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"Big systems change requires big systems to change."
That's what the Chief Medical Officer for Health Share of Oregon told me was the approach to change that the new Coordinated Care Organization, created out of the State of Oregon's health reform plan, needed to take. I had a chance to meet leaders in this effort when I travelled to Portland September 19. One change that was visible was who was at the table. Big hospital systems are pairing up with nonprofits that have been delivering care on the streets and at community clinics, hoping to learn from the work that organizations like Central City Concern have been doing for years. One of the premises of health homes and accountable care organizations, called Coordinated Care Organizations in Oregon, is that the only way to achieve the "triple aim" of health reform that is, better care, better health, and lower costs, is to change the whole approach to patient care. That can start with big systems like hospitals and their data about who has multiple hospital admissions or many trips to the emergency room. And it also has to start with actual patient care.