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

Appendix 5 - Clinic Floor Plan

Appendix 6 - Policy Issues and Recommendations

Issue Summary	Discussion and Issues	Proposed Recommendations
Governance	The Clinic requires a Governing Body that has the expertise and background to help oversee the Clinic’s performance, help the Clinic with external relationships, and report to the Board of County Commissioners. The members of the Governing Board should have appropriate background and expertise to ensure proper oversight of the Clinic for the Board of County Commissioners.	Establish a three person Clinic Governing Board. Issues to be discussed: Membership of Board is appointed by BOCC, stagger 2 year terms Authority (i.e., oversee Clinic operations, provide direction to the Clinic Administrator and Medical Director, and control budget within parameters established by BOCC)
Space and Options	The current Clinic only has six exam rooms and the Clinicians have to share offices. To maximize the efficiency of the Clinic and reduce waiting times, the Clinic should have at least 3 exam rooms per Clinician, meaning there should be 9 exam rooms plus an office for each Clinician. In addition, there needs to be space for the lab, x-ray, and so on. In the long-run, the Advisory Board believes a new building will be required. However, in the interim and remodel and addition can do the job.	Build an addition to the existing Clinic and remodel the existing space to allow for adequate exam rooms, Clinicians offices, improved patient flow, and other improvements: Seeking a combination of local and grant funds to complete these remodeling and addition Estimated cost is approximately $250,000 Complete this project by the end of 2009.
Service Mix, Staffing, Proforma	Issues: Mix of service Lines of service (i.e., Jail, Columbia View Care Center, etc.) Staffing today, mid-term Patient base and projected growth (i.e., Marketing Plan Revenue generation	Adopt a staffing mix of 1 doctor and 2 to 3 ARNPs until the patient base increases to 3700, then reevaluate. Continue to provide service to the Columbia View Care Center. Meet with Sheriff to discuss the needs for the Jail. Maintain lab, x-ray and EKG services at the Clinic.
Hospital Rounds	Continuing to admit patients directly from the Clinic and visit those patients in the hospital on a daily basis costs the Clinic more than it brings in. In addition, the Clinicians have not been reimbursed for mileage to and from the hospital which in 2008 is about $400 per month, per Clinician. Work with PeaceHealth to identify a Family Practice Hospitalist who can work with Family Practice Clinic Patients. There are an average of 1 or 2 patients in the hospital per day, requiring one Clinician visit to the hospital each day. New state regulations also require that a Clinician see a patient at the hospital within the first 12 hours of their admission. This requires that the Clinicians make a second trip to the hospital to see patients admitted during the day. Office hours begin 1.5 hours later than normal (equal to time to see 6 patients) when round are being conducted. Mileage reimbursement would equal approximately $9,600	Discontinue direct admission of patients and hospital rounds. Seek an improved relationship with PeaceHealth and encourage the hiring of a new Family Practice Hospitalist who will be able to serve the Clinic’s patients.
Medical Director - EMS	Medical Director establishes the protocols with the EMS Trauma Council that EMS personnel follow when responding to an emergency. Medical Control refers to the party responsible for taking radio calls from EMS personnel regarding protocol and actions they are taking in the field.	Dr. Wright was the Medical Director for EMS. When he left, the EMS Council is recommended that Dr. Schnieder and PeaceHealth assume the Medical Director responsibilities. This action is agreed to by the EMS Trauma Council.
Medical Director - CVCC	Presently, the Clinic serves as the Medical Director for the CVCC. This requires 24/7/365 availability by phone to a Clinician	Continue this line of service.
Open Practice	Beginning in the fall of 2007, the Clinic was not accepting new patients because of the declining number of staff and Clinicians. Closing the practice to new patients was always considered a temporary policy. .	As of April 2, 2008, the Clinic again accepted new patients in anticipation of the arrival of a new Clinician and the stabilization of the staff.
Method of Accepting New Patients	Presently, the Clinic requests the medical records for each new patient and after a review of their records makes a determination to accept or not accept the patient. Issue: Many people object to this practice (see survey) An alternative is to establish a contract with each new patient outlining the Clinic and Patient rights and responsibilities A policy can be established regarding what constitutes failure to uphold the contract and what actions the Clinic will take.	As of March 1, 2008, the Clinic accepted all who request services from the Clinic. Each new patient will be given the Clinic and Patient Rights and Responsibilities Statement for the Clinic. The Clinicians and Business Manager are authorized to establish procedures for reviewing problem cases including failure to pay, failure to compile with medical orders, etc.
