Learn how pilot projects are transforming health care delivery in the region.
“The landscape is changing, and with that change we have an opportunity to make real change in our communities.”
– Beck Fox, Delivery System Transformation community co-chairperson.
Creating new and innovative systems and approaches to delivering health care services is a top priority of the region’s Intercommunity Health Network Coordinated Care Organization (IHN-CCO), which serves Benton, Lincoln and Linn County. Coordinated care organizations, or CCOs, provide health coverage for Oregon’s Medicaid population.
As Oregon begins its second five-year contract with the state’s 15 CCOs, IHN-CCO has emerged as a recognized leader for impacting and influencing health care transformation.
A key reason is its Delivery System Transformation Committee (DST), which was created “from the ground up” and funds innovative pilot projects designed to reimagine how health care is delivered.
“Nobody else is doing this,” said Sherlyn Dahl, former executive director of the Community Health Centers of Benton and Linn Counties and the founding cochair of the IHN-CCO’s Delivery System Transformation Committee (DST). “It’s not about funding something good. It’s about finding something new.”
The DST’s formula for success is to target where funds are spent, focusing on spreading and sustaining successful projects and deepening the impact of the work through community partnerships. By working with community partners, IHN-CCO is improving health outcomes, while increasing access and lowering the cost of health care.
“The landscape is changing, and with that change we have an opportunity to make real change in our communities,” said Beck Johnson, the new community cochairperson of DST and director of the Bravery Center at the Olalla Center.
Since 2013, more than $20 million has been invested in 65 pilot projects that have been completed in collaboration with more than 50 community partners. Pilot projects funded through IHN-CCO’s Transformation Plan represent some of the most innovative work.
“We are at a critical juncture,” said Johnson. “The projects we choose to support now must reflect our commitment to health equity, increasing access and improving care for the most marginalized populations in our region. “
This includes the Tri-County Traditional Health Worker Training Hub, which prepares people to fill critical roles in health care and social services, including the frontlines of the COVID-19 response. The training hub, the first of its kind in the Willamette Valley, began as a pilot project. During the six-week program, participants who share ethnicity, language, socioeconomic status or life experiences with people needing services learn to navigate the healthcare and social services systems.
“Traditional health workers are good at breaking barriers because they’ve already had to break barriers for themselves or their family members,” said Kelly Volkmann, health navigation program manager for Benton County Health Services.
Those who complete the course are eligible to obtain state certification to work in the health care or social services industries. Certified workers fill positions, such as doulas, addiction and recovery peer support specialists and health navigators providing culturally and linguistically appropriate assistance. This local network of skilled traditional health workers stands ready to bridge the gap.
When Benton County issued an emergency declaration because of COVID-19, Ulises Fraile-Martinez was chosen as the spokesperson to deliver video briefings tailored to the Spanish speaking community. Fraile-Martinez was in the first class to complete health worker training in 2018. Since then, more than 80 people have received training to work in this emerging and important role in health care, and courses are regularly offered in all three counties.
“The Traditional Worker Training Hub is a collaboration of community partners that care, want to be successful and maximize our resources together,” said Volkmann. “I couldn’t imagine doing this on our own.”
Learn how the Community Doula Program is improving birth outcomes and experiences by providing emotional and physical support during pregnancy and childbirth.
“For all moms, the support of a doula is important.”
– Yesenia Sequera, Community Doula Program.
The birth of Sebastian Lechuga Ramirez was not the uncomplicated, on-time delivery that his mother Isabel Ramirez Lopez of Albany had hoped for.
When the due date passed and an induced labor stalled, doula Yesenia Sequera kept the first-time mom involved with making decisions about her labor and explained why the doctor was recommending a C-section.
“That has a big impact on a mom’s experience of birth,” Sequera said. “I make sure all of her questions are answered.”
The healthy arrival of a 9 pound, 7 ounce boy is one of the many successes of the expansion of the Community Doula Program, a 2022 Delivery System Transformation pilot project of InterCommunity Health Network Coordinated Care Organization serving Benton, Lincoln and Linn counties.
Doulas provide emotional and physical support during pregnancy and childbirth.
“My role is to help the mother so that she has the best possible birth experience and is well set up for early parenting,” Sequera said.
Through the pilot project, the Community Doula Program was able to train and increase the number of Spanish speaking doulas, particularly in east Linn County and Lincoln County, to serve as health care interpreters.
The goal is to improve birth outcomes and reduce instances of prematurity, C section and pain medication use. The pilot project expanded doula services already available at hospitals in Albany and Corvallis, where Lopez gave birth, to Lebanon, Lincoln City and Newport.
As a result, the region now boasts one-third of the total number of doulas working in Oregon. That ensures access for every pregnant member of the coordinated care organization.
