Texas Family Physician, Q1 2020

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TEXAS FAMILY PHYSICIAN VOL. 71 NO. 1 2020

MIND &BODY Integrating Behavioral Health In Primary Care TFP Profiles Winners Of The Academy’s Innovation Competition

PLUS: Annual Session Highlights 3 Ways To Boost Your Practice




INSIDE

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TEXAS FAMILY PHYSICIAN VOL. 71 NO. 1 2020

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And the innovation contest winners are …

Mental health and physical health come together in three award winning Texas family medicine practices. They share their secrets for integrating behavioral health into primary care. By Jonathan Nelson

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Three ways to boost your practice

Improve your Yelp ratings with these excellent tips from our resident marketing expert. By Sandra Scott

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Coming soon: CPAN

Thanks to the passage of Senate Bill 10, the Texas Child Mental Health Care Consortium prepares to launch Texas’ first child psychiatry access network. By Laurel L. Williams, DO

6 FROM YOUR PRESIDENT “How Disney saved my life” 10 ASPCS HIGHLIGHTS News from the 2019 Annual Session and Primary Care Summit in The Woodlands 11 MEMBER NEWS Three TAFP members tapped for AAFP appointments 11 TAFPPAC DONORS 12 FOUNDATION DONORS 22 RESEARCH The impact of the UTHealth medical legal partnership on utilization and health harming legal needs 29 PERSPECTIVE A welcome reminder a long way from home


New from CDC

HIV Nexus is a new comprehensive website from the Centers for Disease Control and Prevention that provides the latest scientific evidence, guidelines, and resources on: • Screening for HIV. • Preventing new HIV infections by prescribing PrEP and PEP. • Providing treatment to people with HIV to help improve health outcomes and stop HIV transmission. To access tools for your practice and patients, visit: www.cdc.gov/HIVNexus.

HIV NexusAd_LPCA36_7-875 x 10-25_v1.indd 1

11/15/19 3:26 PM


PRESIDENT’S COLUMN

TEXAS FAMILY PHYSICIAN VOL. 71 NO. 1 2020 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. TEXAS FAMILY PHYSICIAN is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org. OFFICERS president

An excerpt from the inaugural speech of the new TAFP President By Javier “Jake” Margo Jr., MD TAFP President

Javier D. “Jake” Margo, Jr., MD

president-elect treasurer parliamentarian

Amer Shakil, MD, MBA

Mary Nguyen, MD Emily Briggs, MD, MPH

immediate past president

Rebecca Hart, MD

EDITORIAL STAFF managing editor

Jonathan L. Nelson

associate editor

Jean Klewitz

chief executive officer and executive vice president

Tom Banning chief operating officer

Kathy McCarthy, CAE

advertising sales associate

Audra Conwell

CONTRIBUTING EDITORS Christine Bakos-Block, PhD, LCSW Alissa Chen, MD Alvin Chen Lesca Hadley, MD Winston Liaw, MD, MPH Thomas Murphy, MD Thomas Northrup, PhD Christian Pineda Sandra Scott Angela Stotts, PhD Robert Suchting, PhD Asra Waliuddin, MD Laurel L. Williams, DO Dongni Yang, MD, PhD

Articles published in TEXAS FAMILY PHYSICIAN represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publica­tion of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. LEGISLATIVE ADVERTISING Articles in TEXAS FAMILY PHYSICIAN that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2020 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6

A celebration of family medicine: How Disney literally saved my life

TEXAS FAMILY PHYSICIAN [No. 1] 2020

a couple of summers ago, on a rare day off, I was working on a detailed email advocating to keep the electricity on for our not-for-profit community center, when my son James, who was 7 at the time, walked into my office — or as my Harry-Potter-centric friends have dubbed it, the “Room of Requirement,” because anything you need can be found there. He and I were the only two people in the house since my daughter, Ella, was at Girl Scout Camp and my wife, Lisa, was at work. He had given up trying to teach the cats play catch when he walked in, stopped just short of my elbow, stared silently with his big brown eyes, and asked, “Daddy, will you play with me?” I asked James to give me a few minutes to finish what I was doing, knowing we had to be on the road shortly. Now I know many of you have received that same question in one way or another. With all the distractions of technology: messaging, voicemails, emails, prior authorizations, prescription refills, and yes, sometimes being creative as to how to pay the bills or meet payroll, it’s so easy to miss those little moments. As family physicians, I think we get to experience or share in more of those moments: invitations to birthdays, weddings, quinceañeras, anniversaries, and

even funerals, because we are so integrated into our patients’ lives. Many of our patients are our friends and family. Many people who undergo a brush with the great beyond say they feel different afterward. They feel changed. They often circle their wagons and spend more time with their family, go on wild adventures, change careers, maybe they go travel the world with their favorite person or people. I, too, had my own brush with the great beyond just last March, when my family and I spent spring break aboard a Disney cruise ship. I believe in God. I know many of you do in some way or fashion. And this isn’t going to be a sermon, though I will be sprinkling in a little of my beliefs here and there because “A scout is reverent.” (I am forever and always a Boy Scout.) What did I want to do after my experience? I wanted to spend time with my family, also with my TAFP family. I really wanted to be at our TAFP Interim Session that April, but I was just starting back on my first full day of work in the emergency department back home in Rio Grande City after having been septic on the high seas three weeks earlier. Actually, I was already septic when I boarded the ship, I just didn’t know it yet.

When I am asked what I do for a living, I say I’m a family doctor. I don’t say I work in the ED, perform operative obstetrics and comprehensive newborn care in a rural hospital on the U.S.-Mexico border while also serving as the team physician for two local high schools. I say I’m a family doctor.


Reiner Consulting & Associates Practice ManageMent ServiceS Now I know we are all doctors, so I won’t go into the details of my exact symptoms, but one of my doctors was so excited about having a possible adult epiglottitis on board the ship that he was literally writing the paper in his head as he examined me. I’d like to thank Dr. Bart, who first saw me teetering on that exam table on day one in the infirmary, Dr. Angus and Dr. Arnot, along with the entire nursing staff, who brought me back from the brink. What do all these physicians have in common? They are all family doctors. Why am I proud of that? Because when I am asked what I do for a living, I say I’m a family doctor. I don’t say I work full time in the emergency department, perform operative obstetrics, and the accompanying comprehensive newborn care in a rural hospital on the U.S.-Mexico border while also serving as the team physician for two local high schools. I say I’m a family doctor. After my little adventure on the high seas, I can truly say I have a little more appreciation of those little moments. I look at them as little blessings from God, or if you will, little reminders of those precious things we often take for granted. I wanted to be at the TAFP Interim Session because for me, many of those little moments have happened here, in my 21 years of being a part of this great organization. When we get together, we do so much more than sit in committee meetings and attend lectures. We pile into cars to go see a movie. We laugh together over great meals. We share silly jokes and pull silly pranks. We make memorable moments together. There’s so much more that unites us than divides us. As members of TAFP, we

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[cont. on 8]

CORRECTION In our last issue, Vol. 70, No. 4, in the President’s Letter entitled, “Private practice: Are we approaching the end of the road?”, we stated that Martin Franklin, DO, is with Peterson Health in Kerrville. That is incorrect. Martin Franklin is the founder and co-president of Alliance ACO in Kerrville and several surrounding rural communities. We apologize for the mistake.

Bradley reiner, Ba reiner consulting & associates 212 covered Wagon Way, Driftwood, texas 78619 p (512) 858-1570 | m (512) 413-5678 | f (512) 858-1580 fax

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JONATHAN NELSON

COMING SOON ON TAFP’S

CME SCHEDULE Texas Family Medicine Symposium June 5-7, 2020 La Cantera Hill Country Resort & Spa San Antonio, Texas Annual Session & Primary Care Summit Nov. 6-8, 2020 Nov. 4-5: Business meetings and preconference workshops

Gaylord Texan Resort & Convention Center Grapevine, Texas C. Frank Webber Lectureship & Interim Session April 16-17, 2021 Renaissance Austin Hotel Austin, Texas 8

TEXAS FAMILY PHYSICIAN [No. 1] 2020

TAFP’s officers for 2020 from left: Mary Nguyen, MD, treasurer; Amer Shakil, MD, MBA, president-elect; Javier D. “Jake” Margo Jr., MD, president; Rebecca Hart, MD, immediate past president; and Emily Briggs, MD, MPH, parliamentarian. [cont. from 7]

provide a community, one in which you can feel comfortable and welcome, whether you live and work in the Panhandle or the Gulf Coast, West Texas to East Texas, down in the Valley or somewhere in between. As I walk around conference centers and hotels at our meetings, some of the greatest things I see are the random outbursts of hugs as friends reconnect and quickly begin chatting excitedly. It’s so easy to fall back into our regular patterns of behavior. I know I did after my experience in March. The routine is comforting, often mindless, tapping at a keyboard, lost in the memory of a patient encounter. But let’s try to be present in the moment, to watch for those little precious occurrences that memories are made of.

As Gandalf said to Frodo in J.R.R. Tolkien’s masterpiece, “The Fellowship of the Ring,” “All we have to decide is what to do with the time that is given us.” I am humbled and honored to serve as TAFP President. I look forward to an adventurous year and I know we’ll make great memories together. And I want to invite you to be a part of this community we share, whether it’s being a mentor to another physician, being a preceptor in the Texas Family Medicine Preceptorship Program, donating to the TAFP Foundation or the TAFPPAC, or whether it’s simply sharing your time with us, your TAFP family. What will you say, when I ask, with all the enthusiasm and anticipation of a 7-year-old, “Will you come play with me?”

