Success Story

Community CarePort HUB


Cascade Pacific Action Alliance (CPAA) was established as an Accountable Community of Health (ACH) to provide health and social needs-related care and access to improve the health of individuals within a region. In 2018, CPAA combined Washington’s Medicaid Transformation Project (MTP) goal with Washington’s Section 1115 Medicaid waiver funding to launch Community CarePort HUB as a solution to reduce barriers to care for community members. CarePort partners with local agencies that are trained to identify and reduce individual and household social determinants of health.

CCS Health™ and Community CarePort teamed up at the HUB’s conception, and have continued to grow the relationship and the HUB’s capabilities since. Community CarePort HUB now contracts and administers services to more than 10 care coordination agencies and operates across seven counties, while servicing more than 1,500 clients by over 80 Community Health Workers (CHWS).

  • Enroll 1% of the Medicaid population in the region (~4,000 people) in their services as part of their accountability to the Medicaid Transformation Project
  • Identify health-care and social-support gaps within the community and work to address them as part of their Accountable Community of Health commitment.
  • Provide accurate and timely reporting of quality and care outcomes to Care Coordination Agency (CCA) Supervisors
  • Contract with funders to generate sustainable work for local Community Health Workers (CHWs)
Our Partnership

Given the complexity of the work, the large region (8,322 square miles), and the volume of the agencies, CHWs, and clients they were serving and integrating, CarePort needed a solution that would make their work more efficient and provide simpler tracking and measurements of client and CHW activities across the HUB. After a careful review, CCS Health™ was chosen for its robust capability, speed of implementation, and integration with the Pathways model.

CCS Health has worked with the Cascade Pacific Action Alliance since the beginning to get the CarePort Community HUB from concept to creation. To ensure that the solution met their needs and aligned with best practices, CCS Health provided consultative services from design through launch. The HUB was grateful for the support as it allowed them to quickly build and scale their caseload and service offerings as a new HUB.

CCS Health works with CarePort to effectively manage, track and report on staff and clients using the capability of CCS Health Fortify. The Community Health Record supported Community Health Workers, Supervisors, and HUB administration to keep records up to date, focused on effective client engagement, and moved clients through stabilization and empowerment phases of care coordination.® allowed them to leverage and integrate robust resource and referral platform functionality with the support of the Community Based Workforce. Reporting and data extraction increased outcome ownership and enhanced Supervisors’ ability to create and share reports with the community and governance. Data and reports also make it simpler to evaluate community outcomes and make changes to improve quality assurance and improvement (QA/QI) metrics. The CCS Health invoicing module generates invoices for outcome-based work (e.g., services completed, or resources received by the client) that community health workers and care coordinators support. This increases efficiency and significantly improves the organization’s ability to create sustainable revenue.

The robust functionality and trusted support that CCS Health provides continue to support Community CarePort HUB’s operations, allowing them to make quick and meaningful strides toward improving health in their community.

  • 3,441 of the 6,789 clients enrolled since the HUB’s start had Medicaid documented as their insurance-of-record, nearly meeting their initial goal of 1% Medicaid population enrollment
  • Identified food insecurity and housing needs in the communities they serve and used innovative solutions within the technology to address those concerns:
    • Hunger Response Initiative: As a result of data captured through the Community Health Record, the HUB identified a high rate of food insecurity within their community. The Supervisor worked with the CCS Health’s team to create a custom form within their Community Health Record to track “Fruit & Veggie Vouchers” that Community Health Workers shared with their clients. The form allowed them to collect usage data every time those vouchers were returned by local grocers and supermarkets after they had been redeemed by clients. These data were then consolidated into a report that was used as support documentation to increase funding for the project—from a $5,000 grant for the initial pilot to between $25,000 to $50,000
    • Housing: The CarePort HUB network uses the Community Health Record and to track and manage education and referrals, and last year successfully completed the most Housing Pathways of any HUB on the CCS platform in the country
  • Captured inputs and developed reports to show quality assurance and improvement (QA/QI) data within all CCAs over time.
    • Data enhanced dialogue about performance between HUB and CCAs and between Supervisors and CHWs that led to process enhancements to address quality assurance metrics

    • Reporting allowed those measurable improvements to easily be shared with HUB Advisory to then make decisions about and/or adjust their approach

“It allows us to work in a broader scope of how we can work with clients,” she said. “Before, I might work with one client on employment only, and now I can work with a client on finding a doctor, finding a dentist, going with them to their appointments, helping them feel comfortable, going with them to an interview, job coaching — there’s so many things.”

– Jennifer Brackeen, Program Director, Cascade Pacific Action Alliance (CPAA)