Family Medicine News

Building Leaders from within: OHSU program wins national challenge

Originally posted on OHSU Now

Brian Park, M.D., M.P.H., assistant professor of family medicine, OHSU School of Medicine, is one of eight winners of the Trust Practice Challenge, a national effort to showcase best practices that build and promote trust in a variety of health care settings, contexts and relationships.

The challenge encourages new approaches to enhancing trust. ABIM Foundation received nearly 70 entries, describing strategies and approaches for strengthening trust between patients, physicians, health care teams and larger health care organizations.

OHSU program builds leaders by emphasizing emotional intelligence, engagement, trust

Dr. Park’s winning approach focused on a three-month leadership learning collaborative called the Relational Leadership Institute (RLI). Participants in the program learn to rely on their emotional intelligence to engage with others and cultivate trust and psychological safety on teams.

What is relational leadership and why is it important?

Some of the highest performing teams in health care use relational leadership practices. The approach can lead to improved quality of care, patient satisfaction and provider satisfaction.

Launched in 2017, the RLI recently finished its fourth cohort. Based on success at OHSU, Dr. Park and colleagues plan to expand to University of North Carolina and Utah this fall.

The following people have been involved in making RLI possible:

  • From the Department of Family Medicine: Patrice Eiff, M.D., Marcel Tam, M.D., M.B.A., Shannon Vannier, Elaine Uchison, Andrew Morris-Singer, M.D., and Leah Gordon, M.P.H.
  • From the School of Nursing: Teresa Turnbull, D.N.P.
  • From the School of Medicine: Kelsey Priest, Ph.D., M.P.H.
  • Colleagues affiliated with OHSU: Veronique Johnstone, Cally Johnson, M.P.H.

Are you interested in taking the RLI course? The next offering at OHSU will start in September; for more information, visit the Relational Leadership Institute website. Learn more about the Trust Practice Challenge on ABIM’s website.

Family medicine is making headlines

The future of trans health care is in Portland
Allison Fox, F.N.P.
, and Christina Milano, M.D., both appeared in Portland Mercury's story, "The Future of Trans Healthcare is in Portland." Read the full article

Testimony in support of SB 823
Laurel Hallock-Koppelman, D.N.P., F.N.P., 
submitted testimony in support of senate bill 823, which addresses violence against health care employees. Read her compelling story here.  

Medication for opioid use disorder in primary care: 7 myths dispelled
Joan Fleishman, Psy.D., 
co-authored, "Medication for Opioid Use Disorder in Primary Care: 7 Myths Dispelled," for Integrated Care News

Medical student featured by Japanese news station
Medical student Emily Jack traveled abroad via the JADECOM exchange program. While there, her presentation to Japanese students in Miyazaki was featured in the local news. Following her presentation, many of the students commented that they felt inspired to choose a career in medicine. 

Nominated by Drs. Fran Biagioli and Carol Blenning, Dr. Christina Milano accepted this year's Faculty Excellence in Education Award from the School of Medicine. The award came as a result of Dr. Milano's outstanding leadership, teaching, and commitment to OHSU’s educational programs. Dr. Milano received the award at the annual School of Medicine Honors and Awards Ceremony on June 2, 2019. 

In May, Carol Blenning, M.D., was honored with an induction into the Gold Humanism Honor Society (GHHS). Members of the GHHS are “exemplars of compassionate care and who serve as role models, mentors, and leaders in medicine.” Click here to learn more about the GHHS chapter at OHSU. 

The School of Nursing's Mentoring Award is presented to a nurse who provides positive professional influence, guidance, and support to other nurses in any setting. This nurse inspires others to transform service and care. This year, the award was presented to Family Medicine at Richmond's Holly Herrera, B.S.N., RN, CHFN during Nurse's Week. Originally published by the School of Nursing, Ms. Herrera's reflection reads: 

"It is difficult to get her off of my mind – the young patient who solely supports her spouse and four children on a minimum wage job, who traveled from across the world at age 13 for her first of three open heart surgeries, who once responded to the question of what her ideal job would be with the answer that she never imagined she would live long enough to dream of such a thing. Supporting her to access medical care is no small task: echocardiograms rescheduled five times, overcoming barriers to medication adherence and collaboration with behavioral health to secure housing. My experience with this patient captures the essence of what it is to be a nurse: at once an advocate, an innovator, an educator and a communicator.

My individual clinical work wouldn’t be possible without innovative systems and strong nurse leaders. How do we structure the clinic; what is the role of a nurse in primary care; and what are nursing-sensitive indicators outside of the hospital? These are some of the challenges I am excited to approach in my role as Lead RN Care Manager. My passion is to support nurses to meet the primary care needs of those in our community who are most vulnerable. Working at an OHSU primary care clinic and federally-qualified health center positions registered nurses to change the lives of individuals, families and communities. A primary care model that centers around chronic disease prevention and management, while addressing trauma and social determinants of health, provides one space for improving our complex and often fractured healthcare system. I am proud to work alongside innovative nurses and interprofessional colleagues as a catalyst for the improved health and wellbeing of our communities."

Faculty member, John Heintzman, M.D., M.P.H., was honored with the School of Medicine's Early Career Achievement Award. He accepted the award at the School of Medicine's Alumni Association Awards Presentation on Friday, May 10. Established in 2013, the Early Career Achievement Award recognizes an alumna/us from the OHSU School of Medicine who has made significant career contributions to improving health and social welfare in a community setting or in the areas of scientific research or academia within 15 years of graduation.

Faculty member, Robyn, Liu, M.D., accepted a ROSE award for her above-and-beyond patient care and commitment. Her nomination read: 

"Dr. Liu provided wonderful support to a patient and their family during an unexpected child death. When the hospital chaplain wasn't available overnight to provide a baptism for the child, Dr. Liu went out of her way to call her own pastor at home to ask him to come in to provide a service for the family.

Due to Dr. Liu's commitment, the family was able to have a last-minute service for their child. Dr. Liu’s compassion, support, and dedication to this family evidenced by helping get a religious provider to the hospital on a weekend night was so cherished by the family. Her advocacy was more healing to them than any medication or medical-decision making during this time of exquisite grief

Mary K. Nordling, M.D., FAAFP will join us in Oregon this summer as the Program Director of the new Tuality Family Medicine Residency in Hillsboro.  Dr. Nordling helped launch the first residency on Hawai’i Island in 2014 and cared for patients from rural Hawai'i. As Program Director, she steered the Hawai’i Island Family Medicine Residency to full accreditation and helped graduate the first two classes.

“I have spent my entire family medicine career training and working in community hospital settings and serving underserved communities, both urban and rural,” Dr. Nordling shared. “I am honored to join the Tuality team and look forward to working with the hospital, community partners and OHSU to help create an excellent family medicine residency program in Hillsboro.”

Prior to moving to Hawai'i, Dr. Nordling was an Associate Program Director at the Lawrence Family Medicine Residency in Massachusetts and served patients who were primarily Spanish-speaking at a federally qualified health center (FQHC). She completed her family medicine training at St. Margaret’s in Pittsburgh and her medical school at the George Washington University in Washington DC.  

Dr. Nordling will be a fantastic addition to OHSU Family Medicine, and will contribute incredible energy and expertise to Tuality as they begin the process of applying for, and building, the first family medicine residency in Washingon County. Tuality hopes to welcome the first class of residents in July 2021.  

Licensed practice nurse, Michelle Gallego, accepted a ROSE award for her above-and-beyond efforts to get a baby home safely. Her nomination read: 

"Michelle is a Licensed Practical Nurse [at South Waterfront]. She found out that one of our patients, who was close to her delivery date, had not found a car seat and could not afford one. Michelle took the next two days calling at least eight local agencies to try and locate a free or reduced cost car seat. After many emails and phone calls she located a car seat and contacted a very happy mother-to-be. She even helped facilitate the scheduling of a class for the patient to learn how to use the seat.

Listening to Michelle go so far out of her way to make sure this patient had what she needed gave me so much joy. She gave our patient so much support and encouragement. Her heart was really in it. She truly lived out the motto ‘meeting your needs while exceeding your expectations’. This patient will now receive a free car seat for her newborn and will know how to use it to keep her baby safe! Michelle, you are amazing!”

Jennifer DeVoe, M.D., D.Phil., has been appointed to the National Heart, Lung, and Blood Advisory Council (NHLBAC). The Council, made up of 18 members appointed by the Secretary of the Health and Human Services (HHS), makes recommendations about funding and program activities carried out by the National Heart, Lung, and Blood Institute (NHLBI).

An important role of the NHLBAC is to advise the Institute on its future plans and directions for scientific research, with an emphasis on their public health implications. The Council provides its findings, recommendations, and advice to the Secretary of HHS, the Assistant Secretary of HHS, the Director of the National Institutes of Health (NIH), and the Director of the NHLBI. 

Mary K. Nordling, M.D., FAAFP will join us in Oregon this summer as the Program Director of the new Tuality Family Medicine Residency in Hillsboro.  Dr. Nordling helped launch the first residency on Hawai’i Island in 2014 and cared for patients from rural Hawai'i. As Program Director, she steered the Hawai’i Island Family Medicine Residency to full accreditation and helped graduate the first two classes.

“I have spent my entire family medicine career training and working in community hospital settings and serving underserved communities, both urban and rural,” Dr. Nordling shared. “I am honored to join the Tuality team and look forward to working with the hospital, community partners and OHSU to help create an excellent family medicine residency program in Hillsboro.”

