Keli Christman of Winding Waters Clinic
Keli Christman of Winding Waters Clinic

Primary care transformation: Winding Waters' remarkable journey

Clinic Operations Officer Keli Christman discusses the ways her 45-year old organization in rural eastern Oregon has used various forms of coaching to meet the demands of today’s primary care environment.

I’ve been in health care in Wallowa County for 26 years, and during my time at Winding Waters Clinic, we’ve completely transformed the care we provide.

To give you a better picture of our community, there are about 7,000 people in Wallowa County, with approximately 2.1 people per square mile. We are very frontier and very remote. Twenty-six years ago, I was working in assisted living, and I used to dread taking my patients to Winding Waters Clinic! Two physicians took care of the entire patient population: They worked in the emergency room and the hospital — and saw clinic patients. You could sit in the waiting room for hours, waiting for your patient to be seen because her physician was called to the hospital to deliver a baby or see a patient in the emergency room.

Heading in a new direction
I joined the staff at Winding Waters in 2006, a short while before we became involved in what would become the biggest influence in our transformation journey, the Safety Net Medical Home Initiative (SNMHI). At that time, we also brought a new physician on-board. New leadership, combined with the SNMHI collaborative and practice coaching structure, really helped push us in a new direction. Among many other changes, we implemented open access scheduling, a 24-hour physician advice hotline, and we started the shift to team-based care.  Our dream of true team-based care was realized in 2012 when we were invited by our local critical access hospital to design a new space within their medical office building being constructed next to Wallowa Memorial Hospital.  

In that time of transition, Wallowa County became a Governor Designated health professional shortage area, one of only two such areas to date in Oregon, and we became a rural health clinic. We applied for and were awarded federally qualified health center (FQHC) status in August 2015. These designations opened so many doors for us — paving the way to partnership and networking with folks across the state struggling with the same things we were. 

Whether we’ve compiled measurable data or not, quality has always been at the forefront of what we do. SNHMI set the framework for us to start getting good at quality improvement. It’s been evolving over time, and we’re getting better and better at it.

Our FQHC designation allowed us to officially become a non-profit organization. We’d been a for-profit acting like a non-profit, which I can’t recommend as a business strategy. Now we do more reporting, compile more metrics, and are under more scrutiny — and all of that gives us the opportunity to continually raise the bar. We’re in alignment, and it’s been phenomenal.

Grant funding opened even more doors
About five years ago we partnered with Northeast Oregon Network  and Wallowa Valley Center for Wellness (WVCW), our local community mental health agency, to apply for a Health Resources and Services Administration (HRSA) Small Practice Quality Improvement grant for the integration of behavioral health into our primary care setting.  That grant project provided salary support to WVCW to embed three part-time behavioral health coaches into our clinic.  All had previously worked as counselors and participated in a behavioral health certification process, which was a combination of online education and face-to-face training.

The coaches immediately became an integral part of our patient-centered team.  One of the coaches remained and became part of our organization after the grant ended. During that project it quickly became second-nature for our physicians to rely on coaches for help with motivational interviewing toward lifestyle changes around weight loss, diabetes, healthy eating, or anxiety — with the primary goal of having a positive impact on patient health. The providers have gotten very used to having our health coaches around: When one of our coaches is on vacation, and we only have one, I hear “Where’s our coach, I need her!” Having behavioral health coaches in our clinic is now completely natural to how we function.

When benefits for patients rise above costs
There’s an important aspect to health coaching I want to address: costs. We have a high Medicare and Medicaid population: almost 40 percent of the county’s population subsists below 200% the federally designated poverty level. Health coaching was initially offered to patients as a free service through the resources in our HRSA grant. After the grant ended, we felt compelled to collect revenue for this service so we instituted a five-dollar fee for each 30-minute visit.

Our uptake just tanked. Our coaches told us, “I’m not very busy. I feel like I’m missing patients, they’re not coming back to see me.” A five-dollar charge was truly a barrier.

So we re-evaluated this and went to our board of directors. Their perspective was:  if our providers and clinicians really think this is a valuable service, then let us provide it without charge.

Our board’s support has enabled us to go back to offering behavioral health coaching as a free service. It has been almost a year now, and we’ve seen the tide turn. Coaches are once again busy, and health coaching visit counts continue to grow. Patients have better controlled diabetes and hypertension, and there is a lot of engagement around healthy eating. Our health coaches can connect patients with vouchers to purchase fruits and vegetables at the farmer’s market. We also have a budget for helping patients with temporary housing, transportation, dental care, and prescription drugs. 

Keeping our good work going
Our coaches are constantly coming up with new ideas—like let’s do a cooking class, etc. Behavioral health coaching provides services that fall into the ‘soft’ category:  We can’t always attach hard data to outcomes, but they make a definite impact on our patients’ lives and their engagement with health care.

We look for every opportunity to continue improving, and we’re always on the search for the right people to lead projects. Two years ago, we enrolled in Healthy Hearts Northwest to help us get a better handle on cardiovascular risk factors. That project brought coaches into our clinic once again, but this time to work with staff in helping us sharpen our capacity to compile metrics.

Today we have 52 employees, including a full-time data analyst and a quality improvement director. We treat the entire person by integrating behavioral health, oral health, and primary care services. I am exceptionally proud of the care we offer to our community. Winding Waters is going places I would never have dreamed possible. 

Keli Christman is Operations Officer at Winding Waters Clinic in Enterprise, OR.

For Wallowa County citizens, community health centers like Winding Waters provide affordable, high-quality and patient-centered primary health care that would otherwise be out of their reach. Learn about the history and growth of the Health Center Program and its national impact on the health of underserved and vulnerable populations.

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