Albertina Kerr improves care with Epic’s Coordinated Care Management platform

The Oregon provider is the first to use the care coordination application to support programs for people with developmental disabilities and mental health challenges.
By Bill Siwicki
01:24 PM
Albertina Kerr improves care with Epic’s Coordinated Care Management platform

Albertina Kerr, Portland, Oregon.

EHRs are known for their ability to track height, weight, blood pressure and other standard health information – but a group in the Pacific Northwest is using EHR technology in a new way to also track broader goals for people with intellectual and developmental disabilities.


Portland, Oregon, healthcare provider organization Albertina Kerr, in collaboration with health system Legacy Health, recently became one of the first groups in the country to launch Epic’s new application for coordinated care management. Albertina Kerr is the first to use coordinated care management to support programs for people with intellectual and developmental disabilities, mental health challenges, and other social barriers.

Before launching this new technology, staff at Kerr were documenting on paper and Excel spreadsheets, so they had to spend a lot of time writing and rewriting the goals and progress toward those goals for each of their clients. One of the programs offered by Kerr is Employment Services, which is designed to help people develop the skills needed to be productive members of the workforce.

“While Kerr has maintained electronic health records for years, those records are an island of data, not easily or readily shared with other providers,” said Craig Rusch, Kerr CIO. “Kerr staff also struggled to access the records for clients stored with hospital systems and other medical providers. Communication between health systems and Kerr staff was accomplished primarily via phone calls and faxes, which created delays and information inaccuracies.”

"We’ve already seen that the system is making medication administration safer for our clients."

Craig Rusch, Albertina Kerr

While many clients’ needs span multiple service lines and programs, Kerr has operated as more of a federation of services rather than a client-focused provider of programs. Its previous electronic health platforms mimicked this approach, perpetuating the silos. It needed a system that would help break down barriers.

“Another significant challenge Kerr faced was the management of client contacts,” Rusch said. “The personal and familial relationships our clients have are critical to their well-being. Knowing which relationships are healthy and beneficial and which can be negative is critical to providing exceptional clinical care.”


Epic is the EHR choice for 90% of hospitals in Kerr’s region, Rusch noted, and for the majority of hospitals across the country, including Legacy Health, Kerr’s partner for all Epic-related initiatives.

“Implementing Epic as a part of Legacy Health’s Epic Community Connect Program opens access to health information for Kerr’s entire population and allows other providers access to Kerr’s knowledge base,” Rusch explained. “The program enables organizations of Kerr’s size to have the benefits of an integrated EHR without the significant investment and resources it takes for a full-scale EHR implementation.”

Kerr had additional challenges that needed to be solved. Staff in group homes, where Kerr cares for individuals with intellectual and developmental disabilities in a 24/7 residential setting, spend most of their time working with clients. They are not tethered to a computer – they are transporting clients to events, cleaning, cooking and helping clients with other daily activities.

Kerr staff needed a system that would allow them to complete documentation on mobile devices while performing their daily tasks.


There are many vendors with electronic health records systems on the health IT market today, including Allscripts, Cerner, eClinicalWorks, Epic, Greenway Health, HCS, Meditech and NextGen Healthcare.


The Coordinated Care Management platform in Epic gives Kerr caregivers a fuller picture of the social, behavioral and clinical factors for each client all in one place. This complete picture helps caregivers make important decisions about how to improve the overall health and quality of life for each individual.

“It is not only about tracking typical indicators of health like blood pressure, height and weight,” said Rusch.

“Coordinated Care Management also gives us a way to track employment skills, sleeping habits and key relationships in a person’s life. The technology is available to all care team members, not just clinical professionals, and it is fully mobile.”

Using Coordinated Care Management’s nested episode functionality, it is easy for Kerr’s caregivers to start with the client and add services as required.

“Now, when clients are enrolled in more than one program, such as a youth group home and outpatient mental health services, we’re able to treat the whole person rather than providing segmented care across different services,” Rusch explained. “With Epic’s mobile Rover application, caregivers document daily activities, such as sleep, behaviors, goals and much more, without interrupting the normal flow of the day.”