Prior to moving to Hawai'i, Dr. Nordling was an Associate Program Director at the Lawrence Family Medicine Residency in Massachusetts and served patients who were primarily Spanish-speaking at a federally qualified health center (FQHC). She completed her family medicine training at St. Margaret’s in Pittsburgh and her medical school at the George Washington University in Washington DC.  

Dr. Nordling will be a fantastic addition to OHSU Family Medicine, and will contribute incredible energy and expertise to Tuality as they begin the process of applying for, and building, the first family medicine residency in Washingon County. Tuality hopes to welcome the first class of residents in July 2021.  

As of January, 2019, Joe Skariah, D.O., M.P.H., has officially stepped into the Director role of OHSU Family Medicine's Portland residency program. Dr. Skariah replaces Roger Garvin, M.D., who served as the program's director for 11 years and will continue with the department as the Director of Family Medicine Graduate Medical Education Outreach and Expansion.

OHSU Family Medicine's Portland residency program is one of a small handful of family medicine residencies in the country that last four years rather than three. "We've realized that there's more to being a family physician today than we've been preparing for traditionally," explains Dr. Skariah. "The healthcare landscape is constantly changing and we need to have physicians with unique skills in leadership and population management." For this reason, the residency program is both longer and highly customizable, "allowing learners to create an experience that's all about the provider they want to be in the future."

"I think we have the premiere residency program in the country," said Dr. Skariah, "so when the opportunity came to lead the program, I wanted to jump right in!" When informed of his selection, Dr. Skariah felt "incredibly honored."

Dr. Skariah has been a member of OHSU Family Medicine's faculty since 2012. In 2014, he became the Medical Director of Family Medicine at Scappoose as well as an Associate Residency Director for the Portland residency. In addition to maintaining a full-scope family medicine practice, Dr. Skariah completed a fellowship with the National Institute for Program Director Development (NIPPD) through the Association of Family Medicine Residency Directors (AFMRD) in 2016.

"We look forward to having Dr. Skariah lead our Portland residency into the next decade," wrote Jennifer DeVoe, M.D., D.Phil., OHSU Family Medicine Department Chair in an email announcing the transition, "as we continue to pursue new opportunities in graduate medical education."

Originally written and posted by Jennifer Smith, OHSU School of Medicine

Laurel K. Hallock-Koppelman, D.N.P., F.N.P.-C., N.P., A.P.R.N., assistant professor of family medicine, OHSU School of Medicine, and graduate of OHSU School of Nursing (M.N., '13), has received a prestigious award from the American Association of Nurse Practitioners®. Dr. Hallock-Koppelman is the 2019 recipient of the Oregon State Award for Nurse Practitioner Excellence, an annual award given to a dedicated nurse practitioner and N.P. advocate in each state. She will be honored at an awards ceremony and reception held in June during the AANP 2019 National Conference, in Indianapolis.

The State Award for N.P. Excellence, founded in 1991, recognizes an N.P. in each state who demonstrates excellence in practice. In 1993, the State Award for N.P. Advocate Excellence was added to recognize the efforts of individuals who have made a significant contribution toward increasing awareness and recognition of the N.P. role.

Dr. Hallock-Koppelman practices as a family N.P. at OHSU Family Medicine at Richmond, a federally qualified health clinic serving patients with primarily Medicaid and Medicare insurance. She received her undergraduate degree in nursing from New York University and her master’s and doctoral degrees from OHSU.

Her doctoral work focused on the importance of relationships as they relate to health. “If we don’t ask, they may not tell: Screening for Intimate Partner Violence in Primary Care,” investigated the barriers to screening for health care providers and created a protocol for use in clinics throughout Oregon. Most recently, Dr. Hallock-Koppelman was awarded the 2019 National Institutes of Drug Abuse (NIDA) training grant to develop and carry out a plan designed to increase clinical knowledge of the management of substance use disorder. She will work to enhance collaboration between the emergency department and primary care providers in order to help fast-track entry to care.

January 2019: Meet OHSU School of Medicine's Diversity Coordinators, Including Family Medicine's Anthony Cheng, M.D.

New faculty positions complement M.D. student affairs, coaching and wellness efforts

Faculty members Anthony Cheng, M.D. R ‘16, and Donn Spight, M.D., are the School of Medicine’s inaugural diversity navigators for M.D. students who self-identify as belonging to diverse or underrepresented groups. In these roles, Drs. Cheng and Spight will provide individual and group support and mentoring to medical students who request to be paired with a diversity navigator.

“During our selection process for these positions, it was clear that Dr. Cheng and Dr. Spight both bring a deep understanding of just how remarkable strong, positive relationships can be to an aspiring physician who may feel marginalized or underrepresented among their peers,” said Amy Garcia, M.D., assistant dean for student affairs in the M.D. program. “They both have innovative ideas for addressing issues faced by these students. I look forward to seeing our medical students benefit from their guidance and mentorship.”

Donn Spight, M.D. (left), and Anthony Cheng, M.D. R’16, are the school’s inaugural diversity navigators.

Dr. Cheng, assistant professor of family medicine, OHSU School of Medicine, practices full spectrum family medicine, and has special interests in addictions treatment, LGBTQ+ health and health equity. He also serves as assistant director for the family medicine residency program, which he graduated from in 2016.

Dr. Spight, associate professor of surgery, OHSU School of Medicine, is a minimally invasive foregut and bariatric surgeon, is associate director of the general surgery residency program and is actively involved in the graduate medical education “second look” days, which aim to foster diversity among GME trainees. He has been involved in simulation since 2007, and is currently medical director of OHSU Simulation.

Drs. Cheng and Spight were selected, in part, because of their understanding of the importance of culture to relationships, and the potential additional burdens that feeling like an outsider can bring to learners studying to become physicians. They join other faculty members and the administrative team who oversee the school’s undergraduate medical education Colleges Program.

“Supporting these students, who naturally interact with so much of our institution, will create opportunities to bring our OHSU community together in ways that help us see our diversity, honor our unique contributions and unite around our shared missions of training the health care workforce for the future, providing excellent patient care, and advancing science,” said Dr. Cheng. “Much work remains to be done and I am inspired by OHSU’s commitment to promoting the success of these students who have worked so hard to succeed.”

The UME diversity navigators complement and extend beyond what is offered by the Office of Student Affairs and the Colleges Coaching program, for students who desire additional culturally sensitive and culturally competent mentorship and advising throughout a student’s enrollment in the M.D. program.

“It is an honor to be chosen for this role, which is a natural extension of the work I and others have been doing,” said Dr. Spight. “It is encouraging to see the organization recognize that intentional, personalized guidance for learners who may not have access to mentors can help create the culture of diversity and inclusion we want at OHSU.”

Skender Najibi, M.D. ‘18 (pictured left), developed the vision for these positions in his scholarly project before he graduated. Goals of the diversity navigators include addressing isolation and disparities affecting student health and well-being, ensuring equitable opportunities for students, and advancing a culture that demonstrates and advocates respect for all.

The diversity navigator positions are among examples of initiatives that have resulted from dialogue between students and School of Medicine leaders around fostering diversity and inclusion.

Originally published for OHSU Staff News by Tracey Lam

What’s in a name? By itself, it means someone who heals others. As an acronym, HEAL-R stands for Health Equity and Leadership at Richmond. Whichever way you look at it, it represents the mission of Family Medicine at Richmond.

HEAL-R started in 2015 at the Richmond Clinic in southeast Portland by a group of family medicine providers who noticed that many of their patients’ health issues were the result of food and housing insecurities. They partnered with the community organization Metropolitan Alliance for Common Good to help increase socioeconomic and political power to people in communities that are traditionally marginalized. In other words, they wanted to empower patients to be self-advocates.

Prescribing a purpose

The program offers free leadership training and brings other leaders, patients, staff and organizations together to build campaigns around issues affecting patients. “The program teaches them to not see themselves as patients, but as leaders in the communities,” said Fidelis Wachana, an administrative assistant who has worked at the Richmond Clinic for 15 years.

A recent victory highlights the importance of this model. A team of patient-leaders joined Metropolitan Alliance for Common Good in a campaign to increase funding for affordable housing in Portland. Because of their testimony and advocacy, the city council voted to increase funding by $67 million.

One patient wrote: “HEAL-R prescribed me a purpose. One year before I joined the team, I was living on the streets. This program gave me an opportunity to see myself as a leader and give back to the community so that no one else has to experience what I did.”

Helping each other

Today, the program continues to be a grassroots effort and has added a second core component that seeks to bring more diversity and inclusion among the Richmond Clinic’s providers and staff. While it’s in the beginning stages of planning, the team has already hosted listening sessions to identify priorities. One recommendation so far is for all of its 170 employees to take the unconscious bias training offered by the Center for Diversity and Inclusion.

For its work in reducing health disparities through community-organizing principles and patient-centered care, the Health Equity and Leadership at Richmond received the 2018 Diversity and Inclusion Award earlier this year in the category of Champion Program. The annual award ceremony is hosted by the Center for Diversity and Inclusion and the Diversity Advisory Council.

“HEAL-R gives me a peace of mind that I’m not alone,” said Wachana. “We are a group that can make a change.”

