NHCW 2016: Giving Consumers A Voice

Aug 08, 2016

While Samm McCrary wasn’t entirely sure what to expect at her very first Central City Concern Health Services Advisory Council (HSAC) meeting, the last thing she expected was to arrive at the same time as her former clinical supervisor, who was now working for CCC. For Samm, this chance meeting wasn’t just a reminder of her past—it was a preview of the opportunity and voice HSAC would afford her.

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Until 2008, Samm was living in a comfortable home and doing what she loved as an alcohol and drug counselor. But she began experiencing major mental health crises. Suddenly, she found herself without a job and without a home, living on the street. “I felt invisible to most of society,” Samm remembers.

With the help of local agencies, Samm was able to access permanent housing. Soon after, she became a patient at the Old Town Clinic, engaging in primary care, acupuncture, art therapy, and occupational therapy. There, she found community, which “nourished both my body and soul.”

Three years ago, her neighbor—also an Old Town Clinic patient—invited Samm to check out CCC’s Health Services Advisory Council.

“She basically said that the council was like a liaison for our peer patients to the CCC administration. We could share praises and concerns.”

What Samm found was a group of people engaged in CCC’s health and addiction recovery services—the majority of whom were homeless or recently homeless, diverse in ways that reflected the patient population—that had been meeting in various iterations since 2003. 

“Their purpose is to advise CCC Health and Recovery Services about client needs and ways to improve delivery of health care services,” says E.V. Armitage, who has provided invaluable administrative staff support since 2008. “HSAC is a great mechanism to give consumers a way to provide input into the agency's growing array of health services.”

Now with several years of HSAC service under her belt, Samm’s been able to identify the common thread found among all members of the council. “These people have integrity and they want to make positive change. Everyone on HSAC has a spark like that,” she says. “They’re all service-oriented and want to lend their voice to others.”

Samm recalls a time toward the beginning of her council membership when she was still hesitant to share anything that could be perceived as a complaint, but chose to go ahead and share a concern that a fellow patient had brought to her. What Samm shared on behalf of her peer was a problem CCC Health Services wasn’t even aware of that could have affected many other patients. But thanks to the opportunity to speak up, CCC took action, identified the source of the problem, and remedied it immediately.

“I learn something new every time I go to a meeting,” says Chief Clinical Operations Officer Leslie Tallyn, who attends all monthly meetings. “HSAC members hold us accountable—they illuminate areas where we can and should do better, and they also recognize where we’re doing well.”

And while HSAC’s benefit to CCC is built into the purpose of the council, Samm is clear that the benefit travels in both directions.

“It’s immense that they actually listen. I’m someone who dropped out of high school and went to college when I was 34. I waited tables for 15 years. And yet they hear me and take me seriously.”

Samm pauses and breathes deeply before she continues, as if she’s collecting and revisiting the experiences of the last several years. “A thing about being diagnosed with a mental health condition is that there becomes a sense of powerlessness; it’s like you no longer have any credibility. If anything goes wrong in your life, it’s perceived as being because of your mental health. Having a voice with your peers and with the administration who will listen is really meaningful.”

Which brings Samm back to her first HSAC meeting when she ran into her former clinical supervisor. Samm had worked hard to rebuild her life after losing her career as a counselor (ironically, “a profession where once I said something, it was accepted!”) and the roof over her head. She had felt powerless, invisible, unheard. But here she was, in a meeting where her word counted for just as much as those of her former supervisor.

“To have a voice that people will listen to and actually take you seriously is a healing thing,” Samm explains. “Peer patients who have a problem feel heard when they share them with us because they know we’ll bring it to the council. They see action from the administration. I think people get how powerful that is.”

Samm’s thankful to be a part of HSAC because it gives her a chance to share the voice she’s found with others.

“They might be discounted in other parts of their lives. Not here.”

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NHCW 2016: Offering Another Tool for the Recovery Toolkit

Aug 08, 2016

Central City Concern promotes high quality addiction treatment, which is founded on counseling, life skills and community support—with medication for those who need it.

Eastside Concern, CCC’s addiction and recovery outpatient facility in east Portland, offers Medication Assisted Treatment (MAT) that frees people from the highs and lows caused by drugs, as well as thinking about drugs all the time. MAT helps take away cravings and allows people to focus on positive change in other areas of life.

“MAT makes some people feel normal,” says Nickolas Reguero, a counselor in CCC’s Eastside Concern’s MAT program. “It gives people breathing room to look at their lives and relationships. They can really examine their identities: who they are, how they want to be remembered by others.”

