program-models

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Program/Project Name Every Step Community of Care
Affiliation Name Health Share Oregon
Website URL https://www.healthshareoregon.org/commitment-to-health/every-step
Model Type A collaborative regional network of foster care medical homes
City Portland
State OR
State specific location Oregon Tri-Counties (Multnomah, Washington, Clackamas): Community-based private pediatric offices; hospital-based pediatric and adolescent clinics; FQHC
How is program/project funded? Medicaid Coordinated Care Organization (CCO)
Describe how it's funded

Payments through fee for service for direct encounters; advanced practice model funded through an alternative payment methodology.  

What services does it provide Entry to care health assessment, Comprehensive health assessment, Standardize screening (developmental, mental health), Subspecialty referrals, Ongoing primary care/medical home, dedicated care coordination; trauma informed parenting workshop; integrated oral & behavioral health service; support during transitions of care or placement; personalized care plans; child & adult psychiatric phone consultations (OPAL-K, OPAL-A
Where does it provide services Locally-based
Description of program/project

​Every Step clinics offer an advanced primary care model designed to meet the needs of children in foster care. There are currently 11 Every Step clinics. Health Share began funding Every Step clinics at Legacy Randall Children's Clinic, OHSU Doernbecher, and Hillsboro Pediatrics in 2017 upon completion of a yearlong learning collaborative designed to establish and implement best practices in supporting the population. Six Metropolitan Pediatrics clinics and Gladstone Health Center began providing Every Step services in 2019 and Hillsboro Pediatrics clinic applied the model to a second pediatric primary care practice site. Approximately 1,700 children have received services from an Every Step Community of Care clinic since 2017.

How are patients tracked? Commercial electronic medical record, Quarterly reports submitted to CCO using Oregon Health Plan identification number; CCO enrollment data
Provide special focus Developmental delay/issues, Mental health, Developmental Issues, Children in family foster care, Youth in group home/residential care, Young Children, Adolescents, newborn, children & youth with medical complexity; CYSHCN; foster care teens transition to adulthood; teens in residential out of home foster care placement settings
Program/Project strengths

Leadership and Collaboration: 

  • A collaborative structure exists to promote the ongoing improvement efforts across the network of clinics.  Clinical and administrative leadership meet regularly to strategize program quality and improvement efforts, alignment of the experience of care, clinical and documentation best practice, and program sustainability.  Clinic teams and external stakeholders engage in quarterly learning sessions with team updates, topical presentations, and discussion.  Clinic care coordinators meet monthly with child welfare staff to discuss success, barriers, and intervention strategies.

Data and Outcomes:

  • Every Step clinics outperform the overall DHS population and the overall Health Share population on quality incentive metrics.
  • Youth in Every Step clinics have increased primary, dental, and behavioral health care in the year after they start receiving these services. They receive this care at a higher rate than a reference group of DHS-involved youth. The majority of youth remained assigned to their Every Step clinic for at least a year, even those youth with a history of multiple care assignments.
  • Among a subgroup of recent DHS entrants, youth at Every Step clinics saw increases in primary, dental, and behavioral health care, and decreases in emergenc department visits. They had increased PCP, dental, and behavioral health visits and decreased ED visits when compared to a group of recent DHS entrants with similar demographics.

Access and Capacity:

  • Broad geographical distribution of clinics ensures family convenience and limits transportation barriers.
  • Multiple clinic and hospital options within the network allow for member choice.
  • Active collaboration between clinics, child welfare, and CCO ensure potential utilization or access barriers are visible and resolved.

Supportive Investments:

  • Health Share supports two DHS Medical Liaison positions housed within local child welfare to ensure capacity within the taxed system for consistent engagement, case support, and alignment of efforts.


Program/Project challenges

​Long term sustainable funding model is yet to be determined.

Information sharing with child welfare is an ongoing effort. 


Contact Name Bobby Martin, Children's System Manager
Email Address grigsbyt@ohsu.edu; martinb@healthshareoregon.org; bgolson@lhs.org; chhuber@lhs.org
Phone Number 503-416-4974