Case Study Highlights How We Ensure Safe Hospital Discharges

By August 16, 2018 One Comment

The Center for Health Care Strategies, an organization which “advances innovations for healthcare delivery for low-income Americans,” earlier this month highlighted our C3 Community Assistance Program in the case study titled “Project Access NOW’s C3 Community Assistance Program: Ensuring Safe Discharge from the Hospital.”

The case study is

We reprint the case study here with the Center’s permission in full, with minor formatting edits.

Ensuring Safe Hospital Discharges: C3 Community Assistance Program at a Glance

  • Summary: Connecting individuals in Portland, Oregon to needed paid community-based services along with social services to ensure safe hospital discharges from emergency and inpatient hospital settings.
  • Partners: Project Access NOW, Kaiser Permanente, Providence Health and Services, FamilyCare, and Health Share (coordinated care organizations [CCOs]).
  • Goals: Improve care transitions for uninsured and low-income individuals.
  • Partnership Model: Referral services.
  • Scope of Services: C3 Community Assistance Program connects patients to resources such as transportation, medication assistance, and temporary housing to mitigate challenges that might result in additional care or hospitalizations.
  • Funding: Donations and payments from participating health system partners/CCOs.
  • Impact: Since its inception, C3 Community Assistance Program has served more than 17,000 clients and filled more than 26,000 requests; 740 hospital days were avoided through C3 Community Assistance Program services.


Addressing social needs, particularly among vulnerable populations, is critical to improving outcomes and ensuring health equity. In Portland, Oregon, Project Access NOW, a local community-based organization (CBO), is improving the health and well-being of uninsured and low-income individuals by connecting them with health care, non-medical services, and other community resources.

The C3 Community Assistance Program, a Project Access NOW service supported by six area hospital systems and two coordinated care organizations (CCOs), helps individuals successfully transition from the emergency department and inpatient hospital stays back to their homes by addressing social determinant needs that impact health and recovery.

The end goal is simple: to keep people healthy and avoid unnecessary readmissions.

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Project Access NOW connects vulnerable residents in the metro Portland area to needed health care and social services by building on the strengths of local health care systems and community-based organizations. Since 2008, Project Access NOW has partnered with local health systems, hospitals, and CCOs to:

  1. provide uninsured low-income community members with primary and specialty care;
  2. pay health insurance premiums for people who qualify for coverage under the Affordable Care Act, but cannot afford their premiums; and
  3. connect low-income people being discharged from the hospital to non-medical resources to help them get home safely and ensure access to follow-up care via the program known as C3 Community Assistance Program.

In addition, Project Access NOW’s Pharmacy Bridge Program offers prescriptions at no cost or with low-copays.

This case study describes Project Access NOW’s C3 Community Assistance Program, which partners with hospitals and CCOs to facilitate safe transitions from inpatient hospitalizations and emergency department visits to home settings.

C3 Community Assistance Program: Replicable Approach for Ensuring Safe Hospital Discharges

C3 Community Assistance Program offers a potentially replicable approach for other communities seeking to streamline access to post-discharge community-based services. C3 Community Assistance Program supports frontline hospital staff, including discharge planners, social workers, and care managers, to connect low-income patients to resources, such as transportation (bus fares, taxi cabs, and ambulances), medication assistance, and temporary housing (hotels, rental assistance, respite care). The program is focused on ensuring safe hospital discharges and mitigating challenges that might result in additional care or hospitalizations.

Project Access NOW works with over 100 vendors to provide patients with vouchers as they are discharged from the hospital that are reimbursed by Project Access NOW using donated hospital funds.

Since its inception in 2014, C3 Community Assistance Program has served more than 17,000 clients, and filled more than 26,000 requests.

And, while it is difficult to prove a linkage between the provision of non-medical services and avoided re-hospitalizations, anecdotal evidence suggests that the program is cost effective.

