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Oregon Wellness Network Leads in Health Innovation

The Oregon Wellness Network (OWN) has achieved a remarkable milestone by leading a national team that won the federal Health at Home Challenge. This competition, organized by the Administration for Community Living within the U.S. Department of Health and Human Services, aims to enhance care possibilities for older adults and individuals with disabilities who rely on Medicare and Medicaid.

OWN is now recognized as the Lead Community Care Hub in a collaborative initiative that brings together eight community care hubs across various states. The initiative involves partnerships with CCH Medical Group, which helps bolster healthcare services. With support from the Oregon Association of Area Agencies on Aging and Disabilities (O4AD), OWN's team was among the top ten winners selected nationwide.

Purpose of the Challenge

This initiative is tailored to enable older adults and people with disabilities to maintain their health and autonomy while residing in their homes. It emphasizes reducing hospital admissions and managing healthcare costs more effectively. The challenge emphasizes several key areas, including navigation services, care coordination, transitions in care, and evidence-based programs aimed at health promotion, like fall prevention strategies and nutritional support.

The Consortium of Community Care Hubs

Under OWN's leadership, the consortium includes various community care hubs across different regions, including:
1. Oregon Wellness Network: Present throughout Oregon, serving as the lead hub.
2. SARCOA / Community Care Solutions: Operating in southern Alabama and the Florida Panhandle.
3. CATCH Greater Houston: Alongside the Houston Health Department serving the greater Houston area.
4. Western New York Integrated Care Collaborative: Covering areas in Western New York.
5. TLC-Maryland: Catering to statewide Maryland.
6. Piedmont Triad Regional Council: Representing North Carolina.
7. Region IV Area Agency on Aging: Focused on southwest Michigan.

Together, these hubs aim to provide services to over 100,000 beneficiaries who have chronic conditions covered by Medicare and Medicaid.

Impact on Oregonians

For residents of Oregon, this victory represents an acceleration of a healthcare model that OWN has been nurturing for several years. The network comprises an array of reliable community-based organizations, such as the Area Agencies on Aging and Disabilities. These organizations are directly connected to the healthcare system, fostering a smooth transition for older adults returning home after acute hospital care.

Key expansions in services include enhanced support when discharging from hospitals, the availability of nursing and community health worker-assisted care plans, and local evidence-based fall prevention classes. Additionally, nutrition support will be available readily across the Portland metro area and more rural and coastal communities throughout Oregon.

OWN’s forward-thinking approach aims to collaborate closely with local health systems, accountable care organizations, and managed care plans to revolutionize care delivery models. The focus is on improving clinical outcomes while maintaining a reduction in overall care costs. Expected benefits include increased healthy days at home for Oregonians and enhanced performance on HEDIS, which gauges healthcare effectiveness.

The connection to services will occur through referrals from local hospitals, primary care practices, and health plans that guide individuals through five key care transitions: hospital-to-home, primary care and ACO referrals, nursing home-to-community transitions, fall prevention strategies, and support addressing depression and social isolation.

Leveraging Technology for Better Care

One of the standout features of this initiative is its use of the AthenaOne electronic medical record, a novel application within community-based care. This integrated platform not only promotes a cohesive record system across all eight hubs but also incorporates artificial intelligence tools to analyze population health trends.

The AI component empowers care teams to identify at-risk individuals promptly, offers guidance to community health workers in real-time, and provides measurable outcomes around the critical goals of maintaining home health and minimizing care costs.

As Lavinia Goto, Director of OWN, highlights, “This award is a strong validation of the efficacy of Oregon’s aging and disability network. Community-based organizations paired with shared clinical infrastructure represent the most effective and economical model for promoting the health of older adults at home. A cohesive collaboration of eight hubs functioning under a single network is an unprecedented capability led from Oregon.”

Next Steps

The successful team is set to advance to Phase 2 of the Challenge, which will run from August 2026 to July 2027, in which they will further implement their innovative strategies both locally and nationally. By summer 2027, up to five teams will be selected to transition into the final scaling phase, potentially transforming the landscape of community health services.

In summary, the Oregon Wellness Network's recent win not only marks a significant achievement but also underscores a promising future for healthcare at home for older adults across the nation.