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background resources in PDF |
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some CAM/IM publication links |
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Center for Natural Medicine: How Portland's Founding Naturopathic, Integrative Center Became a PCMH |
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Written by John Weeks
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Center for Natural
Medicine: How Portland's Leader Naturopathic Integrative Center Became a Patient-Centered Health Care Home
This
article is produced as part of a recent partnership between the Project for Integrative Health and the Triple Aim
(PIHTA) and the North American Board
of Naturopathic Examiners (NABNE) for which the Integrator is providing media
support. The partnership's goal is to stimulate understanding
of naturopathic, integrative patient centered medical homes (PCMH) via portraits
of ND-PCMHs in Vermont and Oregon. PIHTA is an initiative of the Academic Consortium
for Complementary and Alternative Health Care (ACCAHC).
Prior articles in the PIHTA/NABNE Series:
"They say I was an angel who walked through the door."
Melissa Porter, LPN chuckled even as the words flowed from her mouth.
.jpg "Image") 32-year-old integrative center becomes PCMH
Change-agent
may be more descriptive. Her colleagues were speaking to multiple roles Porter
continues to play as clinic manager in the Center's transition to its present
status as a Level 3 patient-centered
primary care home (PCPCH).
What does Porter do? The Center's website says "Clinical Case Manager." Her
answer- before she recalled the "angel" title: "Patient care. The IV therapy. Phone triage. Urgent Care.
Marketing. Find the funding opportunities to help us grow. Painter, if needed.
Gardener. Be on call 24/7." She ticks off a couple others then concludes:
"Basically, I'm Marty's right-hand lady."
.jpg "Image") Martin Milner, ND: Center founder
The year 1983 was yet a dark age for the naturopathic
medical profession. Naturopathic doctors in Oregon were operated under an outdated licensing act. Fewer than 500
licensed naturopathic doctors existed in the United States. Just 7 states had licensing. Yet Milner had a vision
for his profession's future and chose to build a clinic that would be a beacon.
The task in 1983 was significant. Milner would need to make a go
of covering all that overhead and making a living with then very little
third-party coverage of naturopathic services and a more limited scope of practice.
Milner has since been chosen one of Portland's
top natural doctors. He's also served 18 years as faculty in cardiology,
pulmonology and endocrinology at National College of Natural Medicine for which
he provides an accredited residency.
____________________________
Table 1
Provider Mix at
the Center for Natural Medicine
| # |
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Type |
| 8 |
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Naturopathic doctors
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| 2 |
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Licensed acupuncturists
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| 1 |
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Massage therapist
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| 1 |
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East Asian medicine practitioner
|
_____________________________
Some 3 years ago, Milner chose to point his entrepreneurial
energy with the Center in a new direction. He decided to convert his now 12-practitioner
clinic into Oregon's first naturopathic doctor run PCPCH. This was when Porter appeared
at the Center, "right when the PCPCH application was on the line" in her words.
The time, remembers Porter, "was very chaotic - a lot of
scrambling." The conversion to PCPCH was "a huge learning curve for a lot of
the doctors." She reflects that "those from small clinics don't usually have a
full understanding" of culture and practices in large payment and delivery
organizations.
Transforming the
Physical Plant and Processes
Porter notes that when she went to work on transforming
the clinic Milner "was skeptical." The changes undertaken
over the 3 years all sought to move the Center toward becoming what Porter called "more of a homey feeling
place, and a PCPCH combined." Among the steps:
- Planted a succulent/medicinal flower garden and a
raised bed herb garden
- Removed big desks from the exam rooms to make
space for patient care
- Painted all exam rooms to make them friendlier,
picked out "warm art, mobiles"
In addition, Porter engaged a series of tasks that
directly related to PCPCH status as a community provider, thoroughly linked to care
providers in large delivery organizations in which Porter formerly worked. They are in Table 2.