In May, OHSU honored South Waterfront's John Heintzman, M.D., M.P.H., with a ROSE award for taking one patient from extreme back pain to living a full, active, pain-free life - including a full marathon. Dr. Heintzman's nomination came straight from the patient he helped, who wrote:

I have been a patient at OHSU since 2005 and Dr. John Heintzman has been my primary care physician since 2010. During that time he has overseen my pain management program. When I first met Dr. Heintzman I was taking approximately 80mg of methadone a day due to several back surgeries and fusion and was consistently a 6-8 out of 10 on the pain scale. 

Dr. Heintzman worked with me to develop a plan to slowly reduce my intake of methadone while at the same time increasing my physical activity. He closely monitored this with me and always had words of encouragement. Dr. Heintzman's work with me has been truly amazing. 

Four years ago I ran my first half-marathon. The following year I ran a full marathon. Dr. Heintzman was a big supporter of doing both events which I'd never dreamed of when I first met him. 

Now I continue to run and also hike, backpack, lift weights, and garden with little to no pain. I'm now transitioning to an even lower dose of methadone, and hope to be completely off of it by this summer. 

My relationship with Dr. Heintzman and his involvement in my pain management program is one of the primary reasons I continue to come to OHSU. He is compassionate, down to earth, and listens to what I have to say. He takes an active role in my physical and mental health which has seen a vast improvement from when we first met. He is by far the best primary care physician I have ever had and I'm grateful for all his help in getting me to where I am today.

In May, OHSU honored South Waterfront's Dave Stevens, R.N., with a ROSE award for jumping in not once - but twice - when medical emergencies came into the clinic. His nomination, from clinic manager Jeanine Smith, reads:

David Stevens came to us from the [OHSU] ER a year ago. A couple of weeks after he arrived we had a patient code in our lobby. His ER mentality immediately kicked in and he took control of the situation and helped us to facilitate the emergent situation without even thinking twice. What we only see occasionally, he has obviously seen regularly and it was evident on that day. 

I noticed it and acknowledged him in our clinic, but neglected to submit a ROSE nomination. One year later, we had a patient who came for an office visit and began to have a stroke. Dave, who just happened to be walking by, jumped in to assist the physician as well as the assigned nurse. Once again his ER instincts kicked in with Dave grabbing suction cups and assisting the paramedics to the point where the paramedic had to ask, "Hey where did you come from?" and Dave modestly replied, "Oh I'm from the ER". 

The paramedic noted how much it pays to have an ER nurse on your team and I couldn't agree more. Dave is probably the most selfless nurse I've ever met as in both of the above instances, neither time was this his patient. He just happened to be walking by. We are so fortunate to have him on our team, and our patients are very fortunate as well. He is an amazing nurse and a true asset to our team.

OHSU Family Medicine, Internal Medicine, and Addiction Medicine received a $360,000 grant from the Department of Justice to expand the outreach and educational components of Project Nurture. Project Nurture integrates substance use disorder treatment with primary care (including pain management), prenatal care, intrapartum care, postpartum care and well-baby care that women with substance use disorders need while pregnant and in the first year of the child's life.

With funding from HealthShare, Project Nurture has already been able to transform the way women are cared for in clinics and in the hospital. For example, OHSU's Project Nurture team has directed efforts to re-write OHSU's inpatient neonatal opioid withdrawal protocol. Now, the process is much more effective and patient-centered, with less intervention.

With the new grant from the DOJ, the OHSU's Project Nurture team will further develop educational programs for physicians in training and regional outreach and educational activities for the medical community in Oregon. Specifically, the team will be able to fund four fellows (post-doctoral students) as well as additional education and outreach for two years.

To learn more about the DOJ's grants and how they will be used to combat Oregon's opioid epidemic, read here.

In partnership with community organizations Home Free and Raphael House, OHSU Family Medicine at Richmond announced receipt of a 30 month-long Community-Based Advocacy and Health Care Partnerships grant from the Department of Justice. The purpose of the Community-Based Advocacy and Healthcare Partnerships funding initiative is to expand the availability of services to survivors of intimate partner violence (IPV) through partnerships with local health care providers. 

With the funding, two full time IPV advocates will be placed at Family Medicine at Richmond. Rotating through Richmond, the Walk-In Clinic and the high school-based Benson Wellness Center, the two advocates will help perform: 

  • Safety planning
  • Emergency shelter assistance
  • Connection to housing resources
  • Support groups
  • Youth services
  • Legal advocacy
  • Emotional support
  • Assistance with screening
  • Confidential support
  • Trainings and education
  • Support for survivors navigating the health care system
  • Referrals
  • And more 

"Having advocates on site will increase patient access to IPV specific resources and support, and will also improve health care provider recognition of intimate partner violence and its impact on health," explains Tara O'connor, P.M.H.N.P., Assistant Professor of Family Medicine. "Similar partnerships have been found to reduce violence and improve patient well-being over time."

Ultimately, O'Connor explains, this grant will "improve IPV survivors' access to both advocacy services and health care, improve quality of care, and potentially reduce overall healthcare costs to our community."

At the Women in Academic Medicine's annual conference, individuals are recognized for their support of the success of women in academic medicine at OHSU. Family Medicine faculty member, Deborah Cohen, Ph.D. was selected as a finalist for the 2018 WAM Mentorship Award. Her nomination, submitted by OHSU Family Medicine Chair, Jennifer DeVoe, M.D., D.Phil. reads:

Dr. Deborah Cohen is an exceptional investigator, a dedicated collaborator, and a valued colleague and mentor;in addition to being an emerging international leader in qualitative research methods and healthcare communication, she has also contributed to the careers of countless female colleagues and mentees. Dr. Cohen has developed a wildly successful career, and every step of the way, she lifts the careers of others around her. It is my great honor to nominate Dr. Cohen for the OHSU Women in Academic Medicine Mentoring Award on behalf of the Department of Family Medicine.

Deb's ideas are demonstrably worthy of financial support, publication, and dissemination, as clearly evidenced by her extreme success obtaining grant funding: she is currently funded by 11 federal grants (in addition to other awards), on all of which she is a PI, Co-PI, or Co-I. This includes leading one of the largest grants ever funded by the Agency for Healthcare Research and Quality (AHRQ), a project that promises to be critical to future primary health care delivery and has tremendous potential to advance the dissemination and implementation science field. This award is high profile, high-resource, and potentially highly scrutinized, and speaks to Dr. Cohen's national prominence and the respect she garners from peers and funders. Rather than take credit for these accomplishments herself, she frequently creates leadership opportunities for mentees. For example, she was the PI on a successful R01 from AHRQ and recently transferred the PI role to a junior colleague who is an underrepresented racial minority..

Dr. Cohen has authored numerous widely-read publications and presentations, and consistently publishes peer-reviewed manuscripts in high impact journals focused on clinical care, health services, and implementation science. She always offers opportunities for newer and junior researchers to publish with her team and has included dozens of mentees as co-authors on her many publications. Several years ago, she was nominated by mentees and received a Special President's Award from the North American Primary Care Research Group, given for "extraordinary leadership in the area of primary care research." In addition to her amazing scientific discoveries, Dr. Cohen is pioneering new methods in our discipline and has been an inspirational leader and mentor to junior scientists in primary care. Again, this past year, her mentees nominated her for the prestigious mid-career award from the North American Primary Care Research Group, and she won again!

In addition to her faculty appointment as a Professor of Family Medicine, I created a new Vice Chair for Research position in our department a year ago, and needless to say, Deb was the unanimous choice for this new role. Prior to this, Dr. Cohen also served our department in a substantial position as the Research Director for three years, overseeing 18 faculty members and 22 Research Assistants. Dr. Cohen enables the success of these valuable colleagues by working with department leaders to ensure they have the infrastructure and environment to support their success, and this group brought in over $9 million in grant funds in 2015 alone, with more since that time.

While Dr. Cohen's career has been focused on the study of healthcare quality improvement within primary care, in her work there emerges a consistent theme of stimulating multi-disciplinary, team-based approaches to this research. She has been instrumental in bringing together diverse collaborative international and intergenerational teams that include physicians, epidemiologists, nurses, biostatisticians, and social scientists, and her research team is spread across many different organizations across the country. Dr. Cohen's leadership is underlined by her ability to seek out collaborators and then integrate new perspectives into her work—many of the ESCALATES collaborators are among the top in their respective fields so it is a tremendous testament to Dr. Cohen's skills that she was able to coalesce this team into an effective working group. She features learners and mentees on all aspects of this work, giving them great connections and exposure to international leaders at very early stages in their careers.

Dr. Cohen has held a wide variety of teaching roles here at OHSU, and is a mentor to trainees across every level of development;she is actively involved in the education and mentorship of residents, research fellows, junior faculty with clinical backgrounds, and junior and mid-career faculty focused on qualitative research, and has developed a post-doctorate fellowship in research for the department, for which she serves as the Director. As our Family Medicine Residency program expanded from a three- to a four-year program, Dr. Cohen was the research lead on the team developing the Capstone experience for residents; in addition to helping develop this program, she has continued to review and provide input on Capstone projects, to provide mentorship to residents, and works with residency leaders to establish sustainable infrastructure to support researcher involvement in resident education. Deb is a sought-after mentor, and several of her mentees have gone on to have successful careers of their own, achieving doctorate degrees and winning career development awards. I am proud to consider myself one of Dr. Cohen's learners – I have learned so much from her in our years as collaborators and colleagues.

