Richard* is in his 50s, has schizophrenia and a complex physical health history, and, earlier this year, he suffered a liver infection that nearly killed him. Weeks in the hospital left him weak, and he’s still recovering.
He has come to the Old Town Clinic in downtown Portland, Ore., to get a referral for an eye doctor, but he also talks to medical director Rachel Solotaroff about his ongoing physical therapy and dose levels for his psychiatric medications.
Due to injuries related to his hospital visit, Richard hasn’t been sleeping well, so Solotaroff recommends prescription pillows he can pick up in Old Town’s pharmacy. She also asks him if the clinic could send a physical therapist to his home to make sure it’s safe for him to maneuver there.
“Yeah, he can come,” he says.
“He’s awesome,” Solotaroff says, writing out the prescription.
“Yeah, he’s such a good dude. You can talk sports,” she says.
Most of Solotaroff’s patients are homeless, transitioning out of homelessness, or, like Richard, living in transitional housing owned and administered by Central City Concern, the nonprofit that runs the Old Town Clinic. Founded in 1979 as the Burnside Consortium, the agency was created to address the “street inebriate problem” in Portland’s Skid Row area. Initially, the organization provided alcohol recovery treatment, then affordable housing management. Gradually it expanded its services to include physical and mental health care—and, most recently, dental care.
The Old Town Clinic has achieved national recognition as an outstanding example of a patient-centered medical home—one that provides patients with not just physical health care but also “wraparound care,” including mental health services, addiction treatment, and complementary care all in the same building. When Harry*, a retired dockworker, mentions during his visit that he’s had muscle cramps, Solotaroff asks if he’s eating enough fresh produce and hands him a calendar of upcoming wellness events, including cooking and nutrition classes for people with limited grocery budgets, meditation and movement classes, and support groups for those dealing with co-occurring chronic pain and opiate addiction.
“There’s a lot of talk about teams, but they have really embraced the concept,” says Brian Austin, deputy director of the Robert Wood Johnson Foundation’s LEAP (Learning from Effective Ambulatory Practices) Project, which named the Old Town Clinic one of 30 model primary-care practices nationwide after a visit last year. “We were all struck by the care and compassion they had for what’s universally viewed as a very difficult patient population.”
“This is actually a calm day,” Solotaroff says, walking from the exam room to the team room, where she and her colleagues regularly confer about the status of the patients they are working with that day. In one corner, Kerith Hartmann, a health assistant, calls patients to remind them of their appointments and offers to reschedule or even send cabs for those who tell her they can’t make it. She turns in her swivel chair and asks Autumn Bolds, the care team manager, about one patient’s pending referral to a neurologist. Melissa Garza, the team’s medical assistant, brings in records and updates Solotaroff briefly on the status of each patient before she visits with them.
The Old Town Clinic implemented the patient-centered medical home model in 2006, when Medicaid insurer CareOregon approached a few community clinics about providing more wraparound care for the populations they serve.
Once a month, the medical team examines charts mounted on poster board detailing how patients are faring in terms of certain metrics used by most medical homes to evaluate the progress of their patients: what percentage of female patients are up to date on their pap smears, for instance, and what percentage of patients over 50 have had a colonoscopy within the last year. Diabetic patients are frequently called; if numbers drop in any metric, staff vow to do more outreach.
There’s a lot of talk about teams, but they have really embraced the concept.
The only problem, Solotaroff says, is that many of those metrics—while relevant to the U.S. population as a whole—aren’t especially relevant to Central City’s clients, who are more likely to overdose, commit suicide, or die from environmental injury than to die from colon cancer.
“That’s my beef about population management, that we apply the same measures to very different populations,” she says.
Apart from quibbling about metrics, Solotaroff is proud of the kind of wraparound care the clinic is able to provide—and says even the generic metrics provide “a really good process measure” for how patients are progressing.
When Solotaroff graduated from medical school in 2001, she thought she’d go into rural practice and envisioned herself bartering services with farmers in Maine.
It was her husband’s job—he’s a professor at Reed College in Portland—that brought her west. Initially, she went into research. Her project focused on health outcomes of uninsured populations, a project she says made her ask, “Why are you paying me? Why not just give them the insulin?”
From there, she went on to practice general medicine and geriatrics at Oregon Health and Science University, where she learned that Central City Concern was looking to establish a partnership with an academic institution, and that OHSU was looking to expand its social medicine curriculum.
In 2006, Solotaroff became medical director of Old Town Clinic. At the time, she says, “I was really green around urban environments, addictions, and mental health.” The clinic had just then begun to adopt the patient-centered medical home model, and Solotaroff has helped spearhead a tiered, cutting-edge program for helping patients cope with co-occurring chronic pain and opiate addiction. Central City has also continued to expand its housing offerings and to advocate for the idea of housing as a cornerstone of health care. More recently, Central City opened a dental clinic in response to a crying need for low-income dental care in the area.
“We try to do a good job of making it as nonjudgmental and low barrier as possible,” Solotaroff says. That approach extends well beyond the confines of the exam room or the recovery meeting: Nobody at Old Town Clinic wears a white coat, and everybody goes by their first names, including Solotaroff, who is just Rachel to her patients and colleagues.
While it’s “a far cry from bartering hogs in rural Maine,” Solotaroff says, she’s found at Old Town Clinic what she first sought when she went to medical school: a holistic community of care.
“One thing that’s important to me is community and how you enter into a community—but also how a community cares for itself,” Solotaroff says.
* Names and identifying details of patients have been changed