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The Rogue Challenge

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Content Running head: THE ROGUE CHALLENGE 1
The Rogue Challenge
722 Doctoral Capstone
by
Ryan Bair
Doctor of Social Work
Suzanne Dworak-Peck School of Social Work
University of Southern California
Dr. Ronald Manderscheid, Advisor
May 2020
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Executive Summary
Inequity exists in healthcare. How people live their lives, where they live and the well-being
they have is all affected by broader social factors, how people interact with their health and
healthcare is a product of these social factors. Poor health outcomes can be avoided through
appropriate and practical community engagement. Rogue Community Health, through the
Rogue Challenge innovation, is positioned to lead a successful community collaboration to close
the health gap between those with privilege and those without.
Rogue Community Health (RCH) was founded in 1972 as Ashland Women’s Health Center
as the result of an extensive, community-based grass-roots effort. Today, RCH is a private,
nonprofit Federally Qualified Health Center (FQHC) (since 2004) with a mission to improve
health, especially for the most vulnerable, in partnership with the community. RCH currently
operates clinics in Ashland, Butte Falls, Medford, Prospect and White City, Oregon, as well as
six school-based health centers. To advance the mission, RCH offers core services, including
sliding-fee discounted medical, dental, mental, telehealth, substance use disorder treatment,
integrative health, lab and perinatal health care, and complimentary services such as pharmacy,
health- legal services, outreach, and insurance eligibility assistance. Pharmacies are located
inside the Medford and White City Clinics; dental services are available in Medford and Butte
Falls; and mental health is integrated into the health services provided at each location. Beyond
medical, the expanded list of services allows RCH to treat the whole person, including the social
determinants of health. RCH is recognized by the Oregon Health Authority as a patient-centered
medical home and by the National Committee for Quality Assurance (NCQA).
RCH operates in Jackson County, a mixed county in the southwest corner of Oregon,
supporting metropolitan, rural, and sparsely populated areas within an expansive 2,784-mile
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landmass, larger than the state of Delaware. The county is located on the I-5 corridor and is
bounded to the south by the California state line and the Siskiyou Mountain Range, to the east by
the Cascade Mountain Range, to the north by the Rogue/Umpqua drainage; and to the west by
the Applegate River and Valley. Jackson County is about 350 miles north of San Francisco and
270 miles south of Portland. Community populations range from 440 to 81,600 residents.
Jackson County’s total population of 212,000 is composed of 81.7% white, 12.2% Latinx and
3.26% two or more races. The unemployment rate as of November 2019 was 3.2%, while the
rate of poverty remains high at 16.7%, a telling marker for endemic family poverty in the
communities. The 2017 Census update revealed that 48.2% of Jackson County residents pay
more than 35% of their income in rent, which HUD considers the threshold for non-affordable
housing. Further adding to the challenges faced by residents, median household income in
Jackson County is 26% lower than statewide. These indicators demonstrate that Jackson County
residents are much more economically disadvantaged than their peers statewide. Data from the
most recent 2018 Community Health Assessment of Jackson and Josephine Counties indicated
that better engagement was needed to address the areas of greatest interest and concern from
individuals and families in the community. People of color in Jackson County experience a two-
fold higher rate of poverty compared to people who identify as White and non-Hispanic.
The Grand Challenges for Social Work and Society (Fong, et al., 2018) describes the 12
grand challenges for social work. And one of the challenges is closing the health gap. In 2018,
RCH launched a cross-sector collaboration network, with six community partners, known as the
Rogue Challenge, to support community members’ access to the resources they need to be
healthy. The Rogue Challenge now includes 17 partners from social services, healthcare,
education, and public health that are all equal partners under a shared governance structure for
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which Rogue serves as a collaborative partner and a backbone administrator (though not the
owner) of the Rogue Challenge community hub database.
RCH and its partners refer to this cross-sector care coordination network as the Rogue
Challenge. The structure is informed by Social Learning Theory and Reciprocal Determinism
(Bandura, 1977, 1986) that furthers the notion that engaging community partners in a shared
language and accountability structure creates a sense of belonging and a no-wrong-door
approach to engagement. The Rogue Challenge is built upon the idea that creating systems of
accountability and transparency between partners will increase appointment completions,
improve consumer satisfaction, and decrease barriers to accessing resources. This is
accomplished through strong collaboration and relationship building across multiple touchpoints
at each agency and by the use of a proprietary shared closed-loop referral technology.
Executives from each agency are part of a shared governance structure that
meets monthly and commits to the unique mission of the Rogue Challenge. Agency staff at the
director, manager and front-line level also meet regularly and have collaborated to enable
common, cross-agency forms, referral workflows, and training for case managers from all
agencies. Adopting shared languages supports consistent service quality at each point of entry.
Additionally, this governance structure includes patient and client advisory teams; RCH has an
established recruitment and engagement process that creates shared space for decision-making
with patients in their Patient Advisory Team (PAT) while other Rogue Challenge partners have
parallel structures for client informed decision-making to enhance and improve services and
address barriers to improved population health.
This collaborative work is supported through closed-loop referral and case management
software that allows real-time communication about resource availability and waitlists.
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Members’ goals are documented in their own words, putting the individual at the center of all
activities. The technology also allows for common metrics across agencies. Since launch, 82% of
individuals served have completed their initial appointment at the referred organization. The Hub
has also increased efficiency among agency staff, reducing time spent following up on referrals
by up to 4 hours per week. This time is reallocated to support families. Hub partners have
learned that 22-27% of the population served has an unmet need, and within the Hub, 25% of
families report more than one unmet need. These statistics would have been impossible to
capture previously with resource providers working in silos collecting data on only the
individuals each organization serves and according to measures that are not shared across the
network.
The Rogue Challenge currently operates in two counties but is exploring the viability of
replicating this model to additional counties. This requires a deeper understanding of the impact
of the Rogue Challenge on the community it serves (e.g. its contribution to health and social
impacts and equity), a better understanding of community needs to inform resource investments
in those needs, as well as implementation guidance on what factors contribute to impact and
therefore a pathway to sustainable funding. While previous research, as well as the preliminary
analysis of existing data from the Rogue Challenge, suggest standardized screening and
navigation to resources can improve health outcomes and increase cost efficiencies, it is not yet
clear how Social Determinants of Health collaborations work best and for whom. The Rogue
Challenge seeks to explore these questions through a longitudinal, quasi-experimental approach.
Through a qualitative and quantitative approach, the Rogue Challenge will investigate how
aligning across systems can be better supported through collaborative relationships and a shared
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governance structure that ensures that measures and financing strategies are not driven by any
single sector but rather, by a collective commitment to improve health and wellbeing.
Conceptual Framework
Social justice requires equity in all aspects of society, including healthcare. Healthcare must
understand that a person’s environment has a greater effect on health outcomes than genetics or
exam room interventions. Healthcare must understand the person in the environment, understand
that trauma, poverty, racism, sexism, classism, homophobia are all part of the patient’s
perspective. Society has been built to be inequitable and healthcare must work to be experts of
the overall problems to find success in the exam room (Levy & Sidel 2013).
As these inequities drive poor health outcomes and increase health disparities, thus widening
the health gap. In this paper, the author examines four areas to demonstrate this wicked,
intractable problem; the chronic illness of diabetes, race, poverty, and sexual orientation.
Incidences of measurement for diabetic patients yields many results pointing to health
disparities. For 2019 the U.S. Census Bureau estimated 37.9 million Blacks or African
Americans (13.4% of the U.S. population, 42.7% Hispanics or Latinos (18.3%) 12.7 million
Asians (5.9%) 517,600 Native Hawaiians or Other Pacific Islanders (0.2%) and over 2.9 million
American Indians and Alaska Natives (1.3%). Racial and ethnic minorities are more likely than
non- Hispanic Whites to be poor or near-poor. In addition, Hispanics, Blacks, and some Asian
subgroups are less likely than non-Hispanic Whites to have a high school education. (United
States. Agency for Healthcare Research Quality (n.d.). National Healthcare Disparities Report).
Unmanaged diabetes is an important factor in chronic illness treatment and outcome disparities.
In this paper, unmanaged was defined with the criteria of diagnoses of Diabetes Miletus with an
HbA1c of nine or greater. Foot and eye exam documentation is an indicator of appropriate
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diabetic management through primary care. In 2004 the rate of lower extremity amputation was
three times higher for Blacks and Hispanics than it was for Whites. Unadjusted Eye exams for
whites increased from 56% in 2002 to 59% in 2009 and at the same time decreased for minorities
from 56% to 49% (Shi, et al., 2014). There are many contributing patient and provider factors for
these disparities, but racism cannot be overlooked. The two underscored points in meditated
racism point out that it may occur subconsciously or with harbored assumptions. Both are
powerful in impact and determine that racism does not need to be deliberate to be significant
(Peek, et al., 2010).
More than a tenth of the U.S. population (13% = 41 million people) is currently living in
poverty. The socioeconomic, cultural, and environmental conditions have increased poor health
effects such as higher rates of chronic diseases, communicable illnesses, health risk behaviors,
and premature mortality. People living in poverty also face exclusion in social, psychological,
and political power, leading to generational chronic health issues. Healthcare is responsible to
ensure equity for people in poverty and by addressing policy (Price, et al., 2018).
In research of the disparities between straight and LGBTQ populations, much of the anecdotal
observation is described as a poor sense of belonging and poor sense of respect and dignity when
entering the clinic. According to Lambda Legal, nearly 56% of respondents to their 2010 survey
reported at least one time in which a medical provider refused to care for them, touch them, took
excessive precautions or were verbally or physically abusive (Johnson, 2015). Despite advances
by some providers in addressing LGBTQ health needs, physicians lack adequate skill or data to
determine the best clinical practices. In the past, information on sexual orientation or gender
identity was not collected, and as collection begins, the experience can be insulting or offensive.
Staff may feel discomfort or have a poor understanding of the health benefits behind asking
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sexual orientation and gender identity questions. Improving the care of LGBTQ patients comes
down to greater knowledge and sensitivity among individual healthcare professionals. That
determines whether LGBTQ people feel comfortable using the healthcare system. "It only takes
one person to create a really bad experience for somebody and create that atmosphere of
discrimination" (Johnson 2015). What should be simple dichotomies of race and sexual
orientation with healthcare is, in fact, much more difficult than recognizing the possible
differences in exam procedure and the likelihood of greater risk. This dichotomy has been
layered with generational oppression that increases the disparities significantly. Intersectionality
or the concept of multiple issues within a single problem looks at the power differentials between
provider and patient within the system and as it relates to generational oppression and disease
diagnosis. Ongoing intersectionality is a focus for the maturation of the deviant in both
formulation and implementation.
Innovation Dynamics, when applied to the Social Determinants of Health to establish norms
and deviants, assists in focus and direction during the change process. The “health in all
policies” movement supported by several federal agencies and some local counties in which
policy supports the government to “Create social and physical environments that promote good
health for all.” (Hahn & Truman 2015). There is ongoing difficulty in health center change
management experienced by all employees. A Federally Qualified Health Center(FQHC) is an
environment that has the stamina to withstand change, the bi-partisan support to continue and
highly qualified and caring people to work with a diverse population of patients. There has been
poor understanding from both executive leadership and front-line workers regarding the
importance of health equity and the focus needed. Medical Providers often feel the weight of
change and in the past have been held accountable for poor health outcomes. This causes them,
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right or wrong, to try to maintain tight control of who interacts with their patients. This behavior
will push systems to quickly come out of alignment due to the individuality of each provider
making focus blurred on any implementation project, specifically around equity. In a recent
address to Medical Doctors in Scotland, Professor Sir Ian Gil challenged doctors to adopt Social
Determinants of Health as another task when engaging with patients in the exam room
(Atkinson, & Cottam 2011). This demonstrates the overwhelming pressure medical providers
feel from the system to control all change and to be leaders in healthcare. This is also
counterintuitive to success within the Social Determinants of Health. Medical providers should
be aware of the challenges patients face but it should be strongly discouraged for them to attempt
to relieve barriers in the medical exam. It is already incredibly complex to diagnose and
appropriately treat comorbid chronic-illness and asking a medical provider to also address Social
Determinants of Health is not realistic and has led to poor assessment, diagnosis, and treatment
as well as little support around the determinants. Federally Qualified Health Centers have
difficulty in long term vision based on the fluidity in which they change based on federal policy
revision and the executive leadership turnover rate. The system may become more prepared in
policy development and change but still have poor implementation and quality metric
documentation. “Population-wide health equity monitoring remains isolated from mainstream
healthcare quality assurance. As a result, healthcare organizations remain ill-informed about the
health equity impacts of their decisions – despite becoming increasingly well-informed about
quality of care for the average patient” (Cookson, et al., 2018).
Problems of Practice and Innovative Solutions
Poverty, racism, sexism, classism, and homophobia exist in healthcare as demonstrated
through disparities in health outcomes. There are more than 1100 FQHCs receiving Bipartisan
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support in the United States. FQHCs were created to provide services regardless of the above
classifications of people yet the data continues to show the growing disparity. The deviant lies
within the community’s ability to make meaningful and lasting relationships. To demonstrate the
ability to function as an aligned service using a no wrong door approach, similar language, and
sophisticated cultural awareness and acknowledgment. When engaging in design thinking it is
crucial, in planning, to present community collaborators with innovative tools for co-creation.
The decisions cannot live within one agency, nor can one agency be the driver for innovation,
change, and implementation. The community collaboration must be the overall entity working
for change.
The why behind the disparities has much to do with social justice as it relates to our society in
the United States. The system has been built on a narrow perspective and does not change
without appropriate incentives. The idea that oppression is the root cause of poor health
outcomes is not new and movement towards studying intersectionality as it relates to power,
exploitation, and subordination has begun (Reyes 2017). Community-based health centers only
change as funding dictates and will not acknowledge the disparity in diabetic results in the Black
or Latinx community until the funding mandates documentation of effort. This is the case for
transgender patients not receiving appropriate prostate or PAP exams because primary care
didn’t think to ask. The system has been built on a specific set of desired outcomes for white
men and has difficulty in creating space for those of a different background.
There has been an increase in policy and quality metrics related to the social determinants of
health and health equity but little movement in implementation. Health equity refers to a state
characterized by the “absence of systematic inequalities in health” (Farrer et al., 2015). Health
inequities in the United States are tied to social and economic factors. Research has
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demonstrated and established strong links between socioeconomic disadvantage and poor health
outcomes across the life span (Braveman & Gottlieb, 2014). When receiving appropriate disease
management and insurance, the cost per patient is lower and the outcomes improve (Newsrx
Health editors). The Healthcare system needs to focus individualized treatment through the use
of Social Determinants of Health for people of a different gender, socio-economic, sexual
orientation, cultural, spiritual and racial background than white, middle-class, heterosexual,
Christian men. The healthcare system needs to engage the whole person when managing chronic
illness. Appropriate care and benefits can have positive results on a person’s well-being and
demonstrate a higher quality of life.