There’s so much more that unites us than divides us. As members of TAFP, we provide a community, one in which you can feel comfortable and welcome, whether you live and work in the Panhandle or the Gulf Coast, West Texas to East Texas, down in the Valley or somewhere in between.


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TUBERCULOSIS: Tuberculosis screening is a required part of childhood checkups in Texas. This tutorial is a guide to screening, testing, and when necessary, treating young people with tuberculosis infection.

Content on the Texas Health Steps Online Provider Education website has been accredited by the Texas Medical Association, American Nurses Credentialing Center, National Commission for Health Education Credentialing, Texas State Board of Social Worker Examiners, Accreditation Council for Pharmacy Education, UTHSCSA Dental School Office of Continuing Dental Education, Texas Academy of Nutrition and Dietetics, Texas Academy of Audiology, and the International Board of Lactation Consultant Examiners. Continuing Education for multiple disciplines will be provided for some online content.


MEMBER NEWS

Highlights from TAFP’s Annual Session • November 8-10, 2019 The committees, commissions, and sections of the Texas Academy of Family Physicians met in The Woodlands and deliberated on many important items. Thanks to all the members who participated. Here are a few of the highlights from the recent meeting.

WORKING FOR YOUR PRACTICE AND YOUR PATIENTS The Texas Legislature will not be in session again until 2021, but work continues in the interim. The Commission on Legislative and Public Affairs and the Commission on Health Care Services and Managed Care discussed opportunities to propose policy strategies for containing health costs in Texas. Following the meeting, the Select Committee on Statewide Health Care Costs was appointed by outgoing Speaker of the House, Rep. Dennis Bonnen. Members of both commissions will be involved in discussions on strategies to propose to the Select Committee including investment in primary care services and care coordination, direct contracting, insurance benefit design, reinsurance, and more. The Commission on Health Care Services and Managed Care voted to recommend that TAFP support the creation and utilization of an all-payers claims database in Texas. Other states have databases with public and private payers and they introduce a new level of transparency to discussions and negotiations. The commission also recommended that TAFP submit a resolution to AAFP entitled, “Reduce regulatory burdens required by CMS and Joint Commission inspections.” The intent of the resolution is to suggest that regulatory agencies be required to prove the efficacy of regulations before implementation. The Board of Directors met with staff and physician leaders from Texas Medical Associa10

tion and agreed to collaborate on an initiative to combine traditional advocacy with lobbying and communications to increase support for Medicaid expansion and access to health care. TMA is developing a coalition and TAFP has pledged to join the effort. MEMBER SERVICES AND WORKFORCE DEVELOPMENT The Commission on Academic Affairs discussed the ongoing programs and initiatives that TAFP and the TAFP Foundation engage in each year to encourage interest in family medicine among medical students and support residents and faculty in various ways. They recommended that TAFP fund one first- or second-year medical student at each Texas medical school to attend AAFP’s National Conference. The TAFP Foundation already funds students to attend National Conference but does not focus on their year in medical school. TAFP Member Community groups are overseen by the Commission on Membership and Member Services. Three groups met during Annual Session: early career physicians, international medical graduates, and solo and small group practice physicians. PUBLIC HEALTH AND RESEARCH The Commission on Public Health, Clinical Affairs, and Research heard from Claudia Rodas with the Campaign for Tobacco-Free Kids on efforts to prevent youth from using e-cigarettes and discussed the dangers of vaping. The com-

TEXAS FAMILY PHYSICIAN [No. 1] 2020

mission recommended that TAFP provide education for physicians on electronic nicotine delivery systems and they created a workgroup to draft a resolution to AAFP. They also discussed corporal punishment and Hepatitis C.

MEMBER HIGHLIGHTS

The Section on Research discussed inviting winners of the TAFP research poster competition to present their research during their monthly conference calls. The sessions would be 10-minute presentations with five minutes for questions. Members interested in participating in the monthly conference calls should contact Jean Klewitz at jklewitz@ tafp.org.

Oscar Garza, MD — Commission on Continuing Professional Development

ORGANIZATIONAL ISSUES Dr. Rebecca Hart led a robust discussion during the TAFP Member Assembly on Friday, November 8. The voting representatives to the Member Assembly elected these 201920 leaders: President-elect: Amer Shakil, MD, MBA Treasurer: Mary S. Nguyen, MD Parliamentarian: Emily D. Briggs, MD, MPH Delegate to AAFP: Troy Fiesinger, MD

Several members completed terms as committee chair and they were thanked for their years of service: Farron Hunt, MD – Leadership Development Committee

Anne Marie Ponce de Leon, MD — Commission on Health Care Services and Managed Care Jorge Duchicela, MD – Commission on Legislative and Public Affairs Alyssa Molina, MD – Section on Maternity Care and Rural Physicians Puja Sehgal, MD – Section on Special Constituencies 2019 AWARD RECIPIENTS Physician of the Year — Sheri J. Talley, MD Sheri J. Talley, MD, grew up in West Texas and returned after residency to practice full-spectrum family medicine in the medically underserved area of Fort Stockton. Presidential Award of Merit — Thomas E. Mueller, MD

New Physician Director: Mary Anne de la Cruz Snyder, DO

Thomas E. Mueller, MD, of Columbus, was honored for his leadership and dedication to the specialty of family medicine and his outstanding contributions to health care in Texas.

At-large Directors: Lindsay K. Botsford, MD, MBA and Brian D. Jones, MD, CPE

Presidential Award of Merit — Steven J. Spann, MD

Alternate Delegates to AAFP: Kaparaboyna Ashok Kumar, MD and Tricia C Elliott, MD

Special Constituencies Director: Puja Sehgal, MD Resident Director: James Paul Moody, MD Medical Student Director: Emily Tutt At the annual Business and Awards Lunch, the membership approved bylaws amendments recommended and published in Texas Family Physician last year. These changes update TAFP’s Vision and Mission statements, add the transitional member category, and change the process for appointing members to TAFP’s Nominating Committee.

Stephen J. Spann, MD, of Houston, is the founding dean of the University of Houston College of Medicine, a new medical school aimed at transforming the way care is delivered by taking a more cost-effective, patient-centric, and teambased approach to care. Patient Advocacy Award — Rep. Armando Walle State Representative Armando Walle of Houston, Texas, represents Texas House District 140, which consists of portions of North Houston and other parts of North Harris County where he grew up.


Public Health Award — Cynthia Brinson, MD Cynthia Brinson, MD, of Austin, has spent her entire professional career addressing the HIV epidemic through clinical research and evidence-based clinical care including prevention, screening, and treatment. She amplifies her work by providing educational lectures to colleagues and teaching residents and medical students. Exemplary Teaching Award (Full-Time) — Fozia Ali, MD Fozia Ali, MD, of San Antonio, is Associate Professor at UT Health San Antonio Family Medicine Residency where she has taught for more than eight years. Her engaging and warm demeanor makes her a natural mentor. Exemplary Teaching Award (Part-Time) — Tharani Ravi, MD Tharani Ravi, MD, of San Antonio, is part-time faculty at UT Health San Antonio Family Medicine Residency, where she trained. As a resident, her passion for teaching and scholarly activity were noticed by the faculty and she was asked to join the program. Special Constituency Leadership Award — Ikemefuna Okwuwa, MD

Three TAFP members receive AAFP appointments Two TAFP members were named to participate on AAFP commissions and one member was appointed to serve on the AAFP delegation to the American Medical Association this year. Those serving on AAFP commissions will serve four-year terms while the delegate to AMA will serve a two-year term. Lawrence Gibbs, MD, MSEd, was appointed to the AAFP Commission on Education. After residency Gibbs served in the U.S. Air Force including as assistant professor at the Uniformed Services University of Health Sciences School of Medicine and as medical director of the 768th Expeditionary Air Base Squadron Medical Clinic. Now he is a faculty physician at the MethodistCharlton Family Medicine Residency Program in Dallas. He currently serves as vice chair of TAFP’s Commission on Academic Affairs and has completed TAFP’s Family Medicine Leadership Experience. James Mobley, MD, MPH, will serve on the AAFP Commission on Health of the Public and Science. Mobley has a long and distinguished career including service in the U.S. Army and more than 35 years of practice in Portland, Texas. He has been an active member of TAFP’s Commission on Public Health, Clinical Affairs, and Research since 2012 and received our Public Health Award in 2010. Emily Briggs, MD, MPH, was appointed to the AAFP delegation to the American Medical Association. She owns a private practice in New Braunfels, Texas, Briggs Family Medicine. For more than a decade she’s served on various state and national Academy committees and has been active in strengthening the full-scope physician community. She currently serves as TAFP Parliamentarian.

Thank you, 2019 TAFPPAC donors! Lane J. Aiena, MD

Thomas David Greer, MD

Sherri D. Onyiego, MD, PhD

Kelly Alberda, MD

Ajay Kumar Gupta, MD

John Kindley Ray, MD

Ikemefuna “Ike” Okwuwa, MD, of Odessa, is the program director at the Texas Tech Permian Basin Family Medicine Residency Program.

