Oregon's approach to keeping seniors healthy at home has earned national validation. The Oregon Wellness Network, leading a consortium of eight community care hubs across the country, has been selected as one of ten winning teams in the federal Health at Home Challenge—a competition designed to test whether coordinated, community-based care can reduce hospital stays and improve quality of life for Medicare and Medicaid beneficiaries with chronic conditions.
The win addresses a persistent problem in American health care: older adults with multiple chronic conditions cycle between hospitals and home with little coordination between systems. Hospital discharge planning often fails, community supports remain fragmented, and the result is preventable readmissions, unnecessary costs and seniors spending their final years shuttling between institutions rather than thriving in their communities.
Oregon's winning model connects community-based organizations—Area Agencies on Aging and Disabilities, local nonprofits, and health systems—on a single shared electronic medical record. The consortium aims to serve more than 100,000 eligible beneficiaries across eight states.
When an older adult is discharged from a hospital under the new system, they receive coordinated care rather than simply a discharge summary and instructions to follow up with their doctor in two weeks. Nurses and community health workers develop personalized plans and connect people to evidence-based programs in their neighborhoods, including fall prevention classes, home-delivered meals and screening for depression and social isolation. A care coordinator in Portland can see what happened when that same person visited a clinic in rural Eastern Oregon, and vice versa.
The system uses artificial intelligence applied to population health not to replace human judgment but to support it—flagging which individuals are at highest risk of complications, helping community health workers prioritize their time, and tracking whether people stay healthier at home rather than returning to the hospital.
"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, director of the Oregon Wellness Network.
The eight hubs stretch from Oregon to Alabama, the Florida Panhandle, Houston, Western New York, Maryland, North Carolina and Southwest Michigan. The model is designed to work across urban, suburban and rural markets, serving dual-eligible beneficiaries—the population most likely to be low-income and facing steep health and social barriers.
The Health at Home Challenge reflects a strategic shift at the federal level. The Administration for Community Living is testing whether community care hubs can be the primary entry point for coordinated services, rather than hospitals or specialists.
The consortium enters Phase 2 of the competition from August 2026 through July 2027, implementing its strategy across all eight states. Up to five teams will be selected in summer 2027 to advance to a final scaling phase.
For Oregon, the win accelerates infrastructure the state's aging network has been building for years. Oregon's Area Agencies on Aging and Disabilities have long worked in communities, understanding local needs and existing support systems. Now those organizations are connected to clinical data and hospital systems previously inaccessible. A community health worker in Bend has visibility into what a geriatrician in Portland recommended. A fall prevention instructor in coastal communities has data on who's at highest risk.
The shared electronic medical record—AthenaOne, operated across all eight hubs—required independent organizations in different states to solve technical problems as well as governance and trust challenges. It means agreeing on data standards, privacy protocols and how insights are shared.
Winning a federal competition and sustaining a model at scale present different challenges. The hubs must demonstrate that their approach works not just in controlled conditions but that they can maintain quality, coordination and outcomes as the program expands to serve 100,000 people. Early results will be crucial—whether fall prevention programs reduce fractures, whether hospital readmissions decline as projected and whether older adults report better quality of life.
Research has shown that when community organizations have real-time access to clinical information, when care coordinators can reach people at home, and when health systems invest in navigation and support rather than just treating acute episodes, outcomes improve. Oregon's win suggests federal agencies are finally funding what research has demonstrated for years: community-based care, properly resourced and connected to clinical systems, works.