The Grand Challenge of closing the health gap directly relates to health equity and the impact
poor equity has on positive health outcomes in the United States. The evidence is clear regarding
the disparities between those with privilege and those without. When looking at the whole
system of engagement concerning patients diagnosed with unmanaged diabetes, addressing the
education of staff in patient attribution, risk stratification, and care coordination. The education
needs to ensure staff has ongoing training and a deep understanding of Trauma-Informed Care,
Diversity, Equity and Inclusion principles. As part of dual engagement in training and resources;
The system needs to ensure the patients have access to resources for further understanding of the
healthcare system, including transparent benefits and limitations, awareness of their precipitating
factors as they engage in a new system and clear role delineation as the expert of their care and
overall well-being. The Rogue Challenge specifically addresses inequities in healthcare and
disparities in health outcomes. The logic model (Appendix 1) has assisted to create an iterative
approach and focused project plan for implementation. Through relationships with community
partners and shared case management, this intractable problem can be resolved.
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The following core statements provided direction for the logic model (Appendix 1) creation:
• Comprehensive assessment assists in creating a dynamic and individualized
treatment for the primary care provider (Monfre, Kelechi, &Teresa 2012).
• The ability to measure and address patient’s Social Determinants of Health, will
reduce cost per patient and improve health outcomes.
• Attributes and predictive health scores enable stratification of population-based
on risk and, gain an understanding of future risk (Benson, 2017).
Social determinants of health are conditions in the environments in which people are born, live,
learn, work, play, worship, and age that effect a wide range of health, functioning, and quality-
of-life outcomes and risks (Healthy People 2020). Social Determinants of Health (SDoH), in the
context of the innovation, are those determinants that effect a person’s health outside of medical
assessment, diagnosis and treatment, and genetic predisposition. The main categories for
exploration are:
• Economic Stability
• Education
• Social and Community Context
• Health and Health Care
• Neighborhood and Built Environment
Federally Qualified Health Centers are positioned to have opportunities to demonstrate a large
impact on health disparities through understanding and implementing screeners. Through long-
standing bipartisan support, FQHCs have been the provider designated to see patients regardless
of their ability to pay. The model correlates directly with social justice to include poverty as it
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disproportionally relates to those of diverse ethnicity and sexual orientation and gender identity.
The ongoing efforts of FQHCs to improve whole-person care is evident through the additions of
behavioral health, pharmacy, dental, integrative health, addictions, and case management.
“Create social and physical environments that promote good health for all” (Healthy People
2020).
In a comparative analysis, there are several tools in the market to collect the data from
patients, one popular tool is PRAPARE, but like most others, continues to be functioning as a
data collection tool as opposed to a way to engage with patients in meaningful dialogue. The
implementation of simple engagement tools in which patients are encouraged to work with
Community Health Workers from the time of registration help to engage with the patient at the
time of the medical appointment to begin activation prior to the next visit. Ongoing training for
behavioral health and member services staff in Motivational Interviewing, Patient Activation and
Empathic Inquiry creates a well-balanced pool of knowledge that helps in aligning presentation
to the patient. Federally Qualified Health Centers are positioned to be leaders in social
innovation and work to provide better access to healthcare for patients. Patients will engage yet
continue to demonstrate poor medical outcomes and dissatisfaction. With the organizational
policy and process in place, there is support from payers but continued stagnation in individual
health outcomes while the disparity grows larger between people with privilege and those
without. Reducing inequality in healthcare will not alone change health outcomes. “Reducing
inequality may well be a good thing for many reasons, including improving health, but it will not
solve the persistent and sometimes worsening problems of population health and wellbeing.”
(Eckersley 2015). While creating health equity may not solve the problem of worsening health it
will assist in closing the health gap. There has been innovative research done at the Oregon
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Health Science University around measuring the effect of receiving services from a like culture.
The results demonstrate significant improvements in health outcomes when a patient is engaged
with a provider from a like culture. This is the type of work needed to amplify how students are
selected and how university recruitment is conducted. Oregon Health and Science University has
been studying diversity in nursing students to see if the way the university is recruiting for
minorities has an effect on the disparity in health outcomes. They know that most people from a
diverse culture will end up providing services to and within a diverse culture. When providers
with a culturally diverse background provide services within their culture the outcomes improve.
“Non-English-speaking clients may be more likely to keep follow-up appointments when
working with health care providers who speak their language, contributing to better treatment
utilization” (Noone, et al., 2016).
The Rogue Challenge innovation will assist in eradicating the intractable problem of poor
health equity. Research and observation demonstrated several norms and deviants that will have
an impact on the problem. In the review of organizational capacity as a baseline for building
the foundation for the community collaborations, there must also be acknowledgment and
representation of the possible diversity benefit the partner organizations will have. In
building the collaborative, the health center will fund and share the tool, staff the software
hub but have no ownership over the referral and follow-up process. Each partner must feel
they are an equal part of the collaborative (Nowell & Foster-Fishman 2011). Each partner
must feel they are appropriately representing their mission, values, and customers. The
Rogue Challenge innovation includes the following elements:
1. Developed shared case management software with community partners
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2. Developed training protocols for FQHC staff, who are already trained in the medical
clinic process, that includes, as a packet: Trauma-Informed Care, Diversity, Equity and
Inclusion, Patient Activation, Crisis De-escalation, and Customer Service.
3. Provided inter-agency staff training with community partners
4. Presented resources for patients to engage with healthcare on their terms
• Patient as the expert
• Understanding of the system
• Sense of belonging
• Access convenient for them
• Individualized barrier reduction
• Limitations and rewards
The shared case management software includes a consent to treat, release of information,
SDoH screener and closed-loop referral. The two organizations with the most robust Consent to
Treat and Release Of Information are the Rogue Community Health Center and the Addictions
Recovery Center. Both have been built to protect information under 42 Code of Federal
Regulations part 2(42CFR part 2) and the Health Information, Portability, and Accountability
Act(HIPAA), which are in place to protect patient Protected Health Information(PHI) and to
improve the efficiency of health care delivery. This ensures that patients engaging at another,
less protected agency, are signing the consent and release with indications of the highest privacy
protections available. The forwarded referral includes the top two goals from the patient and a
brief note for progress in identified areas. Along with sending a referral through the software
platform, the case manager and/or the organization’s point of contact calls the organization being
referred to while sitting with the patient. This warm connection allows for patient engagement in
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a familiar setting with a familiar staff making the whole process trauma-informed and
transparent. The training protocols create experts in engagement with basic knowledge of the
aforementioned topics and resources for deeper development, time to practice(role-play) and
time to debrief experiences. The patient resource accumulation is based on Empathic Inquiry at
the time of the SDoH screener and is meant to be individualized. A shared Social Determinants
of Health screener is vital to the collaboration. The agreed-upon screener provides information
regarding patient needs no matter where they present within the collaboration. Through
experience and observation, health centers often go to patient education as a modality for
engagement this has not proven to be successful. Anecdotally, patients report with sophistication
regarding these educational attempts “I know being overweight affects my health”, and “I know
smoking is bad for me.” More intimate knowledge of the patient and how they interact with their
environment is needed. Inter-agency training in Trauma-Informed Care, Diversity, Equity, and
Inclusion as well as customer service, and crisis de-escalation, will align language, perspective,
and continuity in engaging with shared patients. This inter-agency training provides a safe space
for staff to learn together, practice, role-play and debrief with common language regarding
engagement with shared patients. It also allows staff from partner agencies to interact and build
relationships crucial to trusting case management.
The Prototype, The Rogue Challenge Training Manual (Appendix 4), presents the training
manual used to introduce and train new case managers in the philosophy of the Rogue challenge
and the shared case management software. The manual includes recommendations for language
to engage clients as well as a step by step process for interacting with the software. When this
manual is introduced it is often the first time interagency case managers train together so it is
important to build a supportive and learning environment. This initial relationship building is a
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first step in ongoing shared training and is consistent with the philosophy of the innovation. This
relationship building spans from executive level leadership to direct care and on to our clients
and vendors.
Developing a strong interpersonal relationship with the software vendor is crucial to ongoing
development. The person or persons in charge of this relationship must be prepared to accept
calls regarding software development at all hours, provide instant feedback for developers
regarding workflows and agree to strict deadlines coherence. The software developer’s
accessibility and willingness to adapt is also very important. The developer must be able to
attend to workflow issues in the system in real-time, especially while patients are engaged in the
software platform.
Project Structure, Methodology, and Action Components
The American Academy of Social Work and Social Welfare(AASW 2018) and The Grand
Challenges for Social Work and Society (Fong, et al., 2018) analyze the social factors
fundamental to the progress of humanity. Closing the Health Gap relates to health equity and the
impact poor equity has on positive health outcomes in the United States. To improve health
outcomes community service providers must decrease silos and enter meaningful relationships
that enable efficient and reliable services.
Through long-standing political bipartisan support, Federally Qualified Health Centers
(FQHCs ) have been the provider designated to see patients regardless of their ability to pay
(Kantayya, 2010). The model correlates directly with social justice values, including poverty as it
disproportionally relates to those of diverse ethnicity, sexual orientation, and gender identity.
The ongoing efforts of FQHCs to improve whole-person care is evident through the additions of
enabling services to include: Behavioral health, pharmacy, dental, integrative health, addictions
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services, and case management. Social Learning Theory (Bandura, 1977) is used to engage
community partners in a shared language. Reciprocal determinism creates a sense of social
belonging between partners and the community being served. This learning occurs through direct
experience, symbolic information (language) and observation. Most new behavior is learned
through observation, the effect of modeling. Stimuli are encoded into memory and function,
driving future responses (Weisner, 1981). This innovation strives to build upon the ideas that
accountability between partners and those served will increase initial appointment completions.
Modeling assists in learning, and with an FQHC managing the hub-based referral software, the
system can learn from experts. The Rogue Challenge can teach and learn best-practice case
management, inclusion, and customer service. These best-practice modalities increase referrals
completion. Improving community referral completions will decrease healthcare disparities.
The Rogue Challenge needs to ensure that participating organizations can maintain individual
missions and metrics while engaging in shared metrics to demonstrate a reduction in the cost of
care, achieve expected volumes of completed initial appointments, and client activation and
satisfaction. The Rogue challenge is using a multifaceted implementation strategy using the
Expert Recommendations for Implementing Change (McHugh 2012) including:
• Evaluative and iterative strategies
• Providing interactive assistance
• Adapting and tailoring
• Developing stakeholder interrelationships
• Training and Educating stakeholders
• Supporting the clinicians
• Engaging the clients
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• Utilizing financial strategies
• And Changing the infrastructure
Aligned with ERIC and within EPIS the Rogue Challenge developed a services array to
demonstrate to the Case managers(clinicians) and key stakeholders that there is a strategic
engagement for each partner to meet as least one need represented on the SDoH screener.
Retrospectively, The Rogue Challenge was implemented and is aligned with the Jackson
County Public Health community needs assessment (JCPH, 2019). Results from the needs
assessment indicated the top 3 needs were Housing, Mental Health/SUD and Strengthening
families. The Rogue Challenge addresses findings from this needs assessment by providing
closed-loop referrals to housing, mental health, addictions, and family services including
childcare and parenting development.
The Rogue Challenge will decrease healthcare outcome disparities through creating a ‘no
wrong door approach’ (Brill, 2001) for community members. This approach to shared case
management will develop a sense of belonging in the community and accountability among the
providers. This service is available to any person 18 years and older who screens with one or
more SDoH needs at any partner location within Jackson and Josephine County Oregon.
The Rogue Challenge has adopted a shared Gannt chart to allow access to project
documentation between the partners. The Rogue Challenge has used an iterative approach to
implementation, developing preliminary workflows and structures to begin testing the software
and partnership concurrent with interagency training and software development. The Rogue
Challenge has developed a train the trainer system with clear workflows taught by the developers
that allow for easy dissemination from each agency’s point of contact. The next iteration will
begin in August 2020 and close in December of 2020.
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The Rogue Challenge Training Manual Prototype (Appendix 4) demonstrates the method in
which partners and stakeholders engage in the innovation. The training manual was developed
to present to case managers, using the system, a recipe style process in which to engage. The
training manual is presented to inter-agency case managers in groups of eight to ten, allows for
practice and is bound for them to take back to their workstations for review. The manual includes
the theories that led to the innovation as well as step-by-step instructions on engaging with the
client, software and each other. Potential collaborators for partnership in improving health equity
through the use of the Social Determinants of Health need to be strategic in selections and
engaged with systems thinking. The partners will include local services that represent the
community and can provide access to a minimum of one determinant need. With interagency
training to staff, the collaborative will be aligned in presentation to the community, have an
awareness of trauma and engage the patient with respect and dignity. The following is a list of
strategic partners with contracted engagement:
Rogue Community Health: Medical, behavioral, addictions, dental, case management and
pharmacy services.
Addictions Recovery Center: Addiction related services to the people in our community. The
health center also provides this service but not to the same level of care complexity.
Southern Oregon Goodwill: Clothing vouchers, GED completion classes, and workforce
development.
Head Start: Child and family intervention, pre-school classes and case management.
Family Nurturing Center: Child care respite, parenting class and, 40-acre community garden and
Department of Family Services contracts.
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21
Access: Housing and food bank access and mobile food pantries with twice-monthly services at
the Rogue Community Health clinics.
Credit Relief: Free credit and financial planning classes.
Ontrack Inc.: Residential treatment for addictions patients as well as holding housing for patient
members of the collaborative.
Young Men’s Club of America: Inexpensive or free gym memberships, wellness classes, and
childcare.
Care Coordination Organizations: Funding, policy, and statewide exposure.
Oregon Primary Care Association: Process development and nationwide exposure.
Siskiyou Community Health: Medical, behavioral, addictions, dental, case management and
pharmacy services.
Grants Pass School District: K-12 Public Education
Eagle Point School District: K-12 Public Education
Ashland High School: Public High School
Jackson County Early Intervention: Screening, diagnoses, and treatment of children 0-6
Care Coordination Organizations are the pass-through funding entities for Medicaid in
Oregon. They have been tasked with assisting health centers in providing appropriate services
and have a list of metrics each of their supported health centers must meet. Depending on the
achievement, they share incentive funding. They have opportunity and funding to support change
projects, adopt and implement on a larger scale and provide incentives for meeting metrics. The
collaboration will work towards 25 shared patients in the first 90 days. As the collaboration
adopts a case management tool in which all partnered agencies can refer, track and follow-up
with each other. This shared case management tool allows the patient to engage in no wrong
ROGUE CHALLENGE