________________________________
Table 2
Some Key Tasks in the Center's Conversion to PCPCH
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| Re-worked the front desk and patient flow
processes to heighten patient experience |
| Instituted a one system log-in for all
reimbursement |
| Put computers in every room for electronic
record keeping |
| Create a flag
system. |
| Taught the Center's NDs how to communicate
better with hospital personnel |
| Hooked Center's practitioners to medical
doctors/administrators from her former work |
| Built relationships with Care Oregon's team
members |
__________________________________
Finally, Porter brought in a wound-care specialty -
something she'd done in the past, clinically. This would support an important
PCMH function: limiting the need for expensive ER visits.
While Milner was skeptical of Porter's initiatives early
on, she recalls, when he saw the potential she was creating, he "said ‘Wow!'" He was won over.
Porter Unhooks from
Regular Medicine
For Porter, the transition to the Center was also right.
She tells a disturbing story from her professional career that illustrates what drove her to work at the Center. It captures in microcosm the kind pressure to produce procedures in regular medicine that birthed the accountable
care and medical home reform efforts.
Porter was working in a wound care and in a hyperbaric medicine
unit with a local hospital. She also served as the head of safety. While working in hyperbarics, she had a patient with dementia. Her superiors told her to run additional
sessions - at roughly $1500 plus each. Porter knew that
the patient, who had initially come in with a chronic leg ulcer, was deemed healed. But, in her terms, the patient had become "easy money" due to his dementia. When Porter protested, her superiors
at the hospital told her to go ahead anyway.
To Porter, this was anything but
"patient centered care." She also considered it wasteful and questionable at
the level of values.
_______________________________
Oregon
Medicaid Promotes
Non-Pharmacologic Approaches for Pain Care
Oregon Medicaid has taken a bet that including
non-pharmacologic services can reduce opioid dependency.
This for pain treatment
Medicaid covers services of:
Massage therapists
Acupuncturists
Chiropractors
Naturopathic doctors.
See From Pills to Pins: Oregon Is Changing How It Deals
With Back Pain
________________________________
Porter's need to transition out of her prior work was
further driven home when a personal health issue led her to explore the care of a
naturopathic physician. In that treatment, she found values and approaches she
increasingly embraced. She became uncomfortable choosing one type of care for
herself, yet providing another to others.
As Porter tells it, she began work at the Center
intentionally in a low profile role at the front desk. Then she stepped up to
help in the Center's laboratory. She began to do the Center's difficult blood
draws. The job kept growing. She laughs: "Then one day I was clinical manager!"
Quality Initiatives and Special Projects
Center for Natural Medicine has chosen "3 metrics to make
our practice better for Care Oregon," according to Porter. These are the Center's required quality
improvement initiatives.
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Better care for hypertension patients
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Continuous medication reconciliation
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Increasing the number of patients among those
assigned who are served.
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A PCPCH
has a responsibility
to reach out to its assigned
members and get them
participating in preventive
and health-related behaviors.
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The clinic has also applied successfully to the Care Oregon for
funding to support some additional initiatives. One example was when the agency announced a program to support PCPCHs seeking to enhance "patient
engagement" in their care processes. At the level of cost, the equation in simple: If a patient is "engaged" with the primary care team, they are less likely, for
instance, to go directly to the expensive ER and be put through expensive imaging and other procedures.
Engagement entails more than the "better
patient-experience" leg of the Triple
Aim. In that framing, "patient experience" addresses such prosaic concerns as
phone services, patient-flow, parking, and wait times.
Patient engagement runs deeper. From a business perspective, the relationship to the patient in a PCPCH is the opposite of that in an exercise
club, for instance, where the best member is the one who pays monthly fees but never shows up at the club. A PCPCH, on the contrary,
has a responsibility to reach out to its assigned members and get them
participating in preventive and health-related behaviors.
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On Changes
"We were [formerly] seeing many people
who were basically healthy. Now as a
PCPCH we have many
more people with
multiple chronic conditions. Many are in
poverty. No
shows are a big deal."
-- Melissa Porter
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Porter quickly learned that only 52% of the individuals
assigned to the Center had ever seen a practitioner at the Center. She
applied, and the Center received grant support from Care Oregon to help
pin-pointing "why 48% have not come in." To reach more patients, the Center began
reaching out via newsletter and call reminders. They also began to promote
their unusual clinical attractions. They began promoting their yoga, and acupuncture as potential
draws.
