Exclusive: Dr. Ana Valdés on primary care workforce in California’s safety net

Dr. Ana Valdés, Chief Health Care Officer / source: HealthRIGHT 360

Dr. Ana Valdés, Chief Health Care Officer / source: HealthRIGHT 360

State of Reform met Ana Valdés, Chief Health Care Officer of HealthRIGHT 360, during a California Health Care Foundation (CHCF) panel presentation on the future of safety net clinics. With provider burn out and the difficulties of maintaining a primary care workforce a perennial topic, we were surprised to hear Valdés comment that her clinic—which has been delivering integrated mental, behavioral, physical, and housing services to San Francisco’s most vulnerable populations—is seeing relatively low rates of physician burn out.

Valdés talked to us about how community clinics are beginning to wrap their minds around the idea of whole person care and are prioritizing workforce issues in 2016.

JJ Lee: It seems like HealthRIGHT 360 has a jump start on the integration discussion. But in this post-1115 space where everyone is wrestling with seeing physical health, housing, mental and behavioral health, and substance abuse as one, what’s changing for you?

Ana Valdés: Integration is one of those things that you get going, but it needs to keep happening on an ongoing basis.

While behavioral health and mental health have walked side-by-side with physical care of the patient—they haven’t really been thought of uniformly as “health care.” When we think of health care we still generally think of the doctor’s visit. People don’t also think that you might be getting your medically-assisted treatment for opioid addiction, your mental health care, referral for outpatient substance use disorder services, and maybe even be put into a residential program if that’s what you need. That has all changed. We are expanding the primary care side and the access to treating some of these social determinants of health for patients.

In my role, I oversee the both the medical and behavioral health—which is daunting because I’m a family practice trained physician, and I learned a huge amount around behavioral health which I thought I knew having worked in the safety net my entire career.

One piece that I’ve always felt was missing, that we are interested in having access to, is permanent supportive housing—very easy to say, very hard to do in San Francisco where there is practically no housing market available. But what has changed for the clinic, and for the organization as a whole, is bringing people into the realization that health care is health care and reflecting that in our roles.

JL: Help me understand burnout in the clinical context. Where are you seeing burnout? What’s causing it?

AV: Globally, some of that burnout is just due to lack of workforce that is available and willing to do primary care. Before the ACA, going back to the 80s, managed care moved everybody into a model with a Primary Care Provider. It focused the attention on primary care. But I don’t know that we’ve ever had the primary care workforce to address that change and [this problem] is even more so post-ACA with so many patients coming into the system.

When you ask an administrator like me, “what’s your biggest stressor?” It’s health care workforce.

In general, our disjointed system adds so many layers of administration, such as billing, documentation, referrals to specialty care, on top of face-to-face patient care. People get burnt out just trying to do everything that is related to patient care beyond the face to face visit, unless we come up with innovative systems to deal with the aspects of medical care that are not clinical.

At the safety net level, we deal with really high-risk populations. It’s not just the complicated care that we have to deliver, but their stories. You hear enough stories from people, and you can’t help but be affected by it. You’re not just a primary care provider; you’re a social worker, you’re a case manager. Many times patients don’t have access to therapy and mental health support, so you’re also put in that role.

One of the innovations that we’ve engaged in is practicing in primary care teams. It’s not just going to be all on the provider who sees the patient. The front office, the medical assistant, the nurse, the provider, the behavioral health provider, the safety staff—anyone who can in any way touch the patient and influence their care is someone who should be considered part of the primary care team.

That is a way that we’ve been thinking about transforming primary care so we can avoid the burnout. Patients do not always need to see a provider. Sometimes they need health education or self-management support that can be provided by another member of the team such as a nurse or health educator. The problem is that’s not how we get paid. If the nurse sees the patient, we don’t get paid. If the health educator sees the patient, we don’t get paid. We only get paid on the face-to-face visit with the provider. So the payment doesn’t support the innovations that are happening.