Lopez chose to have a doula so that she could feel prepared for childbirth and being a mom. It was a comfort to her knowing that Sequera would be with her during labor.
Relying on her doula’s experience made everything easier, Lopez said.
Sequera is bilingual and is often paired with Spanish speaking moms. She meets with each expectant mom twice before birth to build a trusting relationship.
During labor, a doula can lead exercises to help things progress and provide massage for pain relief. At hospitals, translation services through a tablet device are available for medical decisions. Doulas trained as medical interpreters can also interpret when a mother asks.
“No one wants to be talking through a tablet while they are pushing,” Sequera said.
Within a few weeks of a baby’s arrival, doulas meet one last time with the new mom and baby for a postpartum checkup. Sequera became a doula after the birth of her daughter.
She wanted to serve Hispanic women in the community to overcome barriers and reduce health inequities.
“For all moms, the support of a doula is important,” Sequera said. “It starts with having someone there who understands you and knows your culture and needs.”
Learn more at communitydoulaprogram.org.
Learn how dental hygienists are working alongside doctors, nurses and other clinicians, improving the lives of patients at Samaritan hospitals, one tooth at a time.
“It would be fantastic to have expanded practice dental hygienists working in every hospital.”
– Linda Mann, director of Capitol Dental.
Dental hygienists, who have expanded practice permits allowing them to practice without a dentist present, are improving the lives of patients at Samaritan hospital, one tooth at a time.
Since 2020, a hygienist with Capitol Dental has been working at the Samaritan Lebanon Community Hospital alongside doctors, nurses and other clinicians to assess and treat patients, make referrals and provide oral health education.
Recognizing how oral health affects overall wellness, InterCommunity Health Network Coordinated Care Organization Delivery System Transformation committee funded a hygienist from Capitol Dental to work at the hospital and provide oral health services, education and patient navigation.
With overwhelming positive results, including developing a process to integrate oral health services in hospitals, the pilot stands as a model for others to replicate.
“To our knowledge, the collaboration with Samaritan was the first and is the only one in Oregon to offer dental hygiene services in a hospital setting,” said Linda Mann, director of Capitol Dental. “It would be fantastic to have expanded practice dental hygienists working in every hospital.”
Before, hospital patients did not always receive oral health care, and many went without dental care for years. Now, everyone from new moms in the labor and delivery department, to people receiving treatment for cancer and diabetes to patients intubated with serious conditions are benefiting.
Additionally, when a hygienist is available, they can assist with triaging patients who present with dental issues in the emergency department, providing assessments and referrals for follow up care.
“Having an expanded practice dental hygienist has been a huge benefit for the hospital and patients,” said Wendie Wunderwald vice president of Patient Care Services at Samaritan Lebanon Community Hospital.
The hygienist also has educated hospital staff, who are primarily focused on the medical aspects of care. Alexa Blake is a speech language pathologist with Samaritan and worked alongside the hygienist. Access to dental care can be restrictive in rural communities, due to transportation, finances or difficulty finding a dentist.
“Having a hygienist on site makes it so convenient,” Blake said.
The collaboration between physical and oral health isn’t a new idea in rural Linn County. The idea began with an arrangement between Capitol Dental and Sweet Home Family Medicine, where an expanded practice dental hygienist has worked alongside clinicians for more than seven years.
Samaritan Lebanon Community Hospital CEO Marty Cahill was eager to become the first to integrate oral health in a hospital setting and is pleased to share the results with others. IHN CCO and Capitol Dental continued funding for the program in Lebanon.
And the program has been replicated by Capitol Dental at Samaritan North Lincoln Hospital in Lincoln City and by Advantage Dental Care at Samaritan Pacific Communities Hospital in Newport. The coastal hospital programs are funded through a federal grant.
“The program is growing in ways that we did not expect,” Cahill said. “It’s been very positive.”
Learn how the Bravery Center is supporting rural LGBTQ+ youth by providing affirming behavioral health care and other services.
“Strength comes in numbers and shared experiences.”
– Des Swisher, Bravery Center youth leader.
Growing up in a rural community can feel isolating.
For LGBTQ+ young people, those challenges can be compounded by a lack of awareness within the community, increased harassment and discrimination, family rejection and lack of support. There are also fewer opportunities to explore and develop their identity and connect with similar people.
Des Swisher, 18, of Lincoln City, remembers how it felt when all the posters for the Gender-Sexuality Alliance Club at Taft High School were torn off and stolen.
“Some were found ripped apart,” Swisher said. “From then on, all our posters were kept in classrooms under surveillance.”
Swisher, who graduated in 2021, recalled how club members would come to him distraught over incidents like this. “Of course, the removal of posters was far less dehumanizing than some of the verbal bullying we experienced,” Swisher said.