The integration of data between Kerr and health systems has significantly improved the way that Kerr communicates and has allowed it to provide more holistic care, he added. Kerr uses clients’ information from health systems to evaluate their medical needs and outcomes before, during and after they receive services from Kerr.

“We review the medical histories of clients entering our service to help us to evaluate whether a client is appropriate for our programs,” he explained. “While they’re in our care, we now manage clients’ medications electronically and verify that they’re aligned with doctors’ orders. With about one million medications administered each year by Kerr, it’s critical that we are 100% confident that we are administering the correct meds each time.”

Kerr also uses data from health systems to evaluate the success of its services, including reviewing whether a Kerr client visited an ED within 60 or 90 days after discharge from care.

“The integration between Kerr’s documentation and information from health systems is also beneficial for clients’ healthcare providers,” Rusch continued. “When clients visit providers who work outside of Kerr, the providers can now see what normal behaviors are when assessing the effects of new medications or procedures, and they can view sleep patterns to see the effects of the treatments they’ve prescribed.”


Kerr launched Epic’s Coordinated Care Management platform for its mental health programs 18 months ago. It began using the platform in its four Intellectual and Developmental Disability programs in October of last year. While it is still too early to report on hard metrics, Rusch said, Kerr has seen some important anecdotal successes.

“We’ve already seen that the system is making medication administration safer for our clients,” he said. “For example, within the first week of implementing Epic, one of our staff received a notification about a medication conflict and quickly resolved the issue. Previously, our group homes managed medication administration on paper, and this issue would never have been discovered had it not been for Epic’s contraindication functionality.”

The platform enables better coordination across services so all staff can take a collaborative approach to helping clients achieve their goals, he added.

“The experience of one of our clients, Ashley Call, exemplifies this coordination,” he recalled. “Ashley moved into one of Kerr’s group homes after sustaining a traumatic brain injury. At the time of her injury, she was a student at a culinary school with a passion for baking. Kerr’s employment services team helped her relearn key employment skills to place her in her dream job – making cookies at a local bakery.”

Due to her loss of short-term memory, ongoing support is complex. Dozens of Kerr’s staff who support Ashley around the clock – in her group home, at doctor’s appointments and at work – are able to stay connected and assess all her needs using the new platform.

“For example, when Kerr’s residential staff schedules a medical appointment for her, the employment services team can see if she will have a work conflict to assist her with notifying her employer,” Rusch explained. “Because her employment goals are tracked in the same system, her group home caregivers can further assist her with skills training. If she experiences a medical event that impacts her ability to perform her job, employment staff can communicate with her doctors and group home caregivers to better support her at work.”

This collaborative approach helps Ashley continue to enjoy her passion for baking while getting the ongoing care she needs, he added.


“The concept of healthcare has shifted,” Rusch contended. “To understand the total picture of what health and wellness looks like for any individual, there is so much more to consider beyond the standard vital signs like height, weight and allergies. This is especially true for the clients of Albertina Kerr, who count on us for highly specialized care around the clock and support to help them lead fulfilled lives as engaged members of the community.”

Coordinated Care Management is helping the Kerr team by putting the right information in the right hands at the right time. Software must support this concept and help prevent care silos, Rusch said. This is a complex concept and very difficult to implement in real-world scenarios, but it is a core function to consider when evaluating technology, he advised.

There are two overarching recommendations that the Legacy Project Team leading the Coordinated Care Management initiative has for peers considering a similar initiative, said John Kenagy, Legacy Health senior vice president and Chief Information and Administrative Officer.

“First, establish a high degree of trust between all parties involved,” he advised. “There will always be surprises along the way for initiatives that strive to push the boundaries of traditional models and systems in healthcare. Nurturing an environment of trust allows for true collaboration, where individuals assume positive intent and are able to focus their minds on the groundbreaking work they’re doing.”

And second, maintain flexibility, he said.

“Remaining open to trying new tools while also embracing opportunities to redefine how existing tools, technology and workflows could be used in different ways were critical factors for us,” Kenagy advised. “A flexible mindset in leaders and staff allowed us to successfully navigate scenarios that our organizations had never encountered before.”

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