According to Project Access NOW’s analysis, C3 Community Assistance Program costs are roughly $638,000 per year, while the program helps to avoid nearly 740 inpatient days annually, saving an estimated $2.78 million.

History of Partnerships with Hospitals

Project Access NOW’s partnership with hospitals started when Providence Health and Services, the local health care system, recognized that patients leaving the hospital often faced many non-medical barriers, such as unstable housing or inability to fill prescriptions. These barriers compromised their recovery and impeded follow-up care regimens. Although hospital staff worked to refer patients to suitable social services, the approach to referrals was inconsistent and not systematized and staff were faced with considerable administrative challenges. Moreover, hospital staff often felt challenged to connect patients with appropriate resources since they lacked familiarity with the full range of community service vendors available.

Partnering with Project Access NOW has allowed Providence to deliver non-medical services in a more efficient, tailored, and comprehensive manner. Project Access NOW, which serves as a single point of service, was seen as an ideal partner due to its extensive community ties and existing online referral and tracking system.

While Project Access NOW had been working with community-based partners for over a decade, their partnerships with hospitals via the C3 Community Assistance Program introduced new relationships, expanding referrals in areas deemed high priorities by hospitals and connecting high-need patients with programs and services aimed at reducing lengthy hospitalizations and readmissions.

Project Access NOW has since partnered with Kaiser Permanente, and more recently FamilyCare[1] and Health Share CCOs, to help administer the health-related services component of Oregon’s Medicaid program.[2] Project Access NOW expects other CCOs and health systems to participate in the C3 Community Assistance Program by the end of 2018.

Through C3 Community Assistance Program, hospitals and CCOs have access to a secure, electronic referral system, which serves as a screening and monitoring tool, and allows frontline hospital staff to connect eligible patients with vouchers for an array of services and programs to meet their needs.

C3 Community Assistance Program provides training and support, and facilitates vendor agreements and payments.

The data platform allows health care partners to monitor social service utilization and related costs, as well as evaluate associated patient outcomes.

C3 Community Assistance Program enables hospitals to assist with their patient’s social determinant needs, such as housing or food insecurity, while remaining in compliance with Centers for Medicare & Medicaid Services rules around gifting.[3] Hospital staff can rely on C3 Community Assistance Program’s extensive network to connect patients with necessary community services and supports and stay focused on the provision of health care services.


As an independent, non-profit entity, Project Access NOW has a board of directors that provides input on all of its programs, including the C3 Community Assistance Program.

The C3 Community Assistance Program program itself utilizes eligibility policies, a scope, and processes to help navigate unusual requests and/or denial appeals.

Each health system employs a program coordinator to coordinate with Project Access NOW’s deputy director and program manager.

Partnering health systems have a letter of agreement and/or a Business Associate Agreements with Project Access NOW to administer the C3 Community Assistance Program. Project Access NOW has a formal contract and Business Associate Agreement with Health Share, which pays for C3 Community Assistance Program services from their global budget.


During the discharge process, care managers at partnering hospitals and CCOs identify needs that could potentially jeopardize the transition and recovery process. Patients with identified needs are screened for eligibility for C3 Community Assistance Program by using an online tool known as CLARA (Community Linked Assistance Referrals Assessment). C3 Community Assistance Program staff train hospital and Health Share users on program eligibility criteria, and how to access and use CLARA.

Screening assesses insurance coverage status, income level, and access to community or family support. During the screening process, care managers often identify one issue, such as lack of reliable transportation, and in so doing, uncover other needs, such as short-term and stable housing needs.

Based on the screening results, social service requests are entered into CLARA and are either accepted immediately, or reviewed by Project Access NOW staff if service requests are more extensive. For example, the Recuperative Care Program offered by Central City Concern, which provides temporary housing post discharge for patients without stable housing, requires prior approval from Project Access NOW before vouchers are issued. When service requests are accepted, eligible patients receive a printed voucher in the hospital for immediate use with participating vendors.