22
door for community services. The partnerships are strategic, and each partner can attend to at
least one of the identified Social Determinants of Health. Beyond the initial partnership, the
collaboration must be willing to grow using iterative processes in software and workflow
development. In the first iteration, the team focused on building criteria for appropriate shared
patients. Though all patients are eligible this does not allow for targeting the patients with
chronic disease, like diabetes, nor does it allow for segmentation of the population to address the
inequities between those with privilege and those without. To resolve the wicked problem of
healthcare inequity this system’s overarching goals and outcomes must be able to accurately
attract and treat people with a diverse cultural and socioeconomic background. The team will
develop measurements to determine success or failure in each iteration as well as provide
narratives for reports to the Care Coordination Organization for future funding, support and
spread.
The Oregon Primary Care Association(OPCA) is a Federally granted agency in place to
support FQHCs In achieving its mission and improving patient outcomes. The OPCA has several
positions on staff dedicated to improving patient health through the use of the Social
Determinants of Health. They continue to provide research and training on multiple strategies in
operationalizing common survey tools. The OPCA will be valuable in changing policy around
funding, coding and practice as the collaborative starts reporting measures.
Sustainment of the Rogue Challenge (2018) will be measured through community
governance, consistent workflows, and ongoing program development to improve outcomes.
Key sustainment is the community ownership of the shared case management system, including
the process for staff training, community engagement, and software development(inner context
facilitators). Key performance indicators will assist in maintaining fidelity within the system. As
ROGUE CHALLENGE

23
discussed in preparation, appropriate adherence to privacy law and holding people’s
confidentiality in high regard will be a facilitator in the outer context of sustainment. Currently,
this author owns the licensure to the software and drives the agenda for partner meetings. This is
in slow evolution and will be transitioned to a governance board of seven executives from the
original partnerships. As these leaders develop strong criteria for governance they will be able to
create policies to guide the Rogue Challenge Director in ongoing growth and development. The
governing body will rely on data from the system as a way to leverage Medicaid into applying
Alternative Payment Models to the SDoH work being done in the community. The Rogue
Challenge will have an advisory council made up of the case managers working the system. This
council will implement workflows, use data to maintain interagency accountability and system
fidelity. This compliance in case management and systems will provide concise and accurate
reports to the governing body. In order to sustain this system of care, this body of case managers
must be able to disseminate findings both to implementers and governance (Brownson, 2014).
Currently, the hub used to disseminate referrals is managed by this author’s staff as a stop-gap in
the trans organizational resource allocation. This staffing model will be converted to a dedicated
hub manager reporting directly to the executive director of the Rogue Challenge. Changes to the
hub manager and access to the administrative hub will allow the partners to engage on equal
footing as administrative rights are present for the governing body, a dedicated director, and hub
manager. Community ownership of the Rogue Challenge will ensure sustainment and
meaningful relationships.
The research question will be used to guide the evaluation of the effectiveness of the Rogue
Challenge. The intent is to measure the system’s ability to improve initial appointment
completion rates. The outcome research question is: Does a closed-loop referral system increase
ROGUE CHALLENGE

