Putting the Whole Patient Back Together
Friday, July 12, 2013
Posted by: Joy Ingram
Primary Care Co-Locates with Behavioral Health
by Erwin Teuber, Executive Director, OHSU Family Medicine at Richmond Clinic
“One door – two services.” That’s the message spoken by the sign over the door of the new Walk-In Clinic that unites Family Medicine at Richmond with Cascadia Behavioral Health. An 18-year relationship as friendly neighbors who shared some patients has recently become a full collaboration and co-location that is most beneficial to our patient population. The whole person has come back together (except for the mouth, but we’re trying to reel that in as well)!
Oregon Health and Science University (OHSU) Family Medicine at Richmond achieved FQHC Look-Alike (FQHC-LAL) status in 2004, and in June of 2012 it reached full FQHC status with the arrival of a Notice of Grant Award for $650,000 and strong federal urging to get the New Start operational quickly. That culminated about three years of discussion and deliberation with Cascadia Behavioral Health (CBH), a large non-profit multi-site comprehensive mental health services provider serving the larger Portland Metropolitan Area. The June 2012 juxtaposing of a new grant with a history of exciting and hopeful conversations about collaborating between our “two silos” (i.e. mental health and primary care medicine) set the stage for plunging forward.
We have become collaborators, but we have been neighbors far longer – about 18 years – and we are located only three blocks apart in southeast Portland. For years we have had many of the same patients, and as time went on our clinical staffs started having conversations about specific patients, about referral procedures, and about how desirable it would be to improve our coordination. Indeed, there were literally discussions about how fabulous it would be if we as providers could put the “whole person back together again,” not sending the head one direction, the foot another direction and such. Shortly after my arrival here 3.5 years ago, our Medical Director, Dr. Nicholas Gideonse, and I injected ourselves into some of those conversations involving primarily the OHSU Department of Family Medicine (DFM) Behavioral Health Director (Dr. John Muench, also a primary care provider at our clinic) and the Chief Medical and Operating Officer for CBH, Dr. Maggie Bennington-Davis. These were the discussions that led us to mutually visualize a clinical operation where primary medical care and mental health care would be offered side by side, and, eventually, in fully coordinated/integrated fashion.
It was just an attractive concept at first, and shortly after we began discussing it the Health Resources and Services Administration (HRSA) announced another opportunity to apply to become a full blown bona fide Community Health Center (CHC), funding and all. This had been a goal of our Board of Directors and the Department of Family Medicine for a long time. We found ourselves confronting a rare opportunity to go after CHC funding, but feeling that to be competitive with that we needed to add some value to what we were already doing as an FQHC-LAL. Our existing clinic at 3930 SE Division Street was already operating essentially at capacity. The answer we came up with was twofold: (1) to add two physicians to our current operations, by expanding the number of appointment slots available in the evening and on Saturdays, and (2) to start up a new clinic alongside the existing mental health walk-in clinic at CBH. The leaders of CBH were willing to make space for us because they felt many of their mental health patients did not have access to the primary health care they needed, and they liked the idea of closer collaboration and working toward greater and greater integration of services. They also seemed to like the idea of being associated with OHSU.
In June 2012 we learned OHSU had been funded as a new start Community Health Center. Implementation went quickly on the expanded capacity at our existing clinic part of the grant proposal, but the opening of the new clinic took considerable time due to having to move an existing CBH program and the challenges of remodeling that space.
On Monday, June 24, 2013 we opened the new Walk-In Clinic for business, following a well attended VIP/Media event and a public Open House the Friday before. We were especially proud to show off our main entrance and our shared lobby/reception area. A theme we’ve stressed – “one door, two services” is illustrated by the wording on the awning flap over the door. It says:
Behavioral Health Walk-In Family Medicine
The automatically opening glass doors under the awning have our respective organizational logos, names, hours and phone numbers on them. While we maintain separate adjacent reception desks, the entire lobby and rest room area is totally shared. Another physical integration that goes beyond co-location is a new shared break room for the staffs of both organizations. We are hoping for many fertile conversations to occur there in furtherance of moving down the care integration pathway.
The choice to make it entirely a Walk-In Clinic arose from several factors: (1) Our CBH collaborator was already operating a Walk-In Mental Health Clinic at the site 3 blocks from our existing clinic, so making it all openly accessible made sense; (2) For years at our current clinic we were turning away people who wanted to come in, either same day or later, but we had no capacity to serve them; (3) The Portland market does not have a large number of immediate care or retail clinics available, so there is pent-up demand; (4) We believed that many low-income uninsured residents would be attracted to a clinic where prior planning or long-term commitments were not required; and (5) We felt that a walk-in clinic could serve as sort of a filtering mechanism for our Patient-Centered Primary Care Home delivery model at the existing clinic. Not everybody necessarily wants a Patient-Centered Primary Care Home (PCPCH) and some need one far more than others. We are expecting to establish a certain proportion of Walk-In Clinic patients with primary care providers (PCPs) at our nearby PCPCH where there is good continuity of care provided.
At this point, in terms of the full continuum of care, we are now in a position to offer:
- Episodic walk-in care (via the FQHC Walk-In Clinic)
- Patient-Centered Primary Care Home continuity care (via the FQHC continuity clinic)
- Inpatient care (via OHSU hospitals)
And we make referrals for:
- Specialty care (via OHSU specialists and other cooperating community specialists)
- Hospice care (via cooperating community hospices)
- Home health care (via cooperating community agencies)
- Long-term care (via cooperating community homes)
For patients who are already established at our previously existing continuity clinic, we are discouraging but not prohibiting their use of the Walk-In Clinic. Each day we reserve up to 50 time slots for established patients to get in same day, thus preserving continuity most effectively.
The choice to co-locate the Walk-In Clinic alongside (and partially integrated with) a mental health clinic was driven by strong convictions about the importance of integrating these two services more effectively over time. Early on, there were discussions about the so-called Four Quadrant Clinical Integration Model:
Behavioral Health Risk
Low → Behavioral Health Risk
BH ↑ PH ↓
(Best served in behavioral health setting)
BH ↑ PH ↑
(Best served in BH/PHintegrated delivery setting)
BH ↓ PH ↓
(Best served in either setting with appropriate screening and linkages as needed – yet, still good to have a medical home)
BH ↓ PH ↑
(Best served in primary care setting)
Low → Physical Health Risk Status → High
Our general thinking was that we wanted to position ourselves (CBH and OHSU) to gradually integrate so as to effectively perform in Quadrant IV, serving patients with high behavioral and physical health needs. Quadrant III we felt we could handle without much if any collaboration. Conversely, CBH was comfortable with handling patients in Quadrant II. The Quadrant I patients were “ideal” patients for our respective two walk-in clinics in that they have low need levels on both the physical and behavioral side. In a meat-oriented society we might see these patients as “gravy,” from a financial and ease of care perspective. A lot of the work in this category would be health promotion and disease prevention oriented.
So now we have a “co-located” clinic and are working eagerly with our collaborator - CBH – to tweak and tune our working relationships and our processes so that we gradually enter the realm of an integrated practice. Our hope is that this will include eventually being on the same clinical information system (we are using OCHIN) and fully sharing records on mutual patients. There is also hopefulness about partnering in “alternative payment methods” that would cover patient costs for primary care and behavioral health care in global fashion and being mutually accountable for producing good outcomes. Another topic to be pursued early on will involve shared and coordinated care management services for high risk patients. The possibilities for additional kinds of coordination and integration are huge, but change takes time and we want to be reasonable about how rapidly we can make these transformations. Now though, the stage is set and we are off and running.
NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.