James L. Atteberry, MD

Natalia Gutierrez, MD

Katie Lael Kucera Ray, MD

Gerald Clifford Banks, MD, MS

Lesca C. Hadley, MD

Rashmi Rode, MD

Lee Hagar Bar-Eli, MD

Suhaib Haq, MD

Kristi Salinas, MD, CPE

Justin V. Bartos, MD

Rebecca Eileen Hart, MD

David Schneider, MD

TAFP Foundation Philanthropist of the Year — Adrian Billings, MD, PhD

Stephen Douglas Benold, MD

Clare Arnot Hawkins, MD

Linda Marie Siy, MD

Lindsay K. Botsford, MD, MBA

Farron Cheryl Hunt, MD

Emily D. Briggs, MD, MPH

Janet L. Hurley, MD

Mary Anne de la Cruz Snyder, DO

Adrian Billings, MD, PhD, is a generous donor to the TAFP Foundation, but he also embodies its mission through the work he does on a daily basis. He’s been a full-spectrum family physician providing care in West Texas for more than 10 years.

Matthew Alan Brimberry, MD

Brian D. Jones, MD, CPE

Mary Carmen Spalding, MD

Chris Casso, MD

James Lackey, MD

Joshua Nathaniel Splinter, MD

Chinglin Lillian Chan, MD

Cameron Paul Lancarte, MD

Sherri J. Talley, MD

C. Mark Chassay, MD, MBA, MEd

Cyrus Timothy Lambert, MD

James R. Terry, MD

Don A. Lawrence, DO

Lloyd Van Winkle, MD

Todd K. Cowan, MD

Javier D. Margo, MD

John R. Vanderzyl, MD

Lilette Daumas-Britsch, MD

Dale C. Moquist, MD

Andrew H. Weary, MD

Antonio Falcon, MD

Louis V. McIntire, MD

Keith W. Wilkerson, MD

Lewis Emory Foxhall, MD

Alyssa Beth Molina, MD

Walter D. Wilkerson, MD

Troy Treanor Fiesinger, MD

Nancy Naghavi, DO

Robert Allen Youens, MD

Kelly Gabler, MD

Mary Suzanne Nguyen, MD

Richard A. Young, MD

Lisa Biry Glenn, MD

Uzoamaka Mma Obinabo, MD

Roland Goertz, MD, MBA

Ikemefuna C. Okwuwa, MD

TAFP Political Action Committee Award — Lane Aiena, MD Lane Aiena, MD, of Huntsville, Texas, advocates at the Texas Capitol and has been to D.C. to fight for funding for Federally Qualified Health Centers several times.

www.tafp.org

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FOUNDATION FOCUS

2019 TAFP Foundation donors

Thank you to these 2019 TAFP Foundation donors, whose contributions fund scholarships for Texas medical students, family medicine research grants, and travel scholarships for residents to attend continuing professional development activities.

★ = TAFP Foundation monthly donor

James Orms, MD Grant Pham James H. Phelan, MD Barbara Pierce, MD Didier F. Piot, MD ★ H. David Pope, MD Ted Ramsey ★ John R. Richmond, MD ★ Shelley Poe Roaten, MD Alejandro Rocha, DO Leon Rochen Rashmi Rode, MD

Abbvie

★ Seth B. Cowan, MD

Richard L. Hozdic, MD

Stephanie Roth, MD

Austin Regional Clinic

Douglas W. Curran, MD

Ann Hughes Bass, MD

Peter Ruggero

StratiFi Health

Tuan A. Dao, MD

★ Farron C. Hunt, MD

Bruce Russell, MD

Tarrant County Academy of Family Physicians

Lilette Daumas-Britsch, MD

★ Janet L. Hurley, MD

Kristi Salinas, MD, CPE

Kenneth Davis, MD, CPE

Tony Hussey, MD

★ Sarah Samreen, MD

Rebecca Davis

★ Jamal Islam, MD, MS

★ David Schneider, MD

★ Chrisette Dharmagunaratne, MD

Bruce K. Jacobson, MD

★ M. Sandra Scurria, MD

★ Jorge Duchicela, MD

Lee Janson, MD

Roberto A. Duran, MD

★ Brian D. Jones, MD, CPE

★ Bruce A. Echols, MD

Bharat Dev Joshi, MD

★ Tricia C. Elliott, MD

Manuel Juson, MD

★ Sheridan Scott Evans, MD

★ David A. Katerndahl, MD

★ Christopher S. Ewin, MD

Art L. Klawitter, MD

★ Robert Ezell, MD

Russell Kohl, MD

★ Antonio Falcon, MD

★ Shelley Kohlleppel, MD

★ Troy Fiesinger, MD

★ Kaparaboyna Ashok Kumar, MD

★ Triwanna Fisher-Wikoff, MD

★ C. Timothy Lambert, MD

★ Madhumita Banga, MD

★ Aimee Flournoy, MD

★ Don A. Lawrence, DO

Gerald Banks, MD, MS

★ Lewis Foxhall, MD

Eric Ted Lee, MD

★ Tom Banning

Gregory Fuller, MD

Benjamin J. Leeah, MD

David T. Barr, MD

Kelly A. Gabler, MD

Donald E. Lovering, MD

★ Lynda Barry, MD

Conrado Galindo, MD

Miguel A. Maldonado, MD

★ Justin V. Bartos, MD

Oscar Garza, MD

★ Javier D. Margo, MD

Christopher Bell

★ Lawrence Gibbs, MD, MEd

Oksana Marroquin, MD

Jerry Bell

Jim Gillen

Samuel Mathis, MD

Melissa A. Benavides, MD

★ Lisa Biry Glenn, MD

★ Kathy McCarthy, CAE

★ Stephen Benold, MD

★ Roland Goertz, MD, MBA

★ William Mike McCrady, MD

David B. Vaughan, MD

Adrian Billings, MD, PhD

★ John E. Green, III, MD

Louis V. McIntire, MD

Miguel A. Vazquez, MD

Maria Susan Blahey, MD

★ T. David Greer, MD

★ Susan Clymer McMullen, MD

Samuel C. Wang, MD

★ Teddy Boehm

★ Ajay Gupta, MD

Tasaduq Hussain Mir, MD

★ Sally Pyle Weaver, MD

★ Lindsay K. Botsford, MD, MBA

★ Natalia Gutierrez, MD

Li-Yu Huang Mitchell, MD

John M. Weed, MD

★ Emily D. Briggs, MD, MPH

★ Lesca C. Hadley, MD

★ Dale C. Moquist, MD

★ Jim and Karen White

Timothy J. Caffrey, MD

★ Suhaib W. Haq, MD

Thomas E. Mueller, MD

Walter D. Wilkerson, MD

Gregg Ceniza Castillo, MD

★ Rebecca E. Hart, MD

James A. Murphy, MD

★ Hugh H. Wilson, MD

Annabelle Catterall

Bill and Gail Hartin

Terry Newman, MD

Elizabeth L Yang, MD

★ Chinglin Lillian Chan, MD

★ Clare Hawkins, MD

★ Mary S. Nguyen, MD

★ Khalida Yasmin, MD

★ C. Mark Chassay, MD, MBA, MEd

★ James Michael Henderson, MD

Donald R. Niño, MD

★ Robert Allen Youens, MD

Samuel T. Coleridge, DO

John Henderson

★ Ikemefuna Okwuwa, MD

★ Richard A. Young, MD

Claiborne Cowan

★ Terrance S. Hines, MD

★ Paul B. Oliver, MD

★ Yanqiu Zhao, MD

Texas Association of Community Health Centers Texas Medical Liability Trust TMA PracticeEdge Village Medical Lane J. Aiena, MD Marian C. Allen, MD Michael Alan Altman, MD Adanna Amechi-Obigwe, MD ★ Charles Anderson, MD James L. Atteberry, MD Ichabod L. Balkcom, MD ★ Diana Ballesteros, MD

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TEXAS FAMILY PHYSICIAN [No. 1] 2020

Puja Anil Sehgal, MD ★ Dan Sepdham, MD Nihita Shah, MD ★ Amer Shakil, MD, MBA Tayma Slaiman Shaya, MD ★ Linda Siy, MD Mary Anne de la Cruz Snyder, DO ★ Mary Spalding, MD Freya Spielberg, MD, MPH ★ Joshua Splinter, MD Dana Sprute, MD, MPH ★ Charles Stern, MD ★ Sharon Stern, MD ★ Donald E. Stillwagon, MD Irvin Sulapas, MD ★ Sheri J. Talley, MD Elizabeth Tran, MD Elliot J. Trester, MD ★ Lloyd Van Winkle, MD ★ John R. Vanderzyl, MD


PRACTICE MANAGEMENT

3 Valuable ways to increase your patient census By Sandra Scott

A

s a physician in today’s health care environment, you have many important and pressing requests on your time. From practice demands to increased and mandatory documentation necessary for regulatory compliance and insurance approvals, running a practice involves more than providing great patient care. Many physicians feel that managing administrative demands does not allow them to spend as much time with patients as they would like. These constraints also leave physicians with very little time if any to market their services to the growing number of patients who need the quality care they provide. As such, physicians are concerned about how they will grow their practice given competing demands on their time. If this is a feeling you can relate to as a family practice physician, there is encouragement. Listed below are three of the most valuable ways you can increase your patient census while managing the responsibilities of your practice.