Swisher is a member of the Bravery Center’s youth leadership team, where he’s learned to provide peer support and assistance. Bravery Center is based in Lincoln County and helps LGBTQ+ youth survive and thrive in a rural community. It’s part of the Olalla Center, a nonprofit organization that provides family mental health services.
Bravery Center was created in 2020 as a pilot project with InterCommunity Health Network Coordinated Care Organization. Providing affirming behavioral health services is one of the health outcomes the program has achieved, despite the disruption caused by COVID-19, which has resulted in most of the service delivery moving to a virtual platform.
Through Bravery Center, LGBTQ+ youth across Lincoln County have felt connected.
“Strength comes in numbers and shared experiences,” Swisher said. “At Bravery, we have access to a loving community and resources.”
The center is also fostering future leaders. With support from Beck Fox (they/them), Bravery Center’s director, Swisher and other youth from the leadership team successfully petitioned the Lincoln County commissioners to declare June 2021 as Pride Month. Fox was impressed by the success of their advocacy.
“We’re empowering youth and helping them to develop the skills to be resilient and find their voices in the face of adversity,” Fox said. “They are a tremendous inspiration to me.”
To learn more, visit olallacenter.org/project-bravery.
Learn how the Disability Equity Center is addressing gaps in health care delivery, educating health care providers and improving partnerships within disability support services.
“We are reducing stigma, raising awareness and increasing opportunities for people with disabilities to be as healthy as possible.”
– Allison Hobgood, Disability Equity Center Cofounder.
When the COVID-19 vaccine first became available, Laura Estreich, a young woman from Corvallis with Down syndrome, relied on an expert source for health information.
Her mom is a pharmacy professional. But lots of people she knows had questions and there were also rumors and myths.
Estreich is a student in the Wings Transition Program in the Corvallis School District and is also an intern with the Disability Equity Center, a grassroots disability justice organization providing inclusive and cultural resources to meet the diverse needs of people with disabilities.
Disability Equity Center is addressing gaps in health care delivery, educating health care providers and improving partnerships within disability support services through a 2021 Delivery System Transformation pilot project with Intercommunity Health Network Coordinated Care Organization serving Benton, Lincoln and Linn counties. One of the health outcomes the pilot targets is to ensure that people with disabilities are actively engaged in their health care.
In February, leveraging Estreich’s family connection and Disability Equity Center’s community partnership with Cornerstone Associates, an organization serving adults with intellectual and developmental disabilities, an online presentation was planned for people to learn more about the COVID-19 vaccine.
Cornerstone’s community health nurse worked with Estreich to plan the meeting. People with disabilities were invited to ask questions.
“And to know your rights,” Estreich emphasized.
Misha Marie is community engagement manager with Cornerstone, and is also involved with Disability Equity Center. She called the vaccine presentation a “lightbulb moment.”
“Partnering with them to create that and share it back in the community was just a really lovely collaboration,” Marie said.
The pilot project is finding new ways for people with disabilities to understand the care they receive. Another aspect is educating health care providers about how to improve communication for people with disabilities.
Marie recalled a Disability Equity Center meeting where people with disabilities, family members, allies and health providers discussed how a very small number of people with disabilities are eligible for formal services.
“It shifted my whole view. Absolutely, we need to find a way to support our whole community.”
Disability Equity Center organizers want to break down silos, bridge gaps and unite people, groups and organizations in new ways.
“Through the Disability Equity Center, we are reducing stigma, raising awareness and increasing opportunities for people with disabilities to be as healthy as possible,” said Disability Equity Center co founder Allison Hobgood.
To learn more, visit DisabilityEquityCenter.org.
Learn how the Traditional Health Worker Hub prepares people to fill critical roles in health care, social services.
“The heart of a community health worker is to help out the community.”
– Analuz Torres, Training Hub Coordinator.
When a friend first told Analuz Torres about a health navigator job at Benton County Health Services, she didn’t think she was qualified. Despite a wealth of experience advocating, interpreting, translating and breaking down communication and cultural barriers for her family and friends in the California farming community where she grew up, she couldn’t imagine doing it as a career.
“Do I really think I can do this?” she questioned herself.
At that time, Torres was working on her bachelor’s degree and didn’t think she had enough education to be a health care team member. But despite her reservations, Torres applied and got the job. When she started working for Benton County, she did outreach and enrollment for the Oregon Health Plan. She picked up the terminology and moved to working in care teams.
Fast-forward three years, Torres is now a training coordinator for the Tri-County Traditional Health Worker Training Hub where she teaches others to use their lived experience to become community health workers.
A 2018 Delivery System Transformation pilot project from Intercommunity Health Network Coordinated Care Organization serving Benton, Lincoln and Linn counties, helped to establish the Training Hub where Torres is now a leader. It supports many different types of health and community agency workers, including birth doulas, community health workers, health navigators, peer support specialists and peer wellness specialists.