In summary, Dr. Cohen is an extraordinary researcher and an outstanding mentor, and to quote one of her peers is "a bible of knowledge in the complex art of qualitative research and is always very engaged and available to move projects along and advance science. She provides very thoughtful advice and challenges you to revisit your project objectives, thing outside the box, and keep adapting to solve challenges." Dr. Cohen is changing the world of primary care research and has made a huge impact on the future of our discipline through her mentorship of junior researchers, and we are extremely lucky to have her here at OHSU. She exemplifies what a medical school faculty member should be, and I am so very pleased to nominate her for the OHSU Women in Academic Medicine Mentoring Award.

At last month's OHSU Women in Academic Medicine annual conference, Christina Milano, M.D. was announced the winner of the Clinical Excellence Award. Her nomination, submitted by OHSU Family Medicine Chair, Jennifer DeVoe, M.D., D.Phil., reads:

On behalf of the OHSU Department of Family Medicine, I am honored to nominate Christina Milano, M.D. for the OHSU Women in Academic Medicine Clinical Excellence Award. We are inspired by her impressive record of service to the University and the community, and by her tireless dedication to advocating and caring for underserved populations in her practice, in the region, and nationally.

Dr. Milano is an incredibly compassionate primary care physician and supportive member of the amazing team at OHSU Family Medicine at Richmond. As a family physician, she has dedicated her career to making quality health care accessible to members of underserved communities. Much of her academic, clinical, and service work has been centered on practice and care transformation, and she has been recognized as an expert and leader in the field of ambulatory health care transformation.

Dr. Milano has shown remarkable service leadership at the Richmond clinic, which is a Federally Qualified Health Center largely serving low-income and vulnerable populations. In addition to her work as a practicing clinician, she has developed new tools for facilitating appropriate preventive health care, for increasing efficiency of work between faculty and medical assistants, for integrating the electronic health record (EHR) into good patient care, and for optimizing workflows in the clinic. Her work creating a high-functioning multidisciplinary team to engage with and support their most vulnerable patients resulted in demonstrable improvements in the quality of care for patients with chronic diseases, such as diabetes and depression, and has helped reduce health disparities at the Richmond clinic. The success of this program garnered positive media attention for the approach and for OHSU, including visits from NPR's Morning Edition, Marketplace, and Modern Healthcare programs; Dr. Milano has also presented about her successes at regional and national conferences. Largely due to her efforts serving as the Richmond clinic's Patient-Centered Primary Care Home (PCPCH) Clinical Champion, the clinic was among the first and highest-scoring clinics in Oregon to receive Tier 3 recognition by the Oregon Health Authority.

Dr. Milano's expertise has earned the confidence of multiple Portland-area health systems and the local government, resulting in her helping to restructure Oregon's Medicaid program and being asked to serve as the Medical Director of CareOregon Metro's Tri County Providers. This collaborative effort is part of Health Share of Oregon, a Coordinated Care Organization serving the Portland metropolitan area, involving many major healthcare organizations, including OHSU.

Above and beyond her work transforming traditional practices into high-functioning PCPCHs, Dr. Milano is a passionate and effective leader advancing care for transgender patients. She was an early advocate for, and partner in the creation of, what became the OHSU Transgender Health Program, and serves on several community-level committees and panels related to transgender care. Dr. Milano has been working with transgender patients for over 15 years, and treated her first transgender primary care patient at the Richmond clinic in 2006. She saw the unfilled primary care

need and wanted to make a difference—she realized that caring for this population was about more than just surgery or prescribing hormones, but that they needed safe and competent care options at every stage of life;many of these patients struggle to find a doctor willing and/or able to treat them. Dr. Milano helped push for cultural changes at a University level, and these changes made by OHSU leadership, in addition to the creation and success of the OHSU Transgender Health Program, have contributed to OHSU being consistently and continually recognized as a Leader in LGBTQ Healthcare Equality by the Human Rights Campaign.

Dr. Milano's many contributions to improving patient health exemplify a leader whose efforts move far beyond the medical care of individual patients and advocacy work throughout the Portland metro area—she also serves as a mentor and resource for her colleagues and the broader LGBTQ community. She provides transformational feedback and advice to peers, helping support them and their work, and serves as a role model in numerous ways. As a leader in this field, she has been invited to lecture nationally on the subject of transgender health advocacy, discussing the impact of collaborative care organizations and partnerships on the experience of transgender individuals being able to access services and competent providers. In her national work, she has served as an excellent ambassador for our institution by teaching others how programs she's helped to implement at OHSU could be effected in other areas and care environments.

Dr. Christina Milano has been a true inspiration, and we enthusiastically nominate her for the 2018 OHSU Women in Academic Medicine Clinical Excellence Award.

Happy New Year! As we ring in 2018, it is a wonderful time to reflect and celebrate the many miles we've traveled together over the past year. And, what a year we've had together! Thank you for your contributions to our wonderful Department of Family Medicine team. At the beginning of 2017, we announced the Department of Family Medicine's revamped strategic plan. With newly-appointed Vice Chairs of Research, Education, and Clinical Care at the helm, we embarked on a journey to find new ways of integrating all of our mission areas and improving primary care from all angles. We faced many challenges and opportunities, and I am happy to say that we succeeded in making some big changes. Here's just a few highlights from 2017:

New primary care clinics

In February 2017, we and our OHSU Internal Medicine partners opened two primary care clinics in Washington County.

  • Primary Care at Beaverton found its home in the Knight Cancer Institute building near the Nike campus. This primary care clinic is now one of many new clinics in the building providing our Washington County patients with the care they need, when and where they need it.

  • Primary Care at Orenco Station was formerly a Tuality Healthcare clinic, and continues to be "westward facing" as we give our Washington County patients the opportunity to receive care in their own neighborhood.

In December 2017, Primary Care at Beaverton and Orenco Station launched open scheduling, which gives people completely new to the OHSU system the opportunity to make primary care appointments online. Preceded only by the OHSU Comprehensive Pain Center, these two clinics are helping OHSU roll out new and exciting ways for patients to connect with our system.

The launch of these two clinics is also exciting because: (1) We've taken a great step towards building an expanded clinical system that will support growth in our educational and research programs; (2) We are collaborating with Internal Medicine and other primary care partners to join forces in taking care of our communities; and (3) We are strengthening our relationship with Tuality Healthcare, which will help both organizations care for families across quickly-growing Washington County.

Postdoctoral fellowships

In the fall of 2017, we launched a new postdoctoral fellowship program and welcomed three new postdoctoral fellows. The Department's postdoctoral program is unique in that fellows spend a significant amount of time embedded in our clinics, both learning and teaching. I am excited to watch these three fellows help us integrate our research and clinical mission areas in ways we might not have even imagined.

Launch of a new "clinic-first" curriculum in the Portland residency

For Family Medicine residents in Portland, the 2017–2018 academic year marked the start of a "clinic-first" curriculum: interns began their residency with a month-long clinical experience at their home clinic, and rotation schedules for all classes now follow a "2+2" model (two weeks on outpatient rotations, followed by two weeks on inpatient rotations). This clinic-first approach improves patient access by providing residents a more consistent clinic presence while also providing a better educational balance between inpatient and outpatient experiences.

Cascades East residency emerges with sense of resiliency and community

2016 was a difficult year for our residency in Klamath Falls. A bus accident rendered several residents and faculty injured, a retired faculty member passed away, followed by the death of a recent Cascades East graduate. Having learned important lessons in resilience and the importance of community, the program forged ahead to complete a successful 2017. Recent successes include a resurgence of national presentations by faculty, with one group even presenting on best practices and lessons learned for surviving a residency disaster. The team also grew their Point-of-Care Ultrasound curriculum, with faculty presenting a workshop at AAFP's National Conference for Residents and Students in Kansas City, MO.

Varied electives and continuity offerings added to Medical Student Education

In addition to the four-week core rotation (formerly known as the clerkship), MSE now offers an eight-week continuity core as well as twelve-week rural continuity rotations. The OHSU Cascades East faculty developed several rural electives, and the Portland faculty worked to offer new/improved electives in inpatient and outpatient settings. These varied course offerings enable students to choose the practice focus that best meets their future interests in medicine.

JADECOM Endowed Scholarship

In October 2017, we celebrated the gift of an endowment from our dear friends in JADECOM, as well as the naming of our first JADECOM Endowed Scholar, Daisuke Yamashita, M.D. From this exchange, we have learned a great deal about "the degree to which [JADECOM's] doctors and hospitals are connected to the needs of the community they serve." Several of our students, residents, and faculty have had the opportunity to travel to Japan over the past 20 years;and we have had the opportunity to welcome JADECOM students, residents, and faculty to Oregon. We look forward to our continued partnership with JADECOM and place great value on this unique friendship.

John and Sherrie Saultz Endowed Professorship

In May 2017, we announced the John and Sherrie Saultz Endowed Professorship, and I was very honored to be named the first John and Sherrie Saultz Endowed Professor. With the funds, I committed to "support the department's efforts to seek innovative ways of creating community laboratories and classrooms in places where people live and to bridge the department's research, clinical, and educational programs, especially those related to generating practice-based evidence." These funds are currently helping to support our new postdoctoral fellowship.