FOCUS ON CUSTOMER SERVICE Although we have facts about a product or service, we base most of our final purchasing decisions on how we feel as consumers. A product can be safe, affordable, healthy, or a sound investment. However, once all our information boxes are checked, we make our end decision based on how we feel. Patients today are more aware than ever. From television commercials encouraging viewers to discuss a drug with their “prescriber” to the plethora of internet sources enabling us to self-diagnose, patients do not lack for information. So, how does this apply to your family practice? When patients visit your practice, they’ve either done their research or selected you from the available options provided by their insurance provider. Although you listen to patient concerns, educate them during the office visit and inform them regarding next steps, it is also vital to ensure that patients have a positive experience.

Is the atmosphere of your waiting area pleasant, warm, and welcoming to patients or is the perception that it is cold and sterile? Does your medical team who greets your patients at the reception desk engage them with hospitable smiles extending warmth and courtesy? As a physician, do you make a connection with your patients in the time you have such that they feel heard, understood, and supported? If asked, how would you describe what differentiates your practice from that of another family physician or medical group that on paper provides the same medical services you do? To achieve great customer service is an investment in training that does not have to cost a lot of money or a lot of time. Once a week provide an in-service for your staff focused on hospitality-based customer service. Have one goal or focus for the week and ask your team to share examples of how they went the extra mile to provide information or greet a patient warmly. You will be amazed by how expressing gratitude to a patient at check-out merely by saying “thank you for allowing us to care for you today” can make a difference in how that patient feels about your practice. Focusing on customer service and a ensuring a positive experience at your practice can increase the likelihood of a patient’s return and promote positive referrals.

ENGAGE IN PUBLIC RELATIONS Public relations is a great way to increase your patient census. From paid spots on your local morning show, which positions you as an authority in your field, to the appropriate social media platform, which can act as an educational arm of your practice sharing safety initiatives, research findings, or community involvement — all can be utilized to help build an awareness of your practice in your community. As you are practicing great customer service, encourage your patients to leave online reviews. Online reviews are not only a cost-effective way of growing a customer base, it is also a way to build credibility and trust with future patients who rely on the shared experiences of others to make decisions. According to websitebuilder.org, “84% of people trust[ed] online reviews as much as they trust[ed] recommendations from friends” in 2019. Asking for a review at the end of a patient’s visit is not only cost effective, it does not put an additional burden on your time as a physician. It is important to note that you must take time to manage your practice’s reputation by addressing online reviews, both positive and negative, as it is essential to the success of your business. According to websitebuilder.org, in 2019, 95% of consumers read reviews on sites such as Google, TripAdvisor, Yelp, and Facebook before making a purchasing decision. Do not be afraid to address negative reviews about your practice online. While protecting your patient’s privacy, be proactive in addressing a post by saying, “Thank you for sharing your experience with us. We value your input and ask that you contact our office directly so that we can address and resolve your concerns.” It is equally important to thank patients who leave positive reviews. You can simply say, “Thank you for your valuable feedback. Every patient matters and your health and well-being are important to us. We are glad you had a positive experience.” Managing how you are perceived by your community is vital to your practice. Addressed correctly and proactively, it will not only build goodwill, but it will lead to long term growth. www.tafp.org

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Managing how you are perceived by your community is vital to a practice. Addressed correctly and proactively, it will not only build good will, but lead to long term growth. HAVE A MARKETING PLAN As a physician, you did not go to medical school to be a marketer. You became a doctor to support patients who need your skill and expertise, to help them live healthy lives, and to provide the care they need and deserve. However, for those patients to find you whether they’ve lived in your demographic area for a long time or have recently moved to the area, you need to rely on more than a provider’s list that names you as in network. You need a plan. Your marketing plan can vary based not only on your budget, but on your goals, mission, vision, and growth strategy. Your plan does not need to be complex or take a great deal of time, but it should take thought. For example, if your family practice would like to grow in the number of patients you serve, you may wish to provide a direct mail piece educating recipients with clear messaging about how you can help them thrive. Create a series of direct mail pieces that focuses on this theme, featuring positive patient reviews as well as your quality measures.

You can also choose to create an email campaign that focuses on your practice’s location and the convenience for patients because you are a certain proximity to where they live or work. Whatever your strategic approach, concisely explain why someone should select your practice, put their trust in you, and become your patient. Executed correctly, a plan can build value with prospective patients both online and off. Remember that patients have choices. Your existing patients will remain loyal to your practice and you will gain new patients if they feel they are valued, that they matter, and their care is important to you. So, give your prospective patients a reason why they should choose you and ensure that they realize a great customer experience when they visit your practice.

Scott Marketing and Consulting Group located in San Antonio, Texas provides marketing consulting services to the health care and senior living industries. For more information visit www.scottgroup.consulting.

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5/10/12 10:40 AM


Texas Child Mental Health Care Consortium prepares to launch Child Psychiatry Access Network

ACT to help them quit.

By Laurel L. Williams, DO Co-Chair, Texas CPAN Workgroup

one in five children suffer from a mental health disorder but upwards of 50% of youth do not receive any treatment, and for many, treatment is both delayed and may not be evidence informed. There is a nationwide shortage of child and adolescent psychiatrists, or CAPs, and even then, they are often not available in rural and underserved areas. In the U.S., 36 states have turned to a novel approach: standardizing the “curbside consultation,” in a format called Child Psychiatry Access Networks, or CPAN. The longest standing network is in the state of Massachusetts. This program has been running more than 10 years with evidence for its effectiveness in supporting primary care physicians through consultation in real time during a patient care visit. In 2019, the Texas Legislature passed Senate Bill 10, creating the first-ever Texas Child Mental Health Care Consortium. This consortium is charged with five specific activities to increase access and improve care for youth in Texas: • development of CPAN across Texas, • development of urgent tele-mental health care for youth in schools, • increased fellowship stipends for CAP training, • improved access to quality fellowship rotations in specific community mental health care centers, and • coordinated research across academic institutions on child mental health care topics. CPAN will be a statewide initiative that is currently planned to deploy in spring

2020. All medical school departments of psychiatry in Texas have been assigned regions of the state with the goal of reaching and enrolling all primary care physicians who wish to participate in this free consultative service. Once a primary care team enrolls in CPAN, the next step is calling the toll-free number for a consultation when a mental health concern is identified during a patient visit. The PCP can expect a return call from the coordinator within five minutes. If the question involves assistance in considering and locating referral options for families, the coordinator will walk the PCP through the request and provide options along with basic behavioral plans. If the question involves assessment, diagnosis, and treatment planning for which a CAP physician is needed, the PCP can expect a return call within 30 minutes to consult on the issue and provide guidance. PCPs can call as frequently as needed to assist care of the patient in their office. Family physicians are on the forefront of helping families navigate complex mental health needs. My own father, Timothy E. Williams, MD, is a recently retired family physician who often lamented to me his continued lack of access for psychiatric consultation and care. I have him in mind when I think about the goals of CPAN to help the PCP help the family and their child. Together we can improve children’s lives. Next steps will be CPAN teams reaching out to PCPs in spring. As CPAN has finalized plans, our team will be reaching out to state family physician organizations with more detailed information on how to enroll. Stay tuned!

For more information on the Texas Child Mental Health Care Consortium, visit https://www.utsystem.edu/pophealth/tcmhcc/.

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15


MIND &BODY

Learning best practices from the three winners of TAFP’s Behavioral Health Integration Innovators Competition By Jonathan Nelson

F

amily physicians know all too well how difficult depression can be for patients. According to the Centers for Disease Control, almost 8% of Americans ages 12 and older are estimated to suffer from depression for at least two weeks each year. Only a fraction of those receive any treatment and often the treatment is inadequate. For patients with one or more chronic conditions, depression just makes things worse. Patients with diabetes and depression have a 50% higher mortality rate, a 30% higher likelihood of losing a limb, and significantly worse glucose control than patients with diabetes alone. Their medical costs are much higher, too. Medical expenditures for patients with diabetes and depression are more than four times higher than for patients with diabetes alone. Behavioral health conditions like depression pose particularly frustrating problems for busy primary care physicians trying to provide the best care for their patients. David Bauer, MD, PhD, is the director of the Memorial Family Medicine Residency Program in Sugar Land, Texas, one of the winning clinics in TAFP’s Behavioral Health

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Integration Innovators Competition. He says behavioral health and physical health are inescapably intertwined, each affecting the other, yet medicine has traditionally separated the two. “The question has always been, well, yeah, we know [depression] is there, but what do we do with it? Are we really trained to recognize it? Are we trained to manage it? Do we have the time to manage it?” In the traditional model when a patient tells a family doctor they’re depressed, the physician either starts the patient on an antidepressant or refers the patient to a therapist, he says. “Then you never hear anything back and 50% of the time, they don’t even go.” Lack of adherence to medication directions and the stigma patients may feel about seeing a therapist are major barriers to behavioral health treatment. In many communities, access to psychiatric services for referrals doesn’t even exist. Many primary care clinics around the country have found success by integrating behavioral health services into their practices and there are some excellent models and resources out there to help physicians who want to give it a try.


www.tafp.org

17


BASIC COMPONENTS OF A COLLABORATIVE CARE MODEL Integrating behavioral health services into a primary care practice generally means bringing care managers or behavioral health consultants into the clinic to provide counseling and enhanced patient engagement. In 2017, the Centers for Medicare and Medicaid Services introduced a set of CPT codes to pay for behavioral health services in primary care through the Psychiatric Collaborative Care Model. The guidelines and requirements to use those codes constitute a good checklist for integrating behavioral health. The Psychiatric Collaborative Care Model includes a care team consisting of: • a treating physician or other practitioner who will bill for services; • a behavioral health care manager who has training in social work, nursing, or psychology; and • a psychiatric consultant who is not required to be on site. The service components of the model include: • an initial assessment by the physician and the health care manager complete with the administration of a validated rating scale, like the PHQ-9 (Patient Health Questionnaire) or GAD-7 (Generalized Anxiety Disorder); • care planning by the care team and the patient, with revisions to the plan if the patient isn’t improving adequately; • proactive and systematic follow-up by the behavioral health care manager with the patient using validated rating scales and a registry; and • case reviews with the psychiatric consultant occurring at least weekly. The process is more complex than this brief overview but these are the main components of the model. The Medicare Learning Network offers a booklet entitled “Behavioral Health Integration Services” that provides more detail on the roles of the care team members, the requirements of the services, and how to use the codes to bill for the monthly behavioral health fee.