24
the completion of first appointments for community services? The process research question is:
How well are case managers adhering to this system at months four, 12 and 18?
This is a longitudinal, quasi-experimental study used to determine the effectiveness of the
intervention. The study will measure the efficacy of using strategic partners providing services
designed to meet SDoH needs through timely and appropriate referrals and initial appointment
completion. Trained community partners will use the closed-loop system to make referrals to
other partners within the hub. The partners will use program guidelines and shared workflows to
ensure referral completion. Families experiencing many barriers have a greater risk of
incomplete referral. Improving family/community factors may increase satisfaction; however,
improving health system factors may be the best way to reduce incomplete referrals (Zuckerman,
2013). Complexity theory examines the influences, connections, and decisions that people make
and how these influence emerging group behavior. Three issues are paramount to understanding
what comprises complexity: self-organization, feedback, and emergent behavior. Social workers
may easily grasp concepts from emerging research and evaluation approaches that focus on
community engagement, such as empowerment evaluation, as many of these approaches seek to
obtain grassroots input and action(Wolf-Branigin, 2013). This study will measure the
effectiveness of implementation using Social Learning Theory, Systems Theory and to an extent
Complexity Theory.
Patients who present for an appointment, and at the time of registration, will complete a broad
screening tool, Patient Support Survey, a one-page tool created to assist in immediate
identification of environmental needs. This screener provides the patient the opportunity to circle
an SDoH need they may have, and to select if they want to engage with a Community Health
Worker. Participants will be selected based on a shared SDoH screener demonstrating one or
ROGUE CHALLENGE

25
more needs. When patients screen positive on the broad screening tool, they are connected with a
Community Health Worker to complete the larger screening tool. The complete facilitated
screener provides an assessment like environment for assistance to reduce barriers. The
workflows are very similar for our participating partners and the system includes interagency
training of empathic inquiry for the facilitation of the screens. The initial sample for efficacy is
50 patients with one or more determinant needs, which provide over 100 referrals.
The participants eligible for referral are adults, over the age of 18. The participants’ sign
informed consent for the referral but are possibly experiencing a vulnerable time in life. Care
will be taken to use the software system as a tool to assist case management, as opposed to
replacing human interaction. Shared language and specific training will create a sense of
belonging, and a no wrong door approach to engagement (Brill, 2001). It is important to involve
community stakeholders because their participation improves the duration of the study, anecdotal
to accompany the data, and the adoption of solutions more likely (Shaw, 2010). While
community partner involvement has been extensive, the patient as a stakeholder involvement is
limited at this time. A patient advisory council and the Patient Activation Measure (PAM)
(Hibbard, 2004) is being established and will be used to provide valuable input in future
iterations of the system.
The Rogue Challenge system, including the software and training, allows for shared data
collection, measurement, and analysis. The initial sample for efficacy is 50 patients which
provide over 100 referrals for measurement. The initial sample will be completed in four months.
The research intends to demonstrate a 90% initial appointment completion rate. This improves
from the baseline data of 82% initial appointment completion rates. The baseline was determined
through a similar process using a smaller sample size, 10 patients. The baseline data provided
ROGUE CHALLENGE

26
meaningful information which led to some minor changes to the software allowing for more
complete accountability between partners. The software and training provide reliable usage
across organizations and case managers, and the system provides a hard stop for consent before
making a referral. The PAM is used to demonstrate post-intervention engagement outcomes. The
Rogue Challenge system, including the software and training, allows for shared data collection,
measurement, and analysis.
The closed-loop referral functionality sends a message to referrer, patient, and referee when a
referral is made and when the referral is accepted. Shared progress notes in the system provide
for notification when the initial appointment is complete. The registry, or flagging system, assists
in ensuring referrals are receiving follow-ups between the referral acceptance and initial
appointment.
Case management style may lead to variation in the SDoH screener outcomes, but the system
will not allow for variation in completed initial referrals. This will demonstrate a reliable data
set. Limitations to completed referral may occur if the established case manager does not follow
workflow, specifically, entering progress notes. This lack of compliance will not harm the patient
but may impact the reliability of the measure. For instance, completed appointments are
measured by a case management notation in the progress note. If the progress is not noted it will
measure as an incomplete initial referral. This limitation will be mitigated by the registry and
weekly case management meetings. This will be measured at 4, 12, and 18 months for
compliance.
The measures are quantitative and will be analyzed using statistical Packaging for the Social
Sciences (SPSS, 1984). The interagency governance team that reviews capacity and usage
weekly will refer to analytics produced from the Rogue Challenge analytics department’s
ROGUE CHALLENGE

27
licensed access to SPSS/Descriptive Statistics software (Stehlik-Barry 2017). The method
measures the total volume of referrals made against the total volume of initial appointments
completed, providing the percentage of completed initial appointments. The interagency
governance team reviews documentation including volumes of referrals made and initial
appointments completed to maintain compliance and accountability among the partners. The
analysis will be used to improve relationships among the partners, increase trust with patients
and report successes to payors. This evaluation will also drive ongoing system workflow
development for optimal referral and engagement practice.
This evaluation will demonstrate the percentage of completed initial appointments but will
also benefit from producing a secondary measure. As a result of the evaluation for effectiveness,
the system will also demonstrate the social determinant need in percentages across the sample
population. This data will help in identifying future strategic partners related to the highest
percentage of need demonstrated by the sample population.
The analysis will be used to improve relationships among the partners, increase trust with
patients and report successes to payors. This evaluation will also drive ongoing system workflow
development for optimal referral and engagement practice. Improved relationships will be
achieved through shared information and strong theory to guide the practice. Patients will
achieve a sense of belonging through transparent referral information, shared language across the
continuum and health outcomes reports. The payors will be able to see the cost of care across
the continuum of social service agencies allowing for clear vision and targeted funding. These
together will increase inclusive practices, demonstrate successful outcomes and eradicate the
wicked problem of healthcare disparities in southern Oregon.
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Rogue Community Health, as the developing agency, works under the auspices of a
community governed board and Chief Executive Officer. This governing body and executive
leader exercise final authority and approval over the Rogue Challenge’s financial plans, budgets,
and high-level spending activities. This allows for ongoing participation in leadership and budget
oversight from one paid executive and 12 volunteer leaders from the community. Rogue
Community Health is a Federally Qualified Health Center with significant federal funding and
benefits, is mandated to have 51% patient participation and must uphold the Health Resources
and Services Administration (HRSA)19 requirements for FQHCs. Looking into funding
auspices as they relate to the Rogue Challenge it is vital that the Rogue Community Health
Board continues to approve Value-based pay. This system of payment is critical to ongoing
SDoH work in the health center and the community partnerships.
The internal stakeholders in the Rogue Challenge are comprised of multiple agency staff and
leadership. Each partner in the Rogue Challenge has agreed to participate in presented
expectations through a formal written agreement. The Rogue Community Health staff has been
key to implantation as they model expectations for partners. This alignment in the system allows
for Rogue Challenge leadership to hold each independent organization accountable to the Rogue
Challenge mission, vision, and workflows while honoring individual organizational
responsibilities outside of the partnership.
The external stakeholders represented in the Rogue Challenge include community members,
payers, and policymakers. The Rogue Challenge has developed a Member Advisory Board
which meets two times per month, to discuss, review and make recommendations to ongoing
software development and patient engagement techniques. The payers are just now becoming
involved through presentations of the system to key contract managers within the multiple payer
ROGUE CHALLENGE

29
system. This allows for minimal participation from the payers in development while keeping
them comprised of the ongoing efforts. These early presentations will be key in the future asks as
they relate to ongoing revenue streams. The policymakers referred to here are specific to the
State of Oregon initially. The Oregon Governor’s office, as well as legislators, have a significant
interest in creating meaningful nonprofit community partnerships to improve patient outcomes
and reduce the total cost of care.
The current revenue stream supporting the Rogue Challenge system of care is drawn from the
value-based payment Rogue Community Health receives from Medicaid Per Member Per Month.
This payment model allows for significant work to be done outside of the fee-for-service exam
room interventions. As the Rogue Challenge demonstrates successful outcomes across multiple
service organizations, these successes will translate to higher Per Member Per Month payments
allowing for greater access. The Rogue Challenge system, including the software and training,
allows for shared data collection, measurement, and analysis. The software and training provide
reliable usage across organizations and case managers and the system provides a hard stop for
consent prior to making a referral. The closed-loop referral functionality sends a message to
referrer, patient, and referee when a referral is made and when the referral is accepted. Shared
progress notes in the system provide for notification when the initial appointment is complete. The
registry, or flagging system, assists in ensuring referrals are receiving follow-ups between the
referral acceptance and initial appointment. The shared software is important for best-practice
among case managers but also is extremely important in shared data collection. The software
ensures all partnering agencies are aligned in process and screeners, producing the same data points
within the metrics. As the Rogue Challenge begins to leverage more funds from the Value-Based
model currently in use in Oregon, leveraging a larger data pool will be essential. This will
ROGUE CHALLENGE

30
demonstrate the cost of care across the nonprofit continuum as it relates to the Social Determinants
of Health, describing the shared savings and improved outcomes.
The budget format is line-item and the cycle is an annual, calendar year. The format was
chosen because line-item budgeting provides the assumption of input separability ( Banker,
2011) or that each input is determined separately and independently of other inputs. The cycle
aligns with the Rogue Community Health, Federally Qualified Health Center budget and award
periods. The revenue projections for Rogue Community Health as they relate to the Rogue
Challenge include:
• Increase in Full-Time Equivalents (FTE) expense to manage the Rogue Challenge Hub
and case manage new referral sources.
• First-year decrease in cash due to FTE ramp up and limitations on SDoH funding
• Increase in membership (PMPM payments) due to new referral partners using the
software referring only to Rogue Community Health for Medical, Dental and Behavioral
Health services.
• Increased Per Member Per Month based on data regarding continuum cost for the Social
Determinants of Health demonstrated to the Oregon Health Authority. If successful in
this endeavor, Rogue will see a significant increase in Medicaid Value-Based payments.
The phases for implementation are noted in the logic model, (Appendix 1). The long-term
outcome expectations drive the process for implementation. Using a multifaceted
implementation strategy, the Rogue Challenge will deliver a reduction in healthcare outcome
disparities, eliminate competing and duplicated social services and complete a sustainable and
replicable system of community collaboration to deliver an inclusive practice across multiple
sites of engagement. The major steps for the Rogue challenge are Phase 1, software and policy
ROGUE CHALLENGE

