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Portland clinic a model of coordinated care, focus on prevention

Primary care nurse Julie Flindt ensures untreated depression won't derail her patients' health treatment plans.

When Julie Flindt graduated from nursing school in 2008, she knew where she didn't want to work - an emergency room. She had spent too much time there already, taking care of patients with conditions that could have been managed much more cost-effectively outside the hospital, or prevented altogether

"I knew my goal would be to keep people out of the hospital and keep them healthy," says Flindt, a nurse at the OHSU Richmond Clinic in Southeast Portland.

The Richmond clinic and its team-based practice is a model for the coordinated approach that is a centerpiece of Oregon's proposed transformation plan -- aimed at improving the health and care of people on the Oregon Health Plan. Keeping people with chronic illnesses such as asthma, diabetes, depression and congestive heart failure out of the hospital is a key component.

Team-based clinical teams typically include doctors, physician assistants, nurse practitioners, social workers, medical assistants and support staff, along with a nurse/case manager, such as Flindt. Her job is part triage planner, part listener, part coach, part cheerleader, part nag.

Another principle is care of the whole person. No patient is simply a diagnosis or a line in the chart. Dealing effectively with a condition such as diabetes requires more than a pill or an injection.

Maybe insurance issues or side effects prompted the patient to skip or quit treatment. Maybe trouble at home, or chronic pain, or a drinking problem, is the underlying issue. Maybe the patient, knowingly or not, is depressed.

"Nearly half our patients have depression on their problem list," Flindt says. "I can't get anywhere with them eating vegetables if I can't get them out of bed."

She spends a lot of time on the phone, checking up on patients.

"A little bit of coaching and reassurance on the phone goes a long way," Flindt says. If she finds out that one of her patients ended up in the emergency room for chronic back pain, she calls to check in and remind that patient:

"These are our hours and here's my phone number, and next time this happens, please call me first."