Health Care for the Future: Growing the Family Practice Clinic Report to the Community From the Wahkiakum Family Practice Clinic Advisory Board October 2008

Executive Summary

In August, 2007, the Wahkiakum County Board of County Commissioners appointed a group of citizens to work with the Wahkiakum Family Practice Clinic and the County to determine a future course for the Clinic. The immediate challenges facing the Clinic Advisory Board and the Board of County Commissioners included developing a successful strategy for stabilizing the staffing, services and funding for the Wahkiakum Family Practice Clinic by the end of 2008. Central to that charge was finding the best way for the clinic to operate sustainably, under the guidance of physicians and clinicians, and at a level supported by the citizens of the county.

The Clinic Advisory Board divided its work into three major areas:

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  Recruiting and Retention
  
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  Financing Issues
  
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  Operational and Policy Issues
  

The Clinic Advisory Board worked with Dr. Janice McClean, Medical Director, Dr. Keith Wright (through 4/2008), ARNP Margie Godfrey and Business Manager Kathy Patterson to understand and analyze all issues. The Advisory Board made a series of recommendations for immediate action, which were approved by the County Commissioners, including:

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  Developing and posting job announcements for Nurse Practitioners and Clinicians,
  
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  Requesting the County provide reasonable financial support to the Clinic through 2008 to ensure current staff would remain, new staff would have a clear expectation of job security, and the patients of the Clinic would receive continued care.
  
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  Taking actions to ensure the Clinic would be eligible for State Loan Forgiveness and could access the State Recruitment program.
  
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  Hiring a temporary Nurse Practitioner, while recruiting for a permanent replacement.
  
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  Hiring a new Doctor to fill the role of Medical Director and Clinician prior to the departure of Dr. Keith Wright.
  

These actions were taken and a series of administrative and policy actions were also discussed and implemented over the course of the Clinic Advisory Board’s work. These include:

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  Conducting a community wide survey to gather input from the entire county
  
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  Opening the practice to new patients, providing a sliding scale for cash payments, and providing discounts for cash payments made the day of service
  
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  Developing a plan for expanding the space at the Clinic
  
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  Evaluating the sustainable service mix resulting in the elimination of direct hospital admissions and rounds, but maintaining the laboratory and x-ray capabilities at the Clinic.
  

Issues yet to be resolved include:

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  Method for providing oversight and governance of the Clinic
  
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  Method for funding the interim expansion of the Clinic’s space
  
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  A Clinic fund raising approach that encourages the patients and community to make fair share contributions to the Keep the Clinic Operating Fund.
  

There are ongoing challenges that are being managed jointly by the Clinic Advisory Board and the Clinic staff that will continue to require attention and effort. These include the recruitment of an additional Nurse Practitioner, stabilizing of staffing, and increased marketing to bring in new patients.

Conclusions
Maintaining quality health care in rural communities has become very difficult due to unfavorable insurance reimbursements and the costs associated with operating a physician lead clinic in a small community. To continue to operate the Wahkiakum County Family Practice Clinic it is essential that the following actions are supported:

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  Community and patient financial support for the Clinic is critical while the patient panel is enlarged and the space limitations are resolved. Voluntary support in the amount of $220,000 per annum is being sought from the community.
  
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  Finding external support, such as grants or gifts, to allow for the expanding and remodeling of the existing clinic space is essential to ensure efficient patient flow and to improve revenue generation. Estimated costs for this expansion are $250,000.
  
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  Recruiting and retaining necessary clinical and support staff.
  
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  Stabilizing the staff at current levels and introducing marketing activities to provide revenue increases that will support the growth of the clinic into a four clinician model.
  
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  Providing expert oversight, in the form of a qualified governing board, is necessary to ensure that wise business decisions are made in the near-term, and to position the clinic for privatization.
  

The Community Setting

Wahkiakum County is located on the Columbia River in southwest Washington State. The county cherishes its history and heritage, rural character, and its pristine environment. Although one of the fastest growing counties in Washington State, Wahkiakum County is still the second smallest in population. The county has been experiencing an annual growth rate of nearly 15% in recent years. Cathlamet has been called the Jewel of the Columbia because of its charming, historic river town ambience surrounded by lush forests and wetlands.

Historically, Cathlamet and Wahkiakum County hosted very profitable timber and fishing companies, along with an active agricultural community. With the shift from resource extraction beginning in the early 1980s, the county has been experiencing growth in the recreation and tourism elements of our economy. A discussion of the business climate and community is included in Appendix 1. In addition, Wahkiakum County is seeing growth in residential development specially aimed at a growing population of retired couples moving from the urban areas in Washington, Oregon and beyond.

Photo by Erick Erickson.

Wahkiakum County

Wahkiakum County is one of 39 counties in Washington State. There is one incorporated town in Wahkiakum County, Cathlamet, which is also the County Seat. There are several locations of importance in the County including Skamokawa, Grays River, Rosburg, and Deep River. These communities are located along State Route 4, the main transportation corridor across the county.

Wahkiakum has been enjoying a high and increasing growth rate in recent years due to the pristine quality of the land, the accessibility to larger communities and facilities, and the quality of life in the county. This growth rate is reflected in the recent increase in building permits and other investments in the county. Wahkiakum County and southern Pacific County (naturally linked to Wahkiakum County by geography) are rapidly becoming important retirement and recreational destinations for people from southwest Washington and northwest Oregon.
Wahkiakum County has an older population. In fact, at the state level, the percent of the population over 65 is 11.6%, while in Wahkiakum County, the average is 20.16%, nearly double the state average. See Figure 1 which follows. The majority of the population is White, with a sprinkling of Black (10), Native American (63), Asian (18), Pacific Islanders (3), and individuals of Hispanic Origin (101). As of April 2005, the net migration figure was 196 and this number has increased in subsequent years.

Figure 1. Wahkiakum County Population by Gender and Age, April 2005

Age	Total	Male	Female
0 - 4	195	100	95
5 - 9	203	112	91
10 - 14	261	129	132
15 - 19	262	138	124
20 - 24	144	81	63
25 - 29	132	62	70
30 - 34	166	61	85
35 - 39	229	112	117
40 - 44	248	128	120
45 - 49	300	152	148
50 - 54	365	188	177
55 - 59	369	174	195
60 - 64	311	158	153
65 - 69	221	119	103
70 - 74	161	81	80
75 - 79	132	61	71
80 - 84	117	59	59
85 +	82	17	65
Total	3,900	1,953	1,947
Median Age	46.84	46.09	47.61
Source: Washington State Office of Financial Management Wahkiakum County Profile

Availability of local, high quality health care is of increasing importance to Wahkiakum County and its citizens. With increasing costs for gas, limited public transportation, and an aging population, a viable, diverse health care facility is a major priority for the community.