The DO | Patient Care | In the Field

In rural Pa., great need inspires DOs to experiment with clinic model

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Pennsylvania's medically underserved areas/populations are in green and yellow on this map. (Image courtesy of the Pennsylvania Department of Health)

Practicing independently in rural eastern Pennsylvania, family physician James C. Greenfield, DO, and psychiatrist Samuel J. Garloff, DO, were having a hard time coordinating care for their patients.

Many of Dr. Greenfield’s Medicaid and other low-income patients needed mental health services. But when he referred these patients to a mental health professional, they frequently wouldn’t make it there. Sometimes they didn’t have transportation; sometimes the distance was a deterrent.

“I can tell the patient, ‘When you leave here, I need you to go see your counselor, I need you to go do this or go do that.’ Well, the patient probably is not going to do that,” he says.

Dr. Garloff, who practiced nearby, found that many of his low-income patients had serious health problems, yet they didn’t have primary care physicians, as few in the area were accepting new Medicaid patients.

“Many physicians don’t want to take medical assistance patients because of the financial burden and obligation of it,” Dr. Garloff says.

Dr. Garloff

“There’s no separation between mind and body. That’s what osteopathic medicine is all about.”
Dr. Garloff

The two eventually began referring patients to each other in 2000, but they realized the area required greater resources. Dr. Greenfield worked with the state of Pennsylvania to have the area federally designated as underserved so they could set up a rural health clinic (RHC). Dr. Greenfield and Dr. Garloff envisioned an RHC providing primary care, psychiatric care and social services under one roof, which to their knowledge hadn’t been done before. The vast majority of the 3,950 Medicare-certified RHCs in the U.S. focus on primary care.

Cornerstone Coordinated Health Care in Frackville, Pa., opened its doors to patients in June and was designated by the Centers for Medicare and Medicaid Services as a rural health clinic in September. The clinic provides primary care to patients now. It will add psychiatric and social services in January, though Dr. Greenfield now refers some patients to see Dr. Garloff in a nearby clinic. Dr. Greenfield says there are roughly 10,000 patients in the area not receiving care who may become patients.

“I really pushed to do this more because this population needs this help,” Dr. Greenfield says. “There’s a huge need for psychiatric help, there’s a huge need for primary care, there’s a huge need for social work and counseling. Without something like a rural health clinic, we would not be able to provide this type of access to Medicaid or to Medicare patients.”

Bill Finerfrock of the National Association of Rural Health Clinics and John Gale of the Maine Rural Health Research Center also say they aren’t aware of another RHC providing the three services from one building. It’s rare for RHCs to offer mental health services, Gale says. Roughly 6% of independent and 2% of provider-based, or hospital-backed, RHCs have mental health services, according to a 2010 report authored by Gale.

Mental health in rural areas

Rural patients sometimes decline or fail to seek mental health services because of the perceived stigma of mental illness. This is a key reason RHCs should offer such services, Gale says.

“People know each other in small towns,” he says. “If you have a community mental health center on Main Street, it’s obvious if you’re there. People are reluctant to broadcast the fact that they’re receiving services. So if they can get mental health or social services in their primary care practice, that does sort of remove that layer of stigma.”

Another clear benefit, Gale says, is that the transportation barriers that deter some patients are removed, and patients are more likely to get the care they need.

Dr. Greenfield

“Without something like a rural health clinic, we would not be able to provide this type of access to Medicaid or to Medicare patients.”
Dr. Greenfield

“You can connect that patient very easily and you can do a handoff,” he says. “In the industry they call it a ‘warm handoff,’ in which the physician might walk the patient down the hall and introduce him or her to the social worker or the psychologist.”

Dr. Greenfield and Dr. Garloff have already been coordinating care for some patients. Dr. Garloff says he often sees patients who request sleep aids or muscle relaxers but don’t need them. They sometimes then try to get the meds from their family physician, who happens to be Dr. Greenfield.

“He’ll talk to them, and they’ll say, ‘Well, everything is going well, but my psychiatrist won’t give me Xanax.’ And he’ll look at them, and he’s actually said this, ‘By any chance, does your psychiatrist have a beard?’ And they’ll say yes, and he’ll say, ‘Well, I agree with him.’ “

Dr. Greenfield also refers patients to Dr. Garloff. And starting in January, he will be able to refer patients to Dr. Garloff with a “warm handoff” in their clinic.

A model for others

Dr. Greenfield and Dr. Garloff hope that physicians will see their clinic as an example to be emulated.

“My motivation is to get the word out to other physicians, to see if they want to try to replicate this,” says Dr. Garloff. And physicians who aren’t in the position to open an RHC can still benefit from thinking about their mental health patients in a different way, he says.

“There’s no separation between mind and body,” he says. “That’s what osteopathic medicine is all about, but we all practice in our own medical silos.”

Speaking of “medical silos,” why don’t more RHCs offer mental health services? There’s a shortage of mental health care professionals in rural areas, Gale says, and the low reimbursement rates for Medicaid and Medicare patients mean the clinics may not have the money to hire another professional anyway.

Dr. Greenfield sees his clinic as a labor of love. Although he has been seeing patients in the clinic, he says it will be about six months before the clinic starts receiving reimbursement for services, due to processing times for paperwork he filed with the state. Dr. Greenfield has been self-funding the clinic until now.

“We spent our own time, our own resources to get an office in a centrally located area next to bus services and everything else that would be available for people who are underserved,” he says. “You have to put it in the right location to help.”

Dr. Garloff says they won’t make a lot of money from the clinic, but they’ll be wealthy with the satisfaction that comes from helping others.

“When you’re doing something for the greater good, you get a greater personal benefit from it,” he says.