Between July 1, 2015 and June 30, 2016, CCC clinics had 220 patients in MAT. About 60 clients are enrolled in Eastside Concern’s MAT program, which began as a CCC pilot in 2015 and became a program in 2016. To be eligible, enrollees must want to stop using all substances, including alcohol and marijuana, and have a safe place to keep their medications.

MAT includes:

- group and individual sessions for the duration of treatment
- random and regular urine drug screens and pill counts
- no alcohol, marijuana or non-prescribed drug use
- participation in community recover support activities
- and engagement with a primary care provider.

Nickolas has worked in the program for only a few months, but he’s already impressed by MAT successes. “To me, the biggest difference from traditional addiction treatment is the continuum of care. We are able to get people connected to community support and primary care,” he says. “I really like that we help people achieve a level of stability so they can make a change. That’s different from other office-based treatments that tend to be silo-ed.”

The program works because the staff keeps a positive, non-stigmatizing and pro-social attitude—and they utilize trauma-informed treatment. “Clients really struggle, but we use those struggles as opportunities to address deeper issues,” Nickolas says. For example, if someone has continually positive urine-analyses, staff can use them as a positive starting point to delve into the reasons why they’re so challenged.

“Our MAT program is about true relationships,” Nickolas explains. “We develop relationships in a thoughtful collaborative manner. We let clients know: somebody cares.”

Eastside Concern has been in operation for more than 30 years; it joined the CCC family in 2011. In addition to MAT, the facility offers a certified DUII program, domestic violence intervention, a specialized corrections program, patient groups to address substance use, specialized relapse prevention, and intensive outpatient services for those requiring maximum support in achieving and maintaining abstinence and recovery.

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NHCW 2016: Providing Wraparound Care for Complex Needs

Aug 08, 2016

Tyrone Rucker is all about integration. As Central City Concern’s Integrated Health and Recovery Treatment (IHART) program case manager, he is the glue for the team that provides integrated services to about 250 CCC patients. “I love to see people’s faces when I explain IHART to them,” Tyrone says. “There’s a whole team here to help you.”

In 2014, CCC received a behavioral health integration grant from Health Resources and Services Administration (HRSA) to develop a health home model for patients with co-occurring severe mental illness and complex medical needs, blending evidence–based models of care from both primary care and mental health.

Since 2014, the IHART program has provided wraparound mental and physical health care services for patients experiencing severe mental illness and addictions as well as medical issues. The interdisciplinary team has 14 members, including psychiatric providers, mental health and substance use disorder counselors, nurses, peers, case managers, and care coordinators

“I like the team approach,” Tyrone says, “we all get the same information.” On a daily basis, Tyrone has contact with seven to 10 patients. The team makes sure patients have the mental and physical health care they need, as well as other services.

IHART patients receive their primary care at the Old Town Clinic, a patient-centered medical home recognized by both the state of Oregon and the federal government for excellence in care and co-located with the Old Town Recovery Center, where IHART is housed. People placed in the IHART program are dealing with co-occurring severe mental illness and complex medical needs. They need wraparound care to help them achieve basic needs.

Sixty-eight percent of people with a mental illness have one or more chronic physical conditions, often related to their psychiatric medications or conditions, including obesity, high blood pressure and high blood sugar. If not monitored closely these can lead to heart disease, type 2 diabetes and early death.

Every morning, the IHART team has a 30-minute huddle to discuss patient needs that include housing, cell phones, glasses, bus passes and food boxes. They need reminders about dental appointments, lab tests and medication. “We get to treat the whole person,” Tyrone says. “Everything is on site.”

Tyrone feels that everyone on the team is treated equally. “I have a voice,” he says, when talking about providing care. He also believes the team has a special internal integration as well. “We support each other and cover for each other,” he says. Tyrone is a single father and studying for his bachelor’s degree in health care administration. He likes how his work family helps him when times get stressful. “They take care of me.”

The IHART team is seeing positive results. Ninety-two percent of IHART patients kept suggested primary care appointments compared with 75 percent of similar patients who are not enrolled with an integrated team. And 56 percent of IHART patients had the recommended annual screenings for high blood pressure, diabetes, cholesterol levels and body mass index, compared with 24 percent of similar patients. Strong engagement with primary care and completion of recommended screenings can lead to improved health outcomes over time.

IHART has a maximum caseload of 300 people, but CCC leadership intends to continue developing this innovative and successful model. And after working with the IHART team since the beginning, Tyrone believes the integrated approach is the very best way to provide outstanding health care for CCC patients. He says, “I really appreciate all the medical care teams that help integration to succeed.”

