Addressing Social Determinants of Health through Community Information Exchanges
This session will describe early efforts in Oregon to address individual and family social
needs through technology-supported systems and community information exchange
(CIE). Panelists will define CIE, where it exists statewide, and describe how their
organizations are engaging in this work. The panel will also share successes and patient
stories, challenges, and future work in this space.
Liz Whitworth, MPH
Managing Director, OHLC
Liz Whitworth currently serves as Managing Director for the Oregon Health Leadership
Council (OHLC). In this role, Liz is engaged in the adoption and spread of several statewide
health care transformation and technology initiatives involving OHLC stakeholders, key state
agencies and other partners. Most recently, she convened engagement of Medicaid health
plans around a common technology solution to begin to address social determinants of
health in Oregon (known as “Connect Oregon”).
Briar Ertz-Berger, MD, MPH
Director for Social Determinants of Health & Quality Management, Northwest Permanente, P.C.
Dr. Briar Ertz-Berger is an emergency medicine physician and the Medical Director for
Social Health and Quality Management for Northwest Permanente. Dr. Ertz-Berger’s work
focuses on eliminating health inequities and the effects of unmitigated socio-economic
struggles. Dr. Ertz-Berger is currently leading work to improve the health outcomes of her
patients and the surrounding community through the creation of a robust Social Health
program, which includes the development of an Oregon-wide integrated health and
social care network.
Kelly Ambrose, BSN, RN
Advanced Illness Care Program Manager, Housecall Providers
Kelly Ambrose has developed and managed palliative care programs since 2015.
She currently leads the Advanced Illness Care team at Housecall Providers, the only
community-based palliative care program in Oregon focused exclusively on Medicaid
patients. Kelly has more than 20 years of healthcare experience, including 16 years as a
nurse working with high-risk populations in the community and in a federally qualified
health center. Throughout her career, Kelly has worked on multi-disciplinary teams,
addressing socially complex patients’ medical needs as well as their access to care,
housing and food insecurity and navigating the complexities of the healthcare system.
Lavinia Goto, RN, BSN, MPH, MBA, DHA
Project Manager, LTC Innovations & SDOH, NWSDS
Operations Manager, Oregon Wellness Network
Lavinia Goto has spent the last five years developing a network hub for health and wellness
services provided by community-based organizations in Oregon. The programs are
targeted towards people living with chronic conditions that impact an individual’s ability to
live independently. Self-Management education and supporting an individual’s self determination has been Lavinia’s passion for more than a decade.
Michelle Lehr O'Connell, MPA
Director of Primary Care Integration, OHSU
Michelle Lehr O’Connell is the Director of Primary Care Integration at OHSU. Lehr O’Connell
partners with leaders across OHSU Health Primary Care to develop and implement shared
operational strategy, and align and integrate primary care across the health system. She is
the chair of the Social Determinants of Health Ambulatory Implementation Work Group,
and has led efforts to implement Epic-based screening for SDOH, the Connect Oregon
platform for referrals to community resources, and trauma-informed care training for
Margaret Klein, RN, CCM, MSB, MSN, JD
Director, Care Integration and Coordination Program, OHSU Health Services
Margaret Klein is a nurse, attorney, ethicist, educator, and published author with more
than 40 years of experience in healthcare, law, insurance and ethics. She currently serves
as the Director of Care Integration and Coordination Program for OHSU Health Services,
has served as an adjunct professor at Concordia University. Ms. Klein received her JD from
Lewis & Clark Law School and her nursing degrees from Chamberlain College of Nursing.
Ned Mossman, MPH
Director of Social and Community Health, OCHIN, Inc.
Ned Mossman has spent more than 20 years at the intersection of healthcare, research, and
IT. In his current role he oversees OCHIN’s nationally recognized initiatives around
increasing collective understanding of social needs assessment, cross-sector collaboration,
health equity, and value-based care. He also plays an active role in numerous national
stakeholder groups focused on bridging healthcare and social needs. Mr. Mossman
received a Master of Public Health in Epidemiology and Biostatistics from OHSU in 2002.