Reweaving the safety net: Primary Care Renewal initiative takes aim at Old Town Clinic’s challenges
By Jerry Rhodes, CareOregon Communications Writer
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They call them “safety net” clinics. Health care for people who may otherwise have no care at all. The very poor. The homeless. Those who may be ensnared by substance abuse or challenged by mental illness.
There is satisfaction in providing this kind of care, says Barbara Martin, MS, PA-C, of Central City Concern Old Town Clinic in Portland.
“I definitely take great joy in seeing people make enormous changes in their lives, and being a small part of it,” Martin says.
Seeing changes like someone who had been on the streets, now being housed and having the tools to take care of themselves. Or seeing the pride in people sharing that they are clean and sober.
There are frustrations, too, with societal issues and with health care delivery issues.
The societal issues won’t go away. But Martin hopes that frustrations with the delivery system can be reduced by Old Town Clinic’s Primary Care Renewal project in partnership with CareOregon.
Social and system factors complicate care
Too often, health care at a safety net clinic is management of one crisis after another, one crisis at a time.
At the Old Town Clinic, between 40 and 60 percent of patients are uninsured. Many are homeless, or plagued with substance abuse or mental illness. Many have not had preventive care for years.
“You have to prioritize care for each person, and you have to re-prioritize every time you see them,” Martin says. “They could have blood pressure of 200/120 on one visit and that’s your priority. The next visit, maybe they’ve lost their home, and that becomes the priority.”
Giving high-quality health care, getting patients in when they need to be seen and providing services more efficiently. These are the goals Old Town Clinic hopes the Primary Care Renewal project will help it reach.
It’s quite a challenge, says Kelly Moehling, Old Town Clinic Manager.
“It was apparent our system wasn’t the most efficient,” she says.
In the past, if you were primary care provider with an established patient, he or she might need to wait 3-4 weeks for an appointment. It could take two weeks longer if the patient didn't have a PCP.
Sometimes a patient would want to be seen for a cough and couldn’t wait that long. So they would be referred to an urgent care clinic or an emergency room. Others would make an appointment, then not show up. Last January, the no-show rate was 35 percent.
There was no staff to do follow-up care and no resources to use the phone to take care of minor issues or make minor medication adjustments.
“That became the hyperfocus of the face-to-face visit,” Martin says. “Preventive care drops to the bottom when you are dealing with all these other issues.”
There were plenty of reasons for a provider to worry about patients.
“My patients are ‘My People,’ she says. “I feel we’re building a sense of partnership, and if someone misses an appointment or doesn’t come in for awhile, I worry.”
“CATCH” is pilot team for Primary Care Renewal
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Facing great challenges but with great hope, Old Town Clinic was among the first medical offices to sign up for CareOregon’s Primary Care Renewal (PCR) initiative.
PCR clinics are piloting a new way of providing primary care that emphasizes a “medical home” and a family, if you will, of provider and staff, working collaboratively on the health of their patient panel.
“We want to take better care of individuals, do a better job of taking care of the whole population in a more proactive way and do a better job of preventive care,” Martin says.
Old Town Clinic’s pilot PCR team is called “CATCH,” for Collaborative Approach To Complete Health. The CATCH Team includes Martin, Patty Follette, CMA, and Vickie Pedegana, RN, panel manager. Behavioral Health Consultant Eryn Joyce, MSW, LCSW, and Lynnea Amend, administrative assistant, work with the CATCH Team and the other providers in the clinic.
The team does more than just react to patient concerns.
People are surprised at the level of preventive care in a “safety net” clinic, Martin says.
Team members work at their highest license level. Follette is now doing diabetic foot exams, for example. That frees Martin for care only she is licensed to perform. More importantly, it gets important preventive care done.
“Having a nurse as the panel manager has been extremely helpful,” Martin adds. “I feel comfortable with her handling some triage and making some medical decisions.”
And the behavioral health consultant has been very important to the team.
“It’s been a great addition to have someone who can focus on goal development behavior, which tends to fall to the bottom of the priority lists when you’re dealing with crises,” Martin says.
The team shares a workspace so they can collaborate more easily.
They’ve eliminated the lengthy wait time for appointments. In September, all Old Town Clinic providers adopted open access appointing. No appointments are made more than a week in advance. Unscheduled time is left on each provider’s schedule to handle same-day appointments.
“It’s going phenomenally well,” Martin says. “Absolutely better than expected across the board. Patients, staff and schedulers like it. I’ve heard very pleased patients being able to call in the morning and get to see their provider in the afternoon.”
And the no-show rate has dropped to about 15 percent.
Outcomes will be the proof of improvement
“Right now, we are making progress and we hope to get the data to show it,” Martin says. Data collection at the Old Town Clinic is slowed by a paper medical records system, but the clinic has hired an administrator whose duties also include measuring clinical statistics and patient care outcomes.
Enough data has already been collected, as well as anecdotal evidence and staff enthusiasm, to expand PCR.
Old Town Clinic plans to add another team within the next six months and eventually adapt the PCR model in the whole clinic.