31
development, developing interagency agenda for shared learning and the development of
business associate agreements that demonstrate expectation and accountability metrics. The
software and policy development will be done in workgroups involving multiple agencies but no
more than seven people. The training schedule will be developed by the implementation group
using a survey tool to determine organizational priorities. The business associate agreements
will be developed by this author to outline usage, accountability and resource allocation per
partner. These expectations on the front end will set the pace for meaningful relationships.
Phase 2 will be a beta test using current partners to reach 50 patients through the system in four
months. This testing period will allow for rapid change projects and workflow solidification. It
will also assist in determining Key Performance Metrics for measurement of successful
outcomes as well as provide anecdotal stories of success for marketing spread. Phase 3 will
include additional sites and partnerships to continue to build strategic partners in social service
agencies and areas that provide at least one service to decrease SDoH need. Phase 4 will include
a market presence, performance measures, and a shared business case demonstrating the cost of
care across the service delivery continuum. The shared business case will demonstrate the cost of
care per organization for cost per patient to screen, cost per patient to refer and cost per patient to
meet the need/provide the service (Appendix 3). These pieces will provide leverage when
presenting this system of practice to the Oregon Health Authority to increase the per member per
month payments. The units of service are not billable, or fee-for-service. The funding
allocations are directly related to Oregon’s Value-Based payment model in which health centers
receive fee-for-service payment as well as per member per month pay in acknowledgment that
much of a person’s healthcare outcomes are related to their environment. The Community
ROGUE CHALLENGE

32
Health Workers staffing the Rogue Challenge will still be held to productivity standards, but this
is more related to access, capacity and utilization than fee-for-service.
The Rogue Community Health staffing plans are as follows:
Program Director: This position is currently occupied by the author at a .2 FTE but beyond the
sustainment phase will be replaced by another member of the team. The Author is the creator of
the software system and guides the community relationships to provide aligned engagement.
The software development phase is near completion and will need ongoing maintenance, but this
can be accomplished by others in the department. Workflows have also been developed to
maintain meaningful community relationships.
Finance Director: This position ensures all activities within the Rogue Challenge are aligned
with the overall organizational financial plan. This position determines pmpm allocations as well
as completes grant reports. This position is staffed at .1 FTE and will remain in the budget.
Hub Manager: This position will remain funded by Rogue Community Health. The FTE will
increase gradually over time as volumes increase. The system is easy to navigate and simple to
engage with. As part of the overarching theme of community-owned, the hub will not make
decisions regarding where referrals go, only forward to those agencies selected by the referring
entity.
Case Managers: These 2 positions are staffed by 2 FTE Community Health Workers in year one.
In review of the potential surplus, the Case Manager role should increase by 2 FTE per year to
meet increased identified needs.
Attorney: The Health Care Attorney is specific to the Social Determinants of Health needs
identified and creates opportunities for all community members. This service has been
traditionally reserved for people of privilege. This position also provides services unique to the
ROGUE CHALLENGE

33
area increasing Rogue Community Health’s position as a market leader. The attorney salary may
need adjustment in future iterations, or if the current attorney leaves. The author was fortunate to
interview and select an attorney that had already established fiscal security.
The other spending plans and costs relate directly to the Rogue Challenge and the mission of
Rogue Community Health to provide access to a no-cost closed-loop referral system for the
partners. In this Rogue Community Health owns the licensing agreement with the software
company and share it freely with partners who meet criteria and agree to expectations. This
practice provides a community-owned process that feeds Rogue Community Health’s multiple
service lines. There is $20,000 budgeted for the SDoH needs that Rogue Community Health
provides on-site. In future iterations, there will be money budgeted for patient incentives related
to accessing Rogue Community Health services through completion. These incentives will be
based on patient activation and engagement in health care interventions. As they demonstrate
completion of tasks and improved health outcomes they move to more difficult tasks with higher
incentives. This system will eventually allow people to complete education or save money
towards the housing of their choice. These incentives can only be funded with increased per
member per month revenues.
The revenue associated with this innovation is minimal in these early phases and relegated to
current membership, community foundations, and federal grants. A stretch goal is to create a
practice system that can be replicated nationally and owned by the Rogue Community Health
Center but to get there the system needs to understand the nuances of the current community and
build agile workflows that will work within multiple communities. Value-Based pay is a revenue
source intended to supplement fee-for-service at health centers to fund the needed unbillable care
needed to achieve improved health outcomes. The cost is static, and without volumes of usage,
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34
significant. With increased usage and validated key performance metrics, the cost will
demonstrate savings to the overall health system by improving outpatient engagement and
reducing duplicated services. Without strategic partnerships, many small non-profits are
competing for the same patients and funding and many times building programs for grant dollars
that should be spent in existing services.
Conclusions, Actions, and Implications
Inequity exists in healthcare and through innovative collaborations, the community can
address all factors impacting health. How a person interacts with their environment is 80% of the
health determinants as they relate to improving health outcomes. The development of shared case
management software and meaningful community relationships will provide the shift needed to
address this 80%. Shared staff training, and aligned process, concerning closing the health gap,
will provide focus points for ongoing, rich collaboration.
With a focused implementation and financial model, the Rogue Challenge will demonstrate a
plan for reducing the cost of care across the social service and health care continuums. The
Rogue Challenge provides a software platform to capture data with the SDoH work where other
systems have not. This data can be used to leverage higher rates of Value-based pay across the
community and the state. Setting a strong line-item budget gives funders the information they
need to understand that services are being provided while surplus money is being used to expand
access. Through the shared business case, all partners will demonstrate individual organizational
cost per screen, referral and service provided. The shared business case will demonstrate a cost
of care across the social service continuum in each community.
The Rogue Challenge is an innovative, collaborative, approach to using closed-loop referrals
to improve initial appointment completions, reduce disparities and close the health gap.
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35
Thoughtful planning, development, and implementation, this practice will create a powerful trans
organizational system that can be replicated at low cost to multiple communities in the nation.
This combined with analytics and reporting will assist in leveraging sustainable funding and
ultimately, closing the health gap.
Shared staff training and aligned process in regard to closing the health gaps will provide
focus points for ongoing, rich collaboration. As the community collaborative produces results,
the data from the shared case management software it will develop written reports to present to
CCOs and OPCA for an ongoing funding opportunity and spread to additional communities.
The intractable problem is clear in research and experience, the problem is grand and world-
wide. Through innovative design and implementation starting in one small community, the
process can be vetted and proven for future spread and funding. Closing the health gap as it
relates to people with diverse ethnic and sexual orientation and gender identity backgrounds to
include unmanaged diabetes can be accomplished through focused staff and patient resource
training and aligned community support. Staff will be able to identify inequities in their
workflows to better serve their population. Patients will feel a sense of belonging and
empowerment through system knowledge and clear role delineation and the community will
provide a value-aligned, no wrong door approach to treating shared patients. The innovative
approach the Rogue Challenge has created will Close the Health Gap.

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36
References

Atkinson, S., & Cottam, B. (2011). How doctors can close the gap: tackling the social
determinants of health. Clinical Medicine, 11(1), 57-60.
Benson, E., (2017). More than a ZIP code socioeconomic data for improving patient outcomes:
Socioeconomic data can help healthcare organizations determine how to best tailor care
for individual patients. Healthcare Financial Management, 71(12), 72-76
Brill, C. (2001). Looking at the Social Work Profession Through the Eye of the NASW
Braveman, P., & Gottlieb, L. (2014). The Social Determinants of Health: It's Time to Consider
the Causes of the Causes. Public Health Reports, 129(1_suppl2), 19-31.
Chronic Disease; New report: Community health plans improving care for patients with chronic
illnesses. (2011, December 18). NewsRx Health, p. 422. This article was prepared by
NewsRx Health editors from staff and other reports
Cookson, Asaria, Ali, Shaw, Doran, & Goldblatt. (2018). Health equity monitoring for
healthcare quality assurance. Social Science & Medicine, 198, 148-156.
Devoe, J., Bazemore, A., Cottrell, E., Likumahuwa-Ackman, S., Grandmont, J., Spach, N., &
Gold, R. (2016). Perspectives in primary care: a conceptual framework and path for
integrating social determinants of health into primary care practice. Annals of Family
Medicine, 14(2), 104-8.
Dubb, S., (2017) Communities must engage to improve health. Nonprofitquarterly.org
Eckersley, R. (2015). Beyond inequality: Acknowledging the complexity of social determinants
of health. Social Science and Medicine, 147, 121.
Farrer, L., Marinetti, C., Cavaco, Y., & Costongs, C. (2015). Advocacy for Health Equity: A
Synthesis Review. Milbank Quarterly, 93(2), 392-437.
ROGUE CHALLENGE

37
Fong, R., Lubben, J., & Barth, R.P. (2018). Grand challenges for social work and society.
Oxford University Press, 36-55.
Garcia, A., Cheirif, J., Veliz, J., Reyna, M., Vecchio, M., & Aryal, S. (2015). Harnessing Data to
Assess Equity of Care by Race, Ethnicity and Language. International Journal of
Environmental Research and Public Health, 13(1), Ijerph13010045.
Hahn, R., & Truman, B. (2015). Education Improves Public Health and Promotes Health Equity.
International Journal of Health Services, 45(4), 657-678.
Kantayya, V., & Lidvall, S. (2010). Community Health Centers: Disparities in Health Care
in the United States 2010. Disease-a-Month, 56(12), 681–697.
Kuehner-Hebert, K. (2018). When it comes to preventive care, consumers aren't getting the
message. Benefits Selling. Breaking News,
Levy B., Sidel V. (2013) Social Injustice and Public Health
Lubben, J., Barth, R., Fong, R., Flynn, M., Sherraden, M., & Uehara, E. (2018). Grand
Challenges for Social Work and Society. Oxford University Press.
Lynch, J., & Perera, I. (2017). Framing health equity: us health disparities in comparative
perspective. Journal of Health Politics, Policy and Law, 42(5), 803-839.
Malcolm, N. (2006, June 29). Combating the racial disparity in healthcare. New York
Amsterdam News, p. 3.
Mahamoud, Roche, & Homer. (2013). Modelling the social determinants of health and
simulating short-term and long-term intervention impacts for the city of Toronto, Canada.
Social Science & Medicine, 93, 247-255.
McHugh, R., & Barlow, D. (2012). Dissemination and implementation of evidence-based
psychological interventions. Oxford: Oxford University Press.
ROGUE CHALLENGE