Northwest Native American Center of Excellence

In 2017, Oregon became home to the Northwest Native American Center of Excellence thanks to the work of its director, Erik Brodt, M.D. and many colleagues at OHSU and Portland State University. The Northwest Native American Center of Excellence at OHSU will comprehensively and sustainably address the health care needs of all people by increasing Native American voices in the U.S. health professions workforce. 

Starfield Summit: Expanding Primary Care's Role in Achieving Health Equity

In April 2017, we welcomed nearly 200 colleagues from across the globe to Portland for the second Starfield Summit: Expanding Primary Care's Role in Achieving Health Equity. This Summit provided a wonderful opportunity to share ideas and recommit ourselves to health equity efforts, and I am proud that so many people from our department joined a great team of sponsors to help make this event such a tremendous success.

New hires and promotions

As we grow in new and exciting ways, we've had the opportunity to welcome many new faculty and to celebrate the promotion of many current faculty.

In 2017, we welcomed:

  • Robert Alaimo, M.D. (MCMC)
  • Gabriel Andeen, M.D. (Scappoose)
  • Connor Burke, M.D. (Cascades East)
  • Matthew Chan, M.D. (Scappoose)
  • Samuel Crane, M.D. (Orenco Station)
  • Carol Federiuk, M.D. (Gabriel Park)
  • Brian Garvey, M.D. (Scappoose)
  • Kristin Grigsby, P.A. (South Waterfront)
  • Jessica Hart, D.N.P. (Orenco Station)
  • Heather Holmes, M.D. (Orenco Station)
  • Richard Kellis, M.D. (Orenco Station)
  • Sarah Kuppenbender, F.N.P. (MCMC)
  • Sean McHugh, P.A. (MCMC)
  • Ryan Norton, M.D. (Beaverton, Orenco Station)
  • Emma Peiris, M.D (MCMC)
  • Jennifer Schlobohm, L.C.S.W. (Richmond)
  • Carmen Vance, F.N.P. (MCMC)
  • Barbara Weathersby, L.C.S.W. (Cascades East)
  • Leah Werner, M.D. (Gabriel Park)
  • Jennifer Willingham M.D. (Scappoose)

And we congratulated the following faculty members in their promotions:

  • Deb Cohen, Ph.D. from Associate Professor to Professor
  • Nellie Wirsing, M.D. appointment from Provisional Associate Professor to Associate Professor
  • Laurel Hallock-Koppelman, F.N.P., D.N.P. from Instructor to Assistant Professor

From Assistant Professor to Associate Professor

  • Cliff Coleman, M.D.
  • Melinda Davis, Ph.D.
  • Bob Jackman, M.D.
  • Dwight Smith, M.D.

These are just a few of the many, many highlights to celebrate from 2017. I'm looking forward to having another opportunity to celebrate 2017 at our upcoming State of the Department Address in the spring of 2018. Please send me your highlights to include in this year's address!

As we wrap up a busy 2017 and set our sights on 2018, I want to personally thank every person who has diligently kept us on course and propelled our amazing forward motion! In this new year, I look forward to setting even bigger goals and admiring our department as we continue on this successful course, continuing our momentum towards a bright future.  

Have you ever seen a 10 lb. zucchini? The staff at OHSU Family Medicine at Richmond have - it is one of several hardy vegetables that have flourished in their new community garden. We sat down with one of the Garden's coordinators, Treva Drake, to learn all about the clinic's beautiful little plot of land in the middle of the city. 

What is your role at Richmond?

I am the Garden Coordinator / Social Determinants of Health Coordination at Richmond.

How was the idea of a garden conceived?

Brian Frank, M.D. and I, as members of Richmond's Food and Nutrition team collaborate on projects that increase access to healthy foods at a low cost. Dr. Frank had been inspired by Multnomah County's Mid-county and Providence Milwaukie's'  Community Gardens. We had been in conversations with the local non-profit Growing Gardens for some time and were looking for a way to partner with them, and this seemed like a great first step. 

We wanted to find an elegant way to integrate garden education with nutrition education and behavioral health. We also hoped that growing food as patients, staff and neighbors alike, would bring us closer together. For this year's Community Health Center Week celebration my colleague, Laurel Hallock-Koppelman F.N.P., penned our theme, "Community is Health." I think she got it right.

What is the garden's purpose?

The Richmond Community Garden opens a conversation about food and health. We live by Hippocrates' philosophy, "let food be thy medicine, and medicine be thy food" - meaning food is inarguably the most enjoyable and cost effective way to protect the health of families. 

Unfortunately, many of our patients suffer from food insecurity. Food insecurity is one of the most actionable social determinants of health. Our team believes medical professionals have a key role in furthering health equity.

As an added benefit, the garden is a peaceful and contemplative place. I've seen so many admirers gaze at it over these past months. Many of our patients have had lifetimes of trauma, there is something nurturing to the nerves about gardening. In fact, the core team of our volunteer based Garden Club are folks from our Mindfulness Group led by a member of our Behavioral Health team, Myong O, L.C.S.W. Every week after mindfulness meditation practice, club members come and engage in some mindful gardening. We owe our Garden Club and the Mindfulness Group a lot for keeping this project alive.

What were some of the challenges in starting the garden? What are challenges the garden still faces?

Ongoing programming! But I love a good challenge. There are so many different ways to engage a project like this. I work best from an overall vision and getting a hearty vision for what this garden represents and how we can use it to its fullest. It takes time to see what works and doesn't work. What I have learned in general is that the strongest social determinants of health intervention programs are robust in diversity, like an ecosystem. 

I hope to develop programming that can plug all types of people who want to be involved, in from an experienced gardener to a total newbie. I feel confident that we can partner with community members such as the Oregon Food Bank and accomplish this.

What were some of the (good) surprises?

Initially,  leadership and I were concerned that the garden would be neglected. I pictured worst-case scenario, I would be out there doing it all by myself (and I am a terrible gardener, truth be told!). But this hasn't been the case; our community has many avid gardeners who have wrapped their loving arms around our garden. I have been really surprised by how much people like the garden and take care of it as if it were their own.

What are some of the plans for the garden's future?

First of all we need a sign - we are looking for a builder to help. A lofty dream of ours is to expand and replace all the decorative landscaping with food-producing plants. I would also love to create a patient job opportunity out of its management. Something like a rotating leadership model where we provide training (and possibly a stipend) for an interested patient. I am all about raising up our patients. But in the mean time we need to just tend and harvest and get through our first season. 

Social determinants of health, including the economic, social, and environmental characteristics of communities where people live, affect a wide range of health outcomes and risks. A large body of research suggests that SDH may contribute as much or even more to health outcomes than clinical factors. However, care quality metrics typically emphasize disease specific, clinical outcomes, such as the number or severity of chronic conditions (also referred to as clinical complexity), and do not include measurement or adjustment for the SDH that impact health (also referred to as social complexity). In this study, we assessed whether accounting for both social and clinical complexity better explained differences in quality of care and health service utilization rates than accounting for patient clinical complexity alone.

Over a twelve month period, ADVANCE (Accelerating Data Value across a National Community Health Center Network) and OneFlorida, two of the Patient-Centered Outcomes Research Institute funded Clinical Data Research Networks, worked closely with patient, provider, and health system stakeholders to develop and test measures assessing the combined effect of social and clinical complexity on quality of care. ADVANCE and OneFlorida comprise socially vulnerable patient populations largely reliant on Medicaid and safety net services like community health centers. We assessed clinical complexity using the Charlson Comorbidity Index, a weighted measure that predicts the risk of mortality and resource utilization for patients with a range of comorbid conditions. To assess social complexity, we utilized publicly available data on the community-level SDH of the neighborhoods where patients live.

In the first phase of the study, stakeholders prioritized community-level SDH characteristics and clinical quality metric outcomes to include in our analysis. A total of 71 stakeholders participated, representing patient, clinician, and health systems groups in the ADVANCE and OneFlorida networks. Stakeholders reviewed a list of 16 SDH categories and 7 clinical quality outcomes then ranked them according to perceived importance (see Table below). The top three SDH categories were socioeconomic status, neighborhood inequality, and transportation. The top three clinical outcomes were chronic disease management, risk factor screening, and preventive care. 

In Phase 2, we assessed the relationship between clinical complexity (using the Charlson Comorbidity Index), social complexity (using community-level SDH variables), and quality of care. Our sample included Medicaid patients in Florida and Oregon and patients in the electronic health record systems for subsets of OneFlorida and ADVANCE. All established patients, defined as attending a primary care appointment in 2015 with at least one visit at any prior point, were included. Patient addresses were geocoded and linked to US census and American Community Survey data to describe census tract or zip code level SDH factors in the communities where patients lived. 

