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Care Teams: A Reverse-Engineered Solution For Substance Use Disorder Care

Willamette Family, Inc.

Care Teams: A Reverse-Engineered Solution For Substance Use Disorder Care Logo

Program Website
Winner Status:
Program Type:
Access to Care
Target Population:
Individuals with a Substance Use Disorder
Long-Term Residential Care Facility

Nature of the Problem

People with a substance use disorder (SUD) who are receiving Medicare and seeking treatment, often encounter a system that is grossly insufficient to meet their needs. Most treatments available to the Medicaid population pose seemingly insurmountable barriers due to inadequately-funded networks of treatment providers. These networks have capacity limitations for treating approximately 10% of people living with a SUD who rely on Medicaid for treatment payment. These barriers to treatment leave many untreated, even though they have a highly treatable condition. SUD is a chronic brain disease with the potential for recovery and at times recurrence. Despite growing documented evidence about the complexity of this disease and the high prevalence of co-occurring mental and physical health conditions, typically SUD treatment remains segregated from other health services. Many publications provide recommendations to build coordinated, co-located, or integrated systems of care that can work collaboratively with a person with a SUD. Merged integrated systems require willing partners from different organizational cultures to share the same vision and actively work to fulfill the needs of this high-risk population. Underfunded or unfunded efforts to transform traditional treatment systems with limited capacity and/or payer challenges tend to have little success in improved patient outcomes.

Program Description

Care Teams were designed for Willamette Family’s Cheshire long-term Residential Women’s facility as an innovative approach to transform traditional SUD treatment into a complex care system that meets the Medicaid-managed care needs. Unlike traditional SUD treatments, which tend to coordinate services and transport people to needed medical and mental health care, our Care Teams represent multiple-licensed services located within the same facility and operating as one integrated system. This redesigned SUD delivery system is a result of a five-year strategic plan that was completed in 2018. The plan consists of medical providers, psychiatric nurse practitioners, SUD counselors, mental health therapists, skills builders, peer support, housing and life skill coordinators, family interventionists, and parenting coaches. Each Care Team is assembled based on a person’s individual needs. Care coordinators assist in organizing services in the facility, such as enrollment of children 0-6 in our state-licensed child care, tertiary prevention services for mothers involved with child welfare, dental services, and primary medical care. The Care Team meets regularly to facilitate the most comprehensive care possible in addressing complex problems associated with SUD and giving client many tools to help her achieve success in combatting SUD.


By building Care Teams, we gained knowledge about how to successfully implement and sustain multiple practices within an integrated SUD program to adequately treat each person and her family. Before we had Care Teams, barriers to success included trying to integrate the person into external primary care and other behavioral health providers’ facilities. We know that it is difficult to provide intervention services at emergency rooms. Rather than continuing to integrate SUD treatments into established forms of health care with somewhat rigid workflows, Willamette Family reversed that strategy to provide services internally. By changing to a reverse integration behavioral health model, we marched forward to build internal capacity and make services immediately accessible for the Cheshire facility’s SUD population.


Willamette Family is a leader in innovative SUD treatment design in Oregon. The Cheshire Women’s Residence represents 9% of the nation’s co-residency SUDS programs. The Care Team model at our women’s facility exemplifies how to build a comprehensive treatment system for a population historically disregarded by the traditional health care systems. Leadership of Willamette Family developed and supported the Care Team model that currently consists of 64 Cheshire Women’s Residence team members representing multiple disciplines. We plan to share information about Care Teams both locally and at the state level. Team members have already carried the message of the Care Team model to a variety of forums with topics such as: the strategic planning process, developing new internal partnerships, and lessons learned while merging cultures and traditions of service providers allowing them to authentically become a team-based, integrated care system sharing in the same vision.


Many forms of integrated services exist, but no one model worked for our entire SUD population. The challenge we faced was to creatively move beyond traditional treatment programming and build a program that best fits this population. This all-inclusive care model has proven successful for a population of women whose severity of SUD is often incapacitating and whose children have experienced maltreatment. We plan to replicate this design for our Men’s Residential SUD program and the Dad’s Program, requiring enrollment in intensive outpatient treatment and residence in shared housing. Partnerships between the women’s and men’s programs will foster a foundation for new internal partnerships to develop as new Care Teams are built. Additionally, information will be shared with local and state authorities who manage Medicaid funds, as we document that programs and services can improve population health outcomes and reduce cost to the health care system.


Care Teams have coordinated care for over 50 women and their children since full project implementation. – Client Satisfaction Surveys reveal consistently high marks (>4.5 on 5.0 scale). – Complaint and/or grievance filings have decreased by 40% in 2018 vs. 2017. – Recent collection of employee evaluations measuring loyalty and job satisfaction demonstrates commitment to the Care Teams and investment in their purpose. A success story is Tabitha, a 22-year old mother. She has an extensive SUD treatment history, including two prior Willamette Family episodes. Tabitha entered the Women’s Residential program in February, 2018. Tabitha said “everything seemed different” after meeting her Care Coordinator. Tabitha’s Care Team helped her to address her goals for treatment and recovery; she engaged fully in the process; and after graduation, helps others by participating on the Client Advisory Council. Tabitha attributes her success to working with multiple services at one time in one location.