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NHCW 2016: Meeting Patients Where They Are

Aug 08, 2016

Spend enough time in a community health center, and you’re bound to pick up on a common refrain used in conversation, in literature, in staff memos: “meeting people where they are.”

Many community clinic patients, according to Gene Biggs, “haven’t been treated with respect or decency, haven’t had the best experience with medical care." Trauma, fear, and mistrust, says Gene, also mean that this patient population is less willing or able to commit to ongoing primary care. Meeting patients where they are becomes an essential approach to not only getting them the care they need now, but getting them ready to continue receiving the care they'll need moving forward.

Gene is the Clinic Care Coordinator at Central City Concern's Bud Clark Clinic, which, like many other community health centers, provides acute care—care for episodic or urgent health needs—for those who are homeless and marginally housed. Bud Clark Clinic, however, is unique in two distinct ways: how they meet vulnerable people where they are, and their end goal.

The Bud Clark Clinic is located within Home Forward’s Bud Clark Commons, which consists of a daytime resource center run by Transition Projects, Inc. (TPI) and permanent supportive housing (the Apartments at Bud Clark Commons) provided by Home Forward. In this sense, the clinic meets patients where they are, literally.

"For marginally housed patients, the idea of getting on a bus or walking the city blocks to a big clinic with lots of providers and a lot of people to get care can be too much," Gene says. "It's much easier for them to come to a place where they're already going to spend time." That place, of course, is the TPI daytime center, just adjacent to them exam room.

Residents of the Apartments at Bud Clark are served by a second clinic exam room upstairs. Even still, their trauma histories can make traveling down the hall for care too difficult or overwhelming. In those cases, care providers visit patients in their rooms.

Gene has found that setting up operations where patients already are provides, perhaps unsurprisingly, significant benefits to providing care.

"Being here every day, consistently, is a huge part of our care—a consistency that, in their situation, they don't have. Sometimes people just come and want to talk. Being immersed in the community has helped. "

Gene sees their everyday presence as a way to engender trust in and a feeling of safety with Bud Clark Clinic that helps patients believe that the clinic is there to help them, giving them an entryway to provide acute care. But the Bud Clark Clinic is concurrently oriented toward helping their patients become more comfortable with the idea of receiving ongoing care from a primary care provider.

"We can build on that relationship to get them to the next level of care [beyond acute care] that can offer more and ongoing medical services Bud Clark Clinic isn't set up to provide," Gene explains. "The big point of Bud Clark Clinic is to bridge the gap between getting people the care they need now and trying to get them care that's better suited for them in the long run."

At each visit, Gene and other care providers bring up the topic of primary care. Do you have a primary care provider? How do you feel about going to a primary care clinic? What are your reservations?

"We feed off the type of language use about it," Gene says. "We don't push, we don't force. We engage. Like a wading pool before the deep end of primary care."

Until a patient does feel ready to dive into a primary care medical home, Gene and the Bud Clark Clinic remain steadfast in meeting patients where they need to be met. Sometimes that might mean walking or riding in a cab with a patient to their next care site. Other times it might mean tracking down a patient who ended up in the hospital and visiting them.

That flexibility, Gene emphasizes, "is the Bud Clark Clinic. We let them know that we’re here to support them as much as we can. However and whatever it takes."

For Gene, his commitment to the people he sees at the clinic is just as much personal as it is professional.

"I’ve had some times of struggle personally, and family who have struggled with addiction who would be homeless if they had no one to rely on. If I didn’t have the family that I do, I could be here as well."

Meeting patients where they are can happen in a physical sense or a relational sense. Combine the two, like at the Bud Clark Clinic, and patients receive a depth of care that both honors where they are while seeking to propel them toward more sustained care.

"We want to get them to that next level of care. In the meantime, we're not done with their care once they leave the door."

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NHCW 2016: Creating Safety from Race-Based Traumatic Stress

Aug 08, 2016

Since opening a year ago, Central City Concern’s Imani Center program has been providing outpatient mental health and drug and alcohol addiction treatment services specifically tailored to address barriers uniquely experienced by African Americans in mainstream treatment programs.

JoAnna Smith, the Imani Center’s Lead Mental Health Counselor, quickly recognized a trend in the center’s clients that she had begun to see in African-American clients she saw in prior years: addiction and mental health struggles triggered, maintained, and exacerbated by the trauma of racial oppressions.

