COMMUNITY CLINICS UPDATE: We’ve Come a Long Way and Are Still Making Progress

Mitesh Popat, MD, MPH

Marin Community Clinics is the county’s largest safety net provider of medical and dental care to low-income populations. Our mission is “to improve the health of our patients and community by providing high-quality, cost-effective, culturally sensitive care, patient-centered care.”  

When we began offering services 43 years ago, Marin Community Clinics provided very basic medical care to the underserved in church basements in Fairfax and Mill Valley. Everyone did their best with limited resources, and a small number of Marin physicians and nurses generously volunteered their time.

The Clinics have come a long way since then. Today, our not-for-profit organization is not only serving more people with sophisticated medical and dental care, but also playing a vital role in health care reform by providing affordable, accessible care. We have truly come of age.

A quick snapshot of where the Clinics stand today:

Marin Community Clinics is one of only 1,200 Federally Qualified Health Centers in the U.S.; this designation allows us to receive federal funding and enhanced reimbursement.

We now serve 35,000 individuals a year—13.5% of Marin’s population. Half of our patients are children. The people we serve come from all walks of life and include individuals on Medi-Cal, Medicare, Covered California and private insurance.  

Our organization operates four medical clinics (two in San Rafael, one in Novato and one in Larkspur), three dental clinics (two in San Rafael and one in Novato) and two teen clinics (one in San Rafael and another in Novato).

We have 240 staff members, including 40 medical clinicians and 18 dentists.

Our annual budget is $30 million.

Our success is due in great part to strong collaboration with others, including physicians and other clinicians, the County of Marin, Marin General Hospital, Novato Community Hospital, Kaiser Permanente and Operation Access.

We benefit from strong philanthropic support; in the past 15 years alone, we have raised $22 million from generous community donors.

In addition to primary care for adults and children, we provide the following medical and ancillary services:

• obstetrics and women’s health
• optometry
• physical therapy
• on-site labs
• on-site pharmacies

The addition of dental services six years ago was a major development. Today, under the leadership of Chief Dental Officer Connie Kadera, DDS, we have 19 dental chairs and operate seven days a week, serving 11,000 patients a year.

Our facilities are modern and outfitted with the latest in technology. Since 2012, all our documentation is done in electronic health records.

New developments
With the advent of health care reform and the expansion of Medi-Cal eligibility criteria, we are seeing tremendous growth in our patient population for virtually all services. (From 2013 to 2014, we saw a 10% increase in the number of individuals served.)

Consistent with our mission, we are continually looking at how we can meet this increased need.

This past year, we expanded clinic days and hours to meet patient demand; most of our sites are now open evenings. In addition, we are planning to expand our Novato site, where we have purchased the existing clinic buildings and will be converting more square footage to clinical care usage. Soon, we will add x-ray services at our San Rafael Clinic. Having on-site radiology will not only be more convenient for our patients—many of whom lack transportation—but will make for more efficient, effective and timely communication among our provider team. We are building on past success with our on-site pharmacies—and the dividends that improved coordination has created.

Patient-Centered Health Home approach
In December 2014, the National Committee for Quality Assurance gave the Clinics its highest rating (Level III) for our achievements in implementing the Patient-Centered Health Home model.

This model of care, which emphasizes the partnership between provider and patient, has proven particularly effective with our patient population. Specifically, we assign patients a primary care provider. We have created stable “teamlets”—provider and medical assistant. We have integrated our nurses into our call center as well as the “pods” where our providers and medical assistants are based. The goal is to provide genuine team-based care, where a single visit may involve different members of the patient’s care team and allow expanded medical case management, as well as health education for chronic diseases.

We have also expanded other services, including behavioral health, composed of licensed clinical social workers (LCSWs), psychiatrists and psychiatric nurse practitioners. Their integration into the care team helps us meet our patients’ psycho-social needs. We have expanded chiropractic services and group medical visits for diabetes, and we have added a registered dietician to provide greater nutrition expertise.

