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North Olympic Healthcare Network: Recently Hatched, Taking Flight, and Gaining Altitude

Tuesday, November 14, 2017   (0 Comments)
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Michael Maxwell, MD, CEO, North Olympic Healthcare Network


North Olympic Healthcare Network (NOHN) is Washington State’s newest federally qualified Community Health Center, beginning operations on September 1, 2015 shortly after being awarded a 330 New Access Point grant.


NOHN is located in Port Angeles with a primary service area encompassing Clallam County, situated in the northwestern most corner of Washington State’s Olympic Peninsula.  Our northern border extends 100 miles along the Strait of Juan de Fuca, our western border is over 65 miles of Pacific Ocean coastline, and the mountains of Olympic National Park predominate our southern border.  A single transportation corridor, State Highway 101, provides the only access to the area.  


It is a place of exceptional natural beauty, but also one of geographic isolation.  That isolation and a decline in our historically natural resource-dependent industries of logging, millwork and fishing have created an economically depressed region, and associated adverse health outcomes.  A high proportion of Clallam County’s 72,000 residents struggle with unemployment, underemployment, depression, substance abuse, low birth weight, and poor oral health. Our suicide rates and overdose rates far exceed the state and national medians. Poverty is prevalent, with over a third of incomes under 200% of federal poverty level.


Low incomes have presented a barrier to care, with high uninsured and underinsured rates making it difficult to access or afford health care.  While the Affordable Care Act qualified over 19,000 people in Clallam County for Medicaid under Washington’s expansion in 2014, our chronic health professional shortage left few providers accepting any new patients, and particularly those covered by low reimbursement Medicaid.  People were forced to the ED for care, out of the area, or deferred care altogether.


It was against this backdrop that North Olympic Healthcare Network evolved – albeit from atypical beginnings.  NOHN grew from a private primary care partnership (Family Medicine of Port Angeles) that had been part of the community for over 35 years.  My fellow physician partners and I recognized the limitations of our private partnership to adequately meet the growing need in our community, and chose to completely transform the clinic into the Community Health Center model as a more effective approach.  The integrated whole-person focus was consistent with our values, and the expanded services better addressed patient needs. Not only were these services required, but they were delivered within a reimbursement model that recognized the value and cost of providing them.  Further, the consumer-directed, community-board governance structure of CHCs that hard-coded responsiveness to patient needs was compelling.  Our committed core workforce, longstanding community presence, strong community support, solid financial standing, and well-developed quality improvement program made our NAP bid competitive and ultimately successful on our first application. 


We quickly learned that stepping through the looking glass into the CHC world brings many unique opportunities and challenges.  It has taken substantial work and effort to adapt to a new world of intensified oversight, compliance, and reporting – becoming a bit easier and familiar with time.  We are also learning that our new role in our community carries a responsibility to be ever attentive to new needs and to external constituencies.  We are now a much more engaged and effective collaborator within our local health care system, and bring new and powerful tools to the table for the benefit of our community.  We have also, unfortunately, become acutely aware of the significant and immediate impact that politics at the state and federal level have on our ability to effectively accomplish our mission.


Fortunately, we have experienced some significant early successes. We recruited 9 new physicians following our NAP award, bringing us to 20 providers/14.5 FTE. These providers were attracted not only to the beauty of our area, but to our CHC mission of providing integrated care to all regardless of ability to pay, our culture of engaging and involving providers in the development of programs, our commitment to quality, and an opportunity to be involved in medical education – both medical students and residents.  We have partnered with Swedish Medical Center in Seattle and our local hospital, Olympic Medical Center, to serve as the ambulatory care continuity clinic site for a Family Medicine Residency Rural Training Track (RTT).  After many years of planning we matched our first residents last spring – they are spending their first year at Swedish, and we will welcome them to Port Angeles in June of 2018.  Our desire to develop an RTT was a significant factor in our decision to become a CHC – convinced it was the best environment and model for training the next generation of primary care physicians for rural and semi-rural practice.  We hope the RTT provides a “grow your own” workforce and that many residents will choose to practice in our community, or another rural area.


We have doubled our staff to over 75 (and growing), becoming an important economic driver in our community and the largest employer downtown.  More importantly, with this increase in provider and support workforce, we have extended access to care to over 3,000 new patients in the past 2 years – patients who previously had no access to healthcare, and many the most vulnerable in our community. We have over 11,000 active patients, and in 2016 saw over 7,800 unique patients. We continue intake of new patients at a rate of 120 patients a month.  Coming from an established community practice, our patients reflect the complete spectrum of our community – from the families of local government and business leaders, to the working poor, unemployed, and homeless.


In addition to seeing more patients, we are also providing a wider range of services. We have given particular attention to addressing the opioid addiction epidemic that plagues our county, like so many others across the state and nation. We have utilized a Salish BHO grant to expand access to Medication Assisted Treatment (MAT) using buprenorphine for Opioid Use Disorder.  We have implemented a Nurse Care Manager program based upon the “Massachusetts Model” utilized at Harborview Medical Center in Seattle to leverage provider prescriptive capacity more efficiently, and increase the number of patients who have access to MAT.  Since implementing this model in August 2017, we have seen the number of patients with access to MAT increase from 85 to over 190, with a goal to help as many as 300 eventually.  We have also partnered with Peninsula Community Health Services (an FQHC in Bremerton) in a “hub and spoke” model to get additional access for those patients not appropriate for a community-based setting.  Further, we have secured an AIMS (Access Increases in Mental Health and Substance Abuse Services) grant through HRSA to bring on additional behavioral health and substance use disorder staffing to help this population.


Dental services for the Medicaid population has been identified as another area of great need.  While we have a referral relationship for dental care with Sea Mar, a large regional FQHC with a dental-only presence in Port Angeles, the need far exceeds that capacity. We have been working to augment dental access through a contract arrangement with a local private dental clinic, Irwin Dental Center, which is involved in dental resident training.  This has been a welcome resource, with the first patients under this arrangement seen last month.  We have plans to add our own dental chairs and program pending state capital grant funds hopefully available later this year.  Taken together, availability of oral health services should improve substantially for those traditionally without access.


As we grow and expand services, our challenge will be to maintain attention on our quality improvement activities and achieving high-quality outcomes. We consider this high priority and devote precious time and resources toward QI activities- achieving NCQA Level 3 recognition as a Patient-Centered Medical Home in 2016. We utilize Lean problem solving principles in our process improvement activities, and optimize use of a mature EHR with evidence-based templates and decision support. We have installed population health management software, i2i Systems, to leverage reporting, care-gap analysis, and inform team interventions with success in achieving good outcomes.  We have developed internal outcomes-based incentive programs for our provider and support staff to align with value-based purchasing metrics and targets. These factors combined to result in 2016 UDS quality measures that exceeded state and national averages for colorectal cancer screening (70%), cervical cancer screening (68%), blood pressure control (67%), appropriate medication for asthma (99%) and uncontrolled diabetes (9%) among other successes.  We are hopeful these quality improvement processes and activities will position us well to succeed under APM4 and other value-based purchasing arrangements that are in our future.


As we venture forward in our new world as a Community Health Center, we are continually impressed and inspired by the work of our sister CHCs. Many have been doing this difficult and important work for their communities for decades, often under more challenging circumstances.  We are new and have much yet to learn from their example-- but have already benefitted greatly from the knowledge, experience and support that have been shared so generously. We are proud to share in this important work together with other health center professionals around the region. We look forward to more challenges and opportunities in the decades to come.



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