“We see so many clients with post-traumatic stress disorder, a lot of people struggling with unresolved trauma histories,” JoAnna says. “Many of our clients have felt unsafe, unwelcome, targeted and discriminated against by the community for much of their lives.”

JoAnna recognizes the power of past experiences, particularly how they can profoundly shape people, for better or worse. She’s quick to point out that her own past—growing up in Portland, accessing great education, honing her counseling and social work skills at internships in South Central Los Angeles—has culminated in the fortunate position she finds herself in now. JoAnna extends that understanding to Imani Center clients, whose presenting mental health and addiction symptoms are rooted in their trauma.

Looking for ways to improve how she served Imani Center clients, JoAnna started learning about trauma-informed care, which is a framework used in CCC programs. She dove headfirst into learning more about the approach, completing a trauma-informed service certification program.

“Trauma-informed care is not a therapy, it’s not an intervention; it’s a way of understanding those we serve,” explains JoAnna. “It’s a framework that acknowledges how trauma affects people. And it’s an important part of supporting our clients who come to Imani with co-occurring disorders.”

Learning about trauma-informed care excited JoAnna so much that she brought it to the rest of the Imani Center staff, asking them which area of the program they thought could benefit most from utilizing the approach. Unanimously, they decided that they wanted to bring the framework into group work. Doing so, JoAnna says, begins and ends with creating safety.

“According to trauma-informed care, safety is the treatment. Each Imani Center group facilitator is responsible for creating an environment that is safe. Maybe more than anything else that we do, more than any other intervention, if we’ve created a safe environment for our clients, we’ve done our job.”

Each Imani Center staff member has now been trained to be mindful of three areas in their groups to create the safety so essential to bringing trauma-informed care to clients: presentation, tone, and structure. And though this approach was initially geared to integrate into group work, JoAnna is thrilled that trauma-informed care has spread to all parts of the program.

“Starting from when a client enters our building and meets our office manager, to when they do their first intake appointment and screening, to the groups, we ask ourselves, ‘Are we treating clients with worth, dignity, and respect?’” says JoAnna. “That happens when we understand people are coming to us with a lot of trauma history and we remain mindful of that.”

Though a relatively new program, the Imani Center has courageously embraced an effective trauma-informed approach that asks more of each staff member—as JoAnna summarizes, “even more awareness, more hospitality, more compassion”—to better serve their clients. And it’s paying off.

“A safe environment enables clients to integrate their traumatic experiences into their life stories instead of having them at odds,” JoAnna says.

A core goal of the Imani Center is to be a place where clients can be who they are, where they can bring their past and current experiences—with addiction and mental health struggles, homelessness, unemployment, and criminality, as well as race-based discrimination and prejudice—in the hopes of finding healing. JoAnna believes that the training and awareness she and her colleagues have integrated into the program is helping clients do just that.

“We the staff are the agents of the structure. When we approach our clients from that trauma lens, we understand that we get to create the environment of safety for them, which makes a world of a difference.”

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NHCW 2016: Using Data to Ensure Patients Receive the Right Care

Aug 08, 2016

Not long ago, Central City Concern recognized a gap in our health services. CCC’s substance use disorder services and specialty mental health services had multiple tiers of programs designed to meet a variety of needs—including acute teams for more complex clients. Our primary care health services didn’t. To fill that need, CCC created the Summit team, a new care team based on the concept of an ambulatory intensive care unit.

Like our substance use disorder and mental health acute care services, the Summit team was designed to serve patients who usually have compound health issues that place them at greater risk for an extra, higher level of care. The team limited its size by design so patients receive streamlined, in-house care from the fewest people possible. “The idea with Summit is to improve care for those who really struggle,” says Matt Mitchell. “So much of the design philosophy around it is: let’s keep it small.”


The team's low patient-to-staff ratio affords patients longer visits, home or in-hospital visits, medication management, enhanced and around-the-clock access, and more. But CCC quickly found that having the Summit team providing care was only half the battle.

“It turns out identifying who Summit patients should be… is really difficult,” Matt says. By virtue of the type of care the Summit team provides, the criteria for pinpointing patients—advanced illness that’s expected to deteriorate without more intensive care, isolation, a need for extensive medication management, medical complexity driven by untreated or severe behavioral health condition, among others—is only partially helpful.

“There are over a thousand patients who can check all the right boxes on that [criteria] form,” says Matt. “But Summit isn’t meant to serve all of those patients.”

Identifying patients who would be best served by Summit is a balancing act.

