Regional care team response to COVID-19

The Columbia Pacific CCO regional care team more than doubled in size in 2020. We now have a dedicated multi-disciplinary team of nine clinical and non-clinical care coordinators, as well as a new team supervisor. In addition to providing typical care coordination for members — in partnership with our primary care, community mental health provider, area agency on aging and people with disabilities, and community-based organization partners — in March, the RCT pivoted quickly to prioritize response to COVID-19.  

The COVID-19 pandemic created an urgent need to connect with members who may be at greater risk of health decline, hospitalization or death due to COVID-19 infection and/or the effects of social isolation and stress on their behavioral health. A cross-regional outreach protocol was organized and implemented. The RCT and Columbia Pacific panel coordinators made proactive outreach calls aimed at holistically assessing medical, behavioral, pharmacy and social health needs for members at higher risk because of their physical or behavioral health conditions. The RCT completed calls to 1,692 members, about a third of which resulted in some level of ongoing care coordination.

Beyond these proactive outreach efforts, the RCT expanded the typical transitions-of-care workflow to include and prioritize support for members who experienced an inpatient or emergency room visit  related to COVID-19. This expansion helps ensure that these members have access to needed services (social, behavioral health or clinical) and connect with their PCP to achieve the best possible outcome and recovery.  This continues to be a priority for the team.

Early on, care coordinators partnered with county-level public health and incident management teams to create a process for providing support to members who were tested for COVID-19 and awaiting results or had a known positive test and were unable to quarantine due to experiencing houselessness or inadequate housing.  The RCT provided support with lodging, food, basic hygiene items, clothing and connection to non-emergent medical transportation services. After a time, we transitioned members to local CBOs to continue receiving services .
 
To refer members to the RCT, please call 503-416-3743 or email us at ccreferral@careoregon.org

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