Outreach Intervention

Helping Patients Overcome Barriers to Health

Outreach intervention, called Interdisciplinary Community Care Teams (ICCT), is an effort to provide multidisciplinary support to high-utilizing patients to help them build health literacy, address psychosocial needs, and overcome barriers to health. Within the ICCT program, there are four subprograms that have each hired outreach workers with specialized skill sets to meet the needs of the unique population served.

  • Health Resilience Program – This program is run centrally by CareOregon and has sixteen outreach workers (three that are not grant-funded) embedded primarily in primary care clinics, but also in two specialty clinics.

The Health Resilience Program from Resonance Productions on Vimeo.



  • Central City Concern Health Improvement Project – This program employs five outreach workers, including a recovery specialist, a registered nurse, and a mental health professional who are embedded in Old Town Clinic.

  • Tri-County 911 Service Coordination Program – This program employs four social workers who work across the three counties with frequent 911 callers.


  • New Directions – This program employs three social workers embedded in a hospital emergency department who work with frequent ED utilizers with mental health challenges.

  • The Skin Care Clinic at Bud Clark Commons

    Health Share is one of multiple stakeholders in The Skin Care Clinic at Bud Clark Commons, an intervention with goals of meeting immediate health care needs, reducing avoidable ER visits and improving primary care utilization among a population experiencing homelessness, substance abuse, and mental illness. Bud Clark Commons, located in northwest Portland, contains a day-resource center and men’s shelter operated by Transitions Projects, in addition to permanent supportive housing, operated by Home Forward, for vulnerable homeless people. 

Bud Clark Commons from Resonance Productions on Vimeo.


Target Population

The Outreach interventions focus on adults who have had at least 6 or more ED visits or one non-obstetric inpatient hospital admission in a year. Eligible patients are identified using claims data, real-time event notification, and care team referrals. Research is conducted to determine if these admissions were avoidable and might have been mitigated by extra supportive outreach or care coordination.


Why is this Important?

Local and national data provides clear evidence that socially and behaviorally based risk factors underlie a significant proportion of avoidable high-cost healthcare utilization. Outreach workers have the time to customize care to each individual patient while building deep trust and rapport that identifies and even removes barriers. Empowering patients to become more active in their wellbeing will translate into a higher quality of life for patients and fewer expensive admissions.

The grant supports further development of the ICCT pilot and also provides a forum to share best practices and lessons learned across Health Share of Oregon partner organizations. Particular focus will be given to change management within partner organizations to ensure successful community-wide implementation.