Project Access NOW phased hospitals into the program in order to keep pace with referral requests and address workflow challenges. During initial implementation, one Project Access NOW staff member handled all C3 Community Assistance Program requests, after which Project Access NOW hired additional staff, including a program manager and two support staff who answer phones, process referral requests, connect clients to the Pharmacy Bridge Program, and provide additional referral coverage when volume is heavy.

Integrating C3 Community Assistance Program into FamilyCare and Health Share CCOs have highlighted challenges that are unique to managed care plans. For example, Health Share faced initial challenges related to having supplies like bus tickets, phones, and shelter vouchers on hand to provide to members as needs arise.

Unlike hospital-based referrals, where frontline hospital staff interact directly with clients, CCO members often receive referrals telephonically, therefore getting vouchers to members can be challenging. In these situations, services are arranged via telephone and sometimes payment is made via a credit card instead of a voucher. Where possible, vouchers are faxed directly to the service provider, bypassing the need for the patient to have the voucher in hand.

Information/Data Sharing

In 2009, Project Access NOW collaborated with software company VistaLogic to develop CLARA to help support its Classic Program that coordinates health care services for low-income uninsured individuals.

Project Access NOW modified the functionality and user portal of CLARA to better serve C3 Community Assistance Program’s needs. Service requests from hospital and CCO care managers are entered directly into CLARA, and the data platform allows hospital and CCO staff to screen for eligibility and print vouchers in real-time. CLARA supports customized patient screening, data collection and reporting, and also enables information sharing among partnering organizations to support coordinated and appropriate care delivery.

Several other entities, such as the Seattle-based Project Access Northwest and the Columbia River Gorge CCO in Oregon, have also adopted CLARA to support their social service referral programs.

The data in CLARA enable health systems to track utilization and monitor user activity. They also allow Project Access NOW and health care partners to identify areas of need and community challenges. The data platform is customizable, and some health care partners have added measures, e.g., readmission, to evaluate the program’s efficacy. Kaiser Permanente has its staff submit data to CLARA on estimated avoided admissions, avoided readmissions, and avoided days from an inpatient stay as a result of the C3 Community Assistance Program.

The C3 Community Assistance Program faced some initial reporting hurdles. Several early social service requests were for types of services that were not pre-configured in CLARA resulting in uncategorized requests and difficulties determining accurate utilization. Over time, frequent request types have been identified and additional social service categories added to CLARA. These system fixes have allowed the C3 Community Assistance Program to more accurately reflect the nature of the services provided, and enable the participating health systems to better understand client needs and services rendered.

Financing and Sustainability

To support the C3 Community Assistance Program, Project Access NOW charges health system partners an administrative fee to cover staffing, training, operations, and overhead costs, and a per transaction fee to cover CLARA costs. Both the administrative fee and transaction fees are renegotiated yearly. Typically, health systems and the CCOs provide upfront or quarterly payments for Project Access NOW to pay the monthly costs of services, and Project Access NOW invoices against that upfront funding.

The transaction fee is tailored and based on the level of effort required by Project Access NOW to address specific requests. Issuing a bus ticket voucher, for example, requires less staff time than arranging for rent subsidies. Project Access NOW tracks staff time to determine how much each transaction or request costs and negotiates accordingly with partners.

As the program has grown, along with Project Access NOW’s operating costs, the administrative fee has increased to reflect increased utilization. All costs are covered by health care partners under the current funding model. C3 Community Assistance Program’s costs account for roughly 30 percent of Project Access NOW’s overall annual budget of about $6.9 million.

THe C3 Community Assistance Program establishes rates for individual services with vendors and formalizes them with letters of agreement. Some rates are predetermined, such as cab fares, which are preset by the city. Other rates, including hotel room costs, are negotiated between Project Access NOW and the vendor. Some services, such as the Respite Care Program, are delivered over days or months, and reimbursement is based on the level of intensity and duration of interaction with the patient. Vendors invoice Project Access NOW for services based on the number of vouchers redeemed and the intensity of each service.

