At 34 years old, L.D. Warmington was living out of his car in rural Shasta County, CA, and feeling “like everything was falling apart.” He had started using opioid pain killers as a teenager and continued for 18 years. Along the way, he tried a few drug-treatment programs. “It never clicked,” he says. “I never fit in.”
Warmington decided to seek treatment once more. Several facilities turned him down because he had no job, no money, and no health insurance. When he called Hill Country Community Clinic, a federally qualified health center (FQHC) in northern California, he was again told he needed insurance. “I said, ‘Listen, I don’t know that I will be here tomorrow. I don’t have much going for myself. This is my last try,’” he recalls.
The woman on the phone told him she’d call him back in a few minutes. When she did, she got right to the point. “I’m going out on a limb for you,” she said. He showed up several hours early.
Hill Country Community Clinic covered his costs to start medications for addiction treatment (MAT) for opioid addiction and provided care for his other physical, mental health, and social needs. It helped him apply for health insurance and housing and gave him vouchers for assistance with food and gas.
“They took care of all the other distractions in my life so all I had to do was show up, work the program, and develop and use the tools to move forward,” he says.
Now, nearly five years later, Warmington has regained a job in the field he loves, has an apartment of his own, and helps facilitate a Hill Country recovery group. The clinic’s treatment approach works, he says, because “it’s whole-person care, not a drug program.”
A Region with Need
That whole-person focus has been part of Hill Country’s mission since 1985, when it opened its main clinic in Round Mountain, California. Located in the eastern part of Shasta County on the edge of the Cascade Mountains, the clinic sits in a region classified as “frontier,” a designation more remote than “rural.” Redding, the county seat, is more populous, with about 91,000 residents and several Hill Country sites.
They took care of the distractions in my life so all I had to do was show up, work the program, and develop and use the tools to move forward … It’s whole-person care, not a drug program.
The northern California county is poor, with 40 percent of residents living at or below the federal poverty line. About 88 percent of the population is white. Residents experience significant health disparities due to limited access to resources. The county’s adverse childhood experiences (ACE) scores, which measure factors such as living in a home with violence or substance use, “are two to three times that of the state and national averages,” says Hill Country chief medical officer Susie Foster, RN, MSN, FNP. “Those are our patients and our staff as well.”
Shasta County resembles other rural areas across the U.S. where, in recent years, opioid use began to rise dramatically. A California Health Care Foundation report on substance use showed the region that includes Shasta County had the state’s highest average number of nonfatal emergency department (ED) visits in 2012-2014 for both opioid-related use and substance use (alcohol and non-opioid drugs). In 2020, the county had higher than state average rates for ED visits due to opioid overdose, hospitalizations for opioid overdose, and deaths from opioid overdose.
Making Substance Use Treatment and Support Part of Primary Care
From its start, Hill Country has integrated mental health and primary care. The clinic has always had a behavioral health provider on-site to provide patients with consultation and allow the team to treat the whole person. After initial treatment, some services could continue in the clinic, but other work was referred to outside providers. Care was integrated but siloed by specific program funding and criteria for patient enrollment.
As the opioid epidemic burgeoned, Hill Country began seeing a growing number of patients who were misusing prescription medicines and illicit drugs. Many had multiple, interconnected health needs. In 2016, the clinic started a program to provide MAT for opioid use disorder (OUD), in conjunction with other health and social services. That program helped L.D. Warmington when he thought he had run out of options.
We wanted to explore how to set up our integration to provide wraparound care with a case manager based on the patient’s need, not on whether they qualified for a specific funded program.
Hill Country then widened its focus to include MAT for OUD and complex health services in a broader, more integrated approach for patients with substance use disorder (SUD). Renee Brissey, director of the Integrated SUD Program at Hill Country, says it’s a “natural evolution” to expand from treating one substance to treating others. People are often using several substances at one time, she explains, with resulting long-term effects on their health.
The goal became to fully integrate SUD services into a continuum of primary care and mental health care that would benefit from:
- Adding SUD counselors to the primary care team;
- Training all primary care team members and staff in addiction-informed care;
- Creating a new complex care coordinator position; and
- Increasing training in trauma-informed care.
The Center for Health Care Strategies’Advancing Integrated Models (AIM) initiative, supported by the Robert Wood Johnson Foundation, assisted Hill Country in focusing on the foundational pieces needed to build integrated care. These included improving case management services, adding a complex care coordinator position, developing ways to track data better, and cross-training behavioral health coordinators and SUD counselors. AIM also worked with one of Hill Country’s payers, Partnership HealthPlan of California, to help determine ways to make the SUD program sustainable.
Hill Country is also seeking to think through ways to ease funding and care silos between its complex care programs, to eventually expand care management access to all patients. They chose to integrate the SUD program into primary care first because some of its elements could be replicated and developed across the other programs, and because of its relevance to Hill Country patients and the surrounding community.