As expected, patients in our sample live in more socially vulnerable communities than the average US population. For example, the mean Social Deprivation Index (SDI) –a composite measure of the socioeconomic conditions in a given neighborhood –for our population was 84, which means 84% of study patients live in neighborhoods with poor socioeconomic indicators. Almost half of the patients in our sample live in the most vulnerable quartile of neighborhoods (e.g. those with the highest SDI scores) in the US, whereas less than 8 percent live the least vulnerable quartile of neighborhoods (e.g. those with the lowest SDI scores). Our analyses revealed that accounting for patients' social and clinical complexity explains more of the variation in clinic-level quality of care –such as Hemoglobin A1c control or Emergency Department utilization –than does accounting for clinical complexity alone. For example, when looking at the percent of patients with poor diabetes control, those with higher levels of clinical complexity (e.g. a Charlson score higher than 2) had worse outcomes. Interestingly, if we were to assume an SDI level of 50 (the US mean) instead of 84 (the mean of our population), the percent of diabetics in poor control dropped by 2%. Although this effect may seem modest, even this slight decrease from adjusting for social complexity of patient panels could result in improved performance metrics for providers caring for patients within safety-net clinics

In the third phase of this study we again engaged stakeholders to ask if our preliminary results were consistent with their own observations and experiences. Most thought the preliminary findings were "in line with what we see anecdotally, so it's great to see the data showing this." Discussing implications of the findings, stakeholders strongly endorsed provider performance metrics and funding models for service delivery adjusted for the social complexity of patient panels. Stakeholders recommended policy and practice applications including innovations to existing care models, higher allocation of resources in vulnerable communities, and ways to integrate SDH with routine patient assessments in primary care practice. Several stakeholders were surprised the social-clinical adjustment did not have a larger effect in our sample and recommended future studies that include comparison with more affluent, privately insured populations.

For the fourth and final phase, we are developing a toolkit for other data networks to use in assessing their own patient populations, surveying other CDRN's to assess their interest and capacity to replicate the analyses conducted in this study, and pursuing additional mechanisms for broad dissemination of our findings. The study toolkit will include key lessons learned, strategies for stakeholder engagement, and resources for conducting similar research (e.g. data extraction and analysis code). Detailed study findings will be presented at local and national conferences, and are in preparation for submission to peer reviewed journals.

When we discussed findings with stakeholders, one patient advisor remarked, "It seems obvious that [social deprivation] was associated with poor diabetes control –sometimes the point of research is to confirm obvious things." In addition to demonstrating social and clinical complexity in safety net populations and the effects of combining social and clinical risk factors in provider performance measures, this study shows the value of engagement in tailoring the design and interpretation of large scale analyses to stakeholder priorities. Although future research is needed to further refine our models, our initial findings suggest measures that adjust quality measures for higher levels of social risk can help providers serving vulnerable populations better demonstrate the quality of care they deliver and justify more intensive resource use or allocation.

For any questions or more information regarding this project, please contact Katie Dambrun, dambrunk@ochin.org.

The American Academy of Family Physicians has named 17 medical school Family Medicine Interest Groups as the 2017 Program of Excellence Award winners for their outstanding activities in generating interest in family medicine. One of those programs is our very own OHSU FMIG.

FMIGs are medical school-sponsored, student- and faculty-run organizations that give medical students a chance to learn more about family medicine through regular meetings, workshops, leadership development opportunities, and community and clinical experiences.

The Program of Excellence Awards recognize FMIGs for their efforts to promote interest in family medicine and family medicine programming –10 for their overall performance and seven for collaboration, community service, promoting primary care and most improved FMIG.

"It is critical we continue to garner interest and attract students to the specialty of family medicine," said Clif Knight, M.D., senior vice president for education at the AAFP. "The physician shortage in primary care continues, and programs such as FMIGs are key to exposing students to real-world experiences that will help them dig deeper into - and ultimately choose - family medicine.

"The FMIGs we honor this year have gone above and beyond allowing students to put into practice the knowledge they've acquired in the classroom. These programs help students develop leadership skills that will serve them in their future practices and communities, and better understand the vital role that family medicine plays in our health care system."

Opioid use – and misuse – is top-of-mind for many of America's healthcare providers. Since 1999 opioid overdoses have quadrupled, leading to over 30,000 deaths in 2015 alone. In 2014, the American Medical Association called on its members to come together to address the issue, claiming, "It is our professional and ethical responsibility as physicians to help bring this epidemic to an end." This led to the development of the Opioid Task Force.

Since 2014, physician groups and organizations have driven substantial change in how opioids are prescribed and managed, as well as supporting corresponding legislation. The task currently at hand is to address the health of nearly 2.5 million people in the United States who live with opioid substance use disorders or heroin addiction. 

Medication Assisted Treatment (MAT) is gaining popularity as a program to address these substance use disorders, and uses a combination of medication and behavioral health management. OHSU Family Medicine at Scappoose and at Richmond have both developed MAT programs that utilize teams of healthcare providers (physicians, nurse practitioners and/or physician assistants), behavioral health specialists, and nurse case managers with incredible success, and no sign of slowing down in growth and improvement.

Why Medication Assisted Treatment?

Medication replaces opioids within the patient's body. While taking the medication, patients maintain their opioid dependence, but "the difference between dependence and addiction is the body's needs versus the behaviors that surround the dependence," explains David Casey, M.S.W., C.W.S.A., C.A.D.C. II, of Family Medicine at Scappoose. "[MAT] stops the chaos of the drug and offers people a choice...We get to a point where we can manage their dependence as a physiological issue and start to address their behavioral health. Sometimes within three or four days, people are already turning their lives around." 

MAT programs at both Family Medicine clinics also credit their success to the strong collaboration between physical and mental health services. As soon as patients begin treatment, they are connected with behavioral health specialists with whom they work closely and frequently. As patients regain control of their lives, they come into the clinic less often.

Family Medicine at Scappoose makes use of group sessions; some look more like a deep therapy session, others emphasize recovery and development of life skills.

"I've seen people go from addiction to sustaining a low dose of medication and getting their kids back, their relationships back, finding work, and going into mental health treatment," says Rebecca Cantone, M.D., Medical Director of Scappoose's MAT program; "They learn to process what made them become addicted and get their lives back."

So why is MAT still uncommon practice? Unfortunately, in spite of its success in helping people reclaim their livelihood, MAT is not widely accepted in the recovery community. "[Narcotics Anonymous (NA)] and a lot of other treatment facilities don't consider someone 'recovered' unless they are abstinent," explains Casey, "so those who go to NA have to lie about being in the MAT program." This means patients cannot fully shed their dishonesty, which is an important part of recovery. The stigma also persists in the primary care setting, making it difficult to expand across other clinics.

Building a New Model of Care

Providing Medication Assisted Treatment takes a specific skill set and certification, and an interest in addiction management. Not all providers are eager to make MAT part of their practice, so very few clinics offer the service, and at those that do, not all of their providers participate.

At Family Medicine at Scappoose, Rebecca Cantone, M.D. and Bruin Rugge, M.D. were for a while the only two providers offering MAT. With a patient population spanning across Columbia, Tillamook and Clatsop counties, however, the clinic soon became overwhelmed by the number of patients requiring addiction services. Clatsop County alone has an opioid overdose death rate that is twice that of the rest of the state.

Family Medicine at Richmond was in a similar state with only three physicians, Nicholas Gideonse, M.D., Amanda Risser, M.D., and Brian Frank, M.D., providing MAT services.

Seeing a need for change, clinical and behavioral leadership developed a MAT treatment model for both clinics based on the latest research. The model utilizes behavioral health staff and registered nurses to take on the bulk of coaching, counseling, education, and medication management to take some of the pressure off providers and to allow for treatment of more patients. Treatment takes a tiered approach, moving people through phases based on their risk and progress. Initially, patients will come in two or more times per week for behavioral health appointments, and will reduce their visits over time as they gain control of their health and lives.

At Family Medicine at Richmond, Luke Jennings, R.N., M.S.N. takes on the role of counselor and registered nurse for many of the patients in the MAT program. "A lot of patients come in with co-morbidities to go along with their addictions, like diabetes or chronic pain. For those with chronic pain, we work on relaxation, strengthening, and learning to differentiate between pain and suffering. The goal," he explains, "is to free up providers to take on more MAT patients and to have time for their other patients as well."

In 2016, the Comprehensive Addiction and Recovery Act (CARA) made allowances for nurse practitioners (NPs) and physician assistants (PAs) to prescribe for MAT, which also allowed for more of Family Medicine's clinicians to join the team and share the growing number of patients.

Partnerships and Funding

Family Medicine at Richmond received federal dollars to fully launch their MAT program. Family Medicine at Scappoose, along with partners, Columbia Pacific Coordinated Care Organization (CPCCO) and Greater Oregon Behavioral Health, Inc. (GOBHI), recently received a grant from Substance Abuse and Mental Health Services Administration (SAMHSA). Stemming from the belief that behavioral health is tightly connected to addiction and addiction treatment, the SAMHSA grant will allow Scappoose to create a specialized MAT program that will include a more intensive behavioral health component.

Expansion

With both clinics –and many others –maintaining lengthy waiting lists and receiving multiple applications each week, MAT programs need to expand across more primary care clinics. With that in mind, Family Medicine at Scappoose is –as part of the SAMHSA grant – developing a protocol that the clinic hopes to slowly roll out and offer to other community healthcare providers.

MAT is an optimal solution for many primary care providers because it is less complex to dispense than methadone, and does not take the expertise of a pain clinic to manage. "Providers tend to equate it to chronic opiate tapering, which can be a challenging experience," explains Brian Garvey, M.D., who will begin work at Scappoose in July, "so they're hesitant to work with [MAT] at first." MAT is different, however, and often once providers "start doing it, they realize how effective it is and how much of a meaningful difference it makes in peoples' lives."

By OHSU Family Medicine Chair, Jennifer DeVoe, M.D., D.Phil.

This month I had the pleasure of presenting my first State of the Department Address as the Chair of OHSU Family Medicine. It was a huge team effort pulling together data and other information regarding this year's activities, and it also provided a great opportunity to look back on years – decades, even – to reflect on how far we've come, and consider how far we've yet to go.