BEHAVIORAL HEALTH INTEGRATION INNOVATORS COMPETITION Last year TAFP put out a call to Texas primary care practices asking them to submit their models of behavioral health integration for the chance to win $10,000. Entries were judged by the TAFP Behavioral Health Task Force, which was appointed after the Academy identified the need for greater integration of behavioral health services in primary care as a top priority in its strategic plan. The task force members selected winners in each of three care settings: academic settings, integrated health systems, and solo and small group practices. Thirty practices entered the contest. The winners were the Memorial Hermann Medical Group Physicians at Sugar Creek and Memorial Family Medicine Residency Program of Sugar Land in the academic setting category, the Heart of Texas Community Health Center of Waco in the integrated health systems category, and the Hope Clinic of McKinney in the small group and solo practice category. The task force also developed TAFP’s new Behavioral Health Integration Toolkit to help members provide these services to their patients. Access the toolkit at www.tafp.org. 18

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“We have seen the effect collaborative care has had on patients’ health, physicians’ comfort treating behavioral health conditions, and on tightening the connection between mental and physical health. We hope our experience can convince our family physician colleagues that a collaborative care model is effective, feasible, and financially viable for a variety of practice settings and patient populations so that we can increase access to behavioral health services and effective treatment of depression throughout the state of Texas.” Memorial Hermann Medical Group Physicians at Sugar Creek


Winner in the Academic Setting Category: Memorial Hermann Medical Group Physicians at Sugar Creek and Memorial Family Medicine Residency Program

T

he Memorial Hermann Medical Group Physicians at Sugar Creek has been providing integrated behavioral health services to their patients through a collaborative care model since 2009. Their collaborative care team includes more than 50 primary care physicians, a full-time psychologist, and a clinical care manager, along with support and administrative staff. The clinical care managers they’ve employed have been licensed clinical social workers and licensed professional counselors. They also retain a few hours each week with an off-site psychiatrist who consults with the care team about the registry of enrolled patients, with a special focus on challenging cases. According to their contest entry form: “The broad goals of the program are to more effectively meet the mental health needs of patients, improve the physical health and overall functioning of patients with co-morbid physical and mental health problems, and improve the efficiency of the clinic by more accurately targeting services.” The program focuses on depression and anxiety, and it is based on the IMPACT model, or Improving Mood: Providing Access to Collaborative Treatment. The AIMS Center at the University of Washington Department of Psychiatry and Behavioral Sciences developed the model during the IMPACT study, which was the “first large randomized controlled trial of treatment of depression,” according to the center’s website. It took place from 1998 to 2002 with results published in JAMA in December 2002. Patients who received the IMPACT collaborative care were twice as likely to show improvement in their depression and total health care costs were lower for them. The AIMS Center says it has trained more than 6,000 clinicians around the world to implement collaborative care. The model involves: • • • •

care coordination using a behavioral health coordinator who is embedded in the practice; monitoring patients to make sure they are meeting goals; treating patients to target; and sharing progress and information regularly with the care team.

When new patients come to the clinic or each time they come in for a wellness visit, they complete a PHQ-2. If they screen positive,

they proceed to screen with the PHQ-9 and GAD-7 assessments. Once the care team identifies someone as having depression or anxiety, the physician invites the patient to participate in what they call the Care Program. If the patient agrees, they are introduced to the therapist and scheduled for an intake visit. After the initial consultation, the clinical care manager generates a summary of the visit that includes PHQ-9 and GAD-7 scores along with suggestions for interventions. The referring physician receives the report in their EHR. Patients can be treated with medication, therapy or both. A psychiatrist provides consultation to the care manager and primary care physicians, especially focusing on cases in which patients aren’t responding as hoped. Patients receive follow-up visits in person or by phone from the care manager and the care team tracks patients using a data registry system. Back in 2008, Bauer says the clinic saw many patients with chronic diseases compounded by depression and anxiety, and the usual practice of prescribing and referring them out for treatment of those behavioral health disorders wasn’t working sufficiently. “It had been such a huge problem. Terrible outcomes for patients and very unsatisfying.” Then they learned about IMPACT and secured a grant to bring a representative from the University of Washington to demonstrate the model. “Once we knew the process, we had to make sure we were getting patients identified,” Bauer says. That’s when they began universal screening of patients for depression and anxiety, embedded a behavioral health specialist, and launched the program. From 2009 to 2017, grant funding covered the cost of the program. The end of the grant coincided with the introduction of the CMS psychiatric collaborative care codes so they can now bill monthly for services in the program. For more than 10 years, the Memorial Hermann Medical Group Physicians at Sugar Creek has maintained an excellent and consistent record of success in improving their patients’ health through the Care Program. Before its implementation, they report patients achieved a 29% reduction in PHQ-9 scores, whereas with the program, patients’ scores go down by 50% after three months. Patients in the program have significantly fewer primary care visits than they did before enrollment, going from 1.8 visits per month to 0.5 visits per month after being enrolled for three to six months. The clinic reports that after six months in the program, 67% of patients are at goal for LDL cholesterol, up from 50% at intake. They report similar results in diabetes control, with the percentage of their patient population having HbA1c levels of less than 9% improving from 59% to 80% after six months. One question from the contest application asked how integrating behavioral health services had changed their practice, and the response from the Physicians at Sugar Creek reveals another reason to implement such a program. “Our integrated behavioral health program has given us the opportunity to work side by side with a variety www.tafp.org

19


of behavioral health providers. In addition to the improved outcomes, it has made our physicians more comfortable handling the treatment of mood disorders as part of routine primary care. Given that we are a residency training site, having integrated behavioral health has exposed hundreds of trainees to the model. We hope this will normalize working with behavioral health providers as well as increase our residents’ confidence in handling patients with mood disorders as they go out into practice.” Every year, 14 new residents gather for orientation at the Memorial Family Medicine Residency Program and they are told about the Care Program, “along with about 6,000 other things,” Bauer says. “So, of course, they’re shell shocked. The first time we precept with them when there’s a patient they’ve identified as depressed, one of the things we’ll say is, ‘Have you thought about the Care Program?’ and their eyes just light up. It really is so well accepted now and the residents are grateful for it, to have that resource for their patients.” Even though MHMG Physicians at Sugar Creek is a large practice with more than 50,000 patient visits a year, Bauer believes integrating a similar collaborative care model in small and even rural practices can be achieved. A few practices could share the services of a behavioral health care manager and a psychiatric consultant, and employing telemedicine for the therapy sessions and behavioral interventions is an option for remote areas. In the closing statement of their contest application, the MHMG Physicians at Sugar Creek expressed the same sentiment that led TAFP to host the innovation competition. “We have seen the effect collaborative care has had on patients’ health, physicians’ comfort treating behavioral health conditions, and on tightening the connection between mental and physical health. We hope our experience can convince our family physician colleagues that a collaborative care model is effective, feasible, and financially viable for a variety of practice settings and patient populations so that we can increase access to behavioral health services and effective treatment of depression throughout the state of Texas.”

Winner in the Integrated System Category: Heart of Texas Community Health Center

H

eart of Texas Community Health Center has developed a behavioral health program they call Integrated Health Management, which they employ to care for their 59,000 active patients in Central Texas. Headquartered in Waco, HOTCHC is a federally qualified health center with 14 clinical sites and a family medicine residency program that trains 36 residents. The health center has a long-standing commitment to providing comprehensive care to a socioeconomically vulnerable population. Lance Kelley, PhD, is a clinical psychologist and the Human Behavior Mental Health Director for HOTCHC. He says seven years ago, he and his colleagues became concerned about the high prevalence of mental health conditions they were seeing among their patients and the relationship between those conditions and the physical health problems patients experienced. Patients were reluctant to seek specialty mental health outside of the primary care setting, and there was a growing lack of access to those services. In 2014, Kelley and some of his colleagues put together a behavioral health leadership team to plan and implement a behavioral health integration program. They developed a blended model, merging the roles of behavioral health provider and care manager into a single professional position they call the integrated health manager. This person is a licensed clinical social worker who has been trained to perform integrated behavioral health and chronic care management in the primary care setting. “IHMs are core members of the primary care team, working alongside physicians, nurse practitioners, and physician assistants in a shared-care model to enhance primary care and improve population and behavioral health outcomes,” Kelley wrote in the award application. [cont. on 22]

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RESOURCES TAFP Behavioral Health Integration Toolkit www.tafp.org/practice-resources/bhi-toolkit MLN Booklet: Behavioral Health Integration Services www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/Downloads/ BehavioralHealthIntegration.pdf AIMS Center at the University of Washington aims.uw.edu/ VitalSign6 www.utsouthwestern.edu/education/medical-school/ departments/psychiatry/research/center/vital-sign6