FQHC/Level 5 Trauma, Other	Both survey respondents and others have asked whether the Clinic should try to become a FQHC. Others have asked about seeking Level 5 Trauma Status. Others think the Clinic should be sold to private ownership as soon as possible. BOCC considered and rejected FQHC in 2004 with several reconsiderations of this issue. The primary reason is that insurance patients receive the lowest priority in such clinics. Level 5 Trauma requires 24/7/365 availability of Clinicians and is not the direction recommended for the future The long-term goal of seeing the Clinic go back under private ownership still requires getting the clinic on sound footing Establish the Clinic as a 501c3 (Requires additional review before consideration).	For the present time, the Clinic will remain part of the County. Once the Clinic is financially stable, an effort to find either private owners or to form another type of business model will be considered. In the long run, the Advisory Board recommends growing the Clinic into a Wellness Clinic with room for visiting specialists.
Marketing	To grow the Clinic’s business, new patients will be needed. A marketing plan needs to be defined for the Clinic. Issues: What areas are we going to market the Clinic to? What are the target populations that we want to market to? How do we get back patients we might have lost?	Beginning in June 2008, initiate a planned marketing campaign to build the patient base. Outreach to Naselle, western Cowlitz, and parts of Clatsop counties will be made with a brochure, advertising, and other strategies. The Clinic will also try to regain patients who might have left during the recent challenging year.
X-Ray	Issues: Maintaining the x-ray capability in the Clinic makes is faster to diagnose and treat certain injuries and it is convenient for both Clinicians and patients Should a sinking fund be established for capital equipment? The x-ray equipment is relatively new and should not need replacement in the near-term. MAs must have higher skills to take X-rays Services are important to timely diagnosis and response to trauma	X-Ray services will be maintained to save time in making the appropriate diagnosis and treatment decisions and to better serve the Clinic’s patients.
Lab Services	Should the clinic continue to provide lab services even though they are not fully reimbursed because of value to patients and Clinicians? Issues: Maintain capability of managing the Lab (state requirements) Mix of staff to manage Lab, conduct tests, etc Equipment and supply costs Equipment upgrade and replacement Services are important to timely diagnosis and care, saves patients time and travel	Maintain lab services because they are important for timely diagnosis and treatment decisions.
Patient Access Fee or Alternative Fund Raising	The majority of respondents to the Clinic Survey suggested that any subsidy provided for the Clinic should be collected through patient access fees or a combination of fees and taxes. There was little support for taxes and lots of arguments against taxing for the clinic. Other Clinics have used various fund raising events to generate additional support.	Establish a Keep the Clinic Open Fund and encourage all non-Medicaid patients to contribute $10 per month or, if paid in a lump sum, $100.00 per year to support the unfunded costs of the Clinic. Start Date July 1, 2008. If this approach fails to raise the require funds in 2008, adopt a mandatory fee and/or consider making the Clinic a 501 (C) 3 non-profit organization.
Cash Discount	Many Clinics offer a discount for cash paying customers who pay their bill with a check or cash at the time of service. Cash discounts might also be applied to the patient access fee. Many dentals offer a 5% discount to their uninsured cash paying clients when they pay their bill with cash or a check at the time of service. Some offer even greater discounts for more expensive procedures. The group also discussed given a 5% discount to those who pay the annual patient access fee (if adopted) through one payment at the beginning of the year.	Provide a cash discount of 15% for those paying by cash or check, or 10% for credit cards on the day of service. Start Date: June 1
Sports Physicals	In the past, the Clinic has provided Sports Physicals without charge by setting up one or two days for these physicals and using a lot of volunteer help. This approach may no longer be practical or possible.	Provide full, well-teen physical exams rather than sports physicals, starting on June 1, 2008. Develop a scholarship fund for those families or athletes that can afford to pay for the full exam.
ISSUES TO BE CONSIDERED LATER
Urgent Care	The Clinic currently provides urgent care only to established patients and on a time available basis. Should the Clinic provide Urgent Care to anyone who walks in and will pay cash or has viable insurance? Many survey respondents want Urgent Care.	This decision requires additional study and analysis. Defer until Fall of 2008.
Moving Toward Wellness Model	Need to identify a path from today to the idea of a Wellness Clinic in order to ensure today’s decisions do not constrain the path to the desired future. Issues: It is important to discuss the vision for the Clinic in the future Important not to constrain the future by the actions we actions taken now Develop the Wellness model as the long-range goal for the Clinic	This decision also requires additional study and analysis. Defer until Fall of 2008.