“We wanted to explore how to set up our integration to provide wraparound care with a case manager for any patient,” says Jo Campbell, Hill Country’s Chief Operations Officer. “It would be based on the patient’s need, not on whether they qualified for a specific funded program.”
Innovative Program Features
Complex Care Coordinator
To better integrate care and address program silos, Hill Country created the role of complex care coordinator, a staff member who trains, advises, and supports case managers during the integration process and ongoing work. “I’m the elastic arms that wrap around all of our staff,” says complex care coordinator Raven Hoopes, who meets with case managers daily, provides help, and talks with them about difficulties in addressing patient needs. The complex care coordinator has been a pivotal figure in the work of integration. Because supporting staff leads to better care for patients, Hoopes leads staff wellness sessions and monthly group meetings as a place to share resources, provide support, and elevate case managers’ voices. The complex care coordinator also watches for signs of secondary trauma, burnout, or compassion fatigue in team members, and advocates for staff when they need a break.
Substance Use Disorder Counselors
Integrating SUD treatment fully into primary care allows us to connect people who are coming to see their provider for their annual check-up but need support for substance use.
Five certified SUD counselors are now integrated as members of the primary care teams, to help patients who are using drugs, alcohol, or other substances. SUD counselors are skilled in stabilizing and counseling these patients, while the clinic’s behavioral health counselors center on mental health issues such as anxiety or depression. SUD counselors serve as on-site resources for both patients and providers.
“Integrating SUD treatment fully into primary care allows us to connect people who are coming to see their provider for their annual check-up but need support for substance use,” Campbell says.
When patients first enter the program, the SUD counselors and case managers, who help with needs such as housing and food, work with them intensively. Patients gradually move through a tiered system used by Hill Country complex care programs (see Figure 1, below). Each tier represents the frequency and type of care needed. As patients move from entry and stabilization to maintenance and wellness, they transition to primary care.
Figure 1. Hill Country Complex Care Programs: Tiered Steps to Wholeness
Some patients don’t think their substance use is a problem or might not be ready to connect with help. As part of the primary care team, SUD counselors can engage with patients over time, develop meaningful relationships, and then address substance use issues. Having SUD counselors in primary care also normalizes SUD treatment as part of general health care. Such normalization may ease patient resistance to talking with a SUD counselor and participating in treatment.
Training, a key part of the complex care coordinator’s job, emphasizes delivering appropriate care with kindness and no stigma. Hoopes redesigned the organizational training structure so new staff at Hill Country learn about the clinic’s complex care programs, understand the social determinants of health, and gain insight about drugs patients might use. All Hill Country staff, whether working with patients, doing office work, or maintaining facilities, now receive harm reduction training as well. This approach shifts away from a traditional treatment model of abstinence, to build understanding and support for people using substances. Harm reduction helps people be safer even if they continue to use. Hill Country’s harm reduction training is presented in three modules, offered monthly.
Staff also receive training on “addiction-informed care” — the knowledge and understanding of addiction and its pervasive effects to overall health — and trauma-informed care. Both are important for primary care providers serving SUD patients because trauma often co-occurs with substance use and addiction. To benefit interactions with patients and co-workers, Hill Country also recently offered a six-month course on motivational interviewing to build empathic communication skills. This program trained 13 staff members from across departments and prepared them to train others within the organization.
Updated Needs Assessment
Everywhere it said ‘abuse,’ we changed it to ‘use.’ Instead of ‘injection drug user,’ we changed it to ‘person who injects drugs.’
Because Hill Country’s complex care programs were siloed by funders, their data collection varied according to what each funder required. “Case managers in different programs were holding data in all different ways,” Hoopes says. As part of their work under the AIM initiative, Hill Country revised the way they collect data by updating the needs assessment form in the clinic’s electronic health record. Hoopes led the effort to standardize and better capture useful information, improve analysis, and demonstrate the effects of integrated care on patients’ health.
Many changes to the needs assessment form focused on de-stigmatizing language. “Everywhere it said ‘abuse,’ we changed it to ‘use,’” says Hoopes. “Instead of ‘injection drug user,’ we changed it to ‘person who injects drugs.’” Questions were added to gain narrative data that could provide additional context for a person’s situation, such as asking if they had any evictions and whether they have pets. After training case managers on using the new data collection system, it launched in April 2021. Hill Country continues to update the assessment as needed.
Hill Country has worked closely with one of its payers, Partnership HealthPlan, since the clinic began providing MAT. The clinic elevated its business case for the SUD program with the health plan by demonstrating how its tier-based care system supports patients. Each tier in the approach (see Figure 1, above) provides appropriate help as patients move toward Tier 5, known as “wholeness.” Yet maintaining payer support for SUD services is an ongoing process. The program is continuing its efforts to show the benefits of staff such as SUD counselors who are certified to provide individual counseling but, per state policy, are not currently eligible for reimbursement as medical or behavioral health providers.