“We have found that implementing this model has increased joy and satisfaction in practice because I think it allows for our family medicine doctors to get closer to providing the kind of care they really want to provide.” Lance Kelley, PhD

[cont. from 20]

Each day, physicians, nursing staff, and the IHM huddle and identify patients on the schedule who would benefit from behavioral health treatment. Then the IHM joins the physician when seeing those patients. The IHM engages the patients in brief psychological interventions, health behavior counseling, chronic disease care planning, and a host of other activities to address their mental health and chronic care needs. The IHM also follows up with patients over the phone or through secure electronic messaging to check on them and make sure they are adhering to their treatment plans. HOTCHC employs 10 full-time IHMs plus an IHM trainer. “The trainer is key in all of this,” Kelley says. “We spent almost an entire year with our trainer before we went live with our system.” All new IHMs spend eight weeks in a personalized training program, including four weeks working as an apprentice with the trainer in the residency training clinic. For the last month, IHMs train with their intended clinic team while the trainer helps customize the clinic workflow and coaches the team on how to maximize the model. “We quip around here that we want [IHMs] to be really bright and wear running shoes,” Kelley says. “The work is really fast-paced and you have to have someone who is both going to always have the drive to learn more and know more, but not be so paralyzed by the generalist nature of primary care that they can’t act. They need a tolerance for uncertainty.” HOTCHC also has developed psychopharmacology decision support tools to ensure their providers can access clinically proven treatment regimens that are consistent with general family medicine practice and vetted by content experts in psychiatry. The academic faculty at HOTCHC collaborated with a team from the Harvard Medical School Department of Psychiatry to develop the treatment algorithms. Kelley says HOTCHC is currently in the process of making these tools available to physicians outside their system. They are even developing an app, so stay tuned. They have also designed stepped care intervention programs to respond to patients with more complex mental health disorders, including a co-located specialty behavioral health clinic staffed by a physician and a clinical psychologist. “Primary care physicians can refer patients for short-term diagnostic clarification and treatment planning. This consultation clinic does not retain patients long-term, but refers patients back to their family doctor for ongoing management, usually after fewer than four mental health visits,” Kelley wrote in the contest application. Having such a robust integrated behavioral health program greatly enhances the residency experience for family medicine residents in training. “Here we say the clinic is the curriculum,” Kelley says. Since its founding, the Waco Family Medicine Residency Program has instilled a culture of service dedicated to recruiting and training physicians to care for underserved and vulnerable populations. “Having master experiences while you’re in residency is really empowering for you,” he says. “It gives you the confidence to detect things you might not detect otherwise. We are less likely to look for something if we don’t feel we can offer much if we find it.” The Integrated Health Management program at HOTCHC hasn’t just been a success for the people of Central Texas. It’s been great for the health care providers, too. “We have found that implementing this model has increased joy and satisfaction in practice because I think it allows for our family medicine doctors to get closer to providing the kind of care they really want to provide.”


Winner in the Small Group and Solo Practice Category: Hope Clinic of McKinney

A

lmost four years ago, a pastor in McKinney, Texas, came upon a man lying in a ditch. The man was experiencing homelessness and had mental health problems, along with other chronic health conditions. The pastor wanted to help but, in that moment, he couldn’t find any health resources aside from an emergency room, which the man initially refused, afraid they might amputate his gangrenous legs. After this encounter, the pastor approached a member of his church, Stephen Twyman, MD, MPH, and said, “Let’s open a clinic and let’s not charge anything.” That’s how Twyman told the story when he described his awardwinning integrated behavioral health program to attendees of TAFP’s 2019 Annual Session and Primary Care Summit. In 2017, Hope Clinic of McKinney opened its doors to serve uninsured patients who are at or below 200% of the federal poverty level. They provide a medical home to more than 400 patients and are expanding quickly, according to Twyman. They have three full-time staff, two part-time staff, and more than 90 active volunteers, including physicians, nurse practitioners, nurses, social workers, and more. Hope Clinic is a faith-based organization and it is funded entirely through grants and donations. To assess which patients could benefit from behavioral health services, the clinic has a strategic partnership with UT Southwestern Center for Depression Research and Clinical Care to implement VitalSign6, a comprehensive program the school designed to help identify and treat depression and anxiety in the primary care setting. “The cool thing about VitalSign6 is it really gave us a turnkey solution,” Twyman says. “All the things we needed were already there.” The platform comes complete with validated assessments, iPads for data entry, measurement-based care tools to track patient progress, and clinical decision support. Plus, Hope Clinic providers can access psychiatric consultation through the partnership. According to the UTSW website, patients using the VitalSign6 platform complete the PHQ and other systematic assessments “on an iPad during the triage process, thus making screening for depression the sixth vital sign after body temperature, pulse rate, respiration rate, blood pressure, and pain.” The data is immediately accessible to the clinic’s providers and the VitalSign6 team at UTSW, and the program provides clinical support to the providers as they treat patients with depression, anxiety, and other

behavioral and mental health conditions. “What that does is it helps us standardize the care we’re providing and make sure we’re actually following the best evidence for our treatment,” Twyman says. The clinic employs a bilingual licensed professional counselor who sees patients often in back-to-back visits with their primary care provider. The LPC and provider both have access to the electronic health record, so they can share notes and track progress toward treatment goals. The LPC touches base frequently with patients to encourage medication and treatment adherence, to remind them of upcoming counseling sessions, and just to check in. Patients can use a patient portal in the EMR to directly contact their providers and clinic staff with concerns, questions, refill requests, and other issues, but many patients of Hope Clinic have limited or sporadic access to the Internet. In January 2019, the clinic introduced a secure messaging platform, Care Message, which lets patients access their providers via text message. Twyman says implementing an integrated behavioral health program at the heart of a free clinic has helped remove the stigma associated with mental health among patients and providers alike. “I’m a big believer in being as comprehensive of a doctor as I can be. I think there’s good data to suggest that the more comprehensive family doctors can be, the better outcomes their patients have and the lower costs their patients have. Behavioral health interacts with every other aspect of a patient’s life.” He knows the patients at Hope Clinic are getting better. His data shows that “44% of patients who initially screened positive for and were subsequently diagnosed with major depressive disorder or other mental health disorders have since achieved remission.” That compares to a national rate of about 25%. “Our patients are getting better and we are excited to share what we’ve learned,” Twyman wrote in the contest application. One such patient in his early 30s came to the clinic with anxiety, depression, high blood pressure, and obesity. Twyman told attendees at TAFP’s 2019 Annual Session and Primary Care Summit: “He came to us and he said, ‘I don’t know what to do. I can’t keep a job. I’m so anxious I can’t do my normal activities. I find myself worrying myself to death and I just can’t work.’” It took five visits, Twyman says, but through counseling and treatment, he now has had a steady job for almost a year. His blood pressure is under control and he’s lost 30 pounds. His depression and anxiety are much better. “You know, that’s the reason we do this. He is one example of why we cared to integrate behavioral health into our clinic, why we care to try to do wrap-around services. … This has been a really rewarding part of our practice and it’s really enhanced the level of care we can offer to our patients.”

www.tafp.org

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25


RESEARCH

The Impact of the UTHealth Medical Legal Partnership on Utilization and Health Harming Legal Needs Support for this project included a grant from the Texas Academy of Family Physicians Foundation.

Support for TAFP Foundation Research is made possible by the Family Medicine Research Champions.

Winston Liaw, MD, MPH1; Angela Stotts, PhD2; Thomas Northrup, PhD2; Alvin Chen2; Robert Suchting, PhD3; Christine Bakos-Block, PhD, LCSW2; Christian Pineda4; Alissa Chen, MD5; Asra Waliuddin, MD2; Dongni Yang, MD, PhD2; and Thomas Murphy, MD2 1 Department of Health Systems and Population Health Sciences, University of Houston College of Medicine; Houston, Texas 2 Department of Family and Community Medicine, University of Texas Health Science Center at Houston; Houston, Texas 3 Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston; Houston, Texas 4 Lone Star Legal Aid; Houston, Texas

GOLD LEVEL

5 Yale School of Medicine; New Haven, Connecticut

Richard Garrison, MD David A. Katerndahl, MD Jim and Karen White

Introduction SILVER LEVEL Carol and Dale Moquist, MD TAFP Red River Chapter BRONZE LEVEL Joane Baumer, MD Gary Mennie, MD Linda Siy, MD Lloyd Van Winkle, MD George Zenner, MD

Thank you to all who have donated to an endowment.

For information on donating or creating a new endowment or applying for research grants, contact Kathy McCarthy at kmccarthy@tafp.org.

Addressing social determinants of health (SDH) is a critical strategy for lowering costs, improving patient experience, and improving population health.1,2 A vast body of literature connects SDHs to undesirable health outcomes,1,3-8 leading to calls for tighter integration between public health and family medicine.2 One intervention that links family medicine with public health is the medical legal partnership (MLP), which addresses health-harming legal needs (HHLNs) by embedding lawyers in clinics.9 These needs disproportionately affect low-income households, which average between one and three legal problems.10 The evidence base to assess MLPs is growing,9,11 and one pediatric randomized controlled trial found that access to legal services reduced emergency department (ED) visits.12 In collaboration with Lone Star Legal Aid, a legal services non-profit organization, the University of Texas Health Science Center at Houston (UTHealth) launched an MLP in 2018. This study assesses whether access to the MLP was associated with lower urgent care, ED, and hospital visits compared to individuals without access. In addition, we describe the HHLNs identified and services provided by the MLP.

