Salem-based network heads an eight-hub national consortium expanding in-home and community care for older adults on Medicare and Medicaid, powered by a shared electronic medical record with artificial intelligence
SALEM, Ore., Oct. 6, 2026 /PRNewswire/ -- The Oregon Wellness Network (OWN) is leading a winning team in the federal Health at Home Challenge, a national competition run by the Administration for Community Living within the U.S. Department of Health and Human Services. OWN serves as the Lead Community Care Hub of the National Consortium of Community Care Hubs for Health at Home — a network of eight community care hubs spanning eight states, with physician-owned CCH Medical Group as its healthcare partner — which was one of ten winning teams selected nationwide. The Oregon Association of Area Agencies on Aging and Disabilities (O4AD) served as the consortium's lead applicant.
The Challenge is designed to help older adults and people with disabilities who are covered by both Medicare and Medicaid stay healthy and independent at home — reducing hospital stays and lowering the total cost of care. Winning teams were chosen for their ability to deliver navigation, care coordination, care transitions, evidence-based health promotion programs such as fall prevention, and nutrition services at large scale.
Under OWN's leadership, the consortium's eight community care hubs and their markets are: the Oregon Wellness Network (statewide Oregon, lead hub); SARCOA / Community Care Solutions (southern Alabama and the Florida Panhandle); CATCH Greater Houston and the Houston Health Department (greater Houston); the Western New York Integrated Care Collaborative (Western New York); TLC-Maryland (statewide Maryland); the Piedmont Triad Regional Council (North Carolina); and the Region IV Area Agency on Aging (southwest Michigan). Together, the hubs aim to serve more than 100,000 Medicare and Medicaid beneficiaries with chronic conditions.
What This Means for Oregon
For Oregonians, the win accelerates a model OWN has been building for years: a statewide network of trusted community-based organizations, including Oregon's Area Agencies on Aging and Disabilities, connected directly to the healthcare system. Building on OWN's longstanding hospital care transitions partnership with the Providence health system, older Oregonians will see expanded help getting home safely after an acute hospital stay, care plans supported by nurses and community health workers, evidence-based fall prevention classes in their communities, and home-delivered nutrition support — from the Portland metro area to rural and coastal communities across the state.
The Oregon Wellness Network will collaborate directly with local health systems, accountable care organizations, and managed care plans across Oregon to expand these innovative care models, with the goal of improving clinical outcomes and reducing the total cost of care. Expected results include more healthy days at home for Oregonians and improved performance on HEDIS, the quality measures health plans use nationwide to track how well care works.
Oregonians will be connected to services through referrals from local hospitals, primary care practices, and health plans across five care pathways: hospital-to-home transitions, primary care and ACO referrals, nursing home-to-community transitions, fall prevention, and depression and social isolation support delivered through collaborative care.
One Shared Record, Smarter Care
All eight hubs operate on a single shared AthenaOne electronic medical record — a first for community-based care at this scale — with integrated artificial intelligence for population health analytics. The AI-supported platform helps care teams identify at-risk individuals earlier, guide community health workers in real time, and measure what matters most: more days at home and lower cost of care.
"This award validates what Oregon's aging and disability network has demonstrated for years: community-based organizations, connected to shared clinical infrastructure, are the most effective and affordable way to keep older adults healthy at home," said Lavinia Goto, RN, CDCES, MPH, MBA, DHA, Director of the Oregon Wellness Network. "Eight hubs across the country operating as one network, on one record, is a new capability for this nation — and it is being led from Oregon." [Quote pending approval]
The team now advances to Phase 2 of the Challenge (August 2026 – July 2027), implementing its strategy in Oregon and nationally. Up to five teams will be selected in summer 2027 to advance to the final scaling phase.
About the Oregon Wellness Network
The Oregon Wellness Network is Oregon's statewide Community Care Hub, organizing a network of community-based organizations — including Oregon's Area Agencies on Aging and Disabilities — that deliver care coordination, care transitions, evidence-based health promotion, and nutrition services in partnership with hospitals, health systems, and health plans. OWN serves as Lead Community Care Hub of the National Consortium of Community Care Hubs for Health at Home, with the Oregon Association of Area Agencies on Aging and Disabilities (O4AD) as lead applicant. [Supplement with OWN's approved boilerplate.]
The Health at Home Challenge is administered by the Administration for Community Living. This announcement does not imply endorsement by ACL, HHS, or the federal government.
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