Written by: Briana Harris-Mills

This past April, Neighborhood Healthcare opened a new integrated satellite clinic in the main hub of Interfaith Community Services to better reach homeless populations.

We spoke with Wendi Vierra, Director of Operations, Behavioral Health, to learn about Neighborhood Healthcare’s partnership and the new satellite clinic.

What made you decide to open this satellite clinic? 

About three years ago, we began a strategic effort to address the social determinants of health (SDOH) needs of our patients to improve their health-related outcomes and well-being. Our mission is to improve the health of our communities. Our vision is to give people the resources they need to live their best lives. We understand we cannot do that alone. We need the expertise of our community-based partners to provide whole person care and provide a solid foundation for wellness.

We began with small grants to formalize our workflows in working with community-based organizations (CBOs). This grew to co-authorizing grants for larger multi-year projects. With each grant we write in positions for our CBO partner to strengthen our relationship. When they are stronger, we are stronger. At Neighborhood Healthcare we are better together! We live this every day with the partnerships we have been building and thinking outside the box to remove access barriers for our patients.

Why did you decide to partner with Interfaith Community Services?

Approximately 15 years ago, Interfaith Community Services was providing behavioral health services and asked Neighborhood Healthcare to take over. At that time Neighborhood Healthcare was primarily providing medical only services and Interfaith was co-located in one of our clinics. We took over behavioral health and expanded to integrate behavioral health in our primary care clinics. We have allowed Interfaith to remain in that original clinic to date as an in-kind relationship — no rent. Our relationship has been organic during this time, providing literal warm hand-offs to each other in the same clinic (Interfaith provides warm hand offs to Neighborhood’s behavioral health while Neighborhood Healthcare provides warm hand offs to Interfaith for housing, homeless services, food pantry, etc.).

This has been invaluable to our patients with regard to ease of access for our most vulnerable patients. We have expanded this effort through co-locating Interfaith in other clinics and providing a primary care clinic in Interfaith’s main campus since April 1. This satellite clinic provides insurance enrollment, medical, behavioral health counseling, psychiatry, and medications for addiction treatment (MAT) services.

We decided to put a clinic inside Interfaith because they serve the most vulnerable in our community — homeless, severe untreated mental illness, chronic untreated medical conditions. At this site, Interfaith has a 50-bed homeless shelter; Recovery & Wellness Substance Abuse program that provides detox, residential treatment on site, and intensive outpatient; and 50 programs to address the needs of this population. Again, removing barriers to accessing healthcare was our main goal.

How many patients do you serve?

Since April 1, we have provided services to 616 unique patients, with 918 medical visits, 479  counseling visits, and 427 psychiatric visits. We have enrolled 215 patients into Medi-Cal and 101 patients into Cal-Fresh. Key to this partnership that is not yet seen in quantitative metrics is the abundance of care coordination that happens behind all of this – providing warm hand off’s between agencies seamlessly on site.

What services do you provide?

Insurance enrollment, medical, psychiatry via telepsych, behavioral health counseling, and MAT maintenance. Inductions are done in person at a clinic close by.

Who makes up your clinic staff? Which members of your MAT care team are involved?

Our clinic staff includes one Certified Enrollment Counselor, one Patient Services Representative, one Licensed Clinical Social Worker, two Medical Assistants, two Family Nurse Practitioners, and one Physician Assistant.

Our MAT team includes our Medical Assistant, LCSW, and PA-C.

What is your workflow?

We have universal screening at intake and annually for Depression (PHQ9); Alcohol (AUDIT); Drugs (DAST); and SDOH. Any scores above thresholds are provided a warm hand off to our Behavioral Health Consultant (LCSW) who provides a more comprehensive assessment of behavioral health and SDOH needs, collaborates on a treatment plan with patient, and then triages as needed through referrals to additional treatment and warm hand offs to Interfaith.

What have you found is most successful for retaining patients?

Relationships – building a credible, reliable safety net that wraps around our patient and is non-judgmental, has cultural humility, and is trauma informed.

What’s your model for providing counseling and mental health services for your MAT patients?

Our behavioral health consultant provides the MAT intake to make sure criteria is met and determines if the patient is a good candidate for MAT.  She is also assessing for counseling and psychiatric needs. She provides MAT weekly psychoeducation groups that are required to participate in MAT. She also provides Naloxone Kit training and kit distribution.

What other partnerships have you established? What can you recommend to others interested in developing successful coordination and referral pathways?

Too many to list. We are strategic in who we partner with. We assess our patients through universal screening and then identify who in the community provides that resource. We then reach out and request a tour of that CBO to build relationships and fully experience that CBO. This makes a difference when we are referring patients to CBOs — when we can describe what it looks like, who they will meet with, and promote their services.

We invite our CBO partners to also tour our facility. We co-write grant opportunities with them to strategically strengthen our relationship. We provide letters of recommendation for each other when applying for county requests for proposals or other grant opportunities. Taking the time to build a personal relationship with CBOs has been a critical factor in our ability to coordinate care successfully and problem solve as partnership pains come up.

Is there anything else you think is critical to share with the larger network?

Everything is about relationships – whether these are between federally qualified health centers and CBOs, between all of us in learning collaboratives to share information, material, and best practices; or in between our patients and the services we provide – we must include their voice to determine what/how/when they receive services from all of us. We are all better together!



Find this useful or interesting? We’re constantly sharing stuff like this. Sign up to receive our newsletter to stay in the loop.