Methods Overview: In this cohort study, three clinics had access to the MLP. A fourth did not and served as the control. Participants and Eligibility Criteria: We recruited adults aged 18 or older, who were English- or Spanishspeaking, had valid email addresses, and screened positive for HHLNs. 26

TEXAS FAMILY PHYSICIAN [No. 1] 2020

Setting and Recruitment: UTHealth is affiliated with 18 community-based, outpatient clinics. The three MLP clinics include family physicians, and average nearly 17,000 visits annually. The control clinic averages 15,000 visits annually. Staff offered patients with appointments a legal needs screening tool.13 Study Course: Screening started on April 16, 2018 at the intervention clinics and on July 17, 2018 at the control clinic. Six months after a positive screen, we sent an email survey. Survey responders were entered into a raffle for a $100 gift card. Outcomes: We used the following to measure utilization and HHLNs. HHLN Screening: Given the lack of a universallyaccepted HHLN screening tool, we collaborated with researchers and legal professionals to develop one. During this process, we consulted with other MLPs and the National Center for Medical-Legal Partnership and incorporated elements from existing instruments.14-16 When needed, we obtained permission.17,18 The screening tool is 23 items and encompasses legal issues, including income, insurance, safety, guardianship, housing, and food. Utilization: Via email, participants recorded the number of urgent care, ED, or hospital visits over two time intervals: 1) from six months before screening to the time of screening, 2) from the time of screening to six months after screening. HHLNs Identified and Legal Services Provided: Using data from Lone Star Legal Aid, we tracked the referrals to, the HHLNs identified by, and the legal services provided by the MLP from April 16, 2018 to February 1, 2019. Individuals can have multiple cases, and each case refers to a unique legal concern. The


Table 1: Demographic characteristics of respondents

INTERVENTION N %

CONTROL N

Number of respondents

124

86

Number of individuals receiving the survey

437

474

Response rate

28.4%

% p-value

18.1%

GENDER Female

80 64.5% 57 66.3% 0.8

AGE 18-44

75 60.5% 35 40.7% 0.01

45-64

41 33.1% 37 43.0%

65 or older

8

6.5%

14

16.3%

RACE/ETHNICITY Black

75 60.5% 53 61.6% 0.9

Hispanic or Latino

18

White

14 11.3% 9 10.5%

14.5%

14

16.3%

Asian

1 0.8% 0 0.0%

Other

14 11.3% 9 10.5%

Not answered

2

1.6%

1

1.2%

LANGUAGE English

107 86.3% 81 94.2% 0.3

Spanish

3 2.4% 1 1.2%

Arabic

2 1.6% 0 0.0%

Other

3 2.4% 0 0.0%

Unknown

9 7.3% 4 4.7%

Table 2: Mean pre- and post-urgent Care, emergency department, and hospital visits in intervention and control clinics INTERVENTION

SE

Mean

SE

URGENT CARE

Total

5.06 0.19

Pre-screening

2.90 0.13

2.38 0.13

Post-screening

2.15 0.11

2.09 0.13

4.48 0.19

EMERGENCY DEPARTMENT

Total

3.69 0.11

Pre-screening

1.98 0.08

1.19 0.09

Post-screening

1.72 0.07

1.07 0.08

Mean

CONTROL

2.26 0.11

HOSPITAL VISITS

Total

1.33 0.09

2.34 0.11

Pre-screening

0.61 0.06

1.19 0.09

Post-screening

0.72 0.06

1.15 0.08

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27


Figure 1: Poisson regression: Utilization associated with medical legal partnership access, compared to no access URGENT CARE

EMERGENCY CARE

HOSPITALIZATION

Predicted # hospitalizations after intervention

2.00

Predicted # ER visits after intervention

Predicted # UC visits after intervention

2.4

2.2

2.0

1.8

No access

MLP group

Access

1.75

1.50

1.25

1.00

No access

MLP group

Access

1.25

1.00

0.75

No access

MLP group

Access

UC = Urgent care; ER = Emergency room; MLP = Medical legal partnership

legal professionals grouped referrals into four categories: Open, Closed, Pending, and Rejected. “Open” cases were actively managed legal issues. “Closed” meant that the problem had been resolved or assistance had been completed. “Pending” indicated that the client was completing enrollment paperwork. “Rejected” indicated that the MLP was unable to accept the referral. Applicants were most commonly rejected for not responding to communication. Due to Lone Star Legal Aid’s funding model, the MLP could not enroll clients earning more than 200% of the federal poverty level and could not accept cases pertaining to immigration, personal injury, or medical malpractice. The MLP identified legal issues using an intake form and interview and tracked legal benefits to clients using a categorization system developed by the National Center for Access to Justice.19 Covariates: We collected age, gender, race or ethnicity, and language through EHR extraction. Intervention: Those screening positive were referred to the MLP, which consisted of a lawyer and paralegal. The MLP was physically offsite, and staff communicated with clients face-to-face or over the phone. All services were free. Control: Social workers were available and received referrals as needed. Analysis: We calculated descriptive statistics and conducted bivariate analyses by MLP access, using chi-squared tests for categorical variables. Poisson regression was used to model post-period counts for urgent care, ED, and hospital visits as a function of the MLP group while controlling for the pre-period count. Testing did not find evidence that age, sex, or race or ethnicity confounded these relationships. The Committee for the Protection of Human Subjects approved this protocol through the Quality Improvement Project Registry.

Results Nine hundred and eleven individuals received email surveys, with 210 responding (response rate of 23%: 28% for the intervention and 18% for the control). Respondents were primarily female, black, and English-speakers (Table 1). Over the preceding 12 months, the respondents from the intervention group had higher urgent care and ED visits and lower hospital visits (Table 2). These trends were consistent across the prescreening and post-screening periods. 28

TEXAS FAMILY PHYSICIAN [No. 1] 2020

Poisson regression found that having access to the MLP (relative to no access) was related to a 58% increase in the number of ED visits (Rate Ratio (RR)=1.58, p<0.001), no change in urgent care visits (RR=1.00, p=0.963), and a 41% decrease in the number of hospital visits (RR=0.59, p<0.001) (Figure 1). The intervention group most commonly reported that health insurance, personal safety, and transportation were concerns. In the control, the most common concerns included income, health insurance, and the oven or stove not working. Four hundred and ninety individuals were referred to the MLP, generating 559 unique cases. Over 40% of the cases were closed, open, or pending. Among the open and closed cases, 80% were related to government benefits, family issues, housing, or estate planning. Nearly a quarter of the legal benefits related to maintaining income. The next most common benefits were for family matters and housing matters.

Discussion The MLP addressed a wide variety of legal issues, helping its clients obtain Supplemental Security Income, spousal support, housing, education, and insurance. While we did not assess the MLP’s impact on health, there is a theoretical link between these benefits and better health. Improved health may explain our finding that access to the MLP was associated with a 41% decrease in the number of hospitalizations, compared to the control. Several of our findings differ from MLP studies conducted in pediatric populations. For example, a pediatric MLP reported that 37% of cases were related to housing compared to 19% in our MLP.11 Our utilization findings also differ. A previous randomized controlled trial concluded that access to pediatric legal services was associated with a reduction in the likelihood of having an ED visit.12 In contrast, we found an increase in the number of ED visits. Though the factors for this finding remain undetermined, we hypothesize that the increase could be related to having more resources to seek care. Additionally, unmeasured confounders could also account for this increase, including baseline health, insurance status, and comorbidities. Our finding that the MLP was associated with reduced hospital visits needs to be evaluated using more rigorous studies. If confirmed, however, the MLP could reduce spending in a health care system where one in every three dollars is spent in the hospital and the average cost of a hospitalization is $9,700.20,21


These data also highlight areas for improvement, as nearly 60% of the cases were rejected, and several changes could help. For example, a modified screening instrument could improve accuracy. Having the MLP co-located at the clinics could enable warm hand-offs. Tighter integration between the clinic and MLP could allow staff to share salient information. With access to clinic schedules, MLP staff could facilitate in-person communication.

