a collaborative effort on the part of county public health agencies, hospitals, health plans, and community clinics in Portland. 

CORE provided program evaluations to help measure the effectiveness of identified interventions. Specific areas of research and evaluation include:

  • Health Resilience Program
  • The Tri-County 911 Service Coordination Program
  • Intensive Transition Teams Program 
  • ED Guide Program
  • Care Transitions Innovation: C-Train
  • Health Commons Project information

Health Resilience Program Evaluation

The Health Resilience Program (HRP) is an intervention that provides a new workforce of non-traditional health care workers – Health Resilience Specialists (HRS) who are "engagement specialists" tasked with developing meaningful partnerships with a panel of high-acuity/high-cost patients to enable wellness and stability in their lives and reduce the total cost of care and enhance patient experience and outcomes.

CORE’s evaluation used a combination of claims data and surveys to assess key outcomes for HRP participants. Using claims, CORE compared clients’ utilization and expenditure patterns before and after engagement in the program. Using surveys, CORE asked patients about their health care access, quality, and well-being at baseline and following engagement with the HRP. CORE also performed an optimal impact analysis to understand which types of HRP patients had stronger or weaker outcomes than average.

CORE's evaluation found:

  • Participants had fewer ED visits and fewer inpatient events and increased primary care.
  • Medical expenditures decreased dramatically. 
  • Access and quality stayed the same or improved for members. 

Read the full report › 

The Tri-County 911 Service Coordination Program Evaluation 

The Tri-County 911 Service Coordination Program serves Tri-County residents (Multnomah, Clackamas and Washington counties) who call 911 frequently for emergency medical services (EMS) when other health and social services would more appropriately serve their needs. CORE’s evaluation used a combination of Medicaid and American Medical Response (AMR) data to assess the impacts of the program in the context of a counterfactual comparison group to represent what would have happened in the absence of the program. CORE compiled a “control” group of patients with similar 911 calling profiles who had not been in the program, then compared changes in key outcomes between the two groups over time. 

CORE's evaluation found:

  • 911 calls stayed steady while ED visits were reduced.
  • There was reduced inpatient hospitalization for some clients. 
  • Patterns for primary care utilization changed.
  • Costs were lowered. 

Read the full report ›

Intensive Transition Teams Program Evaluation

The Intensive Transitions Team (ITT) intervention provides transitions support specifically for patients who have had a psychiatric hospital admission, deploying mobile crisis support specialists who can meet patients at the hospital and then follow them throughout their transition to outpatient care.

CORE used program records and claims data to evaluate ITT implementation and outcomes, comparing the utilization and costs of ITT clients prior to their admission to a similar period of time after engagement with the ITT program. To understand the significant drivers of utilization after discharge, CORE estimated the likelihood of outpatient mental health connection or inpatient mental health readmission after discharge using a logistic regression model. CORE also evaluated the combined impact of the Peers program, in Clackamas county, on ITT participants.

CORE's evaluation found:

  • ITT clients are medically complex, with mental illness at rates as high as 20 times the typical Medicaid population and an average of three chronic health conditions. 
  • Outpatient behavioral health visits dramatically increased for ITT clients. 
  • Inpatient mental health admissions were reduced for ITT clients. 

Read the full report ›

ED Guide Program Evaluation 

The ED Guide program puts non-traditional health care workers in the emergency department to help patients with non-acute needs find the most appropriate place to get care.

CORE used Health Share of Oregon claims data to create a longitudinal study panel of Medicaid patients to assess the impacts of the ED Guide program on outcomes. CORE used propensity score matching to pair each person seen by a Guide during their ED visit to a similar person who had a similar ED visit, but was not seen by the program. After creating these matched treatment and control groups, CORE compared utilization and cost outcomes across the subsequent six months, comparing trends to estimate program impacts.

CORE's evaluation found:

  • No effect on primary care or ED utilization. 
  • Significant reduction in subsequent inpatient event
  • Reduced costs based on reduction of inpatient care

Read the full report ›

Care Transitions Innovation: C-Train 

C-Train is a care transitions intervention that provides high-intensity support to high-utilizing patients who are discharged from the hospital.  This program helps patients transition from inpatient to outpatient care, provides pharmacist support to increase medication adherence, and links patients to resources to meet psychosocial needs.

CORE used program records, patient surveys, and claims data to evaluate C-Train implementation and outcomes. Propensity score modeling was used to equate characteristics of non-C-Train participants and C-Train participants for comparison of outcomes.

CORE's evaluation found:

  • C-Train served almost 700 Health Share patients
  • C-Train patients were medically and socially complex
  • C-Train did not reduce readmissions or ED use, but it did increase post discharge connection to primary care. 

Read the full report ›

Research Partners 

Providence Health and Services, CareOregon, Oregon Health and Science University, Legacy Health System, Kaiser, the Coalition of Community Health Clinics, Central City Concern, Multnomah County Health Department, Washington County Health Department, Clackamas County Health Department, Cascadia Behavioral Health, Virginia Garcia, The Oregon Clinic


Health Commons Grant, Center for Medicare and Medicaid Innovation

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