CareOregon SPIRIT
Health Resilience Program™ of CareOregon:
A Trauma-Informed Care Intervention program for Clients with Complex
Bio-Psychosocial Issues

Health Resilience team
CareOregon Health Resilience Team

This unique program was created by CareOregon in November 2011. In collaboration with 11 community partners, we applied for and received CMMI Grant funding to increase the scale of our existing program and add four other high risk population care interventions.

With three-year CMMI Grant funding in June 2012, we were able to go from three to 16 primary care (and one specialty care and a detox program) clinics, and 18 Health Resilience specialists. The intention of the grant was to develop effective population treatment interventions for our highest cost, most complex Medicaid patients as quickly as possible. Our most recent data indicate a 35 percent reduction in ER visits and inpatient admissions for clients touched by our program.

The Health Resilience Program is designed to address the bio-psychosocial needs of this high-risk population using a trauma-informed, strength based approach, with the specialist embedded in a primary care clinic as part of the primary care team. We collaborate with the doctor and the client supporting the client’s health goals. Criteria as defined by the grant for inclusion in this intervention are:

  • Established in a clinic where a Health Resilience specialist (HRS) is embedded
  • Have Health Share of Oregon as primary Medicaid insurance, dual eligibility or payer of choice
  • Living in the Portland tri-county area
  • Willing and able to make a change in their lives
  • Recent, modifiable utilization patterns
  • One or more non-OB hospitalization admissions with or without ED visits within 12 months, or six or more ED visits with or without hospitalization within 12 months
  • 18 years or older

Our guiding programmatic principles & actions are:

Programmatic Guiding Principles

Guiding Principles in Action

Reduce barriers

Avoid extensive assessment process or asking for revealing personal information before a relationship is built.


Meet the client/medical staff where they are;  collaborate on client and programmatic goals.


HRS is open about intentions and doesn’t withhold information regarding the work they are doing on the client’s behalf; HRS is open about interactions with a client’s providers (no secrets).

Take time

HRS has time to spend with clients, rather than working on a billable hours model

Build trust

Be honest and transparent; offer choices and collaborate.

Avoid judgmental labeling people

Partner with the client on where to begin in changing their health dynamic.

Community based

Frequent contact in the community with clients, rather than in the clinic, giving the client a non-hierarchical setting to work within the complex, hierarchical health care system.

Mark Baker and I were introduced by his doctor, following some difficult medical issues and subsequent challenges to his normal way of life.

A seizure resulting in a fall left him deaf in one ear. The first time I visited him at home he explained that he just wanted to be able to listen to the Super Bowl broadcast, which his favorite team was playing in. Sadly, this didn’t happen, but we have built a strong connection, working on connecting with community resources such as food banks. We also attended specialty medical appointments together, where I translated the complicated language of medical providers into daily habits of wellness.
Mark is an extremely likeable guy who loves to laugh. He maintains an impeccable collection of antique model cars, and is so loved in his community that his local bank bought him a bicycle for his birthday – which he rides daily.

It has truly been a pleasure getting to work with Mark.

- Marika Shimkus
Community Care Worker

What we have learned about our clients and the health care system gaps which we try to fill/address:

There is a high prevalence of trauma experiences resulting in mistrust of authority figures and high incidence of substance abuse.

We see social isolation and both treated and untreated mental health issues.

Communication about client care between systems of care is minimal due to a ‘broken’ health care system.

Primary care has little support and little training in addictions treatment, understanding the role traumatic experiences play in a patient’s health, or mental health symptoms.

There continues to be lots of education needed on palliative care.

Adverse childhood events and poverty play a role in the health of our clients.

Clients have health literacy challenges.

Mark Baker left, with community care worker Marika Shimkus
Mark Baker, left, with Marika Shimkus, health resilience specialist

The health resilience specialist provides the psychosocial “lens” to the primary care provider’s tool box in order to understand the client’s health from a holistic vantage point. Doctors say that this additional information about their patient has helped them begin to coordinate care more effectively for their high-risk clinic population.

Both our client and PCP feedback surveys demonstrated that this program is filling a void in our health care delivery system for our highest-risk, most vulnerable population. And, perhaps as important, providers report feeling a renewed sense of hope by having this additional intervention available to offer their most high-risk patients.