CLARA, a care coordination platform, supports customized patient screening, data collection and reporting, and also enables information sharing among partnering organizations to support coordinated and appropriate care delivery.

The health systems pay the administrative and transaction fees in a variety of ways.

  • Providence Health and Services makes a quarterly unrestricted donation to Project Access NOW according to their agreement. These donations are largely earmarked as community benefit funds, and Providence does not monitor use of funds at the patient level. Project Access NOW uses these funds solely for the C3 Community Assistance Program and related expenditures. Each quarter, Project Access NOW reports program expenditures and remaining balances to Providence.
  • Kaiser Permanente, on the other hand, uses operational funds to support the C3 Community Assistance Program based on services rendered. Kaiser Permanente pays the administrative fee on a monthly basis along with a per transaction fee.
  • Health Share pays an administrative and a per transaction fee, but instead provides Project Access NOW with upfront funding, which Project Access NOW invoices on a retroactive basis per actual services provided.

Estimating an appropriate level of ‘pre-funding’ to get from the CCOs in order to pay CCO expenses on their behalf can create cash flow challenges as expenses can vary dramatically month to month. However, Project Access NOW is able to negotiate with CCOs, which have increased their upfront funding as program use has grown.

Participating health systems have noted that covering Project Access NOW’s administrative costs is more cost effective and streamlined than internally coordinating relationships with a range of vendors. Cost avoidance through avoided hospital stays and timely discharge allows participating systems to make the case for sustainability of the Project Access NOW partnership to their leadership.

Monitoring and Evaluation

While CLARA provides hospital systems and CCOs the ability to monitor service utilization and successful referrals, it has been difficult to accurately measure how many hospital days have been avoided through the delivery of non-medical services. This is partly because of the complexity of conducting evaluations with a formal comparison group, since this means denying needed services to control group members.

It is also difficult attributing how different services may have contributed to avoided hospital days, given the variety of variables at play. Despite these caveats, program leadership believe that the program is cost effective.

Kaiser Permanente hospital staff noted anecdotally that the program needs a very few number of days avoided in the hospital to make it cost-effective. Project Access NOW estimates that in 2017, 294 clients were able to avoid at least 736 days in the hospital by utilizing C3 Community Assistance Program services.

Providence’s Center for Outcome Research and Education is currently conducting an evaluation on the effectiveness of meal delivery as a means to reducing readmissions and repeat visits to emergency departments by clients of the C3 Community Assistance Program.


Informants offered several lessons gained through the C3 Community Assistance Program and partnership between Project Access NOW and health care systems.

1. Reduced Administrative Burden for Health Care Partners

Partnering hospitals and CCOs see Project Access NOW’s C3 Community Assistance Program as an effective pathway to ensure a safe discharge.

The program serves as a single point of contact for health care partners and links their uninsured and low-income patients to a full range of nonmedical services. This relieves hospital staff of the administrative burden of coordinating with multiple vendors, and the pressure often faced when trying to connect complex patients to reliable and much-needed social services.

2. Maximizing Vendor Relationships

Hospital staff can rely on Project Access NOW’s deep community ties and extensive relationships with social service providers to connect clients with an appropriate referral.

Furthermore, Project Access NOW is not bound by the same federal rules related to gifting non-medical services applied in the hospital settings, giving them more flexibility to be responsive to a range of patients’ needs.

3. Automated Request System

CLARA is the main mechanism of interaction for health systems with the C3 Community Assistance Program. The secure, web-based platform allows frontline hospital staff and Health Share to submit requests 24 hours a day, seven days a week and, as appropriate, print a voucher for immediate use on-site.

The ability to submit requests any time, day or night, is a boon to health systems. CLARA also allows health care providers to track patient utilization and associated costs, and provides information to monitor community need.

4. Trusted Partnership with Vendors

Project Access NOW contracts with over 100 vendors in the metro Portland area. Project Access NOW had to develop trust with these vendors who had experienced challenges with payment from hospitals, and were initially skeptical that Project Access NOW would reliably reimburse for services.

