VHHP is a clinical program that exists within the larger Santa Clara Valley Health and Hospital System. As a context, SCVHHS is a county health care system that operates a number of outpatient clinics in the community, seeing approximately 200K patients per year, with approx 650K visits. VHHP sees approximately 8000 visits per year. - VHHP is a unique program in that we serve those who can’t or won’t access services in the conventional way. Our goal is to stabilize these patients to the extent that they can reenter the mainstream delivery system at SCVHHS. - The VHHP Team consists of 15 staff located at the Puentes Clinic, the mobile units, and the shelter.
We provide these services through an integrated model of care, combining mental, medical, and substance abuse in the same care setting, where possible. Added to this is a case management component which provides information and referral assistance to housing, applying for disability, medication management and basic organization / life skills.
Patient Factors – Disaffiliation, Distrust and Disenchantment, Mobility, Ubiquity of Alcohol, Multiplicity of Needs / Competing Priorities Health Care System – Scheduling, Complicated intake and registration, Fragmented care, Location HCP - “Why can’t he work at a fast food restaurant? There are plenty of jobs there.” “They are all alcoholics and drug addicts.”
Reason for Expansion of Scope came out of a genuine desire to better serve our patient population. We recognized the increased prevalence of a number of conditions, and we wanted to build services specifically targeted to this population that minimized some of the barriers we talked about in the last slide. We realized that many of the targeted services required specialty areas outside of our traditional Internal Medicine scope. And so we worked to better provide these services to our patients.
Highlight three components of our program as a way for the board to get a ‘feel’ for what we do. I am going to cover three components of our program using some statistics but primarily focusing on patient narratives.
I want stop and take a quick side bar to thank my patients for letting me use their stories. While as a physician, I firmly believe that science and statistics provide critical tools for making decisions. I am developing a new appreciation for the importance of patient narratives and anecdotes. In many ways patient stories provide the highest fidelity for a program’s work. Our patient’s stories are tragic and compelling… they have all signed consents to let us use their stories and images... Their hope is that their narratives will help other’s with similar needs… I want to thank them for allowing us to share them with you. Our main clinical site, Puentes, is co-located on the premises of a Methadone Clinic. Just so you can understand the context, my only prior interaction as a primary care physician with the DADs program was with the 1800# that patients had to call to get in. They are addicted, they call. In working in the same site as the Methadone physicians, we develop a relationship and cross-talk. They consult us on Internal Medicine issues, and we see their patients. Likewise, when we have a patient who we think needs to be in a Methadone treatment program and specifically cannot navigate the 1800# we will pull them from their day and have them see the patient with us. W.S. is a great example of how integrating our services can help. 50 something year old man who had 6 years clean having relapsed to heroin 2 years prior heroin. Homeless, on 100’s mg of street methadone and Klonipin. An unsafe candidate for outpatient methadone detox because the actual dose of methadone and klonipin bought on the streets is never accurate (poor QA) and starting at high dosages in an unsupervised environment could lead to the clinic overdosing him on methadone. He ran into us at Puentes after trying for the last 6 months to get off methadone without success. I spoke with Dr. Suma Singh at DADS, we had our psychiatrist evaluate him for any co-morbid psychiatric conditions, admitted him to the hospital for an observed titration of his methadone dose and within 4 days discharged him to Horizon South for continued care. DADS, mental health, the hospital coordinated and integrated at the bedside. Very powerful. Having worked in an environment with easy access to my DADS and mental health colleagues, I cannot imagine practicing primary care in this population without them. Also, curbside consult.
GI has been one of the historically most “impacted” specialties in our county system. We saw a need for HCV treatment targeted at our population. Began a set of dialogues with GI, to emphasize our desire to treat the most “difficult” patients (who people historically don’t like treating). Included our GI doc in the process – site visits to OASIS clinic in Oakland, and began to develop a process for starting this new HCV clinic in the primary care setting. Also available by email
D and S are both successfully completing their one year course of treatment. D is done and S will be done in about a month. They both suffered from various forms of depression and anxiety while on treatment. The innovation in our treatment protocol includes weekly group meetings facilitated by our psychologist and immediate access to our psychiatrist… again as a way of integrating behavioral health into medical care. It is because of this group that we were able to pick up symptoms of depression early enough to treat and encourage continued adherence to the medication. It provides a place for people going through the same treatment to share experiences and stories. The group has been so successful that D is planning on returning every week until she gets her job. It really has become more than just treating HCV, it’s about supporting their recovery… HCV treatment being just symbol of this.
Larry One example of fragmentation of care….What are these phone numbers
One of the key pieces to how we are able to provide care is the integrating these traditionally silo’d approaches to the patient. While each silo may be well funded in its own right and doing a great job, it doesn’t necessarily imply that there is any communication or collaboration among each silo.
