Providence Health & Services — Portland, OR


Providence Health & Services works to improve care, reduce health disparities, and strengthen coordination between clinical and social services at three local clinics that serve many low-income individuals with diabetes.

The program identifies gaps in care and then deploys multidisciplinary teams to address them. Three pilot clinics embed full-time community resource specialists who are multilingual and multicultural; they are also trained in motivational interviewing and trauma-informed care to provide referrals to local resources, social services, and benefit programs. In addition, the organization conducts outreach to community residents who are at risk of diabetes or may have unmet diabetes-related health needs.



Improve access to high quality clinical care for Medicaid and uninsured populations with type 2 diabetes in three pilot clinics

  • Identify patients with clinical care gaps via enhanced registry tools. Use in-reach and outreach strategies to close the care gaps
  • Use EMR order sets to encourage providers to follow standardize pathways for type 2 diabetes patients that maximize outcomes by connecting patients to a variety of medical, social, and other resources
  • Provide multidisciplinary, team-based care management for high-risk patients facing complex health and social challenges.
  • Use provider feedback dashboards to track progress in closing care gaps and give regular feedback to the care teams to drive change

Improve access to social services, and the integration between clinical and social services, for type 2 diabetes patients in three pilot clinics

  • Implement a standard screen and referral process for social determinants of health challenges that uses existing clinic EMR tools and workflows
  • Co-locate a high-performing social service agency in DCII clinics to connect screened patients with needed social services

Improve access to diabetes self-management education and tools for patients and families in three pilot clinics

  • Co-locate in-person, multilingual diabetes management education for diabetes patients and their families in DCII clinics
  • Provide access to a multilingual and culturally appropriate digital diabetes self-management tool for prevention and chronic disease management

Increase awareness of healthy behaviors among community members and strengthen the relationship between the community and the DCII clinics

  • Train community members to conduct community outreach in areas surrounding the three pilot clinics, providing coordinated services and helping to connect community members to primary care and social services

Providence Health & Services and their community partners are focused on supporting unmet medical and social needs:

  • Providence Health & Services and ImpactNW established the Community Resource Desk to assist individuals and families in need of support with connections to resources in their community. This free and confidential service is open to everyone, both patients and community residents, regardless of insurance or immigration status.
  • Providence established a Community Teaching Kitchen and Community Food Market to inspire hope, healing, and health in a warm and patient-centered environment. CTK staff and volunteers facilitate access to nutritious food, teach culinary skills, and navigate visitors to needed resources.
  • Providence has a longstanding partnership with Ride Connection, a local nonprofit organization that provides free transportation options to a tri-county region. In 2019 the partnership launched the Mobility for Health program, which aims to increase positive health outcomes by providing access to transportation resources. The program co-locates a Ride Connection staff on-site at Providence to support staff and patients with real-time direct service support
Trista Johnson, PhD

Bill J Wright, Ph.D.

Vice President
Health Innovation Research

Bill J Wright, Ph.D. is the VP for Health Innovation Research at Providence, where he oversees research designed to advance health care transformation.  Dr. Wright is a sociologist with a principal focus on survey design and specializes in longitudinal research with low-income and vulnerable populations. His research focuses on the intersection between health policy, health systems design, and the social determinants of health. Dr. Wright was principal investigator on the Oregon Health Insurance Experiment, the first-ever randomized trial on the effects of health insurance, and has led numerous other studies of health policy and care innovations.

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