Since the clinic began the Primary Care Renewal project, the number of diabetics who miss their scheduled blood sugar tests has dropped by 26 percent.

When Jenine Napoli, forty-six, walks through the halls of Central City Concern’s Old Town Clinic on W Burnside Street downtown, the nurses, doctors, and medical assistants stop to chat with her. It’s hard not to: Napoli is a habitual smiler, a waver and a gabber, the sort who asks How you doing? and won’t settle for a one-word answer. She’ll talk about anything—including the problems that brought her to the Old Town Clinic in the first place, namely an addiction to crack and alcohol. Low on funds to support her habit, she wrote some bad checks and eventually ended up, for the second time, in Hooper, Central City Concern’s detox center.

“This place is a God shot,” she says of Central City Concern. “It really is.” After twenty-one months of sobriety, Napoli is studying nursing at Portland Community College and lives in an apartment in Central City’s Richard L. Harris Building, around the corner from the clinic. She tells me that her primary care doctor is Barbara, her acupuncturist is Chuck, her medical assistant is Patty. “These guys helped save my life,” she says. On the day I meet her, her doctor has just taught Napoli a song to help her remember the parts of the nervous system for physiology class.

“Our primary commodity is relationships,” explains Ted Amann, Central City’s director of health care. “With no relationships, nothing happens.” Old Town Clinic’s clients, 45 percent of whom have no health insurance and many of whom are homeless, love the clinic not only because they don’t feel judged here, but also because they know their needs come first. Old Town is the closest thing to a home many of its clients have. “Even if my situation changes and I have a good job,” Napoli tells me, “this is where I’m coming [for care]. Barbara is my doctor, and she always will be.”

Since implementing the medical home model, Old Town beefed up its staff for a period of time until it cut its average wait-time for an appointment from seventeen days to three; routine exams and preventive checkups that once fell lower on the priority list now are considered as important as acute problems. The staff works in three teams—Team Burnside Bridge, Team Skidmore Fountain, Team Park Block Pioneers—and each patient knows which team he or she belongs to. Team members’ names are displayed at the intake desk.

Other aspects of the medical home have been more difficult to manage. For one thing, because many of Old Town’s clients are homeless, it’s harder for staff to summon them for regular checkups or remind them about appointments. Old Town lacks the funds to buy an electronic health records system, which can cost some $1 million; this leaves staff to pore over paper files that can stack a couple of inches thick. And while behavioral health consultants at other clinics primarily may help patients with simple concerns like how to set goals for a weight-loss program or how to handle stress that might prevent someone from taking his medication on time, that sort of counseling can have little effect on someone who is worried about where he’ll sleep tonight. “Most people have no family, no nothing,” says Eryn Joyce, the clinic’s behavioral health consultant, who also has treated people who are suicidal, or high on methadone, or in extremely abusive relationships.

Perhaps most difficult is changing the culture of the offices themselves. Each clinic in the Primary Care Renewal project faces a unique set of circumstances (serving immigrants, the homeless, working with a revolving cast of medical residents) that makes it impossible to prescribe a single model that works in every setting. Change, for many staffers, is difficult. “We can only move at the speed of relationships,” says Maryna Thompson, who manages Legacy Emanuel’s internal medical clinic. She adds that developing trust among team members is crucial. “There just isn’t a book out there that says, ‘This is how thou shalt do primary care renewal.’”

Even learning how to manage seemingly minute details requires an endless process of trial and error. When Multnomah County decided to switch off the automated appointment reminder system, for example, teams at Mid-County had to figure out how to make the calls themselves. (No small task considering the language barriers involved.) On DeFontes’s team, one person agreed to coordinate the Spanish calls with an interpreter; one bilingual medical assistant agreed to call the Russian clients; calls made in English fell to the team assistant (and the whole team agreed to create space and time for him to do it); calls in other languages, like Burmese or Arabic, would be funneled through the Multnomah County language line. But not everyone was happy with their new administrative duties. “You have to have buy-in, which is true of all change,” says DeFontes, noting that even the medical home doubters have to be brought along.

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