Appendix 7 – Advisory Board Charter

Wahkiakum Family Practice

Clinic Advisory Board

Proposed Charter
MISSION
Develop a successful strategy for stabilizing the staffing, services and funding for the Wahkiakum Family Practice Clinic that ensures the clinic operates sustainably, under the guidance of physicians and clinicians, and at a level supported by the citizens of the county.
KEY PRINCIPLES
The Wahkiakum Family Practice Clinic Advisory Board (called the Clinic Advisory Board throughout) serves at the pleasure of the Wahkiakum Board of County Commissioners. The Clinic Advisory Board is authorized to gather information and data, conduct research, seek input from the public and the Clinic’s key stakeholders² and to prepare recommendations for consideration by the Board of County Commissioners. Some of principles and values the Clinic Advisory Board will use to govern their work include:

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  Principle – the key to health system sustainability is priority setting
  
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  Principle – the key to priority setting in a democracy is creating an environment in which the decisions made are acceptable to the community.
  
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  Principle – the Clinic Advisory Board is committed to fair process which is characterized by:
  
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    Public involvement in the process
    
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    Dissemination of information throughout the process, and an
    
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    Opportunity for review of recommendations before they are finalized.
    
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  Principle – the Clinic Advisory Council will use consensus as its decision making process to the extent possible and will present both its recommendations and rationale to the public and the Board of County Commissioners.
  
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  Principle – the County Commissioners are the final decision makers regarding implementation of any recommendations developed by the Clinic Advisory Board.
  

The purpose of articulating these principles is to acknowledge that finding a sustainable operating level for the Family Practice Clinic is a complex task that will involve competing values. We acknowledge that reasonable people may disagree on the best approach, but we are committed to making our recommendations and the reasons for our recommendations open and transparent. Finding a sustainable solution for funding the Clinic will require a close examination of the mix of services the Clinic provides and what the public is willing to support. It will also require changing the way the Clinic currently does business to some or a large degree. However, in the final analysis, the Family Practice Clinic must operate in a sustainable manner, by:

1. 
   Earning enough resources to sustain itself and build reserves for the future
   
2. 
   Being supported in part through public funding in the form of a levy or other type of tax, and/or
   
3. 
   Being supported through philanthropic contributions to the Clinic’s endowment fund.
   

GOALS

1. 
   Identify strategies that will stabilize the Wahkiakum Family Practice Clinic’s staffing pattern, service levels, and funding in the near term.
   

2. 
   Conduct data gathering, analysis, and research that will generate recommendations for consideration by the Board of County Commissioners and the Wahkiakum Family Practice Clinic that will:
   

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  Identify the mix of services the community wants from the Clinic and the costs of these services
  
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  Identify methods for funding the costs of the desired level of service and present these to the public, gathering their input and recommendations
  
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  Identify the potential legal entities under which the Clinic might organize itself in order to secure greater funding, higher reimbursements, or better support from state and federal grant programs.
  
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  Develop the task and objectives that must be accomplished in order to achieve the level of service, business model and funding required to move the Family Practice Clinic to sustainable operating budgets by 2008.
  

3. 
   Work with the Family Practice Clinic stakeholders to ensure passage of the any actions requiring a vote of the county for adoption.
   

