It is 2:00 p.m. when Tammy Wilkins and I head out from Central City Concern’s (CCC) Old Town Clinic to go visit one of her patients who lives in a subsidized apartment building in downtown Portland. Tammy, who sometimes visits patients while they are hospitalized, walks at a brisk pace. She is in her sixth week on the job as a health outreach worker for CCC’s new ICCT program at the Old Town Clinic.
At the apartment building, the middle-aged man behind the reception desk smiles in recognition as Tammy and I walk through the front door. Tammy is looking for Pamela*, a slightly stooped older woman with grey-streaked hair and hazel eyes who has bounced back and forth for years between shelters, jail and hospital emergency rooms as a result of her struggles with addiction, mental illness and injuries sustained on the streets.
Pamela has only been off the streets for a few days, and Tammy is here to remind her about a post-operative appointment at the Old Town Clinic where she will have her latest wound checked for infection. First, though, Tammy pays a visit to the building’s case management staff. There, she discovers that Pamela has a scheduled appointment that afternoon, but at the moment, she appears to be a no-show. Tammy fishes out a business card and hands it over to Pamela’s case worker. “Let’s get together about Pamela,” she says. “I’d like to coordinate what we’re doing and get her doing better.”
Standing at Pamela’s door, Tammy knocks quietly. As the door opens, my eyes are caught by a sudden motion and I glimpse the tail of a black and white cat diving under Pamela’s bed. After Pamela invites us in, Tammy mentions the appointment with Pamela’s case worker and offers to escort her to his office. She takes a quick look at Pamela’s healing wound and murmurs, “Yeah, I think we need to have the Clinic look at this.” A few minutes later, in the case managers’ office, Tammy says, “I’ll be back in a half hour and we’ll walk down to the Clinic, ok?” Pamela nods and murmurs a “yes.”
“I take great pleasure in little victories,” Tammy says with a smile.
Tammy and four other team members are officially known as the agency’s new Interdisciplinary Community Care Team. Tammy and two of her colleagues are health outreach workers and their teammates include a nurse and a mental health outreach worker. They are one of five teams in the metro area participating in a three-year Health Commons Project designed to connect people with very complex medical and behavioral issues to the medical and social services that will enable them to stabilize. The project in Portland is one of 107 sites nationally and the only one in Oregon.
Together, Tammy and her teammates strive to build trusting relationships with their assigned patients so they can engage them more fully at CCC’s Old Town Clinic, Old Town Recovery Center and Community Engagement Program. The goal of the project is to help some of the region’s most chronically homeless individuals achieve a higher quality of life while reducing pressure on the region’s emergency response services.
“Our patients all have Medicaid insurance,” explains Tammy. “They can easily come to the CCC’s community health clinic for routine care. Our job is to help them access that care before their medical or behavioral issues land them back in the emergency room. We also help patients secure and maintain housing and cope with other challenges, like completing important paperwork. We take a comprehensive approach to our work since any complication can create a domino effect that can result in someone this fragile living on the streets again.”
Patients with six or more ER visits or hospitalizations within the past 12 months are referred to CCC’s ICCT program by local hospitals or from CCC’s Old Town Clinic itself.
Tammy is constantly on the move visiting her patients, consulting medical providers, and engaging the professionals who help her patients with other critical services. Tammy works to break down barriers, integrate resources and find creative solutions to a myriad of complications from poor eating habits to financial and legal difficulties. She talks with patients after an appointment to ensure that follow-up plans are understood, including prescription instructions.
At weekly ICCT team meetings, cells phones vibrate with calls from medical providers and case managers striving to stay connected and keep each patient’s progress moving forward. The team discusses the status of each patient, and how changes in care plans can help improve their lives. The team was fully staffed as of August 2013 and will soon have 115 individual patients who are enrolled in the program for three to nine months or longer.
Early feedback by patients in the program and their healthcare providers already shows an improvement in patient experience and quality of care. Cost savings and other measurable results are being gathered by the Health Commons Project and will be released in the coming year.
*Pamela is a composite patient based on several individuals who are typical of those in the program.