To help patients with an array of issues ranging from substance use disorder to post-traumatic stress, resource-challenged healthcare clinics in rural settings are taking a more holistic approach by wrapping behavioral and substance use treatment services around primary care. Leaders from Hill Country Clinic in California and Cherokee Health Systems in Tennessee recently outlined their new approaches.
Speaking during a Sept. 17 webinar put on by the National Center for Complex Health and Social Needs, the two organizations described their models of team-based, integrated care.
Hill Country Clinic in Shasta County, Calif., has its main site 35 miles east of Redding. It serves 6,500 patients, and 80 percent are below 200 percent of the federal poverty level. Among the barriers they face are distances to services and support groups. The nearest pharmacy is 25 miles away. Their patients often suffer from food insecurity, transportation issues and a lack of access to utilities. In such a small community, confidentiality about substance use disorders and mental illness is also a big concern.
Hill Country’s primary care teams now include behavioral health consultants and behavioral health care coordinators. The organization is involved in eight complex care programs through the state and county, including Whole Person Care, which targets people who use the emergency department for primary care and are homeless or at risk of homelessness. “We wrap integrated care around them, including primary care and behavioral health support, dental care and care coordinators,” said Jo Campbell, integrated operations director. “We have 200 patients assigned to one of those eight complex care programs. We focus on the relationship between our entire care team and the patient, all the way down to the maintenance staff. We work on leveraging community connections.”
Susie Foster, a family nurse practitioner and medical director at Hill Country Clinic, said they have set up a tiered approach to complex care. Tier 1 involves intensive and frequent contacts and then the intensity of care ramps down gradually. When patients graduate from tier 3 they return to the regular primary care system. Hill Country has had 120 patients enroll in a medicated-assisted treatment program, and 75 percent persisted after six months, she said.
The Whole Person Care program has housed 20 patients in just a few months. In Redding they set up an urgent mental health walk-in clinic, open from noon to 9 p.m. In January they brought a mobile version to the community. In August, it had more than 160 contacts, Campbell said. “Our case managers and clinicians are reaching out to these folks who are often the most difficult to reach. We have established that relationship for when they are open to care.” Another new program, called Reach, helps people re-integrate into the community after incarceration.
‘Stigma is still barrier No. 1’
Eastern Tennessee is grappling with the opioid crisis. It has seen steep increases in substance use disorder and overdose deaths. Cherokee Health Systems, a large federally qualified health center, has 29 locations serving 69,000 patients with a multidisciplinary team of primary care providers, community health coordinators and behavioral health specialists. Three years ago it hired Mark McGrail, M.D., as director of addiction medicine to apply an integrated primary care model that includes screening for SUD at every primary care visit, said Brittany Tenbarge, behavioral health consultant. “We meet the full range of healthcare needs that patients walk in with, including trauma history, social determinants, and other concerns that place them at a greater risk for relapse.”
“Stigma is still barrier No. 1,” Dr. McGrail said, and that includes the patient, family and many medical providers. “It is common for us to hear from patients that they have been reluctant to seek care for fear of being labeled as suffering from a substance use disorder. And unfortunately, there are providers unwillingness to treat those patients. But the reality is that they are seeing them every day anyway, and just not identifying the disorder.” Cherokee is working to reduce that stigma and increase access to care through work force development in primary care settings and through psychiatric residencies.
Politics is also a barrier, McGrail added. “Tennessee is the only state that does not allow nurse practitioners to prescribe buprenorphine. And although there has been more money put toward opioid treatment, he added, there is less money available for alcohol addiction.
McGrail said that like some other health systems, Cherokee is using a “hub and spoke” model of care. The hub is in downtown Knoxville and the spokes extend to 28 other facilities. “We have aggressively pursued education for providers — in person and via webinars,” he said. “We do on-site education in outlying clinics. We have real-time phone consultations every week and we receive informal consultations through the EHR.” Staff members from spoke locations come to the hub to get in-person training.
Cherokee also hired community health coordinators to help patients navigate the system. “There is no spoke if the patient can’t get there,” McGrail explained. “We want to reduce barriers for patients to get to outlying clinics. Those include transportation barriers and parents with child care issues.”
The health system deploys peer recovery specialists with training in resources for addiction treatment. They accept calls from hospitals in the region, and identify patients in the emergency departments or those who have been admitted for SUD or a recent overdose. “They can go to an in-patient ward, share their own experience and try to build motivation for treatment and link them to resources,” McGrail said.
“Unfortunately, even with our expansion, the demand exceeds our ability to meet it,” McGrail said. Cherokee has opened a walk-in addiction medicine intake clinic every Friday afternoon. “We recognize we have to meet people where they are when they are ready and triage to get highest priority patients in treatment right away: those who are pregnant, had a recent overdose, or been discharged from other facilities.”