New CHAS clinic offers integrated care for seniors, complex medical cases

At one north Spokane medical clinic, don’t expect to see kids in the waiting room.

An average age for patients at the site is 67 – by design. Among the 360 patients who regularly book appointments, the eldest visitor is 99.

Community Health Association of Spokane opened its North Central Clinic in late December, gearing it to patients who are older than 60. It’s the only clinic among 16 CHAS sites focused on a senior population.

“There’s more of a team approach to patients here, and there are longer visits because the patients are more complex,” said Dr. William Lockwood, CHAS chief clinic officer.

“We have pharmacists who have experience in elderly care and medications in elderly care, so they’re part of the care team.”

The clinic, at 914 W. Carlisle Ave., offers both medical and behavioral health services. Lookwood said the facility began as a project between Lutheran Community Services Northwest and CHAS, after the closure of Christ Clinic at the site.

“Lutheran reached out to us and said would you be interested in doing a partnership? We considered different ideas, but we hadn’t done (just) adults before,” he said. “Our population in Spokane, just like the general population, is getting older.”

Since a facility remodel, the CHAS site has offered nutrition evaluations, in-depth review of medications, screening for risk of falls and prevention, dementia assessments and other geriatric health issues. Patients are asked about end-of-life advance care decisions.

All clinic providers have experience in geriatric health care, including internal medicine physician Dr. Jeremy Graham, also board certified in lipidology to manage disorders such as high cholesterol and cardio-vascular disease.

“Lipidology is the study of cardio-vascular risk, basically,” Lockwood said. “He’s really good at risk reduction for people with cardio-vacular disease, which is a lot of people once they turn 60.”

Graham has an interest in prevention of stroke and heart attacks, and medicine based on the best evidence for older adults. Amanda Bailey, another staff member, is a nurse practitioner experienced in working with elderly patients.

The clinic’s pharmacists, including lead pharmacist Matthew Conner, work closely with patients to manage medications. Lockwood said Conner also can help educate patients about diabetes and chronic obstructive pulmonary disease.

All medical appointments at the clinic begin with a pharmacist entering the exam room to see patients ahead of the doctor or nurse practitioner, Lockwood added.

That pharmacist spends time with the patient to go over medication history, any new drugs introduced, potential interactions and drug information. The older people get, typically the more pills they take while dealing with health conditions that are more complex, Lockwood said.

“It’s gotten so complex because there are so many meds; so many interactions,” he said.

“The patients we see are regularly coming from specialists who change their meds, and hospital visits where they change their meds. It’s really difficult for somebody with limited training to get an accurate medication list. It requires a lot of discussion with the patient, commonly.”

It often requires 15 to 20 minutes for the site’s medication reviews.

Lockwood said that having a clinical pharmacist assist in direct patient care has worked so well that CHAS is adding it to other clinics. The system now has nine clinical pharmacists, as opposed to having medical assistants do medication reviews.

“Sometimes, patients don’t know which meds they’re on other than they take the little white pill twice a day, and then they take a pink one once in the morning,” Lockwood said.

While the clinic’s main focus is senior care, CHAS providers across its system can refer the most complex medical cases to the north Spokane site, Lockwood said. That might include somebody who has multiple medical issues and behavioral health problems.

The site is better staffed to handle behavioral health, he said, “and we’re using a relatively new form of integrated behavior health called collaborative care.”

Behavioral health services are provided in partnership with Lutheran Community Services Northwest. Anxiety and depression are common among CHAS patients across its system, Lockwood said, but such conditions tend to go undiagnosed among the elderly.

“At the state level, there’s a big push to integrate behavioral health providers with primary care providers, so both we and behavioral health providers are interested in forming coalitions,” he said.

The clinic provides regular screenings for certain cancers, including colon and breast cancer. Annual checkups also are tied to a Medicare request.

“Anybody who winds up on Medicare, so basically people 65 and older, is asked to do an annual wellness visit, and that’s not unique to us, that’s true of anyone on Medicare,” Lockwood said.

“Medicare requests that all physicians do this and will reimburse for a one-hour visit with all the screenings to keep someone healthy. It is a good program, but it can be confusing for patients who want to talk about problems or changing medications.”

Dementia screening is part of that annual wellness appointment.

Common health issues that the clinic’s providers see are heart problems, abnormal heart rhythm, emphysema, strokes, diabetes, anxiety and depression, Lockwood said. Isolation is another concern, so providers will make referrals about community programs that support seniors.

Aging and Long Term Care of Eastern Washington approached CHAS soon after the North Central Clinic opened.

“They came and taught our lead pharmacist and our nurse to do the Matter of Balance class, so we screen people for fall risk and if they’re at risk for falls, we get them into this class,” Lockwood said.

Another referral might be for patients to enter a wellness program being developed with the YMCA.

Overall, CHAS administrators are a little surprised about the intensity of cases handled by the clinic.

“I think the complexity of patients was surprising even to our internal medicine physician, who has been doing it for a long time,” Lockwood added.

“We really did advertise it within our CHAS system as being this is where we’re going to send the most complex patients. Dr. Graham will spend an hour or hour and a quarter with a patient when they come in, and he has a problem list of 13 things to address by the time he’s done.”