Our team

This year, we reached an incredible 409 total FTE  for the department. Keeping in mind many of our employees do not work full time, we have reached over 500 people total on the Family Medicine team. In comparison, we had 332 FTE just two years ago. In 1998, we had 23 faculty FTE – today, we have reached 121 faculty FTE (and a total of 138 faculty members). What an incredible testament to how much we have grown!

Department finances

Financially, we continue to see an increase in department revenues. We receive a similar amount of money from the School of Medicine year after year; however, the growth of our grant dollars, clinical work, and other endeavors has enabled us to build new programs and experience remarkable growth in all of our mission areas. We are excited about this continued growth and will look for more opportunities – particularly in re-igniting our philanthropic efforts – to make sure we stay strong for years to come.

Revising our structure

In January, I talked about our strategic planning process and the restructure of our department to help us fulfill our vision. It is with this structure in mind that we reflect on the past year and set our goals for the future.

Medical student education

This year, the Medical Student Education team sent 20 OHSU medical student graduates – that's 15 percent of OHSU's graduating class – to family medicine residencies across the country. Two of our graduates matched at our Cascades East residency program, and two graduates matched at our Portland residency program. Fifteen percent beats the national average of about eight percent, but it is not enough to make up for the current and future primary care shortage. This year, we celebrate 15 percent, and gear up to grow that number here at OHSU and at medical schools across the country next year.

Residency

The Cascades East residency saw an increase in applicants this year, bringing them to 1,105. The team interviewed 96 of those applicants to find 8 new interns to join the program next year.

The Portland residency received 1,196 applications, 682 of which came from U.S. seniors – an increase of almost 100 from last year. For their 12 open spots, the team interviewed 175 eager candidates.

Recognizing the residency websites are some of our most-visited, the team also combed through, recreated, rewrote, and revamped their webpages.

Research and scholarship

The research team took time this year to develop a list of core areas of expertise, defining them as:

  • Clinical and chronic disease research
  • Population health, equity, and policy
  • Medical education research
  • Dissemination and implementation
  • Innovation and practice transformation

These areas were used to re-design areas of our websites for better sharing work with colleagues, collaborators, and funding sources.

Grants

In 2016, the department received 29 awards from over 20 different funding agencies, and pushed ourselves to aim bigger and higher. Our team even reached for a $100M MacArthur grant, which included a video component. Ultimately the grant was not awarded, but the foundation offered positive insights, and the application process helped us take a close look at primary care and how we, and international collaborators, can work to improve it.

Publications

We had 144 peer-reviewed citations in 2016, as compared to 70 in 2008. We had an overall total number of publications of 196 in 2016, as compared to 103 in 2008. Our work was published in over 40 different journals, including Family Medicine, the New England Journal of Medicine, the British Medical Journal, the Mayo Clinic Proceedings, the Journal of Health Care for the Poor and Underserved, and many other high impact publications.

Clinical

This year, we reflect on 14 clinics and clinical programs, including brand new Primary Care clinics at Beaverton and Orenco Station. As always, our clinic visit numbers grew immensely over the past year. As we celebrate the number of visits we've provided to patients, we are also looking at our numbers a little differently – in lives covered and families kept healthy, rather than just focusing on visit statistics. This year, nearly a quarter of our payments are coming from alternative payment models that focus on population health initiatives and the quality of care we provide, and we look forward to expanding our metrics for success far beyond visit numbers in the next year.

Inpatient care

Our inpatient admission numbers remained steady in 2016 – if not slightly lower than last year. We are happy to consider this a win; patients who spend less time in the hospital, or who do not go at all, are healthy patients – unless, of course, they are having babies! We delivered 279 new family members last year, and hope to grow those numbers in the upcoming year.

Communications

Our department is growing in numbers, in miles traveled, and in communities served; thus, creative ways to stay connected and keep current on department happenings have become even more important. We launched our newsfeed, created a space to talk about our commitment to diversity, and created pages for learners and job seekers.

Over the past two years, social media followers have more than tripled, and newsletter readership has increased by 33 percent.

Looking ahead

We laid out several opportunities for 2017, including:

  • Strategic leadership in primary care growth across OHSU's clinical system
  • Create a blueprint to further expand our residency network
  • Accelerate efforts to transform our model of team-based care and comprehensive primary care delivery
  • Build systems for supporting population health efforts
  • Grow OHSU's Family Medicine Interest Group and reach >20% students matching in Family Medicine
  • Build stronger ties across all of our mission areas
  • Re-ignite philanthropy
  • Continue our tradition of providing national leadership for our discipline
  • Establish a Center for Primary Care Innovation
  • Become the #1 Family Medicine program in the country (we were ranked 2nd again this year!)
  • Focus on faculty development and growth 
  • Integrate Research into clinical systems

It was a great honor to have the opportunity to reflect on our amazing progress in 2016 and look forward into our exciting future. I'm always bursting with pride when describing the wonderful work done by our team every day. I am also grateful to work with such an inspirational group of people who support and challenge each other to be the best we can be and to care so compassionately for our patients and colleagues. As I reached the end of my address (delivered to an enthusiastic group wearing a rainbow of colors across our department), I was reminded of the song "True Colors:"

I see your true colors 

Shining through I see your true colors 

And that's why I love you 

So don't be afraid to let them show 

Your true colors 

True colors are beautiful 

Like a rainbow.

By OHSU Family Medicine Chair, Jennifer DeVoe, M.D., D.Phil.

In 1979, just eight years after our department was founded, Dr. Gayle Stephens published his famous article describing family medicine as counterculture.(1) Dr. Stephens asserted that family medicine successfully harnessed the social movements of the 1960s to affirm the need for a personal doctor grounded in strong relationships with patients, families, and communities. He argued that family medicine aligned with reforms that defined the counterculture of the day: ". . . agrarianism, utopianism, humanism, consumerism, and feminism. These are all themes of reform that can be traced in American history, and their emergence in the 1960s and 1970s created the climate of public opinion that made it possible for family practice to succeed in such an unprecedented way. We benefited from them even though we may not have been conscious that we were drawing on their strength" (p. 104;1).

Fast forward nearly 40 years from Dr. Stephen's article, and we find ourselves with a dominant healthcare paradigm of specialization and fragmentation that is bankrupting our nation and ineffective at achieving its ultimate goal of improving health. Despite the trillions of dollars spent on healthcare in this country each year, our population is leading shorter lives, in poorer health.(2) Practicing medicine in the current healthcare system that is fraught with inefficiencies, inequities, impersonal interactions, and unfulfilled promises is challenging and sometimes paralyzing. Yet, it is amidst this prevailing paradigm that family medicine's counterculture spirit, our healing touch, our commitment to relationships, and our unique connection to humanity is needed more than ever.

After the recent G. Gayle Stephens Keystone IV conference, I was energized to renew my commitment to establishing longitudinal, meaningful, personal relationships with patients and families. I was reminded of the need to leverage our research expertise to identify when relationships matter most in healthcare and to understand how we can better harness paradigm shifts in information technology, team-based care, and population health to strengthen rather than undermine personal doctoring.(3) I was also reminded of how family medicine's core value of personal relationships remains very much counterculture to the more dominant paradigm of today, much like Dr. Stephens observed decades ago.

Working alongside all of you in this amazing department is a powerful motivation to keep our counterculture flame burning brightly in today's tumultuous healthcare environment. Your compassion and dedication to our mission and values is an inspiration to me each and every day. I am proud to play a small part in our counterculture movement and remain committed to ensuring that family medicine thrives at OHSU and that our light shines brightly in the healthcare system.

Note: There was an entire supplement of the Journal of the American Board of Family Medicine, July-August 2016 dedicated to reflections from the G. Gayle Stephens Keystone IV conference. Several short videos were also created using content from the conference. These articles and videos can be used to facilitate conversations regarding some of the important core values of family medicine. 

Thanks to the American Board of Family Medicine foundation for supporting this conference series.

1) Stephens G., Family Medicine as Counterculture. Fam Med 1979;21:103–9.

2) U.S. Health in International Perspective: Shorter Lives, Poorer Health, National Research Council and Institute of Medicine, 2013

3) DeVoe, et al. Personal Doctoring Manifesto: A Perspective from the Keystone IV Conference.

OHSU Family Medicine Gabriel Park has been highlighted as a "Bright Spot" primary care practice by the Center of Primary Care Excellence at University of California San Francisco. The Center published an explanation specifically recognizing Gabriel Park's exemplary model of educating its residents.

The explanation notes that Gabriel Park's high level of success is attributable to the clinic's engaged leadership, well-developed scheduling methods, data-driven improvement goals, excellent team structure, and quality patient care.

The overall goal of Gabriel Park – and all of our Family Medicine clinics – "is 'for resident physicians to become compassionate, competent clinicians and partners who provide patient centered, team based care in all primary care settings.'" Part of how Gabriel Park accomplishes this is by focusing on their "vibe" which comprises three words, "trustworthy, compassionate, and professional," and by keeping an eye on their ground rules "to treat each other with respect and work with each other cooperatively."  

Authors of the honor conclude, "The OHSU family medicine residency program has important lessons to teach other primary care residency programs … The  OHSU model should be considered by residency programs with large, resident‐heavy teaching clinics."