“In the training, we focus on motivating individuals so they can make this change in their communities,” Torres said.
Because she overcame uncertainty, Torres can relate to many people in the training.
“A lot of them have been doing this all of their lives,” she said. “They’ve just been doing it without getting paid.”
As training coordinator, Torres interacts with community agencies to recruit trainees and facilitate new partnerships. Collaborators include agencies and organizations from education, addiction and recovery, housing and homelessness, as well as health and social services.
Torres recently completed her bachelor’s degree in public health and is beginning a master’s in public policy program this fall. But she emphasizes there are no education requirements for the training program. And with training and experience, there are many possibilities for job opportunities and growth.
“The heart of a community health worker is to help out the community. That’s all you need,” she said. “Everything else will fall into place.”
Learn how the CHANCE 2nd Chance pilot program uses community connections to help others.
“A good day is helping someone to meet their goals; giving back and helping people, walking with them and guiding them through barriers I faced.”
– Chelsey Allen, Certified Recovery Mentor.
Many people who work in the addiction and recovery field have what’s called “lived experience.”
Chelsey Allen of Newport is one of them. The certified recovery mentor manages the Newport and Lincoln City offices of CHANCE (Communities Helping Addicts Negotiate Change Effectively). CHANCE provides addiction and recovery centers that help people at all levels of recovery with mental health and substance abuse disorders.
“My past is colorful,” Allen said. “It’s what brought me to this job.”
It’s also what helps her to connect with people who are working toward and staying in recovery.
“A good day is helping someone to meet their goals; giving back and helping people, walking with them and guiding them through barriers I faced,” Allen said.
Sometimes, that means getting someone into treatment. Other days it is finding stable housing. She also facilitates a support group, Dual Voices, for people who are struggling with mental health and addiction. These are among the goals that were outlined in CHANCE’s 2018 pilot project proposal for funds from InterCommunity Health Network’s Delivery System Transformation Committee.
The program, CHANCE 2nd Chance (CTC), focuses on meeting daily needs, reducing health disparities and increasing health engagement for people facing challenges associated with mental health and addiction recovery. The pilot program proved so successful that CHANCE operationalized it, taking a percentage of its monthly budget and earmarking it to fund CTC services.
In addition to helping administer CTC, Allen also completed community health worker training that was funded through IHN-CCO pilot funds.
“I built some long-lasting friendships with community partners,” she said. “What I learned applies in my management position in collaborating with community partners.”
It’s these connections through CHANCE’s longstanding participation with IHN-CCO’s Delivery System Transformation Committee that now leverage the effectiveness of the work it does, from helping people to pay rent and overcome homelessness, to assisting clients attain government-issued identification cards and food handler’s licenses.
“It gives small social service agencies like ours a chance to have an equal voice at the table,” said CHANCE Executive Director Jeff Blackford. “It gives power and validity to the work that we do.”
Learn how the Health and Housing Initiative Pilot made a difference in Linn and Benton counties.
“I want people stay engaged in their health, to be sustained in their housing, to rely on and seek out support.”
– Kara Cuevas, DevNW Community Health Worker.
A friendly greeting can go a long way to making someone’s struggles a little easier.
That’s why Kara Cuevas, a community health worker with DevNW, starts with kindness in every conversation with residents of affordable housing units in Benton and Linn counties.
“It’s an intrinsic ability that everyone has inside them to help others,” Cuevas said.
It was also the impetus for integrating health and housing services by DevNW, a local non-profit housing authority.
In 2016, DevNW became the first community development organization in Corvallis to use housing as a platform to deliver health services through funding from InterCommunity Health Network’s Delivery System Transformation Committee.
The project showcases an innovative solution encouraged by funding from the region’s coordinated care organization. In its first year, the Health & Housing Planning Initiative resulted in more than 700 health and service referrals, intervention and prevention of nearly 100 evictions and health programming for 600 residents.
Based on this success, the program was operationalized and continues with two community health workers, including Cuevas. She relates to the residents she helps with issues such as completing enrollment documents, distributing food and other donations and assisting with scheduling medical appointments.
“I’m a single mother,” she said. “I have a lot of the same life experience as the residents.”
That makes it easy for her to come along beside them to help problem-solve. She also relies on a network of organizations she’s familiar with through her community health worker training. Cuevas seeks to help people feel self-sufficient, engaged in their health and sustained in their housing.
She teaches them it’s okay to seek out support and rely on others.
“You can do this,” Cuevas said. “I can show you the way.”
Learn more about DevNW’s Health Worker & Resident Services Program.
See how a few of our past pilots have made a difference in our communities:
