FEATURE ARTICLE
Integrated Care at
the Santa Rosa Free Clinic
By Michael Kozart, MD, PhD
The Santa Rosa Free Clinic is a free drop-in clinic that provides a broad range of primary medical, mental health and social services to the people of Sonoma County. The clinic is housed in the Family Service Center, a family shelter run by Catholic Charities in downtown Santa Rosa.
The clinic opened as the Homeless Outreach Clinic in 1999. Catholic Charities provided rent-free space, the Santa Rosa Family Medicine Residency furnished a clinical preceptor and a medical resident to operate the clinic four hours a week, and Sutter Medical Center of Santa Rosa donated medications.
Initially the clinic focused on giving care to the homeless, who have always comprised the majority of its patients. In recent years, however, an increasing number of uninsured but fully housed people have sought care in the clinic, including many Spanish-speaking families. In 2005, the clinic changed its name to the Santa Rosa Free Clinic to indicate that it provides accessible free health care to people of all cultural and socioeconomic backgrounds.
The clinic’s operations now include 12 hours of weekly general clinical service, plus an additional half-day of holistic health care involving therapeutic massage and herbal treatments. Medical services include routine primary care, mental health evaluations and treatment, free medications, and TB screening. The clinic is also a point of intersection where other agencies and clinics extend care to targeted populations. For example, the Drug Abuse Alternatives Center offers HIV/hepatitis testing and drug abuse counseling, and Sonoma County Vet Connect provides resources and support to homeless veterans.
Sonoma County’s Mental Health Services Division sponsors several weekly programs at the clinic, including 12 hours of psychiatry service and a combined 16 hours of social work that includes counseling, case management, and assisted enrollment in public insurance and social security programs. County support was made possible by the California Mental Health Services Act, which provides funds to extend integrated mental health care to underserved groups like the homeless. MHSA funds were the single biggest factor in the clinic’s expansion beyond its original four hours of weekly service.
In recent years, the clinic has also solidified a pivotal relationship with the Southwest Community Health Center, which receives most of the referrals for patients who require services not presently available at the clinic. The health center has also agreed to assume the role of fiscal sponsor to the clinic, and to formally incorporate the clinic as an independent satellite. This incorporation will expedite referrals and provide administrative resources and expertise for the clinic’s expanding operations.
As noted above, homeless people represent the largest block of patients seen at the Free Clinic, and much of the organizational structure of the clinic represents an attempt to respond to their distinct care needs. As a population, the homeless have an especially high prevalence of serious medical and mental health problems. While these problems often arise independently, they occur in a uniform context of harsh living conditions. Physically, homelessness presents innumerable risks, including extreme cold and heat exposure, infections, injuries, unsanitary living environments, and animal bites. Psychologically there is the constant fear of theft, hostile encampment raids, and unfriendly strangers, as well as the ongoing stress of squalid living conditions.
Although psychological problems like anxiety and depression arise from the stress of homelessness, serious mental problems often precede the lack of a home. In a society that affords few safety nets for secure jobs and housing, the seriously mentally ill are at high risk for unemployment, impoverishment, and eviction—the ubiquitous precursors to homelessness.
Frequently, the homeless have considerable difficulty accessing the health system. One reason is that different health services, like medical and psychiatric treatment, are often located in different places. This separation adds an undue burden in arranging transportation to different appointments, and it can lead to redundancy in care, along with poor communication between providers.
To resolve these problems, the Free Clinic offers a radicalized version of integrated care. Not only are medical and mental health services offered in a one-stop format, but all physicians in the clinic (including the psychiatrist) provide both primary care and mental health services. While primary care physicians deliver much of the mental health care in the United States, the converse is seldom true. Psychiatrists, who care for the most seriously mentally ill patients in our society, seldom provide much primary care.[1]
For the homeless, and especially for those suffering serious mental illness, there is a lot to be said for having the psychiatrist acquire and exercise competency in primary care. Patients can learn to trust a single clinician who can also manage intertwined mental and medical symptoms. For many homeless patients, medical and mental problems are so interconnected that it makes little sense to allocate their treatment to different providers. Examples include extreme cold exposure due to the fear or intentional avoidance of shelters; substance use that leads to infections like hepatitis or HIV; and psychosis that complicates self-care for conditions like diabetes and congestive heart failure. Having one person be responsible for all aspects of care enhances the ability to tailor treatment to the individual, and to engender the trust that will enable the patient to confidently follow a treatment regimen.
Several other principles aid the Free Clinic’s outreach to the homeless. The clinic operates as a drop-in center, meaning that no advance appointments are necessary. This flexibility can be quite useful for a population that frequently experiences unpredictable shifts in daily routines and has limited access to phones. Moreover, the clinic is located in a zone with many homeless support services in close proximity, such as the Morgan Street Homeless Service Center, which provides showers, laundry and lockers. There are also neighboring food banks, other shelters, and day centers that contribute to the convenience and comfort of coming to the clinic. Since the clinic is itself located in a shelter, emergency provisions and food are within steps of the exam rooms.
The expansion of services has substantially increased the number of patients coming to the Free Clinic. Visits jumped from an average of about 35 per month prior to 2005, to more than 200 per month in early 2008. Many of these visits involve multiple steps, such as medical evaluation, social work consultation, infectious disease screening, and drug abuse counseling. To sustain the delivery of all this care, the clinic has received continued support from Catholic Charities, the Santa Rosa Family Medicine Residency and Sonoma County’s Mental Health Services Division. The clinic has also received funding from Kaiser Permanente and a continued supply of free medications from Sutter Medical Center. Perhaps the greatest resource for the clinic has been the staff of volunteers, including registered nurses.
To ensure its fiscal stability, the clinic plans to acquire reimbursement for care provided to publicly insured individuals. This project will be overseen by the Southwest Community Health Center, whose commitment to the clinic has been truly invaluable.
One of the greatest tasks the clinic faces is to better integrate its patients into the regional health care system. Many patients who come to the clinic are in transit around the county, and indeed the entire state of California. We plan to help these patients acquire public health insurance so they can expand their health options around the county and state, and to facilitate referrals to health organizations that provide services not presently available in the clinic.
The Santa Rosa Free Clinic hopes to be something other than an island oasis for the homeless and other people who lack access to regular health care. Our ultimate goal is to be an interconnected part of a diverse and comprehensive health system that serves everyone.
E-mail: mkozart@sonoma-county.org
References
- Druss B, Newcomer J, “Challenges and solutions to integrating mental and physical health care,” J Clin Psychiatry, 68;4:e09 (2007).
Dr. Kozart, a Santa Rosa psychiatrist, is medical director of the Santa Rosa Free Clinic.
