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Pediatricians implement patient assessments of social determinants and medical complexities to stratify the pediatric population

albert carlson

Learn how over 100 pediatricians in Oregon/SW Washington have implemented a needs-based assessment method that considers high impact social determinants in addition to medical, mental and behavioral health needs. View results for over 103,000 children through meaningful and actionable improvement measures targeting office-based care management supports of high need children/families.


Dr. Albert Chaffin is a full-time pediatrician at Pediatric Associates of the NW in Portland Oregon since 2009 after completing his pediatric residency at Oregon Health & Sciences University. He also currently serves as Chair for Population Health Management at the Children’s Health Alliance where he leads development and implementation of a clinical HIT solution supporting care management and clinical analytics across the alliance of over 100 private practice pediatricians.

Chaffin also serves as co- Chair of the Obstetrics/Pediatrics Department at Legacy Good Samaritan Hospital and sits on the Legacy Health Partners Technology Board Committee. He grew up in Ohio, attended Capital University and the Medical University of Ohio, then moved to the Northwest to train in pediatrics where he now serves the pediatric patients and families in this community. Dr. Chaffin enjoys cooking, baking, piano and hiking.

Dr. Kenneth Carlson is a board certified pediatrician currently working at Childhood Health Associates of Salem since 2001. In addition, he serves as Clinical Practice Consultant for the Oregon Patient Centered Primary Care Home department. With the American Academy of Pediatrics he recently served as a chapter officer and currently sits on national Child Health Finance Committee for the AAP.

Dr. Carlson has a long interest in technology in medicine and has worked in his clinic to shift focus to population health, recognizing the public health role of primary care. Serving a population of majority Medicaid has demonstrated the daily contribution of social determinants on health status. In his clinic he chairs their Quality Improvement Committee. Dr. Carlson is a believer in “going upstream” to improve lives.

E. Dawn Creach, MS is the Manager of Medical Home Delivery & Innovation at the Children’s Health Alliance and Children’s Health Foundation. Dawn leads a variety of quality improvement initiatives within CHA, and brings a diverse background in research and evaluation, program management, public policy, practice coaching, and expertise in the Patient-Centered Medical Home/PCPCH model including integrated behavioral health.

Prior to joining CHA, Dawn worked for the Oregon Health Authority’s PCPCH Program as the lead for technical assistance, site visits, and communications. Previously, she worked at OHSU on various community-based research projects, and directed the evaluation of one of the country’s first national medical home demonstration projects. Dawn also worked with Multnomah County on a strategic plan to integrate behavioral health and primary care, and at the Oregon Pediatric Society as the START (Screening Tools And Referral Training) program manager. Dawn has traveled extensively around Oregon and the country studying innovative medical homes and is passionate about improving healthcare.

Dawn holds a Master of Science in Sociology and a certificate in Project Management from Portland State University, and received her Bachelor of Arts in Sociology from Carroll College in Montana.