In 2016, CareOregon, Oregon’s Medicaid health plan and longtime provider of complex care services to its Medicaid-eligible population, was ready for a big win. CareOregon had worked with the state to apply for a Medicaid 1115 waiver that would allow them to use Medicaid funding more flexibly. The plan was to use Medicaid funds to address the affordable housing crisis in Portland, and to develop what Rebecca Ramsay, current CEO of CareOregon’s Housecall Providers and former Executive Director of Population Health Partnerships at CareOregon, called “a true social determinants of health strategy for Medicaid and complex patients.”

The whole community had been engaged in order to prepare for the waiver’s implementation: the affordable housing and business sectors, the Oregon Health Authority, Medicaid payers, and the local care delivery system. Everyone was on board and ready to begin implementation. But political priorities had changed, and the waiver, unexpectedly, was denied.

The denial of the waiver didn’t mark the end of the fight to address housing need and other social determinants of health in Portland. Strengthened by the partnerships that formed in preparation for the waiver, the cross-sector coalition of stakeholders in Portland is coordinating efforts to fund affordable housing through alternative means, including local legislative measures.

“When the waiver didn’t get approved, at least we had the table set, and people used that disappointment as a way to galvanize even more commitment toward solving the problem,” said Rebecca. “And those partnerships have continued.”

Using collaboration to weather political uncertainty

Rebecca is a nurse by training and has worked in complex care at CareOregon for 14 years. “Healthcare providers most of the time don’t think of themselves as political actors,” she said. “We want to do healthcare, we want to do patient care, and yet we have to become more sophisticated about how we advocate for the work that we’re doing politically.”

As healthcare becomes increasingly partisan, no facet of the sector is immune from political uncertainty, but the growing field of complex care faces particular challenges.

“There’s just so much stigma associated with complex populations and misunderstanding about what’s driving cost and complexity, and that is challenging when you don’t have advocates at the top levels of government,” said Rebecca.

But a major strength of the complex care field is its collaborative, cross-sector nature. Complex care is a “bridging field” that lives at the intersection of healthcare, social services, behavioral health, and more. Complex care brings providers, payers, organizations, and sectors together to deliver coordinated care for those with the most complex needs, and it’s only a small jump from partnerships focused on patient care to partnerships focused on making the policy changes needed to transform patient care.

“In the face of political uncertainty, if you have the right people committed to a common cause, you can use that uncertainty as a catalyst for making necessary change,” Rebecca said.

Flexibility and innovation

When navigating political uncertainty, organizations need to be flexible and strategic in advocating for innovative programs, models, or structures. As Housecall Providers works to find a sustainable way to pay for home-based care for Medicaid and Medicare-eligible patients, Rebecca has found that understanding the priorities of the current federal administration has made all the difference.

Unlike previous administrations, she says, where developing new and previously untested models was actively encouraged, this administration values proposals for new payment models that can be linked to existing models that already have bipartisan support. For Housecall Providers and other home-based practices across the country, that means looking to build on established alternative payment models like Comprehensive Primary Care Plus, rather than building new payment models from scratch.

In the current political environment, Rebecca said, innovation needs to be done locally. “There’s still a lot of room for innovation and piloting, it’s just that you have to start it small-scale, and you have to get local buy-in from various sectors in order to fund the work to figure out something new. Once you have a good story to tell and you have some data, it’s easier to make the case for larger scale implementation.”

Change that comes from the community

The best local innovation often comes from the community itself. In Oregon, community advisory councils are mandatory components of coordinated care organizations’ (CCOs) governance structures, and are tasked with setting priorities and strategies to address the findings of annual community needs assessments.

In one CCO, which covers a three-county area west of Portland, community members used community needs assessment findings to implement a community-wide trauma-informed care program, including training for school systems and healthcare providers, and supportive services for young families living in poverty.

Incorporating consumers and community members into structures that give them real decision making power is key. “Before the advent of CCOs, that kind of consumer activation was not happening as broadly,” said Rebecca. “This is just one example of how the community came together and said, ‘we’ve got to do something about this in our communities, we can use the structure of the CCOs to help us coordinate our efforts.’”

Looking ahead

The field of complex care will not be able to advance without continued government buy-in and support, which is why we want to learn from the experiences of leaders like Rebecca, who have successfully navigated uncertain political environments. Rebecca will be joining a panel of colleagues from across the country at our national conference, Putting Care at the Center 2018, for the plenary session titled “Uncertainty as the Norm: Anchoring to Success in the Midst of Persistent Ambiguity.”

“I want to help people understand that they know people in their lives that could easily be [individuals with complex health and social needs]. Any one of us at any given time, under certain circumstances, could be part of the population we’re trying to serve,” she said. “My biggest hope for the field of complex care is that we’re able to humanize the face of the populations that are suffering the most.”

 

Putting Care at the Center 2018 will be December 5-7 in Chicago. Early bird tickets are on sale now. Students of any discipline can get tickets for half-price, and scholarships are available for attendees from low-resource organizations.

Register for Putting Care at the Center 2018