An example of this is our waiting room. Our psychologist calls it a ‘not-a-group’… All appointments are ‘drop-in’ to facilitate easy access. These creates the alternative problem of people waiting for as long as a couple of hours. Our psychiatrist thought of the idea of throwing a psychology intern in the group and see what happens. It was amazing. At any point, when I call my next patient the room can look like a AA meeting, a how to relax session facilitated by one of the patients with deep breathing exercises, When they hit my clinic room, many of their psychosocial issues are addressed in the room, they are more focused and many don’t really want to see me as much as their colleagues in the waiting room. We have some patients actually coming into the clinic just to participate in the ‘waiting room’. It’s great… you create an environment where the appointment starts right when you hit the waiting room.
Those are the three components. I am hoping that gives you a ‘flavor’ for the kind of work we are doing. It’s our goal to provide ‘the safety-net for the safety—net by creating a medical home for our patients. As with any home, it looks different because of the people it houses… it is defined by those patient’s needs…. Not a group waiting rooms, case managers, outreach doctors, drop-in hours. It’s our hope that by providing a non-judgmental environment, a place where their most pressing concerns are directly addressed (HCV, withdrawals, addiction, mental health)… we can create a place where they have hope and options. We can create ‘home’ where they feel they can get care during their most desparate times.
Santa Clara Valley Health and Hospital System
Valley Homeless Healthcare Program (VHHP) Cheryl J. Ho, MD Charles Preston, PhD Santa Clara Valley Health and Hospital System March 6, 2008
VHHP Mission Statement <ul><li>“ Valley Homeless Healthcare Program seeks to establish a safety-net for the safety-net.” </li></ul>
VHHP Mission Statement “ This program seeks to address the needs of vulnerable populations who require an integrated model of care incorporating medical, mental health, and substance abuse services.” Mental Health Drug and Alcohol Valley Medical
Barriers to Health Care for Homeless Individuals Patient Health Care Provider Health Care System
Health Status of Homeless Individuals: “Multiplicity of Needs” <ul><li>Higher prevalence of : </li></ul><ul><ul><li>HIV, TB, Hepatitis C </li></ul></ul><ul><ul><li>Hypertension (2x) </li></ul></ul><ul><ul><li>Poor dental health (31x) </li></ul></ul><ul><ul><li>Tobacco </li></ul></ul><ul><ul><li>Alcohol problems(6-7x) </li></ul></ul><ul><ul><li>Severe, chronic mental illness </li></ul></ul>
Expanded Scope of Practice Methods and Principles <ul><li>Co-Location : with Addiction Medicine </li></ul><ul><li>“ Mini-Fellowship” Model : HCV Clinic </li></ul><ul><li>Integration of Care, or the “One Stop Shop” : Psychiatry, Psychology and Social Work Services </li></ul>
HCV Prevalence in Population Subgroups: US Civilians (NHANES, n= 21,241) EMT (Philadelphia, n= 2136) VA Outpatient (SF area, n= 1032) Homeless (Palo Alto VA, n= 829) Male Inmates (CA state prison, n= 6536) Female Inmates (CA state prison, n= 577)
Hepatitis C Treatment and the “Mini-Fellowship” Model <ul><li>Difficulty with Gastroenterology access </li></ul><ul><li>“ Mini-Fellowship” for 9 months </li></ul><ul><ul><li>½ day per week </li></ul></ul><ul><ul><li>Own “panel” of patients within GI </li></ul></ul><ul><ul><li>Developing a relationship based on trust </li></ul></ul><ul><li>Site Visits </li></ul><ul><li>Quarterly Conference and Review with Gastroenterology </li></ul>
Hepatitis C Treatment and the “Mini-Fellowship” Model
Barriers to Care: The Health Care System 704-0900 488-9919 334-1000
Barriers to Care: The Health Care System 704-0900 488-9919 334-1000 Mental Health Drug and Alcohol Valley Medical
Integrated Care: A New Model Mental Health Drug and Alcohol Valley Medical
Integration of Care: A New Model <ul><li>Side by Side Practice </li></ul><ul><ul><li>Psychiatry and Psychology </li></ul></ul><ul><ul><li>Sees patient at the same time </li></ul></ul><ul><li>“ Warm Handoff” </li></ul><ul><ul><li>In person, in real-time </li></ul></ul><ul><li>Practice Innovations </li></ul><ul><ul><li>Psychology </li></ul></ul><ul><ul><li>Chat Room </li></ul></ul>
Mental Health In Primary Care <ul><li>Quicker and better access for patients </li></ul><ul><li>More comprehensive care for patients </li></ul><ul><li>Reduced demand on primary care time </li></ul><ul><li>Instant access to consultative relationships with reduced demand on specialists for treatment </li></ul><ul><li>Increased physician satisfaction </li></ul><ul><li>Training of residence- patient self-management </li></ul><ul><li>Expanding services to pre-existing primary care clinics </li></ul>