What we want to improve on is how to tell the story of value-based care and how we show that these services are improving our patients’ health.
The new needs assessment screening tool, which is now part of Hill Country’s electronic health record, will provide metrics on program interventions, results, and more. Analysis of these data will help determine the effects of having SUD counselors and case managers in key roles and show evidence of whether the program helps patients. Although data for the SUD program is still being collected, Brissey says the six-month retention rate for the MAT program, which includes patients who use opioids, stimulants, or alcohol, shows 75 percent or more of patients stay with the program. This number is noteworthy considering recent data from the Centers for Medicare & Medicaid Services shows only 16 percent engagement rate for ongoing treatment within 34 days of the initiation visit across 40 states.
“The AIM initiative has really helped us with how to track data better,” says Brissey. “What we want to improve on is how to tell the story of value-based care and how we show that these services are improving our patients’ health.”
Challenges and Lessons
As the program to integrate SUD treatment with primary care grew during the AIM initiative, its progress was shaped by known issues and unexpected events over the last two years. Below are strategies Hill Country adopted to overcome these challenges.
Addressing bias and stigma related to substance use.
Stigma surrounds substance use and treatment, negatively affecting patients, providers, and communities. Feelings of bias, shame, and rejection influence the care environment in which patients seek help. Moreover, because Shasta County is relatively small, staff and patients may know each other. This can compound patient fears about being judged or talked about in a derogatory way within their communities.
Our expectation is that staff treat all of our patients and their families equally and with equal kindness.
Hill Country openly addresses stigma toward people who use drugs or receiving SUD care. People in the program and throughout the clinic are encouraged to talk as comfortably about their substance use as they would about a condition such as diabetes.
Ongoing staff training helps dispel some beliefs and supports harm reduction approaches in the clinic and community. Through such training, providers learn to remove stigma from interactions with patients by recognizing and getting rid of their own assumptions, judgments, and biases. Organizational policies back up harm reduction. For example, even though all providers are authorized to prescribe MAT, they are not required to work in the MAT clinic. This ensures that staff who want to work with MAT patients choose to do so, thereby limiting negative encounters for patients and building trust. “Our expectation is that staff treat all of our patients and their families equally and with equal kindness,” says Foster.
Overcoming barriers between complex care programs.
Although complex care programs may share some similarities, staff are separated by funding sources. This makes it difficult to support patients across programs when appropriate. By cross-training frontline staff, SUD counselors, and case managers, and pivoting behavioral health care coordinators to function as SUD counselors, Hill Country is doing its best to work within current funding constraints to serve its patients most effectively.
Staying connected in times of crises.
During the first months of the COVID-19 pandemic, fewer patients came to the clinic to meet with SUD counselors. In-person visits became phone check-ins. Because isolation can be problematic for people using substances or in treatment, staff stayed in closer contact with patients via telehealth. The weekly recovery group met virtually and may adopt a hybrid format in the future given the benefits the team observed related to access and engagement. Some in-person training was reconfigured for online education.
Hill Country’s SUD program is looking at several actions to build sustainability and improve services. Drug Medi-Cal, a pilot program of California’s Department of Health Care Services, pays for covered SUD treatments to eligible Medi-Cal members. Shasta County has chosen to participate in Drug Medi-Cal, which will assist some program patients. Under CalAIM, a newly approved state Medicaid waiver emphasizing whole-person care, Hill Country may be able to use alternative payment sources to support SUD services.
We meet the client where they are. If we identify any unhealthy or risky behaviors, we address those as part of our comprehensive care.
To give patients a voice in SUD program priorities and improvements, Hill County is establishing a patient advisory board, with development led by Hoopes, the complex care coordinator. To inform the creation of the board, Hoopes is planning a survey to gather patient input about needs the board could address. Still to be determined: the number of patient-members, how the board can be productive, and how to rotate members to ensure equitable representation, including for those who cannot attend meetings in person. Surveys of staff and patients in the clinic’s complex care programs will also continue, looking at their feelings of satisfaction and inclusion.
Hill Country is focused on making its commitment to equity and access to health care for everyone explicit throughout the organization. A strategic plan for equity is in the works, including compliance and accountability. The SUD program reflects Hill Country’s goal of being an open, accepting health care home for healing the whole person.
“We meet the client where they are. If we identify any unhealthy or risky behaviors, we address those as part of our comprehensive care,” says Brissey. “AIM has really helped us take a look at how we can expand, strengthen, and cross-train staff to have robust services around the individual’s substance use.”