Limitations There were numerous limitations. Some did not sign a client release form, allowing the MLP to share legal data with us; therefore, our results do not include all clients. Second, our results are limited by a low response rate, and the results may differ if we had a higher response. Third, the utilization results are subject to recall bias, as respondents were asked to remember events that took place over the span of a year. The results may differ if we used claims data. Finally, because we wanted an appropriate control, our sample consisted of

References 1. WHO Commission on Social Determinants of Health, World Health Organization, eds. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health: Commission on Social Determinants of Health Final Report. Geneva, Switzerland: World Health Organization, Commission on Social Determinants of Health; 2008. 2. Institute of Medicine C on IP. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington (DC): National Academy Press; 2012. 3. Link BG, Phelan J. Social Conditions As Fundamental Causes of Disease. J Health Soc Behav. 1995;35:80. doi:10.2307/2626958. 4. Berkman L.F., Kawachi I. Social Epidemiology. New York City, NY: Oxford University Press; 2000. 5. Woolf S., Johnson R., Phillips R., Philipsen M. Giving everyone the health of the educated: An examination of whether social change would save more lives than medical advances. Am J Public Health. 2007;97(4):679-683. 6. Zimmerman E., Woolf S.H. Understanding the relationship between education and health. Natl Acad Sci. 2014. https://apha. confex.com/apha/142am/webprogram/Handout/Paper315693/ Final%20BPH-UnderstandingTheRelationship.pdf. Accessed March 10, 2017. 7. Woolf S.H., Jones R.M., Johnson R.E., et al. Avertable deaths associated with household income in Virginia. Am J Public Health. 2010;100(4):750-755. doi:10.2105/AJPH.2009.165142. 8. McGinnis J.M., Foege W.H. Actual causes of death in the United States. JAMA. 1993;270(18):2207–2212. 9. Martinez O., Boles J., Muñoz-Laboy M., et al. Bridging Health Disparity Gaps through the Use of Medical Legal Partnerships in Patient Care: A Systematic Review. J Law Med Ethics. 2017;45(2):260–273. 10. Legal Services Corporation. The Justice Gap: Measuring the Unmet Civil Legal Needs of Low-Income Americans.; 2017. https://www.lsc.gov/sites/default/files/images/TheJusticeGapFullReport.pdf. Accessed September 21, 2017. 11. Klein M.D., Beck A.F., Henize A.W., Parrish D.S., Fink E.E., Kahn R.S. Doctors and Lawyers Collaborating to HeLP Children—: Outcomes from a Successful Partnership between Professions. J Health Care Poor Underserved. 2013;24(3):1063–1073.

individuals who screened positive. The utilization results may differ if we had sampled those enrolled in the MLP instead. In conclusion, the UTHealth MLP has provided critical legal services that affect the basic needs for survival and facilitate access to care. The MLP is associated with decreased hospital visits but also increased ED visits. While promising, these findings need to be confirmed in other sites, using more rigorous methods. Hospital and ED visits are two of the outcomes being assessed in the next phase of this project — an MLP randomized controlled trial that started enrolling participants in February of 2019.22 Acknowledgements: We would like to thank Adeel Qureshi, Bernice Yau, David Wang, Caj Johansson, Isabelle Zare, Jocelyn Abraham, and Michael Connelly for their assistance with data entry and Casey Goodman and Aaron Tracy for their assistance collecting preliminary data. We would like to thank Sandra Stansberry for her assistance with data extraction and UT Physicians for their assistance with data collection and referrals.

12. Sege R., Preer G., Morton S.J., et al. Medical-Legal Strategies to Improve Infant Health Care: A Randomized Trial. Pediatrics. 2015;136(1):97-106. doi:10.1542/peds.2014-2955. 13. Sandel M., Hansen M., Kahn R., et al. Medical-Legal Partnerships: Transforming Primary Care By Addressing The Legal Needs Of Vulnerable Populations. Health Aff (Millwood). 2010;29(9):16971705. doi:10.1377/hlthaff.2010.0038. 14. Pettignano R., Bliss L.R., Caley S.B., McLaren S. Can access to a medical-legal partnership benefit patients with asthma who live in an urban community? J Health Care Poor Underserved. 2013;24(2):706–717. 15. National Center for Medical-Legal Partnership. National Center for Medical-Legal Partnership. Medical-Legal Partnership. http:// medical-legalpartnership.org/. Published 2018. Accessed February 8, 2018. 16. Billioux A., Verlander K., Anthony S., Alley D. Standardized Screening for Health-Related Social Needs in Clinical Settings. Accountable Health Communities Screen Tool Discuss Pap. 2017:2017. 17. Hager E.R., Quigg A.M., Black M.M., et al. Development and Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity. PEDIATRICS. 2010;126(1):e26-e32. doi:10.1542/ peds.2009-3146. 18. National Association of Community Health Centers. Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences. NACHC. http://www.nachc.org/research-and-data/prapare/. Published 2017. Accessed October 1, 2017. 19. National Center for Access to Justice. Tracking Outcomes: A Guide for Civil Legal Aid Providers & Funders.; 2018. 20. Centers for Medicare and Medcaid Services. National Health Expenditure Data Highlights. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Published December 11, 2018. Accessed September 8, 2019. 21. Pfunter A., Wier L.M., Steiner C. Statistical Brief #146: Costs for Hospital Stays in the United States, 2010.; 2013. 22. Liaw W. Expanding the UTHealth Medical Legal Partnership to Improve Mental Health for Low-Income Individuals - Full Text View - ClinicalTrials.gov. https://clinicaltrials.gov/ct2/show/ NCT03805126. Accessed July 17, 2019. www.tafp.org

29


PERSPECTIVE

A welcome reminder a long way from home By Lesca Hadley, MD

on the second day of a spring break medical trip in the mountains of Guatemala, an 87-year-old patient led carefully by her great grandson’s wife entered the schoolroom where I was seeing patients with a UNTHSC medical student, a nursing student, and our Spanish translator. She couldn’t have had another wrinkle on her wizened face. She lived alone on the edge of her village near fields of corn. Everyday she walked her route, selling milk she got from her neighbor to the families in town. She had delivered milk the previous day, but on this day, she was too weak to stand without help. She had a temperature of 99.5, and she felt hot. Her productive cough was audible. She trembled as our small interprofessional team began to examine her, gently raising her clothing. This was her first time to see a doctor. She looked cachectic, obviously having lost a tremendous amount of weight, but now her appetite had declined further. During the visit, as her head hung low, she slowly told us through tears how all her other relatives had died. She was alone. She had no abdominal or urinary complaints, her lungs were clear other than a few scattered rales, and she had no wounds. We had no available X-ray. Her conjunctiva seemed to indicate that she was not anemic and in our makeshift clinic, we had no other way to evaluate the components of her CBC. Intramuscular ceftriaxone was our best available medication for probable pneumonia. Another nursing student who doubled as the pharmacist mixed the medicine into a syringe and then carefully injected it into her bony hip. The needle penetrated the skin like a sewing needle going through leather. With consternation, the patient agreed that she felt too bad to cook and we thought she would be likely to fall on the rocky roads or in her small house in her condition. Usually, even in Guatemala, the recommendation would be a hospital admission. Treating an 87-year-old with pneumonia is risky, but so many adverse events could happen to this woman in a hospital. She did not want to leave her home even to stay with her family, much less go to the hospital, and following much persuasion, she agreed to go with her great-grandson’s wife, the only family she had left. After warning her that her situation could worsen, I promised a home visit the next day. After a long day of clinic on the following day, I gathered the ceftriaxone, a medical student, two nursing students, and our translator and set off to see our patient. For about 20 minutes, we followed a member of her family up a hill over a very rocky uneven road. We navigated around a hole in the road the size of a small car. When we thought we had crested the hill, we passed a mobile concession stand, turned left into a narrow alley, and continued to climb. Upon arrival, we walked through the dimly lit house to where the patient was resting on the sofa. Her face lit up, lifting all the wrinkles skyward. As we sat on chairs surrounding her, she told us how much she had worried about us forgetting to come. She had only eaten a 30

TEXAS FAMILY PHYSICIAN [No. 1] 2020

tortilla that day, but her caretaker was encouraging the liquids and still pressing her to eat. Her forehead was warm, but she felt better than the previous day. She again slightly retracted with each breath, but her cough was improved. Amazingly she had walked alone to her home across town when she had grown bored during the afternoon. Her doting caregiver had only agreed to let her go when she promised to return for our visit. The family repeatedly told us how grateful they felt for the visit. With permission, we took pictures of the patient and her family. When our patient saw herself in a photo, she put her hands on her head, exclaiming she should have fixed her hair. Finally, we ended the visit with the nursing students giving the antibiotic in the other hip. Our team left the house feeling overjoyed with the incredible recovery of our patient. The family waved to us on the porch as we walked down the alley towards the road. On the way back, our translator found a tuk-tuk to give us a free ride, so we had six adults in a tiny tuk-tuk going down the same rocky road. Surprisingly all the tuk-tuk tires survived the trip. I had told the patient we would return the following morning, but clinic was bustling. Lunch came at 3 p.m. when we finished. I left with six others in a truck bound for Guatemala City and the airport. Since I was going to the airport, I was unable to take my interprofessional team again. Instead, I took the same antibiotic in a syringe, along with enough oral antibiotics for ten days. My patient and her caregiver were sitting on the porch, waiting for me. Immediately they began to express their thankfulness for the visit. The excited caregiver told me my patient had eaten at the table with the family. The patient felt afebrile and had no retractions when she talked quickly. She was walking more comfortably on her own. She showed noticeable improvement over the previous day. Missing my team, I gave the injection, and I explained the oral antibiotics to the caregiver in my discharge directions. Both the patient and caregiver hugged and kissed me repeatedly. The caregiver then brought me a small Guatemalan purse made of handwoven Typica material as a gift. At that point, I could not stop the tears as they began to roll down my cheeks and face. Somehow all the pain and frustrations of the last several months seemed redeemed with her gift. The patient told of how lonely she had felt at home by herself, not knowing her family, and now she had found family who truly cared for her. They prayed for God to bless me, and my patient told me to wear the purse across my body to keep it from falling off my shoulder. I wish I could have stayed longer in that small room with my patient surrounded by the green walls filled with pictures of her family. Suddenly, I felt I had been caring for my grandmother again. Through my spry patient, I saw my grandmother’s sweet smile and heard her encouragement. She had a sound mind with a hearing deficit, just like my grandmother had at the same age. On this day through my patient, God reminded me of why I am here: To serve and protect those who cannot care for themselves.


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