Safety-net clinics face heavy burdens, but innovations can help

(This is the second of two posts. Read the first here.)

Before Obamacare went into effect in 2014, pundits predicted California lacked enough doctors to handle the millions patients who would gain access to health care in the wake of the Affordable Care Act’s (ACA) passage.

They were largely right. Since January 2014, Medi-Cal, California’s Medicaid program, has added almost three million patients to its rolls. And there aren’t enough doctors to treat everyone who enrolls.

In some areas, the burden falls to community clinics. The clinics are already a critical part of the state’s safety net, especially for undocumented workers, who do not qualify for state-supported programs. Now at least some of those community clinics are playing a vital role in treating the newly insured.

At La Clínica de la Raza, a large network of community clinics in Northern California, the new Medi-Cal enrollees are a blessing and a curse. A blessing, because these patients now have insurance and don’t have to pay out of pocket. Compared to the uninsured, they have greater access to care.

But for La Clínica, keeping up with the day-to-day demands of treating such a large volume of patients is difficult. Since January 2014, the organization’s clinics have seen an uptick in the number of people seeking care. For example, in just a year, La Clinica’s clinic in Vallejo has nearly doubled the number of patients it sees.

To meet the demand, La Clínica needs to hire more physicians. But it’s struggling to fill vacancies throughout its clinics in the three counties of Alameda, Contra Costa and Solano. Right now, it has positions open for six full-time and three part-time primary care physicians. In addition, it is advertising several temporary positions for doctors, along with jobs for nurse practitioners, physician assistants and midwives. 

“There is way more competition now for physicians, for family medicine providers,” said Jane Garcia, chief executive officer of La Clínica. “It is probably the largest issue that we’re facing to provide services to this whole new group of people who are newly eligible for coverage.”

At La Clínica, each primary care provider serves somewhere between 1,100 to 2,000 patients and may see as many as 24 patients in a day. If that sounds like a lot, it is. The loss or gain of one doctor can make a big difference. For patients, physician shortages translate into longer wait times for appointments, and rushed visits that can’t address all of their needs. Appointment delays can also force La Clínica to send patients who need immediate care to emergency rooms, a far more costly source of care.

“We’re besieged by new patients and many of those patients are very complicated,” said Tracy Macdonald Mendez, director of medical operations at La Clínica. “People who don’t seem to have been in primary care for years and years — they have huge deferred health care maintenance needs.”

The community clinic network serves a largely immigrant population. Its patients are often very sick, with complicated diagnoses and needs. La Clínica’s facilities include a wide spectrum of services, including pre-natal, pediatrics, dental, optometry, and mental health. Still, it’s a no-frills health care system. Even dedicated providers are pushed to their limits, Mendez said. She said many of its providers can’t handle working full time.   

“It’s really hard being a primary care provider in a safety net system,” Mendez said.  “We talk about this a lot. How can we make it sustainable to work here full time? Usually they’re really committed to the mission, but it’s just too consuming.”

Given its limited resources, La Clínica is experimenting in how it delivers care. One example: morning huddles. Early in the morning, before the first patients have walked through the clinic’s doors, teams of health care workers gather to meet. It’s a concept endorsed by the UC San Francisco’s Center for Excellence in Primary Care and the Institute for Healthcare Improvement. The idea is to anticipate health care problems before they happen, and troubleshoot how to deal with them.

There are two versions of the morning huddle. In the first, the whole staff goes over staffing for the day. The second version involves smaller teams that work closely together. At a minimum, this includes a primary care provider and medical assistant, but sometimes also a front desk person, behavioral health clinician or a nurse. Together, they review the day’s schedule and look through patient charts. Does the physician need to review test results from another clinic? If so, do they need to track them down now? Are there any patients with histories of no-shows? Is anyone on staff leaving early?

“They’re anticipating things that could derail the day,” Mendez said.

She says some of La Clínica’s staff have taken to the morning huddles more readily than others. It can be hard to convince primary care providers – who often stay late to catch up on charts – to also come in early, even if there’s a promise of saving time later. But Mendez says some clinics are now doing them regularly.

The potential rewards are large. “The workload is increasing, the patient demand and need is increasing, and there are fewer licensed people at the top to do it all,” Mendez said.

In that kind of environment, anything that can increase efficiency and decrease stress deserves a chance.

Photo by Ted Eytan via Flickr.