"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.
Study after study in communities across the country has shown that permanent supportive housing effectively ends homelessness for people with even the longest histories on the street and the most complex health problems. And in so doing, permanent supportive housing also dramatically shifts the way that people access health care. There is significantly less use of hospitals and emergency rooms and more visits to the doctor. There is better access to medicine, not to mention the stabilizing effect of a home, regular meals, regular hygiene, and a safe environment in which to rest and recover.
Many of the pioneers in supportive housing have also been pioneers in providing integrated health care. In a society where much of the care is siloed and fragmented, you go here for one thing and there for another. But when people have complex health problems, which may include mental illness, a history of drug and alcohol abuse, and the chronic and acute health problems associated with life on the streets, you cannot provide care that way. Good dental care requires an appreciation for someone's psychiatric state. Care for conditions like high blood pressure or asthma or diabetes require an appreciation of someone's use or abstinence. Places like the Old Town Clinic and Recovery Center have a profound appreciation of how everything about a person, including where they live, is critical to providing care and improving health. In Oregon, they have an appreciation that if they can build on that model of care, they can offer access to health insurance and better health care to people who have been on the State's Medicaid plan, people enrolling now through their Medicaid expansion, and eventually all people in the region who have health conditions that make them particularly vulnerable and historically expensive.
Keep an eye on Portland. They have some big ideas about what is entailed in big systems change. And they have some great people working hard to make these new big changes work.