The other thing we are engaging in is integrated care. Our homeless clients are hard to get in to the clinic. Their lives are oftentimes chaotic. They’re spending a lot of time just trying to meet their basic survival needs—where they’re going to eat, where they’re going to sleep. So, multiple trips to the clinic are not always reasonable. When we do a medical and behavioral health visit in the same day, we only get paid for one visit.

We all know that the payment system has to change, but no one can agree on anything. There are several these pilots testing out alternative payment methodologies in California but we will not have any results for a few years.

Yet, in the meantime, we’re still struggling to keep our staff, not having them burn out or have them leave for Kaiser or UCSF or the DPH which can pay more than we can. We want to provide our providers quality of life where they are not working 18 hours a day just get what needs to be done for the patients done.

JL: I’ve been hearing a lot about the corporate responsibility of maintaining of that primary care pipeline. Where does the responsibility fall?

AV: For me development of compassionate workforce starts in the school. Some of the academic centers are doing that now. When I was in medical school, there was no primary care rotation. The family community medicine department consisted of three people. That was the whole family community medicine department.

So if you were interested in primary care or working with the safety net, you didn’t have a lot of exposure. I think the schools are really starting to address this by bringing students in to do community-type work and recognizing the importance for them to have exposure to primary care.

We need to close the loop at the primary care end and be more receptive to students that want to be there. This is why our clinics are so open to having students and residents and fellows. We’re hoping that they get a lot of satisfaction from the work that we do and want to come back to do it. It’s hard work, and the population is super challenging, so it’s not for everyone.

Of course, it’s a shared responsibility across the entire system. Still, when we get private institutions that can blow us out of the water with salary, there is no way for a community health center that serves the homeless safety net population to compete. The whole idea of skewing the salary scale to compete for providers really jeopardizes the whole system.

JL: You mentioned on a CHCF panel that while a lot of integration work is happening in your clinics, physician burn out is pretty low. What strategies are you using to engage your docs and support staff?

AV: From our perspective, first of all, it’s making everyone a part of the health care team. If you divide clinical and nonclinical staff, you will create problems with disconnect not only amongst staff but from patient care.

Making everyone part of the health care team empowers staff because then their job has impact. It creates more ownership of the patient, of our community, and of our population. In the front office you’re just as important as the MA and the provider in patient care by making sure that people get to their appointments, their follows ups, and their referrals which is arguably as important as the care that they are getting on site at the clinic.

All of our clinics have moved into practicing as care teams. Other opportunities to avoid burnout is to provide care in different ways. At a clinic where I was Medical Director, before coming to HealthRIGHT 360, we wanted to address different ways to approach patient care that also addressed the issue of provider burnout. Some of the ways that we did this was to find alternative ways to provide patient care besides the face to face visits.

We learned what areas of healthcare providers and staff were passionate about, such as obesity and nutrition or diabetes or asthma, and empowered staff to develop different ways to provide patient care that spoke to their interest as well. One example is that we had a team of a nurse practitioner, a nursing volunteer, medical assistant and a front office staff who were interested in obesity and nutrition. They researched and created an evidence-based curriculum for patients and their families and held weekly group education and patient visits to teach patients about healthy eating, nutrition, and exercise. We were able to pull them out of the routine of individual patient visits and utilize another forum to address patient health. We allowed them to address a much-needed area of health that spoke to their interests and allowed them to do work that is driven by what they are passionate about. We will be replicating this type of healthcare at HealthRIGHT 360. The bonuses that you see around the retention of good staff are well worth it.

These are the things we have to think about, even though we are paid for the face-to-face visit with the provider, more and more the conversation is moving towards population health management.

Because we are non-profit community health centers, we have to be creative in creating job satisfaction beyond offering more money. We can try to offer things that can’t be done in large systems because those models are locked into getting a certain number of patients in and getting them seen.

JL: Thanks for talking with us, Ana.

AV: Take care.