Eastern WA COHE

"This project is truly a textbook case of community need driving
collaboration and innovation with favorable shared outcomes.
This COHE is an up-close look into the future of healthcare."

Dr. Dan Hansen, COHE Director

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Bringing COHE
to Spokane

In 1999, some very enlightened representatives from businesses and labor unions approached Tom Fritz, CEO of INHS and St. Luke's Rehabilitation Institute in Spokane. They were expressing a strong interest in having SLRI be a 'community sponsor' for an emerging project to implement occupational health 'best practices'. Central to that effort were the early COHE Champions: Ed Wood, Larry Hall, Larry Arnold, Dorthea Walters, Dennis Antonellis, Timm Ormsby, Danny McDaniel, Gary Smith, Judy Heusner and Kelli Pearson.

With the strong commitment of Mr. Fritz, this early group became organized and empowered a community advisory board in advance of a request-for-proposal from the Department of Labor & Industries in 2001. This group performed a community-based needs analysis and formed working committees based on the set of Occupational Health Services white papers released by a study team from L&I and UW.

Following the release of the RFP, the St. Luke's Team prepared a competitive proposal to serve as a Center of Occupational Health & Education in communities served by INHS. This proposal was ultimately accepted and a contract between SLRI and L&I was finalized Dec 12, 2002 (L&I Contract No. 02C-30).






of the Spokane COHE 

Scott Graham was selected as the Program Director through the development phase in the first half of 2003. Importantly, the development time prior to roll-out was only 6½ months. During that time, processes for provider recruitment and orientation, case management / care coordination and information tracking were developed. Dr. Dan Hansen and an INHS web development team developed the prototype Occupational Medicine Information Tracking System (OMITS) that would ultimately be used by provider, employer, worker, COHE staff and some L&I staff end-users to securely share return-to-work information. Additionally, Drs. Judy Heusner and Dan Hansen co-edited the COHE Provider Manual.

Also in this development phase saw the frequent use of community-based working committees -- for the development of forms and job-aids, finalizing care coordination elements to be used by Health Services Coordinators, designing provider education, and strategizing community outreach. Each of these committees were comprised of content experts from the community including members from business, labor unions and providers.

Additional COHE Champions emerged: Karen Gude, Pat Holmstead, Myron Bloom, Norm Charney, Mark Mueller, Pete Zografos, Curt Fackler, Jason Stoddard and Ellen Nagarney.





Spokane COHE Becomes

The Spokane COHE officially became operational July 1, 2003 with 70 Attending Pilot Physicians in Spokane, Grant and Stevens Counties. Within the next year, the COHE would orient a total of over 250 providers, exceeding projections set forth in the COHE contract. Claim volumes would also increase at a significant rate, soon challenging existing information exchange capabilities. SLRI and INHS administrators quickly facilitated necessary improvements in the related hardware needs.

The core COHE staff included Kim Carroll, Pam Cromer and Dr. Dan Hansen. The functions of the Health Services Coordinator (Cromer) continued to improve in efficiency and effectiveness with feedback from community advisors and experts from the Dept. of L&I.

As part of the Program Contract, the COHE is guided by an advisory board of community leaders from business and labor unions. The initial composition of the COHE Business-Labor Advisory Board (BLAB) developed their by-laws, mission statement and leadership roles. They meet at least quarterly in Spokane.

In 2004, members of the UW study team made a site visit to the Spokane COHE, interviewing COHE staff, SLRI administrators, employers and providers. This visit resulted in the first formal evaluation by this study team, the Spokane COHE Process Evaluation.

The UW study team also collected claim-related data of COHE (and non-COHE) claims from 2004-2005, and surveyed injured workers and providers. The subsequent report was the formal Outcomes Evaluation of the Spokane COHE.


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Eastern WA COHE

Prior to the 2005 Washington State Legislative session, staff members of the Dept. of L&I and administrators of SLRI determined that the infrastructure of the Spokane COHE was sufficient to expand into the additional 12 Eastern WA Counties mentioned in the original proposal and served by INHS. L&I put forth a budget request for that expansion. Statewide business and labor leaders sought to include Yakima County in this expansion and accordingly added an amendment to the 2005 State budget. The budget was approved and expansion into the 16 counties now known as the Eastern WA COHE was to begin July 1, 2005 as part of the contract extension (L&I Contract No. 02C-30-2). The Eastern WA COHE does not recruit providers in Benton, Franklin, Kittitas and Klickitat Counties, as they were not part of the original proposal from SLRI.

Provider recruitment and orientation occurred at a fast pace in these expansion counties. Claim volumes seen in the COHE office grew proportionately, requiring upgrades to fax and computer equipment and software. The prototype Occupational Medicine Information Tracking System web application was replaced by a more robust and scalable production version known as Athena. It became necessary to increase administrative support and data entry staff and add an additional Health Services Coordinator (Tom Martin). By 2007, the number of participating providers in the expansion counties exceeded target projections set forth in the COHE contract.

Business and labor leaders in the greater Yakima area saw the need to have a regional advisory function to the COHE and initiated the Yakima-Area Advisory Committee, which continues to meet on a regular basis. Soon afterwards, a similar advisory committee formed in the greater Wenatchee area. Key administrators of L&I's Region 5 offices have played an important role in these advisory meetings. Business and labor representatives of these groups were also added to the COHE Business-Labor Advisory Board.

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Quality Improvement



The Eastern WA COHE is now in its third funding cycle (L&I Contract No. 02C-30-3). The emphasis of this contract extension is to demonstrate capacity for quality improvement, sustainability of gains made, and transferability of processes and tools to new practice settings.

COHE staff and advisors have been able to view contextually-correct process and outcomes data and use it to improve processes and provide close to real-time feedback to providers and health care facilities. These "provider scorecards" have become important to participating providers and their support staff, as they look forward to regular reports of their progress over time, and compared to their peers. Opportunities for quality improvement emerge from these reports.

Additionally, L&I staff provided scorecards to the COHE teams related to overall performance to the best practices of the project. This data has been tracked over the duration of the COHE projects in Renton and Spokane, and evidence of sustainability is realized. A report, COHE Summary Findings, was published in December 2007. This report provides high level findings from multiple formal outcomes, process and performance evaluations. The UW study team evaluated data for the initial cohorts of injured workers of 2004-2005 for a 3-year follow-up study. This Long-Term Follow-Up Study for the COHEs has again demonstrated sustainability in further decreasing time-loss disability, increased savings of claim costs (medical & disability), and other factors.

The UW Study Team has since looked at injured workers treated more recently by the same providers as the initial cohort. The Report on the Outcomes of the Original COHEs' Later Cohorts demonstrates two major points: a "preventative effect" and a "maturation effect" related to time loss days experienced by the injured worker. 

Transferability of the effects of implementation of occupational health best practices has yet to be demonstrated. However, once the UW study team completes their evaluation injured worker claims in the COHE expansion counties, conclusions can be made regarding the ability to transfer the processes and tools associated with these evidence-based best practices.

While there is no claim-related data analysis on the E WA COHE expansion counties to date, the UW Study Team has conducted a series of focus groups with COHE providers, provider office staff and employers. In their Report on the Health Care Provider, Office Staff and Employer Focus Groups, the team found that the "focus group participants were very positive about COHE and its ability to promote best practices and improve quality." Of interest, the employer focus group for Eastern Washington is from Yakima County.

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For more information contact Dr. Dan Hansen, Program Director - (866) 247-2643.

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