We have also deepened our quality improvement efforts. We are currently working with the American Cancer Society to improve our patient outreach efforts around colon, breast and cervical cancer screening. We also work closely with our managed medical plan, Partnership Healthplan; last year, we obtained an all-time high in quality incentive payments for our excellence in a wide range of clinical measures, from diabetes care to childhood vaccination to cancer screening.

Our patient satisfaction rates demonstrate our overall effectiveness, with 98% of our patients saying that they would recommend the Clinics to others.

Wellness and prevention focus
We are increasing our investment in wellness and prevention, working hard to promote healthy diet, regular exercise and early screenings so that our patients can live longer, healthier lives.

I went into primary care to tackle the upstream causes of disease. End-stage renal disease results from chronic diabetes, chronic obstructive pulmonary disease (COPD) results from a lifetime of smoking, and stroke results from uncontrolled high blood pressure. All can have different outcomes. Many of the issues that lead to these conditions are rooted in socioeconomics and social stress, and it should be our imperative to tackle them. Based on the Portrait of Marin 2012 1, we know that there is a 13-year life expectancy gap among towns in Marin. As a community, we can work to reduce this disparity.

One example of our efforts to try to change health behaviors is our Community Health Hubs. They are held weekly at both our San Rafael and Novato sites in partnership with LIFT-Levantate and the food banks. Free nutritious food is provided, along with chronic disease screenings, health education and exercise demonstrations. Each week, we serve hundreds of individuals who might not otherwise have access to these services.

This community-based, family-oriented activity brings multiple wellness and prevention activities together under one roof. Healthy nutrition and education about food choices and preparation has to be at the base of the pyramid of health. This is, of course, not to mention the social stress that patients experience from food insecurity and the bearing that has on individual health. Hopefully, as a system, we can work to reduce health disparities.

Diabetes program
We have also expanded our Diabetes Program. Health screenings are conducted at the Health Hubs mentioned above. If an individual is found to be diabetic, pre-diabetic, or hypertensive, they are referred to the clinic to see a medical provider.

From there, the provider may refer the patient to a series of group medical visits, where education is provided about his/her medical condition, along with screenings for concomitant depression, as well as stretching and relaxation exercises. All this is done while following the tenets of motivational interviewing—which has the clinician meeting patients “where they are.” The basic concept is to make small, achievable changes and build on successes from there.

The goal is to help people manage and take ownership of their illness, while not being defined by it. In chronic disease management, having the understanding and confidence to be in control of one’s own illness—as opposed to being a victim of, or suffering from it—is key to preventing the downstream consequences.

How the Clinics provide specialty care
As a family practice physician, I know my patients can often benefit from seeing clinicians with expertise in a specialty area of medicine, for example orthopedists, gastroenterologists, urologists and cardiologists.

In the past, we relied on a small number of local physician specialists who generously donated their time. Today, a small group of physicians and other specialists continue to volunteer. Their commitment to our Clinics and our patients is truly amazing, and they make a tremendous difference in our patients’ lives.

We are now large enough that, in addition to using volunteers, we have begun to hire our own specialists. Currently, we have staff clinicians in the following specialties: podiatry, optometry, gastroenterology and chiropractic.

When a patient needs care that we don’t provide, our Referral Department works to find an appropriate clinician who will accept the patient’s insurance or see them on a sliding fee scale. Our team makes about 1,200 referrals a month. Referrals for hernias, endoscopies, urologic procedures, cyst removals and biopsies are among the most common. For uninsured adults, Operation Access facilitates free outpatient procedures, and Kaiser Permanente conducts some evaluations and outpatient procedures.

Challenges remain, however. It is sometimes difficult to find a local expert able to see some of our patients. This results in either delays in care, sending the patient out of county for care, or rarely (thankfully) no care at all.

Hiring our own specialists is making a big difference, but we are just getting started. We continue to need specialists, either voluntary or paid.

I invite any interested individuals to contact me at the email address below. We hope you will help us create a bright, healthy and more equitable future for all Marin residents.

For more information, visit www.marinclinics.org.

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Dr. Popat is the chief medical officer of Marin Community Clinics.

Email: mpopat@marinclinic.org

Reference
1. www.measureofamerica.org/marin