Scott McFarland, CEO will appear at the Board of Supervisors meeting Tuesday, June 3 at 10 a.m. to tell the Board what’s going on and then on Wednesday, June 4th there will be a meeting at the Downieville School Gymnasium for the community to listen and give input to McFarland and the Board of Directors for the Western Sierra Medical Clinic. You are encouraged to attend both meetings to hear what is said to the Board of Supervisors and to have a discussion with WMSC powers.
I requested a copy of a statement made to the Western Sierra Medical Clinic Board of Directors by Frank Lang in an effort to have the Board understand the necessity of having an pro-active Clinic and 24/7 emergency care available in western Sierra County. Also here is a site that explains why western Sierra County is eligible for Grant funding http://www.raconline.org/topics/frontier/faqs
Statement by Frank J. Lang, NP, EJD
WSMC Board of Directors Special Meeting
May 22, 2014
Good afternoon. I want to thank Mr. McFarland and the Board of Directors for the opportunity to share my thoughts in the matter of staffing the Western Sierra Medical Clinic, Downieville Site. Mr. President, I would like to present this statement and then be pleased to respond to questions.
The issue is how to provide medical staffing in Downieville. A brief historical perspective may be helpful. The Clinic began in 1974 when a group of Lions Club members developed a community interest committee that evolved into the first Board of Directors. Our story was the basis for numerous grants and the HRSA 330 approval in 2007. That story is still relevant. The Clinic remains a vital clinical, economic and social structure in this community.
Dr. Sutton had provided medical care until he passed away in 1965. There was no medical care available until the Loyalton physician started coming one day per week in the early 1970s.When I arrived in Downieville in 1976 there was virtually no consistent primary medical care or integrated EMS response to medical care and emergencies. The fire department had begun to teach EMTs so the basic infrastructure was in place.
Western Sierra County comprises a 500 square mile frontier area which has no other medical care facilities. The only other acute care resources are local fire departments in Alleghany, Downieville and Sierra city. These are staffed by volunteers and the availability of 1 ambulance in Alleghany/Pike and 2 ambulances in Downieville. There are generally 1-2 EMTs in Alleghany and Pike and 4-6 EMTs available in Downieville and Sierra City. There are currently three (3) functioning Advanced EMTs who are able to start an IV and administer oral glucose and sublingual Nitroglycerin, injectable glucagon, injectable Narcan and auto inject epinephrine. One is in Sierra City, one is in Downieville and one is in Alleghany. They operate under the medical control of the medical provider in Downieville. EMS regulatory control is provided by Norcal EMS in Redding. The Clinic’s interface with EMS is provided by Enloe Medical Center, which has designated the Downieville Clinic as an Alternate Base Station to allow medical control. The Clinic is required to have a Physician or Field MICN available for that control and functioning in the field. There is a contractual Base Station agreement with Enloe Medical Center to that effect. I currently fill that role. There are no functioning Paramedics in western Sierra County. A Paramedic does live in Downieville, however, he works in Nevada County, which is governed by Sacramento Sierra EMS, and he has chosen not to associate with Norcal EMS, which governs Sierra County. Downieville Volunteer Fire Department administers the Ambulance System in western Sierra County. The volunteers are paid when they go out on the ambulance. The EMTs are coordinated by the Training Officer, Jacie Epperson, RN. There is monthly training and Run Review provided in Downieville by Enloe Flight Staff and it is funded by Enloe Medical Center. The Clinic Medical Provider is encouraged to attend.
Western Sierra County EMS statistics from their Intermedix EMR Reports include an average of 10 runs per month a third of which are trauma and 2/3rds are medical emergencies. 1/3rd originate in Sierra City and 2/3rds originate in Downieville. A small number originate in Alleghany. 1/3rd are generally evacuated by a combination of land ambulance and helicopter, mostly serviced by Enloe Flight Care.
Today there is an integrated team response to primary care needs, urgent and acute medical as well as trauma emergencies that comprises the Western Sierra County Primary Care and EMS system. No one aspect of this system is greater than the whole nor is a system whole unless all components are included. The Medical Clinic operational model is consistent with the HRSA goal of Medical Home and indeed is currently designated as a Medical Home.
