• OHSU Scappoose shifted to a patient-centred medical home/value-based care model without a shift in the funding model. 
  • The OHSU Scappoose focus on process and quality improvement projects has improved workflow, and staff engagement.
  • At OHSU Scappoose, data cleansing (led by medical assistants), panel coordinators and team based care have resulted in improved screening, immunisation (but still a long way to go), and health maintenance 
  • One of the key elements of Patient-Centred Medical Homes in Oregon is round-the-clock phone access to health advice and self-management support—with patients at the centre.
  • Care coordinators at OHSU Scappoose are the ‘kind voice in the clinic’—a contact point for patients who are not otherwise well supported.
  • At OHSU Scappoose there are support groups and wellness groups that aim to promote self-care and better health literacy.