38
Moullin, J., Dickson, K., Stadnick, N., Rabin, B., & Aarons, G.(2019). Systematic review of the
Exploration, Preparation, Implementation, Sustainment (EPIS) framework.
Implementation Science, 14(1), 1–16.
Monfre, J., & Kelechi, Teresa J. (2012). Symptom intrusiveness, chronic conditions and health-
related quality of life: development of conceptual and measurement models, ProQuest
Dissertations and Theses.
Noone, J., Wros, P., Cortez, D., Najjar, R., & Magdaleno, L. (2016). Advancing
health equity through student empowerment and professional success: a statewide
approach. The Journal of Nursing Education, 55(6), 316-22.
Nowell, B., & Foster-Fishman, P. (2011). Examining Multi ‐Sector Community Collaboratives as
Vehicles for Building Organizational Capacity. American Journal of Community
Psychology, 48(3-4), 193-207.
Peek, Odoms-Young, Quinn, Gorawara-Bhat, Wilson, & Chin. (2010). Racism in healthcare: Its
relationship to shared decision-making and health disparities: A response to Bradby.
Social Science & Medicine, 71(1), 13-17.
Price, J., Khubchandani, J., & Webb, F. (2018). Poverty and Health Disparities: What Can
Public Health Professionals Do? Health Promotion Practice, 19(2), 170-174.
Reyes, P. (2017) Working life inequalities: do we need intersectionality? Society,
Health& Vulnerability,8:sup1,
Shi, Qian, Zhao, Yingnan, Fonseca, Vivian, Krousel-Wood, Marie, & Shi Lizheng. (2014).
Racial disparity of eye examinations among the U.S. working-age population with
diabetes: 2002-2009. Diabetes Care, 37(5), 1321-8.
Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for
ROGUE CHALLENGE

39
2020. Healthy People 2020: An Opportunity to Address the Societal Determinants of
Health in the United States. July 26, 2010. Retrieved
from: http://www.healthypeople.gov/2010/hp2020/advisory/SocietalDeterminantsHe
alth.htm
Steven Ross Johnson. (2015). Learning to be LGBT-friendly; Systems train providers to
consider sexual, gender orientation in all treatment decisions. Modern Healthcare, 45(34),
0028.
SPSS 16.0 brief guide. (2007). Chicago: SPSS Inc.
Stehlik-Barry, K., & Babinec, A. (2017). Data analysis with IBM SPSS Statistics : implementing
data modeling, descriptive statistics and ANOVA . Birmingham, England: Packt.
Soydan, H., & Palinkas, L. (2014). Evidence-based practice in social work : development of a
new professional culture, 8, 132-144. Oxfordshire, England ;: Routledge.
Weisner, S., & Silver, M. (1981). Community Work and Social-Learning Theory. Social
Work, 26(2), 146–150.

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Appendix 1
Logic Model

Appendix 1

Inputs Activities Outputs Immediate Outcome Intermediate Outcome Long-term Outcomes

Software/Tools

Executive
Commitment

FTE and Facility
Resource

Funding
Software
development 2x
per week

Case
management
meetings

Shared
engagement
trainings

Trans Organizational
policy and
governance
development
Functional shared
case management
software

Case management
workflows

Inter-agency case
management
accountability
Closed-loop referral and
shared case management tool
to support compliance and
shared metrics

Aligned process for
engagement
Trans Organizational
chart with clear
leadership
expectations
including shared
core values, vison
and mission
Multi-
Organizational
Accountability

Consistent language
and engagement

Universal Access
“no wrong door ”
Reduction in healthcare outcome
disparities.

Elimination of competing,
duplicated community services.

Economy of scale

Sustainable, replicable system of
community collaboration
addressing the Social Determinants
of Health to reduce cost of care and
increase inclusive practice
Demonstrated system
of care for presentation
to large organizations
and payers.
Plug and play system for
engaging new organization
with metrics for outcomes,
compliance and
accountability
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Appendix 2
Budget

BUDGET

Revenue

Department allocations 200,000 Percentage of PMPM designated for SDoH
Foundation Grants 86,400 Providence 15,000, Anna May 5,000, Carrico 16,400, AllCare 50,000
Federal Grants 42,200 HRSA SUD 42,200
Total Revenue 328,600

Expenses
Personnel expenses
Administration 17,000 .2 FTE Program Director, .1 FTE Finance Director
Hub Management 14,976 .4 FTE Community Health Worker (Point of Contact)
Case Management 74,880 2 FTE Community Health Workers
Healthcare Attorney 100,000 1 FTE Attorney
Sub-Total 206,856
Benefits 51,714 @25% of salaries
Total Personnel 258,570

Operating Expenses
Space or lease 12,000 Indirect allocation
Software 16,000 3 year contract 48,000
SDoH Needs 20,000 Food 5,000, transportation 5,000, housing assistance 10,000
Supplies 1,000 office supplies, printing
Hardware 3,600 Desktop x3
Travel 4,000 mileage x 3 personnel
Total Operating costs 56,600

Total Expenses 315,170

Surplus/Deficit +70,030 Add case management for improved access
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Appendix 3
Business Case: Cost for Service

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Appendix 4

Rogue
Challenge

Training
Manual

IN PARTNERSHIP WITH:

Rogue Community Health
Family Nurturing Center
Southern Oregon Head Start
Southern Oregon Goodwill
Rogue Valley YMCA
Eagle Point School District
Grants Pass High School
On Track
Siskiyou Community Health Center
United Community Action Network
Consumer Credit Counseling Service
of Southern Oregon
Hearts with a Mission
Ashland High School
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Shared Case Management Training Outline- 1.5 hours

1) CEO of a partner organization completes the NDA and MOU prior to their organization ’s case
managers attending software and shared case management training.

2) Gather 8-10 case managers new to the system for training.

3) Partner two or three case managers (preferably from different agencies) per laptop.

4) Sign in sheet to include agency, services provided, cell number and email.

5) Brief survey to measure pre-training understanding

6) Each case manager gets a Rogue Challenge training Manual to take back to their organization for
future reference

7) Begin with check-in

8) Presents schedule of interagency trainings

9) Trainer presents the contents page and “The Why ”

• Notes to the Trainer: It is crucial that trainer discusses the Grand Challenges and
community need. This is important contextual information and assists with case
manager buy-in and engagement in the system.

10) Trainer presents the RCH process, describing that this is an example of what RCH does to engage
patients in the software platform. The first 4 steps are specific to RCH while the last 5 are universal
across the collaboration. It is the expectation that the trained case managers complete their
organizations first 4 steps using RCH ’s as a guide.

11) Trainer presents the patient flow through the system to include closing the loop with initial
appointment feedback.

12) Trainer presents case manager responsibilities

13) Trainer presents “Creating your own voice ”.

• Notes to the Trainer: This section helps case managers, new to the system, normalize the
software with clients. It enables the case manager to use their own words in introducing
the software portion to clients.

14) Trainer presents three examples of the Broad screener. These are used at initial registration and every
appointment. Each organization is responsible to create their own broad screening tool using these
examples.

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15) Trainer presents the Agency Point of Contact list. List will be updated later to include new case
managers based on sign in sheet information.

• Important for trainer to express that having the point of contact eases the follow-up
process

16) Trainer presents Interagency Service Array. Trainer to note the service agencies are across the top and
down the side are SDoH needs screened for. The meat of the document are the services provided per
agency. This will be updated using services provided in sign in sheet.

17) Trainer presents the paper copies of registration, Release of Information, and SDoH screening tool.
These are available per binder should electronic access be lost due to outage etc..

18) Trainer has teams of two register themselves in the system as resources.

• Notes to the Trainer: Important here to have laptops per team and an example being
worked on presentation screens in the meeting room.
• Trainer to walk between the teams to provide support as needed.

19) Once both or all three case managers are registered in the system

20) Case managers take turns registering their partners in provider/client role-play.

• Case managers should be enrolled as a client at another agency
• The ask is that each case manager complete the role-play referral by meeting at the
organization they were referred too.
• This helps them understand possible client barriers and get to know the other agency.

21) Trainer to answer any questions and offer on-site follow-up with any case managers still feeling
uncomfortable with the software process.

22) Trainer concludes the training with a brief post-survey to measure basic understanding

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CONTENTS
THE WHY
• Healthcare Outcomes
• Disparities
• Systems
• Shared Language

REFERRAL PROCESS
• Member engagement Workflow
• Creating Your Voice
• Agency Point of Contact
• Interagency Service Array

DATA ENTRY

INITIAL ENGAGEMENT
• Registration Form
• Release of Information
• Social Determinants of Health Lifespan Screener
• Lifespan Data Entry

The Road We Walk Together
We envision a society where all people have equitable access to the community resources
they need to live a healthy, enriched, and fulfilled life in pursuit of self-actualization.

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WHY IS THIS IMPORTANT TO OUR COMMUNITY?

How people live their lives, where they live and the well-being they have is all affected by broader social factors, how
people interact with their health and healthcare is a product of these social factors.

The idea that oppression is the root cause of poor health outcomes is not new and movement towards studying
intersectionality as it relates to power, exploitation, and subordination has begun.

Social justice requires equity in all aspects of society.

A person ’s environment has a greater effect on health outcomes than genetics or exam room interventions.

The Community must understand the person in the environment, understand that trauma, poverty, racism, sexism,
classism, ageism, and homophobia are all part of the patient ’s perspective.

Through relationships with community partners and shared case management, this intractable problem can be
resolved.
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REFERRAL PROCESS

Using the Social Determinants of Health to determine risk factors and
individualized goal planning, we will partner with service providers who
share a common vision and we will bring health and vitality to the
community we serve.