Imagine this:

  • Every person in Oregon has a top-notch patient-centered primary care home and receives the right care, in the right place, at the right time.
  • Every primary care team has resources to transform practice, integrate and coordinate care, conduct research, and partner with communities to improve population health.
  • Every primary care team is actively engaged in teaching and learning.
  • Every patient and caregiver has access to technologies that support patient engagement in healthcare, learning, and discovery.
  • Every primary care team and community has the data and partnerships with those who have expertise to make progress toward achieving the quadruple aim (better health care, improved population health, sustainable cost, and a healthy and happy healthcare workforce).
  • Every person, primary care clinic, and community in Oregon is connected with the OHSU Department of Family Medicine through our clinical care, education, and research efforts. 

Through our department's strategic planning process last year, we heard an overwhelming re-commitment to our three mission areas: clinical care, education, and research, and to continue our integration efforts between these mission areas.

It is critically important for OHSU to have world-class family health centers doing cutting edge research to discover how best to transform primary care and teaching the next generation. It is also critically important that we support our family medicine friends and colleagues across the state (and around the world!) to provide excellent primary care to communities and to serve as community laboratories and classrooms.Those of you who know me, know that I'm a big fan of the concept of 'community classrooms' and 'community laboratories.'(1) I am so proud that we are delivering care to communities while also educating future generations and making scientific discoveries. 

Motivated and informed by the passion, energy, and wisdom from the faculty, our leadership team has reconfirmed our vision and made the decision to restructure our department's leadership team for the future. The figure below shows our new organizational structure and our three new vice chairs.

Moving forward, Fran Biagioli, M.D. will lead as the Vice Chair of Education, Deborah Cohen, Ph.D. will be the Vice Chair of Research, and Bruin Rugge, M.D. will be the Vice Chair of Clinical. Together, these leaders will work together to strengthen their mission areas, and to strive toward seamless integration between the three.

As we look to the future, I like to remind myself of something John Saultz wrote in 2013 for Society of Teachers of Family Medicine: "Family medicine needs a larger vision than simply teaching family doctors. Our old mission was to train family physicians. Our new mission is to invent and study new models of primary care and teach learners from multiple disciplines to care for populations of people in community settings as teams. Patient-centered care is not about what physicians do;it is about how individuals and communities receive the care they need. We are fond of saying that family physicians should be leaders in the new health care system. This is the path to take if we are serious." (2)

Our department is serious about taking this path, and we will continue to challenge ourselves with questions that help us grow and improve.

How do we…

…Continue to cultivate and strengthen community "laboratories" and "classrooms" to support learning and discovery?

…Build new community classrooms to facilitate collaborative learning and teaching?

…Build new community laboratories that support the "science of health," complementary to those supporting the "science of medicine"?

1.     Devoe, J. E., Likumahuwa-Ackman, S., Shannon, J., &Hayward, E. S. (2016). Creating 21st-Century Laboratories and Classrooms for Improving Population Health. Academic Medicine. doi:10.1097/acm.0000000000001385

2.     Saultz J. Interdisciplinary Family Medicine. Fam Med 2013;45(10):739-740.

In June 2015, most of OHSU Family Medicine's third-year residents did not graduate. Rather, they celebrated something a little extraordinary – the promotion to their fourth year of family medicine education. Now, they are in the middle of an experience unique to just a few family medicine residents in the country. 

The concept of a four-year family medicine residency is not new; studies and papers have been published as far back as 2004. Implementation of four-year residencies, however, is just now gaining steam. OHSU Family Medicine's decision to move from a three- to a four-year residency in 2012 was not taken lightly. First, the department had to consider what family medicine will look like in the near future, what new family medicine physicians should be capable of and how the department should prepare these physicians. 

"We wanted to reflect on the fact that residency training in family medicine has changed dramatically in 45 years since the specialty was created," said Roger Garvin, M.D., assistant professor of family medicine and family medicine residency director. "It was time to look at the Affordable Care Act, how it affects what family physicians need to do in the future and what it was we wanted to teach and learn."    

Over the course of several years, OHSU Family Medicine's residency team consulted with several groups. They met with physicians in practice to talk about what they wished they had learned in residency and what they hope their future colleagues will know and be able to do. The team also met with present faculty to reevaluate the residents' current scope of practice. "We needed to know if we were trying to teach too much," explained Dr. Garvin, "if we were trying to be too broad." 

Out of all of the department's conversations, some very clear messages evolved: 

  1. Oregon needs family physicians who are broadly trained in terms of the full scope of family medicine. This meant that OHSU Family Medicine would need to continue to train its residents in maternity care, inpatient care and care of all ages –from newborns to the elderly. Exposure to rural medicine would also be essential. 
  2. Training should include development of leadership skills. In the world of CCOs, ACOs and PHOs, family medicine physicians need to have strong voices as advocates of primary care – both for the specialty as a whole, as well as for its patients. 
  3. Family physicians need to have an understanding of population health. Various levels of health insurance expansion across states have shown us that just insuring patients is not enough to understand and improve public health.
  4. New family physicians need to be competent enough to lead as soon as they enter the workforce. "When you graduated from residency 20 or 30 years ago, you would join physicians who knew you weren't completely trained and would help mentor you," explained Dr. Garvin. "Now, if we're going to do what we need to do in the Patient-Centered Medical Home, our residents may need to join practices as mentors rather than mentees." 
  5. Residents had to be adequately trained to use information technology. If used correctly, Electronic Health Records can be an excellent tool in managing population health, and OHSU Family Medicine wanted to be sure their graduates know how to ask the right questions and interpret those answers. 
  6. Residents should have the opportunity to prepare themselves for future practice by focusing on an area they are passionate about. 

Finally, in examining previously-existing four-year programs and surveying students, Dr. Garvin and Patty Carney, Ph.D., professor of family medicine, outlined a study that determined most applicants were not deterred by the idea of a four-year residency. With all of this in mind, the group created the components of a four-year residency. 

At the same time, the Accreditation Council for Graduate Medical Education (ACGME) had begun the process of formulating a Family Medicine Length of Training Pilot, with the intent of studying the effectiveness of extended family medicine programs. Whether or not the pilot would launch in 2013 was still undetermined, but for OHSU Family Medicine, the decision had been made. "We felt strongly enough that it was the right choice to transition to a four-year residency," said Dr. Garvin. "So we decided to go ahead and do it whether or not the pilot launched."

Shortly after OHSU Family Medicine transitioned to a four-year program, the ACGME formally announced that its Length of Training Pilot would begin in July, 2013. OHSU Family Medicine is now one of 12 schools participating. 

Since the inception of the four-year residency, OHSU Family Medicine's curriculum looks very different. Residents see more rotations in population health, leadership and technology. They also spend more time in the community, learning about food banks and other community resources vital to their patients' total wellbeing. Specialized training in pediatric care, maternity care and geriatrics has also increased. Residents with an interest in academics now have the opportunity to shadow faculty and develop skills in education and supervision. And, because residents have more time to fulfill their academic requirements, they have room in their schedules to participate in long-term projects and studies, called capstone projects.

"What we hoped to come out of the capstones," explained Dr. Garvin, "is that a resident can find a passion for something they want to do more. Whether developing a curriculum or conducting research, we want them to have an end product that will further their careers and act as a learning opportunity." Many of the residents' capstone projects, such as improving care for children and adults with Down Syndrome or bringing telemedicine palliative care to rural communities, will live on as services offered by OHSU even as residents leave. Residents will also carry their knowledge and specialized skills to wherever they practice in the future. 

The residency program has also partnered with Kaiser Permanente. The partnership is mutually beneficial in that Kaiser Permanente now has the opportunity to support the growth of family medicine in Oregon by helping fund the fourth year of OHSU Family Medicine's residency. Three first year residents are currently in place at Kaiser Permanente Beaverton, and others are rotating through to gain experience in Kaiser's unique practice structure. By July 2018, Kaiser's Beaverton clinic will host 12 of OHSU Family Medicine's residents. 

"As a department, we have never lacked resources like learning opportunities or mentors, but our residents didn't necessarily have the time to take advantage of them," said Alex Verdieck, M.D., assistant professor of family medicine and associate residency director. "Since we added the fourth year, great mentorships and projects have improved training in pediatric care, adolescent health, leadership skills and other areas that are still evolving." In spite of concerns that residents would balk at a fourth year, applicant interest has, in fact, increased. 

First year resident, Mustafa Alavi, M.D., reflected, "I chose a program with a four-year residency because it would allow me the flexibility to pursue my passions within Family Medicine." Of his fourth year colleagues, Dr. Alavi said, "seeing the first group of fourth year residents go through the program has been so inspirational…they are so confident and knowledgeable in their practice styles and go out of their way to make sure we as interns feel supported." 

"In the fourth year, we have had the opportunity to grow into our roles as independent practitioners in a supportive environment," shared fourth year resident, Anthony Cheng, M.D. "We have been able to learn leadership skills that traditionally fall outside of the domain of residency training but which are important, since physicians inevitably find themselves in leadership roles within their clinical work."

Whether OHSU Family Medicine residents go on to work as physicians, medical directors, educators or leaders in healthcare policy, they leave their residency equipped to advocate for public health and primary care. "When we meet with healthcare leaders across the country, we talk a lot about where the future is going, and they say OHSU Family Medicine is already there," said Dr. Garvin. "No one knows what primary care is going to look like in five years, but we're creating the people who can shape it."