Today’s Medical Home is a cultivated partnership between the patient, family, and primary care provider in cooperation with specialists and support from the community. The patient/family is the focal point of this model, and the medical home is built around this center. The Medical Home has seven (7) crucial characteristics. These characteristic stress that care under the Medical Home model must be accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. The Medical Home has been defined within these 7 principles: These are found on the HRSA Web Site.
1. Personal physician or medical provider:
Each patient has an ongoing relationship with a personal physician or medical provider trained to provide first contact, continuous and comprehensive care.
2. Physician directed medical practice:
The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
3. Whole person orientation:
The personal physician or medical provider is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.
4. Care is coordinated and/or integrated:
Across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
5. Quality and safety are hallmarks of the medical home:
Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, medical providers, patients, and the patient’s family.
Evidence-based medicine and clinical decision-support tools guide decision making.
Physicians and medical providers in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
Patients actively participate in decision-making, and feedback is sought to ensure patients’ expectations are being met.
Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication.
Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the Medical Home model.
Patients and families participate in quality improvement activities at the practice level.
6. Enhanced access to care:
Is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician or medical provider and practice staff.
Appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:
It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit.
It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.
It should support adoption and use of health information technology for quality improvement;
It should support provision of enhanced communication access such as secure e-mail and telephone consultation;
It should recognize the value of physician or medical provider work associated with remote monitoring of clinical data using technology.
It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits.)
It should recognize case mix differences in the patient population being treated within the practice.
It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.
It should allow for additional payments for achieving measurable and continuous quality improvements.
I firmly believe that the Downieville Model has been doing this for 38 years. It should be incorporated at the Miner’s Site in Grass Valley and that recruitment for providers should include an understanding that the Western Sierra Medical Clinic includes 2 sites and that staffing is a mutual system responsibility.
The Medical Provider in Downieville has to have multiple competencies including family medicine, pediatrics, surgical, orthopedic, obstetrical, radiologic, behavioral health, home care, hospice, jail care and emergency medical skills. This is difficult enough to find in physicians let alone nurse practitioners or physician’s assistants, but not impossible.
The Medical Model for the past 38 years has been to provide 24-hour, 7 days per week medical care to Western Sierra County. This has been challenging to say the least and I have experimented with various staffing models to meet that demand. The model requires significant personal commitment and is admittedly not easily found. Nor do I think it can be accomplished any longer with just 1 person. It requires at least 2 if not 3 individuals who can rotate through the clinic to maintain that availability and skill set. Dr. Kellerman and I continue our commitment to assist the Board of Directors in meeting that requirement.
All of you know the challenges of driving 50 miles on these mountain roads which can vary the time to Grass Valley by 1-2 hours depending on the weather and 1-1/2-3 hours to Truckee depending on the weather to meet acute and regular care needs. The whole point of a community Health Center is to meet the needs of the communities that they serve.
The minimum standard, it seems to me, is that everyone in Western Sierra County should have access to regular primary care, ACLS intervention, emergent medical or traumatic injury treatment and care when they are dying. We have saved and lost many individuals over the years and all had the benefit of a responsive and integrated medical care system. The cost for this system should be shared by the consumer, the responsive agencies, the County, the state and the federal government. I fought for the Jail Contract to provide $55,000 to offset the cost of afterhours care. The Sierra County Board of Supervisors decided Tuesday, May 20, 2014, to maintain the Jail. It remains a Clinic Jail Contract responsibility to provide medical care to that facility. I understand the clinical and administrative issues having done both roles for 35 years. I understand the clinical needs of the community. I understand the need to have an integrated Clinic EMS system. The only purpose for all of this is to meet the individual citizen/patient and institutional care needs in this frontier area.
The communities in western Sierra County deserve the opportunity to participate in these decisions. Western Sierra County requires 24 hours 7 days per week on site care to meet the community health care needs. It might be hard to do but it is not impossible. If you abandon us it will be a catastrophic system failure and relegate us to Third World Care.