School of Public Health

Oregon Modifies the Medical Neighborhood

October 2016

Institute on Development and Disability | Oregon Heath Sciences University

In 2017, the Oregon Center for Children & Youth with Special Health Needs (OCCYSHN) will begin implementation of a new medical neighborhoods initiative. Based on the model from the Agency for Healthcare Research and Quality (AHRQ), the work will focus on meeting the needs of the individual patient, but also incorporate aspects of population health and overall community health needs. OCCYSHN has adapted the model to serve children and youth with special health needs (CYSHCN) through:

  • Community partnerships with ‘neighbors’ e.g., educators, mental health providers, primary and tertiary care providers, payers, as well as public health agencies
  • Regional team-based approaches to cross-systems care coordination
  • Family-professional partnership
  • Culturally and linguistically appropriate services

OCCYSHN’s new initiative builds on the State’s well-established medical home model and community-based care coordination experience with Community Connections Networks Teams and CaCoon, a Public Health Nurse home visiting program. OCCYSHN works closely with the Oregon Family-to-Family Health Information Center to ensure that families will be partners in the implementation of the medical neighborhoods.


OCCYSHN will take a two-pronged approach to connect multiple entities . The two components reflect processes that will strengthen support of individual children, youth and families as well as that of regional systems of care.

Shared Plans of Care (SPoC): The SPoC is a tool the ‘neighbors’ and family may use as a team to plan and coordinate care, and to actively work to address gaps, barriers and redundancies in the system of care for children and families. A SPoC promotes cross-system family-centered care for those CYSHCN who are best served by a team-based approach. SPoC Teams will be anchored by public health departments in counties across Oregon.

REACH (REgional Approach to Child Health) Teams: REACH teams will work to improve cross-agency infrastructure to support systems integration for CYSHCN. They will consider the gaps, barriers and redundancies in the system of care identified through the SPoC process, as well as other data, in order to determine areas of focus. For example, teams may develop and test improvements to address gaps in communication infrastructure or funding concerns. OCCYSHN intends to align these efforts with those of other organizations, such as coordinated care organizations, early learning hubs, or mental and behavioral health wraparound systems in a given region.


OCCYSHN did exploratory work in Central Oregon around these initiatives and found that the concept of bringing together broad-based, cross-agency teams to support children and youth with special healthcare needs resonate well with professionals and families. Public health departments across Oregon have already begun working on Shared Plans of Care.

During 2016, OCCYSHN is studying which regions might be most suitable for REACH Team development based on needs assessment and opportunities for leveraging aligned efforts. OCCYSHN will launch REACH teams in five Oregon regions in early 2017.

To learn more about this initiative contact Caroline Neunzert or Marilyn Berardinelli at or call 503.494.8303