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o Notifying of new shared referral and to inform if referral does not come through (they should
also get notification through Lifespan)
• RC Hub will add a progress note to Lifespan mentioning that referrals were made and email sent to
those referred

7) Each person receiving referral will update progress notes with the following information
• Attempts to make initial contact, including barriers
• Date of initial contact and if participant will engage in services
• Updates when key goals are met or all goals complete
• If there are barriers to ongoing engagement
• If engagement ends early due to —declining services, changing goals/priorities, barriers
• Collaboration between partners to meet participant needs
• Can make new referrals to other partners as needed

8) Each person receiving referral is encouraged to reach out to partners via phone(ok per ROI) to address
• Barriers to engagement
• Coordination of services
• Questions about provided services or specific programs

9) Each person receiving referral is encouraged read progress notes left from other agencies to know where
participant is in process able to see
• Needs are being met
• There are barriers that perhaps you can assist the partner agency with coordination of services
• Participant ’s goals/priorities have shifted (perhaps a different referral is now more appropriate)

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REFFERRAL PROCESS

Client
interested

Case Manager
fills out client
information,
release of
information, and
Social
Determinants of
Health Screening
with client
Rogue Challenge
HUB accesses
referral and sends
to identified
partners

All partners receive the same
information simultaneously and
respond, follow-up, and create a
contact log in the database
viewable by all working with
the family

Warm hand-off to partner
organizations

TIME COMMITMENT: 10-15 minutes

CASE MANAGER RESPONSIBILITY
1. Create your own ‘voice ’ for explaining the Rogue Challenge and the benefits of the program.
2. Identify clients that would benefit from multi-agency case management
3. Become familiar with the database
4. Enter client information in database
5. Fill-out Social Determinants of Health Screening with client
6. Fill-out and obtain signature from client on the release of information
7. Set goals together
8. Select agencies that would be the best fit to help the client
9. Call agency and touch base with point of contact to help ease client transition; if possible, on
second meeting, transport client or meet them to make introductions (warm hand-off)
10. Submit referral
11. Follow-up with contact notes

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CREATING YOUR VOICE
Example Message to Client
“Families need help reaching their goals and we recognize that we can ’t always do that
alone. As we get to know you better, we want to make sure you have all the resources
that can help you so we have partnered with local non-profits in the area to start a pilot
program to meet participants at a deeper level. Partners will share notes and think of
strategies to get your needs met collaboratively, so that you don ’t have to go from place
to place telling your story over and over again.
Unfortunately, this doesn ’t always mean that all partners can help right away, but it does
mean that you will not be forgotten or get lost in the shuffle.
To participate, we just need to fill out a quick application, release of information,
and do a Social Determinants of Health survey. This process takes around 10-15
minutes, would you like to participate? ”

Things to Consider When Choosing Your Words:
1. Focus on how this process is getting families the help they need in the space they are in.

2. We collaborate using the Social Determinants of Health screening to drive
our services and break down the barriers for families to find the help they
need in the space they are in.

3. All of our agencies are familiar with advocating and using our voice for those we
serve, now we are just choosing to move towards using one voice, one process,
and one combined effort to streamline processes and foster human connection.
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AGENCY POINTS OF CONTACT
Referrals Incoming into an Agency – who you call when you are referring

Rogue Community Health: Services include; medical, dental, behavioral, pharmacy, OHP application Help,
support with and referral to community agencies for resources. No one is denied care due to inability to
pay, they offer a generous sliding fee discount to income qualified patients based on annual household
income.

Point of Contact Phone Number Email
Ryan Bair (503) 341-9832 rbair@roguech.org
Richelle Marshall (541)-500-0968 rmarchall@roguech.org

Family Nurturing Center: Services include; relief nursery prevention and intervention program serving
families with children 0-5. Therapeutic early childhood classrooms, preschool promise classrooms, home
visits, mental health services, parenting education, respite care and emergency support and advocacy.

Point of Contact Phone Number Email
Beth Jaffee-Stafford (541) 779-5242 X201 beth@familynurturingcenter.org

Southern Oregon Head Start: Services include; programs that promote school readiness of children ages
birth to five. Early Head Start programs are available to the family until the child turns 3 years old. Parenting
education, health and nutrition assessments, home visit to promote family ’s well-being, play groups, and
infant massage classes.

Point of Contact Phone Number Email
Christine Russo (541) 734-5150 X1073 Christine.russo@socfc.org

YMCA: Services include; after school programs for kids, youth and family fitness, wellness classes and
swimming lessons.

Point of Contact Phone Number Email
Brad Russell (541) 772-6295 X121 brussell@rvymca.org

Southern Oregon Goodwill: Services include; employment training, financial literacy to consolidate bills,
waive or reduce interest charges, eliminate collections calls, obtain copies of credit reports and scores,
money management skills. GED prep and many computer learning labs.

Point of Contact Phone Number Email
Kristi Bonham (541) 772-3300 X1047 Kristi.Bonham@sogoodwill.org

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ROGUE CHALLENGE INTERAGENCY SERVICE ARRAY

Social Determinant of
Health
Rogue Community Health
Services
Summary: sliding scale costs; all
ages
Southern Oregon Head
Start Services
Summary: no cost to participant;
children aged 0-5 and their
families
Southern Oregon
Goodwill Services
Summary: sliding scale costs;
employment support
The Y
Services
Summary: sliding scale costs; all
ages
Family Nurturing Center
Services
Summary: no cost to participant;
children aged 0-5 and their
families
Food Program Screenings / Referral Program Screenings / Referral Cooking Classes (with Child Watch if
class is during operation hours)
Cooking Classes
(with Respite Care for ages 0-5)
Fresh Produce (limited)
Housing Program Screenings / Referral Program Screenings / Referral Program Screenings / Referral
Utilities Program Screenings / Referral Program Screenings / Referral Program Screenings / Referral
Employment Program Screenings / Referral Program Screenings / Referral/Intern
program/Volunteer program
Employment Support
Job Training
Program Screenings / Referral
Income Assistance Program Screenings / Referral Program Screenings / Referral Budgeting Classes
Financial Literacy
Collection Call Assistance
Money Management
Credit Management
Program Screenings / Referral
Emergency Supplies (diapers /
clothing; ages 0-7)
Gas Cards
(case managed clients only / limited)
Education Program Screenings / Referral Preschool Classes (includes in-home
support)
Early Intervention Screening
(ASQ & ASQ-SE) (IFSP support and
referral) *IFSP-Individual Family
Service Plan for kids with disability
GED Classes
Computer Learning Lab
Preschool Classes GED Classes
Preschool Classes (w/transportation)
Therapeutic Classes (includes in-
home support, transportation)
Early Intervention Screening (ASQ &
ASQ-SE)
Child Care Program Screenings / Referral Child Watch
After School and Holiday Care
Child Care Program (limited slots)
Respite for Caregivers (limited)
Parenting Skills Program Screenings / Referral Parenting Classes
In-home Parenting Support
Infant Massage
Parenting Classes (w/ Respite care)
In-home Parenting Support
Parent Baby Group
Legal Assistance Program Screenings / Referral Resource Coordination
Health Care Medical
Dental
Behavioral Health
OHP Application Assistance
Transportation for medical dental
(limited to clients)
Dental Prevention / Screenings
Respite for Caregivers during
appointments (limited)
Dental Prevention / Screenings
M edications Pharmacy (on-site Medford, White
City), Prescription Assistance (on-site)
Respite for Caregivers during
afternoon appointments (limited)
Transportation Transportation support (limited to
one-time bus pass/token, fuel card)
Program Screenings / Referral
Transportation support to Preschool
(Bussing)
Transportation for medical / dental
(clients only)
Transportation Support to Preschool
(bussing)
Transportation Support to
Therapeutic Classroom (bussing)
Gas Cards (clients only; limited)
Domestic Abuse Protection Program Screenings / Referral to
Healthy Relationship Advocates
Resource Coordinator
M ental Health Behavioral Health Counseling (on-
site)
Psychiatric Services/medications (on-
site in Medford)
Program Screenings / Referrals
Mental Health Specialist
Observations
(ages 0-5)
Child-Parent Psychotherapy
Parent / Child Interaction Therapy
In-home support
Respite care during sessions
Addressing Childhood Trauma Behavioral Health Counseling (on-
site)
Psychiatric Services/medications (on-
site in Medford)
Program Screenings / Referral
Program Screenings / Referrals
Mental Health Specialist
Observations
Child-Parent Psychotherapy
Parent / Child Interaction Therapy
In-Home Support
Respite care during sessions
Discrimination Program Screenings / Referral Program Screenings / Referral
Resource Coordinator (clients only)
Deportation Program Screenings / Referral Referral Program Screenings / Referral
Resource Coordinator (clients only)
Other: Family Recreational /
Health & W ellness
Program Screenings / Referral Play groups 0-3, Family Fun and
Parent Events
GYM and Fitness Classes
Social Activities
Special Events
Swimming Lessons
Family Fun and Parenting Events
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ROGUE CHALLENGE INTERAGENCY SERVICE ARRAY

Social Determinant
of Health
Eagle Point
School District
Grants Pass High
School
Summary: no cost to
participant; children ages 5-
19 (21 in some cases) and
their families
Consumer Credit
Counseling Service
Summary: sliding scale
costs; employment
support
Douglas Education
Service District
Summary: sliding scale costs;
all ages
On-Track Siskiyou Community
Health Center
UCAN United Community
Action Network
Summary: Access/Referrals no cost
to participant; all ages, various
income levels; many services not
income dependent
Food Limited to enrolled students; free
breakfast and lunch for all
students
Pantry Services on-site; Emergency
Food & Nutrition
Housing Program Screenings / Referral Reverse Mortgage Counseling Rental Assistance, Deposit Tenant
Education; Tenant Advocacy Legal
Utilities Program Screenings / Referral Utilities Assitance; Deposits; Shutoff
Assistance;
Employment Program Screenings /
Referral/Intern
program/Volunteer program
Office supports Workforce Programs
for Veterans through Easter Seals
Income Assistance Program Screenings / Referral Budgeting/Financial
Counseling
Debt Management Plan
Bankruptcy Counseling and
Education
Financial Literacy; Money Management;
Free Tax Preparation, EITC
Education Full K-12 education services for
any child in the district
boundary. We serve ages 5
(must be 5 prior to Sept. 1 of that
school year) through ag 19 (or
21 in the case of Special
Education.
Financial Literacy Classes
Student Loan Counseling
Tenant Education (Rent Well)
Child Care On-site daycare in partnership
with Headstart; serves ages 3-4
Parenting Skills Case Management Support/Referral
Legal Assistance Referral/Resources & Advocacy
Health Care Onsite school-based health
center run by Siskiyou Medical
Insurance counseling for elders;
Medical billing advocacy
Medications Student medications
coordinated through district
nurse. At Grants Pass HS,
Transportation Transportation is limited to
students only; from home to
school and back home again.
Bus passes for homeless/unstably
housed
Domestic Abuse
Protection
Resource/referral
Mental Health Program Screenings / Referrals
Mental Health Specialist
Observations / Onsite fulltime
QMHP licensed counselor
(employed by Options); student
Case Management Support/Referral
Addressing Childhood
Trauma
Program Screenings / Referrals
Mental Health Specialist
Observations/ Staff training to
create TI classrooms
Case Management Support/Referral
Discrimination Administration support for
student dealing with
discrimination issues
Tenant Righst/Advocacy
Deportation Referral
Other: Family
Recreational / Health &
W ellness
Play groups 0-3, Family Fun and
Parent Events
Campus Closet (school age clothing &
supplies); Hygiene supplies; Barrier
Removal services for Homeless (ID's,
Mail, Birth Certificates); Respite for
Caregivers of Older Adults
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FORMS
& DATA ENTRY