Project Access NOW, however, was committed to strengthening these relationships, ensuring appropriate and timely payment, and covering any incidental costs caused by patients (e.g., damage by clients to hotels). This reliability with social service providers has ensured commitment from vendors to provide services to clients during vulnerable transition periods.

Moreover, these successful and enduring relationships have helped demonstrate the value of the C3 Community Assistance Program to health care partners.

5. Estimating Costs

Estimating program costs at the outset was difficult. It took some time to capture accurate program and resource utilization, as well as Project Access NOW’s time to administer referrals and follow up. This required flexibility and patience on the part of health care partners and community vendors, and some renegotiation of the administrative fee that Project Access NOW charged health care partners.

6. Financial Sustainability

While health care partners are generally supportive of the program, hospital priorities can change, affecting funding decisions, which creates some uncertainty for the sustainability of Project Access NOW’s programs. Moreover, Project Access NOW has to renegotiate different contracts with each health care partner on an annual basis, creating some capacity burden for the organization.

7. Evaluation

Ease of access to request and utilization data in CLARA allows some health systems, such as Kaiser Permanente, to collect data on patient utilization and related costs.

While health care partners are committed to evaluating the effectiveness of social service programs, including those funded with community benefit dollars, evaluating whether the provision of social services actually results in avoided use of unnecessary care and hospitalizations remains challenging. This is due in part to the complexity of conducting rigorous randomized trials and withholding services from a comparison group as well as the many factors at play in determining the number of avoided hospital days.

That said, demonstrating avoided hospitalizations and associated costs will help Project Access NOW ensure continued hospital systems and plan support and guarantee C3 Community Assistance Program’s sustainability.

Future Plans

By the end of 2018, Project Access NOW anticipates that additional CCOs will be participating in the C3 Community Assistance Program. The program is also in early discussions with a third health care system.

Project Access NOW is open to offering new services, such as health navigation, working with new vendors (i.e., taxi, hotel, and ambulance providers), and expanding their service area, although funders are needed to pay for them. The eventual aspiration is for the C3 Community Assistance Program to serve as a ‘portal’ for community health workers to connect their clients to needed services more directly.

More broadly, Project Access NOW is also working with health care and community partners to develop a regional network to align payers and providers to create long-term solutions to address the full range of clients’ social needs.

The Regional Community Health Network (RCHN), currently in a pilot phase, consists of local community-based organizations, an RCHN navigator employed by each organization, Project Access NOW, and other community partners. RCHN navigators use the C3 Community Assistance Program/CLARA portal to connect clients directly to services, and facilitate care coordination within their organizations and across all partners within the network.

Currently, Kaiser Permanente, Oregon Health & Science University, and Providence Health and Services are referring Medicaid patients who have new diagnoses of or uncontrolled diabetes, and two or more social determinant needs, to Project Access NOW and the RCHN network, to facilitate linkages to appropriate community-based services to address identified needs.

Authors and Acknowledgments

Anna Spencer, MPH and Sana Hashim, MPH, CPH, CHES, Center for Health Care Strategies

Thank you to the following individuals for their time and input in contributing to this case study: Project Access NOW: Janet Hamilton; Kaiser Permanente: Shannon Barksdale and Peter Johnson; Providence Health and Services: Pam Mariea-Nason and Shelly Yoder; Central City Concern: Jordan Wilhelms; Multnomah County Aging and Disability Services: Bethany Chamberlin.


[1] As of January 31, 2018, FamilyCare CCO no longer serves members of the Oregon Health Plan, and thus is not utilizing Project Access NOW to administer flexible, health-related services.
[2] Health-related services are non-covered services that are offered as a supplement to covered benefits under Oregon’s State Plan to improve care delivery and overall member and community health and well-being.
[3] Office of the Inspector General. Special Advisory Bulletin: Offering Gifts and other Special Inducements to Beneficiaries, August 2002.

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