Lessons from Primary Care Renewal’s next generation

Rachel Solotaroff, MD, and CareOregon member Priscilla Scarborough at Old Town Clinic. —Photos by Eleanor Gorman

With health care reform near the top of the political agenda in Washington, D.C. and Salem, “medical homes” are receiving a lot of attention.

Here in Oregon, a pilot program launched in 2007 with a few teams at a handful of CareOregon-affiliated clinics is now spreading throughout those “Primary Care Renewal” clinics and beyond.

Recently CareNews visited with two of these clinics to find how the next generation of clinicians see the benefits and challenges of the medical home.

Reweaving the safety net: Central City Concern’s Old Town Clinic

Old Town Clinic differs most from the average PCR clinic, with a unique set of circumstances and challenges. As a safety net clinic, Old Town is handicapped by a lack of resources to provide care for an unstable population burdened by chronic medical, mental health and substance issues, says Rachel Solotaroff, MD. Simply converting to a medical home model is not the final answer, but the advantages of being a medical home make every bit of the effort worthwhile, she says.

Collaboration “makes the people who work in these clinics feel connected and reassured that we are not alone.” —Rachel Solotaroff, MD, Old Town Clinic

Old Town’s challenges

Limited resources loomed largest among Old Town Clinic’s challenges last year when the whole clinic prepared to switch to the medical home concept, Dr. Solotaroff says.

For example, a medical home team needs to thoroughly understand its panel of patients to identify those who need preventive care and those who have chronic conditions that need special attention. When you don’t have electronic medical records, it’s a laborious task to sift through all the patient data to determine just exactly what preventive care is needed by whom.

“We still don’t have adequate staff for the needs of the population,” Dr. Solotaroff says. “Our medical assistants do extraordinarily well, but there is a level of clinical skill, administrative and nursing skill that only a nurse can bring.”

Dr. Solotaroff also worried that if the medical home model worked as promised, any gains in capacity might be overwhelmed by demand.

“I guess I was worried that the powerful demand from our patients and our inherent inefficiencies would not allow us to fulfill the promise of the model,” she says.

Finally, there was the challenge of making a major change while continuing services.

“It’s always hard to fix a car when the engine is running,” Dr. Solotaroff says.

Old Town’s successes

But after the transition—and despite the challenges—Dr. Solotaroff has become an enthusiastic supporter of the medical home model. She frequently accepts invitations to speak about it to the health care community.

“We’re better prepared for our patients when they come in the door, both for chronic disease management as well as acute care needs,” she says. “We’re able to wrap around things in a way we never could before.”

Just restructuring the health care team has had a significant positive impact.

“We have the benefits of wonderful camaraderie here,” Dr. Solotaroff says. “We treat one another well, we treat our patients well, and they feel that camaraderie as well. And the patients have been able to develop relationships with individuals other than providers.”

That’s taken some getting used to by the patients, she says, but even the skeptical patients are starting to see the positive impact as well.

“One patient in particular didn’t like that I wasn’t the one returning the calls,” Dr. Solotaroff says. “But she would grudgingly admit that we were returning calls more quickly and she was getting what she needed more quickly.”

Another patient’s story demonstrates the benefit of the new relationships. This patient, a recovering addict, came in regularly to get her blood pressure checked. She developed relationships with the panel manager and other team members.

“She came in one day, didn’t look just right and her blood pressure was way up. My panel manager asked, ‘What happened?’

“She had relapsed and hadn’t told anyone. My panel manager got her into recovery right away. She’s been in treatment. I saw her in the lobby not long ago and she looked good. And that may not have happened had my panel manager not known her as well as she did.”

There are other benefits for the team, says Dr. Solotaroff, who has recently returned from maternity leave. It is much easier for a provider to take leave because the team knows the patients’ needs and can carry on with a substitute.

Overall clinical quality has improved. Anecdotally, Solotaroff has seen improvements in patients’ blood sugar and blood pressure and in reduced emergency room visits.

Collaboration is key

Collaboration with other primary care renewal clinics is critical, Dr. Solotaroff says. Participants gather for training and share the lessons they’ve learned in practice. It’s important for the success of the program and is an added benefit for the team members.

“It’s indispensible,” she says.

Too often, clinicians in safety net clinics are isolated from other clinics and the broader health care community.

“We operate in these silos, but we have so much to share and so much to learn from each other,” Dr. Solotaroff says. ”Primary Care Renewal collaboration has bridged the chasm.

“That’s not only been helpful with the transition (to medical homes), I think it makes the people who work in these clinics feel connected and reassured that we are not alone, that others have frustrations and have ideas to share. That’s been the best part of it for me.”

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