“On one hand, the Summit team is trying to organically figure out who they can best serve and who’s right for Summit. The clinical judgment of the providers is so important.”

Matt, a data and quality specialist assigned to work exclusively with the Summit team, supplements their judgment with data. “On my end, I’m trying to do the same thing in parallel, but with data analysis to identify who are the highest risk patients we serve at Old Town Clinic [CCC’s primary care health center].”

When it comes to the care of patients as vulnerable as those Summit seeks to serve, it would be easy to choose sides or put more faith in one approach over another. Providers versus p-values. Informed hunches versus analysis. Matt doesn’t see it that way. In fact, he believes utilizing a balance of both approaches ultimately serves patients better.

“The clinical judgment piece is so important because there are things we just don’t have data on. Data isn’t truth, it gives us some ideas of where to go,” he says. “But I think it’s really important to put data in front of clinical staff and decision makers to help remind them of things they wouldn’t have thought about otherwise.”

Matt’s role as the Summit team’s dedicated data analyst has proven to be incredibly beneficial to the way he is able to support the aims of the team. He sits in on each morning’s team huddle, participates in their discussions about patients and priorities, and is part of the team’s thought processes—activities reminiscent of the time he spent as a Boston-area outreach worker.

“Understanding what’s happening on the ground and having an idea of what the patients’ stories are helps me understand the limitations of the data so that ultimately I can use that data more appropriately and effectively,” Matt says. “Otherwise I’m looking at numbers and statistics all day. Our patients are more than that.”

In addition to analyzing and incorporating data to identify Summit patients, Matt is working on an exciting project that visually maps out the characteristics of all Old Town Clinic patients, onto which he’ll overlay Summit patients data points to identify areas they tend to cluster. “Hopefully this will give us a new perspective on identifying the patients who are really right for Summit,” he says.

The benefits of this innovative solution won’t be confined to Summit. Matt plans to use this project to explore patients of other specialized teams at CCC, like Community Outreach Recovery & Engagement (CORE) and Integrated Health & Recovery Treatment (IHART).

Matt relishes the freedom he has as Summit’s data analyst to sit with and think through problems. Ultimately, his approach, process, and solutions end up being richer and deeper, which means his work can be valuable beyond Summit.

“Our hope is that Summit can operate like a learning lab for the rest of Old Town Clinic, and ideas and things we pilot can be expanded elsewhere.”

And even when he finds himself deep in numbers, formulas, and maps, Matt is intentional about not losing sight of the people Summit serves.

“I love these patients; this is a population I care about. It’s important to me to use data to ensure that people get the things they need.”

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CCC Celebrates National Health Center Week 2016!

Aug 08, 2016

“We choose to go to the moon … not because it is easy, but because it is hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win.”

President John F. Kennedy’s famous speech at Rice University in September 1962 captured the tone of the United States. It was a time of extraordinary innovation, responding to deep and complex societal problems. Lyndon B. Johnson’s Great Society initiative brought us education reform and the earliest roots of community health centers, which we celebrate this week during National Health Center Week. Civil rights leaders like Malcolm X, Reverend Martin Luther King, Jr., and Medgar Evers, among many others, led the movement against Jim Crow and socially and legally institutionalized racism. Stonewall birthed a new age of LGBTQ activism, while second-wave feminism brought us Titles IX and X and a sea change in societal attitudes toward women.

Today, we face a different but no less daunting set of social ills. Homelessness and poverty, along with the deeply entrenched social and economic disparities that drive them, are problems of such breadth and depth that they can seem immovable. Social planners and others talk about the concept of wicked problems, not merely hard problems that can be solved with enough resources and time, but deeply complex and interdependent problems with no clear causes or easy solutions. Wicked problems challenge us to think with creativity and clarity, to work collaboratively, and to be willing to try harder every day. They are problems of such scale and urgency that we can do no less than bring our very best.

At Central City Concern, our 800 employees, together with the 10,000 people we are privileged to serve every year and our many community partners, are deeply motivated by the wicked problems of homelessness and poverty: challenges that cannot be postponed and must be won. Working with limited resources to solve problems that may seem unsolvable, rather than being Sisyphean, inspires (and requires) us to innovate every day.

In celebration of National Health Center Week, we are profiling Central City Concern staff, patients, and programs within our Federally Qualified Health Center sites who are working to develop innovative and thoughtful solutions to the complex problems we face in community health work. These profiles represent some of the best of what our organization has to offer. I challenge you all to address your problems, no matter how great or small, with the strength of innovation.

Leslie Tallyn
Chief Clinical Operations Officer

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