Porter was not clear on exactly how the Center will
document the outcomes of its patient engagement plan. She notes the potential to take a re-look at the
percentage of patients on its panel who have received care.
She shares an additional grant area with Care Oregon to
which the Center has responded. "Mental
health is huge" in the Center's PCPCH population. Center clinician Carlo
Calabrese, ND, successfully applied for a grant "on a behavior health initiative."
Calabrese, a former member of the NIH National Advisory Council for Complementary and Integrative Health, has a naturopathic practice with a behavioral focus. That program is not yet operational.
Challenges,
Success and Opportunities
The Center's basic transition to PCPCH was essentially a 1.5 year
process, in Porter's estimation. Few aspects of the Center's activity were not
changed in some way.
A major shift was in the patient population. Porter
reflects: "We were formerly seeing many people who were basically healthy. Now as a PCPCH we have many
people with multiple chronic conditions. Many are in poverty. No
shows are a big deal."
One other area of challenge is in billing. "It's all really new
for everyone,"say Porter, "figuring out how much is being reimbursed and why - whether an
insurer covers acupuncture. One minute they will and the next they won't."
In addition, many of the patients assigned to the PCPCH "can't afford their supplements." Porter has been "hounding
Care Oregon on this." She shares a small victory: "They just said they'd cover fish oil." The clinic is also discounting some of its supplement prices for this population.
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On Positive Outcomes of PCPCH Status
"Oh there are so many successes!
One
that warms my heart is the people
coming in with multiple chronic issues.
Then
you see them six months later,
totally transformed." She speaks to the
importance of access: "They would have
never known we existed nor come in
had we
not been a primary care home."
- Melissa Porter
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Porter is excited as she sums up the positive shifts for
the Center since Milner chose to engage the pioneering PCPCH path for his naturopathic version of an integrative
medical center.
"Oh there are so many successes! One
that warms my heart is the people coming in with multiple chronic issues. Then
you see them six months later, totally transformed." She speaks to the
importance of access: "They would have never known we existed nor come in had we
not been a primary care home."
Porter was not yet able to provide any formal outcomes or
analysis of the extent to which these positive experiences can be generalized.
She has some opinions, however, on why the patients she references responded well: "Our
doctors are treating the whole person. They take much more time. We provide
quality not quantity. Our patients are taking part and they are
partnering. We touch every patient who
comes in the door. We do specialty testing. We have more services. We offer a
lot of education, not just medication."
Porter continued with the positive outcomes: "We've had
to double staff. We're continuously offering more services to the community.
Patients are getting acupuncture. Our providers are doing better. We have a
stable number of patients. We're keeping people from the ER. We're diminishing
the number of meds they need." What's not to like about this?
_____________________________________
Comment: The Center
for Natural Medicine's experience of the transition to PCPCH is, in Porter's
account, remarkably positive. The reported success in treatment following the shift in population from a relatively healthy population to a classic Medicaid population with multiple co-morbidities is particularly remarkable.
Porter's report is a positive indication relative to an important perceived barrier to entry for integrative and naturopathic practice in regular medical delivery. That is, for breaking with the idea, prevalent among many who are dismissive toward these fields, that integrative care only works for the worried well.
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Integrative Care and Patients with
Multiple Chronic Issues
Porter's report is a positive rejoinder
regarding an idea prevalent among many
who dismiss these fields as only valuable
for the worried well.
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These outcomes - assuming that they will eventually be backed by experience data - also question a perspective that presently prevails at the NIH NCCIH. Presently research foci assume that complementary and integrative medicine are best viewed as health enhancements and for reduction of symptoms. Research is not focusing on the role that that integrative practice can play in turning around major conditions.
These apparent successes at the Center are yet subjective. (Porter
said for instance that she "hears about limited ER use while patients are
hooked up to IVs.") The claims need the kinds of experience data that are anticipated to drive processes in
accountable care delivered through patient centered medical homes. Will these perspectives on patient experience,
on lowering ER needs and medications, be supported by population data?
Here's wishing for a fruitful experience at the Center in culling data from their electronic health records. The
Integrator will be back in touch with Porter, Milner and the Center staff
to check in for those data. Terrific to have this initial level of sharing of this pioneering experience.
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