OBJECTIVES
GOAL 1: IDENTIFY STRATEGIES THAT WILL STABILIZE THE WAHKIAKUM FAMILY PRACTICE CLINIC’S STAFFING PATTERN, SERVICE LEVELS AND FUNDING IN THE NEAR TERM.
Objectives:

1. 
   Working with the Clinic Manager, identify the immediate steps that will help reduce the funding short fall for CY 2007 budget no later than 7/31/2007.
   
   1. 
      Consider the reconfigurations of services in accordance with the recommendations of earlier studies (i.e., stop pulling charts unless specifically needed for that patient),
      
   2. 
      Consider any recommendations that Clinic staff themselves have identified that will reduce costs in the near-term
      
2. 
   Develop a recommendation for stabilizing Clinic staffing from the fall of 2007 through the end of CY 2008 for presentation to the Board of County Commissioners by their August 21, 2007 meeting.
   
3. 
   Conduct a meeting with local members of the EMS Trauma Council and determine if there are any immediate actions that can be adopted to reduce the impact of EMS on the Clinic in the near term. Establish meeting date no later than 8/24/2007 and initiate this dialogue as part of the short-term and long-term process.
   
4. 
   Attend training session presented by the Washington State Department of Health on Physician and Clinician Recruitment on September 6, 2007.
   
5. 
   Accurately identify and cost out the impact of EMS on the clinic in terms of clinician time, staff time, equipment and supplies, and general overhead no later than 8/31/2007.
   
6. 
   Work with the Commissioners to establish methods of communicating the work of the Clinic Advisory Board including press releases, newsletters, workshops and other devices to keep the community informed throughout the process.
   
7. 
   Coordinate with the Wahkiakum Community Foundation to support the fund raising campaign that will support the Clinic in both the short-term and the long-term throughout the process.
   

GOAL 2: CONDUCT DATA GATHERING, ANALYSIS, AND RESEARCH THAT WILL GENERATE RECOMMENDATIONS FOR CONSIDERATION BY THE BOARD OF COUNTY COMMISSIONERS AND THE WAHKIAKUM FAMILY PRACTICE CLINIC TO MOVE THE CLINIC TO SUSTAINABLE OPERATIONAL BUDGETS WITH THEN NEXT 12 TO 18 MONTHS.
Between September 2007 and December 2007:

1. 
   Initiate a discussion with Kaiser Permanente to discuss contract for trauma services to Kaiser Permanente members
   
2. 
   Initiate discussions with key insurance providers regarding rates of reimbursement for services and fees.
   
3. 
   Gather information about hospital districts, Level 5 Trauma Care, EMS levies, and other potential methods or organizational designs that could be considered as methods for funding part of the Clinic’s costs.
   
4. 
   Conduct public work shops to discuss the business models, costs and impacts on the community.
   
5. 
   No later than 2/15/2008, develop a set of recommendations that include appropriate action by the Board of County Commissioners, votes by the citizens, and the other administrative or legal actions necessary to place the Clinic on firm footing by the year 2009.
   

GOAL 3: WORK WITH THE FAMILY PRACTICE CLINIC STAKEHOLDERS TO ENSURE PASSAGE OF THE ANY ACTIONS REQUIRING A VOTE OF THE COUNTY FOR ADOPTION.

1. 
   Develop a report that clearly provides the options and alternatives considered, proposed business model and its costs, the proposed funding approach and actions required to achieve sustainable funding. This report should also delineate the relationship between each recommendation and the level of Clinic operations so the community fully understands the consequences of approving or not approving the key recommendations.
   
2. 
   Work with all the community stakeholders, the Board of County Commissioners, and the State Department of Health to implement the needed actions, applications, votes, and steps to implement the recommendations supported by the Board of County Commissioners.
   
3. 
   Recommendations and requests for action are expected to occur at several points during the next months with a firm goal of having the major recommendations before the appropriate decisions makers no later than March 31, 2008.
   

1 Chair Dave resigned in mid-2008 and Sandi Benbrook-Rieder became the Chair.

2 Key Stakeholders include those organizations that are dependent on the Clinic for medical direction or patient care as part of their licensing or as a major source of business. The key Clinic Stakeholders include the Cathlamet Pharmacy, the Hotel Cathlamet, the Columbia View Care Center, and the Emergency Medical Services program.