Enhancing Systems of Services (SOS)

Enhancing Oregon’s System of Services for Children and Youth with Special Health Care Needs

In 2014, OCCYSHN received one of twelve state implementation grants from the federal Maternal and Child Health Bureau to work towards a comprehensive, coordinated, and integrated system of care for Oregon's children and youth with special health care needs (CYSHCN). The primary goal of the SOS (System of Services) grant is to develop and implement a State Plan to ensure a coordinated system of care serving CYSHCN and their families, and to increase the percentage of Oregon CYSHCN who receive care through a Patient and Family Centered Primary Care Home (medical home).

The SOS Initiative is consistent with Oregon's healthcare transformation efforts, which support the Triple Aim of achieving better population health, a better patient experience, and lower costs. The State Plan will focus on population outcomes for CYSHCN through systems coordination and integration, patient and family involvement, and medical home.

SOS - An Overview (PDF)

SOS State-Specific Strategies

The SOS Initiative will create and implement a plan of action to create an integrated system of care for CYSHCN (the State Plan). The State Plan (which is in development) will do the following:

  • outline the context for SOS
  • summarize relevant needs assessment findings
  • identify goals, strategies, outcomes and timelines
  • highlight partnerships, opportunities and challenges
  • delineate the roles and responsibilities of stakeholder organizations. 

The State Plan employs three fundamental strategies:

  • Work with four medical practices across the state to increase the number of certified Patient-Centered Primary Care Homes (Medical Homes);
  • Improve capacity for community-based care coordination by working with one community to assess their challenges and opportunities, and using that understanding to inform statewide policy change;
  • Explore possibilities for a statewide "shared resource" for families seeking information, referral and support.

AMCHP Standards for Systems of Care for Children and Youth with Special Health Care Needs

AMCHP's Standards for Systems of Care for Children and Youth with Special Health Care Needs provides a framework for the SOS Initiative. The Standards were derived from a comprehensive literature review, input from key informants, case studies of standards currently in use, and guidance from a national work group of experts. Since the inception of the grant, OCCYSHN has been assessing Oregon's system of services for CYSHCN in relation to the Standards. The State Plan will reflect and incorporate the Standards. 


Needs Assessment

OCCYSHN's Title V Maternal Child Health Block Grant Five Year Needs Assessment (2015) provides data and evaluation on the status of CYSCHN and their families in Oregon. The assessment used a variety of tools and methods to survey youth, families, health care providers, and care coordinators about challenges and opportunities in Oregon's current system of care. The SOS Initiative is using data and evaluation from the Needs Assessment to direct our efforts.

Cross-state Learning Community/Systems Integration Academy

As part of the SOS Initiative, Oregon is participating in a national learning collaborative (the Systems Integration Academy, or SIA) in conjunction with the eleven other states that received a state implementation grant. The SIA is supported by the National Academy for State Health Policy (NASHP) in partnership with the National Improvement Partnership Network (NIPN).  NASHP has convened Strategy Teams with representation from all twelve states in three focus areas: 1) Cross-systems Care Coordination; 2) Integration; and 3) Shared Resource. 

In the first year of the project, each Strategy Team will work together to develop a common goal and measures for success. All twelve states will work towards those goals, using a variety of approaches.  In the second and third year of the project, the Strategy Teams will convene to share experiences, resources, and strategies.

Project Staff and Partners

OCCYSHN convened three groups to pursue the goals of the SOS grant:

State Advisory Committee (SAC) – This group includes the Oregon Health Authority's Director of Policy, who is also the Interim Medicaid Director; Oregon's Title V MCH Director, the President of the Oregon Pediatric Society, and a family representative. The SAC's purpose is to ensure the work toward a comprehensive, coordinated and integrated system of services for CYSHCN aligns with Oregon's health care transformation efforts. The committee works on identifying policy and system changes necessary to create an integrated system of services for CYSHCN. The SAC will vet the draft State Plan.

State Implementation Team (SIT) – The SIT develops implementation strategies for improved systems of services for CYSHCN. Members of the SIT provide input into grant activities, participate on one of three cross-state Strategy Teams through the SIA, review key documents, and provide other counsel and advice as needed. SIT membership includes representation from the Division of Medical Assistance (Medicaid), Title V. the Oregon Pediatric Improvement Partnership, the Behavioral Health Division's Children's Mental Health section, a family representative, Early Intervention/Early Childhood Special Education, Oregon's Transformation Center, the Oregon Patient-Centered Primary Care Home Program, and Oregon's Early Learning Division.

CYSHCN Stakeholders Group – Membership of this group is broad and spread throughout the state. We will share information about grant activities with this group; solicit input on specific questions and, if necessary, ask them to participate in workgroups.



Alison Martin, PhD - Project Director

Laura Rodriguez, MSW - Project Coordinator