May 31 is the first anniversary of Housecall Providers joining the CareOregon health care family. The two organizations have in many ways become one, but Housecall Providers has retained its unique offering of home-based primary, palliative and hospice care.
“Much has happened in the past 12 months since we became a member of the CareOregon family,” says Rebecca Ramsay, CEO of Housecall Providers. “We instituted process improvements that have generated quick wins across all departments. As a result, we are currently serving 100 more patients than we ever have before, and we’ve redesigned our primary care into pod teams.”
The pod team structure, which staff developed when they studied the Lean process used extensively by CareOregon, combats workflow inefficiencies and increases communication across clinical teams. The four pods, each of which care for approximately 300 to 450 patients, are broken up geographically and include primary care providers, care coordinators and a palliative and transitions nurse and social worker. A chaplain and a durable medical equipment coordinator support all four pods.
“Because it was difficult to anticipate the needs of not only Housecall Providers patients, but clinical team members as well, the pods have served to decrease patient wait times for call backs and services like labs, referrals to home health and specialists and imaging,” says Rebecca.
As part of the new collaboration, Housecall Providers welcomed the CareOregon Advanced Illness Care (AIC) unit not only into its building, but into its continuum of home-based medicine, according to Kelly Ambrose, advanced illness care manager.
“Unifying these services has made care transitions smoother, cut down on patient wait times and made communication more efficient,” says Kelly.
CareOregon’s Advanced Illness Care team provides its members with an extra layer of support to help manage multiple chronic conditions. The team includes nurses, social workers, outreach specialists, a chaplain, and a pharmacist who all have the flexibility to make home, clinic and hospital visits. By working closely with providers and health care teams, the AIC unit can focus on the member’s goals of care, symptom management and care coordination. Since moving to Housecall Providers, the Advanced Illness Care team has referred nearly 15 percent of its patients to in-home primary care and hospice services.
“This is providing a true continuum of care for CareOregon members,” says Rebecca. “And is one of the great examples of how working together has improved both organizations.”
“It’s been an exciting partnership for CareOregon, as well,” says Dr. Amit Shah, CareOregon’s chief medical officer. “Our Advanced Illness Care team moved to the Housecall Provider building to better collaborate with these experts in palliative care. It has also helped us clarify when it is appropriate to refer a member to hospice or home-based primary care.”
“At the heart of our collaboration is the desire to be there for our patients, delivering the right care at the right time,” says Rebecca.
“By working together, we can truly serve our members and patients regardless of their needs, whether it is primary care, palliative or hospice care,” says Dr. Shah. “Together, we can improve both the health and the lives of patients and their families, and make a positive difference in the communities in which they live.”