Providence Health & Services — Portland, OR


Providence Health and Services works to improve care, reduce health disparities, and strengthen coordination between clinical and social services at three local clinics that serve many low-income individuals with diabetes.

The program identifies gaps in care and then deploys multidisciplinary teams to address them. Three pilot clinics embed full-time community resource specialists who are multilingual and multicultural; they are also trained in motivational interviewing and trauma-informed care to provide referrals to local resources, social services, and benefit programs. In addition, the organization conducts outreach to community residents who are at risk of diabetes or may have unmet diabetes-related health needs.


Improve access to high quality clinical care for Medicaid and uninsured populations with type 2 diabetes in three pilot clinics.

  • Identify patients with clinical care gaps via enhanced registry tools. Use in-reach and outreach strategies to close the care gaps.
  • Use EMR order sets to encourage providers to follow standardize pathways for type 2 diabetes patients that maximize outcomes by connecting patients to a variety of medical, social, and other resources.
  • Provide multidisciplinary, team-based care management for high-risk patients facing complex health and social challenges.
  • Use provider feedback dashboards to track progress in closing care gaps and give regular feedback to the care teams to drive change.

Improve access to social services, and the integration between clinical and social services, for type 2 diabetes patients in three pilot clinics.

  • Implement a standard screen and referral process for social determinants of health challenges that uses existing clinic EMR tools and workflows.
  • Co-locate a high-performing social service agency in DCII clinics to connect screened patients with needed social services.

Improve access to diabetes self-management education and tools for patients and families in three pilot clinics.

  • Co-locate in-person, multilingual diabetes management education for diabetes patients and their families in DCII clinics.
  • Provide access to a multilingual and culturally appropriate digital diabetes self-management tool for prevention and chronic disease management.

Increase awareness of healthy behaviors among community members and strengthen the relationship between the community and the DCII clinics.

  • Train community members to conduct community outreach in areas surrounding the three pilot clinics, providing coordinated services and helping to connect community members to primary care and social services.

Trista Johnson, PhD

Vice President, Ambulatory Quality & Clinical Services

Trista Johnson, PhD, serves as the system-level VP of Ambulatory Quality and Clinical Services for Providence Health & Services. She leads the system-wide ambulatory clinical governance process that uses data to set priorities and strategic direction. In addition, Trista led the MACRA Quality metric development work, resulting in over 20 metrics submitted for our 7300 providers. From 2011-2014, Dr. Johnson served as the leader in reporting and analytics for Providence, guiding the coordination of inpatient and ambulatory reporting during the transition to Epic. From 2007-2011, she served in the Oregon region of Providence working with local providers on quality improvement. From 2000-2007, she worked for Allina Health System in Minnesota leading patient safety and later reporting and analytics work. With her background in Epidemiology and statistics, she believes that better utilizing our clinical data systems can allow us to see variation in practice and improve patient care.

Contact Trista Johnson