Registration Form
Release of Information
Social Determinants of Health
LifeSpan Data Entry

NETWORKING
INNOVATIVE SOLUTIONS
PARTNERING FOR A FUTURE
PATH TO SELF ACTUALIZATION
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ROGUE CHALLENGE
Facilitated Registration

CLIENT PATIENT / NAME: FIRST MIDDLE LAST

GENDER: Male Female

BIRTH DATE: / / (MM/DD/YYYY) AGE:

ETHNICITY: Hispanic / or Latino

American Indian
Alaska Native
Asian
Black / African American
Native Hawaiian
Pacific Islander
White
Unknown
CONTACT PREFERENCE: (choose one or more)

By Home phone

Best Time to Call: Is it ok to leave a message? Y N

By Work phone

Best Time to Call: Is it ok to leave a message? Y N

By Cell phone

Zip/Postal Code:
Best Time to Call: Is it ok to leave a message? Y N

SSN# (Last 4 Digits):
OR
Mother's Maiden Name:

By Email

By Text

FOR OFFICE USE ONLY:

Additional notifications/prompts: 0

Automate Username: YES
Automate Password: YES
Choose screening? - Social Determinants of Health
GOAL 1:

GOAL 2:

GOAL 3:

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Rogue Challenge: Release of Information and Referral Consent For
Name:
Address:
City, State, ZIP:
If client/member is a minor:
Parent/Legal Guardian Name:
Address, if different:
Date of Birth:
Phone:
Email:

Phone, if different:
City, State, ZIP: Email, if different:

I acknowledge that I am a willing and active participant in the Rogue Challenge, a multi-agency program designed to assist me in
resource coordination and toward self-sufficiency. As a Rogue Challenge participant, I understand that the following information may
be shared if it is determined the information is relevant to an agency referral and/or for coordination of care/services (Please initial
each statement.)
Verbal and/or written information about my background and current personal/family situation
Verbal and/or written information about my health (physical, mental, and behavioral)
Verbal and/or written information about my goals
Verbal and/or written information about services I am engaged in and services that could support me
Verbal and/or written information about diagnoses, medical treatment notes, case notes, and program participation information
and results (Psychotherapy notes and Drug & Alcohol Treatment notes and HIV diagnosis will not be disclosed except as allowed by 42CFR
Part II.)
I understand that information that is currently covered by the Health Insurance Portability and Accountability Act (HIPAA) may be
re-disclosed on the basis of this authorization and may no longer be protected by HIPAA privacy law.
Unless otherwise limited, this authorization is valid for 12 months (one year) from the date of signature. I understand I have the right
to revoke this authorization at any time by submitting a written statement to the organization where you signed except to the extent
that action has been taken on it. I understand that this cancellation will not affect any information/referral that was already released
before the time that I revoked this authorization. I understand that the agencies seeking this authorization are not guaranteeing
treatment, payment, enrollment, or eligibility in any program whether I sign this authorization.
I agree to these terms and understand the following agencies have permission to share information and/or to refer me to services
that will best support me and my goals:

Rogue Community Health
Family Nurturing Center
Southern Oregon Head Start
Southern Oregon Goodwill
Eagle Point School District
Grants Pass High School
On Track
Siskiyou Community Health Center
Rogue Valley Family YMCA

United Community Action Network

Consumer Credit Counseling Service

Hearts with a Mission

I have read the above and understand what this authorization means. I am satisfied with any explanations I have requested and
received. I approve the release of information and consent for referral as designated above. A photocopy, fax, or pdf shall be as
valid as the original. I have been given a copy of this release.

Participant/Parent/Guardian Signature: Date:

Rogue Challenge Representative:
Date:
Rogue Challenge Partner Agency:
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Disability insurance

Social Determinants of Health

Social Determinants of Health Survey
Please answer the following questions as honestly as possible.

1. Describe your current employment status: Choose not to answer
Employed full time
Employed part-time
Seasonally employed
Active military
Unemployed
Retired
Disabled
2. What is your level of education? Choose not to answer
Less than 8
th
grade
8
th
grade
9
th
grade
10
th
grade
11
th
grade
12
th
grade
Trade school
2 year college
4 year college
College graduate
Graduate degree
Post graduate
3. Please specify what government, private insurance, or charitable assistance, if any, you
currently receive (select all that apply): Choose not to answer
None
Food stamps
Unemployment insurance
Worker ’s compensation insurance
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No

Social security
Medicaid
Welfare payments
Charitable assistance
Other :
4. Is your monthly income (including any assistance specified above) adequate to meet your
basic needs for housing, utilities, food, transportation, healthcare, and prescription medications?
Choose not to answer
Yes
No
5. How frequently do you (or your children) NOT have enough food to eat? Choose not to
answer
Never
Sometimes
Frequently
All the time
6. Do you have access to adequate medical/healthcare services? Choose not to answer
Yes
No
7. What is your housing situation today? Choose not to answer
I have housing of my own and am NOT worried about losing it
I have housing of my own, but am worried about losing it
I do not have housing of my own (staying with others, in a hotel)
I am homeless (living on the street, in a shelter, in my car)
I am living in a half-way house, or am enrolled currently in an in-patient treatment program
8. Do problems getting child care make it difficult for you to work or study? Not applicable
(do not have children)
Yes
No
9. Are you periodically or frequently exposed to polluted air, polluted drinking water, or
environment toxins, either in your living environment or your workplace? Choose not to
answer
Yes
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10. Describe the safety of your neighborhood or surrounding environment Choose not to
answer
Very safe
Safe
Unsafe
Dangerous
11. Do you have family members, or a broader network of friends, who you can rely upon for
emotional support when you need it? Choose not to answer
Yes
No
12. Do you have access to transportation? Choose not to answer
Yes, my own vehicle
Yes, public transportation
No
13a. Do you ever feel discriminated against? Choose not to answer
No
Yes
14. Do you experience verbal, physical, or sexual abuse of any kind, or bullying, intimidation or
harassment, either in your living environment or your workplace? Choose not to answer
No
Yes, in my living environment
Yes, in my workplace
Yes, in both my living environment and my workplace
15. Is the fear of deportation keeping you from seeking health or other care or social services?
Choose not to answer
Yes
No
16. As a child, adolescent, or teen, which of the following, if any, did you experience? (select all
that apply) Choose not to answer
Verbal abuse
Physical abuse
Sexual abuse
Neglect
Violence or threats of violence from a parent, caretaker, or other close family
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Abandonment by a parent, caretaker or other close family member
Periodic or ongoing hunger
Bullying
Death or suicide of a parent, caretaker or other close family member
Imprisonment of a parent or caretaker
Mental illness on the part of a parent, caretaker or other close family member
Separation or divorce of your parents or caretakers
None of these
17a. Please indicate which of the following you need help with, if any
Food
Housing
Utilities
Employment
Job training
Income assistance
Education
Daycare/childcare
Parenting skills
Legal aid/legal assistance
Access to healthcare
Paying for medications
Transportation
Protection from domestic abuse
Mental health services
Addressing childhood trauma(s)
Discrimination concerns
Deportation concerns
Other

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ROGUE CHALLENGE
LIFESPAN SOFTWARE

Partner Registration
https://rogue.lifespanplatform.com/ResourceRegistration.aspx

Access Code: rogue

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LIFESPAN SOFTWARE

Fill out Registration and Submit

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LIFESPAN SOFTWARE

REGISTER A CLIENT
https://rogue.lifespanplatform.com/

Click Log-In and fill out your user name and password

Click “Facilitated Registration ”
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ROGUE CHALLENGE
LIFESPAN SOFTWARE

Fill out Client Information
Click to install a “mock email ”
Automate User Name & Password

Choose ‘0 ’ for Additional Notification/Prompts

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LIFESPAN SOFTWARE

Select “Assessment ” for screening type

Social Determinants of Health screening

Review and complete SDOH with client

Submit the results and it will populate a list of needs. These needs will be used to refer to
other agencies and to set goals with clients.
ROGUE CHALLENGE

71

ROGUE CHALLENGE
LIFESPAN SOFTWARE

Refer to Admin HUB (Partners)
To refer to partners, the referral must first go to the Admin HUB.
Return to your home page by selecting my account:

Review the Social Determinants of Health Screening to determine risk factors and to help
develop goals

ROGUE CHALLENGE

72

ROGUE CHALLENGE
LIFESPAN SOFTWARE

Select the “wrench ” then select “refer ”

Add goals and the agencies you would like to refer to

Select Submit
ROGUE CHALLENGE

73

ROGUE CHALLENGE
LIFESPAN SOFTWARE

2932

Admin HUB Referral to Partners
Admin HUB receives the referral in the referral box and reviews the instruction /
comments to determine where to refer the client to

Admin then refers the client by selecting the wrench icon, ‘refer ’, and selecting the
partnering agency name.

An email is sent out to each agency to accept the new referral.
ROGUE CHALLENGE

74

FAQs
Most Common Questions & Answers
by Staff

WORKING TOWARD SUCCESS

Improved Patient Well-being
Increased Access to Services
Personal Engagement and Activation Towards Goals
Shared Common Language for a Shared Common Impact
ROGUE CHALLENGE

75

Abstract (if available)

Abstract The Rogue Challenge is a trans organizational, community governed system of shared case management. The Rogue Challenge uses Social Learning Theory to guide interagency trainings in developing meaningful partner relationships and aligned language for inclusive engagement with consumers. The Rogue Challenge also uses a shared software platform to provide closed-loop referrals for partners.

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Asset Metadata

Creator Bair, Ryan Douglas (author)

Core Title The Rogue Challenge

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Defense Date 04/16/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag equity,intervention,OAI-PMH Harvest,social determinants of health

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Manderschied, Ronald (committee chair), Gosh, Subharati (committee member), James, Jane (committee member)

Creator Email rbair@usc.edu,ryanbair2@hotmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-300650

Unique identifier UC11663549

Identifier etd-BairRyanDo-8473.pdf (filename),usctheses-c89-300650 (legacy record id)

Legacy Identifier etd-BairRyanDo-8473.pdf

Dmrecord 300650

Document Type Capstone project

Rights Bair, Ryan Douglas

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA