‘We started to think about really embracing substance-use disorder as a chronic illness’

At Family First Health, integrating substance abuse treatment with primary care has Jenny Englerth, become a key factor in battling the opioid epidemic. CEO of the York, Pa.-based federally qualified health center with six locations, said that doing so requires a cultural shift among clinicians, but that patients have openly embraced the approach. Even as Family First Health worked over the past year to create this integrated approach, Englerth and her peers watched anxiously as Congress played a dangerous game of hot potato with federal funding. Lawmakers allowed funding for community health centers to expire at the end of September, and the funding then became intertwined in a larger debate over federal spending. Eventually, Congress authorized two years of funding—$3.8 billion in fiscal 2018 and $4 billion in fiscal 2019. Englerth recently spoke with Modern Healthcare Managing Editor Matthew Weinstock. The following is an edited transcript.

Modern Healthcare: What kind of stress did the last few months of not having federal funding—and not knowing if it was coming—have on your organization?

Jenny Englerth: I like to frame it as a cumulative impact. Certainly, over the last few months, we were focused heavily on the reauthorization related to community health center funding, but we also are aware of changes to Medicaid and other benefits that support our patients—food subsidies, employment opportunities. All of those things either create strengths in the most vulnerable parts of our community or create increased vulnerability and stress and tension.

Feeling all those things cumulatively, the reauthorization debate was like an exclamation point on the stress of the past year.

MH: Can you expand on issues like food subsidies and employment and how the political climate affects your patient population?

Englerth: In south-central Pennsylvania, we are blessed with a pretty robust job market. We’re sitting at about 4% unemployment right now, which means that most everybody who’s likely able to be employed is employed in some way. But like most of the country, we’ve seen a shift from full-time, fairly waged jobs with benefits to multiple part-time jobs.

Most of our patients who are able to work are working more than one part-time job, but aren’t receiving benefits through their employer, and those part-time jobs are all vulnerable, so their income becomes more vulnerable over time. All of those factors come together to really impact health at a community level and then impact our role and the clinical burden that providers have to address, whether in a community health center setting or in a hospital or health system setting.

MH: How have those stressors directly affected Family First Health?

Englerth: Internally, maintaining an adequate workforce has become more and more of a stressor. Where people are finding training programs and how we are able to have a pool of candidates that best represents the communities we serve— everything from language to cultural understanding— just becomes more and more difficult. And we see expectations around salary and benefits continue to create more and more pressures on our environment.

As I look at our patient population, there’s a higher burden of mental illness, depression, anxiety and mood disorders that are most likely underdiagnosed and undertreated. And then, like so many parts of the country, we overlay an opioid crisis.

In addition, there’s a longstanding and inadequately served population with substance-use disorder.

MH: Mental health and substance abuse issues tend to go hand-in-hand. What kind of things are you doing to address those problems?

Englerth: We have probably traveled the path of many primary-care providers over the past five years, which was originally focusing on our own internal behaviors and prescribing patterns. In hindsight, changing our behavior without thinking about or understanding the broader picture likely contributed to some of the move from controlled substances to heroin.

Then we started to better understand the issue and started experiencing on a daily basis the stories— everyone from caregivers, parents, sisters, brothers, employers—talking about deaths due to overdoses in our community.

We knew that, just like we had undertaken an effort to integrate behavioral health to better diagnose and treat depression and anxiety in a primary-care setting, we had to play a similar role that wasn’t just about limiting or eliminating our prescribing of narcotics, but it had to be about doing something more.

We’re right in the thick of that cultural shift to really embrace as a primary-care provider that these are needs within our patient population, and we have to adapt and evolve our system in order to meet them. So we’ve taken on prescribing medicationassisted therapy, seeking additional resources so that we can build out a support team, which is the most important thing. It’s not just about writing that prescription for Suboxone or Vivitrol, but having a whole team that can … reframe treatment and recovery from a primarycare plan, which is pretty exciting work.

We’re experts for treating chronic illness. We understand how to do that.

When we stepped back and started to think about really embracing substanceuse disorder as a chronic illness, it opened lots of opportunities for us to engage in treatment.

As I said, we’re in the thick of cultural change and it is not something that all people coming out of medical school and residency have bought in to. There are a lot of adaptations that we have to make, but we’re really working hard among all of our staff to equip them with the knowledge so they can better understand substance-use disorders and chronic illness.

MH: Do you think patients understand this shift of trying to treat substance abuse as a chronic disease? Is that a barrier you have to overcome as well?

Englerth: We find tons of receptivity from patients. Right now we have about 250 individuals who are currently in our center of excellence for opioid use. We’ve only been up and running for about a year, but our experience is that it makes perfect sense to patients. They are accustomed to seeking out their primary-care providers when they’re dealing with any kind of health-related issue. Patients have been really receptive and have consistently provided us with feedback.

One of the things that we started hearing from some of our funding partners was, ‘What’s your discharge plan for people? How many days?’

It was our first abrupt example of, ‘Primary care is just completely different.’ We don’t discharge people; we recognize the treatment of chronic illness as a lifetime event. And we want to be part of that journey all along. That really makes sense to patients and it’s helped us engage with patients.

MH: Another issue confronting FQHCs is the relationship with other providers. We are seeing increased competition for patients between health centers and hospitals, as well as collaboration. What’s the dynamic like for you in Pennsylvania?

Englerth: We see all of the above. And the UPMC health system has just entered our corner of the world. So the dynamic will shift and change a bit, and we’re preparing for that. But in serving rural communities, we need to leverage the idea that we are all on the same team as healthcare providers.

I’ve been fortunate to work within a community where—and I’m not saying there hasn’t been tension and pressure and missteps on all sides—but in general, we’ve been able to have a conversation that really comes from that common framework and trying to leverage the FQHC assets along with the strengths that a health system and hospital can bring.

I know that sounds a little Pollyanna on my part, but my framework continues to be that if we don’t create it locally, someone in Washington is going create it for us, and we won’t be able to blame them at that point.

“In hindsight, changing our behavior without thinking about or understanding the broader picture likely contributed to some of the move from controlled substances to heroin.”

MH: You mentioned UPMC moving in. How have you been preparing for that?

Englerth: This again is probably sounding a little Pollyanna and simple, but there have to be personal relationships involved. People have to know my faith, and I have to know theirs. There has to be a localized connection. If we stay at arm’s length through emails and shooting messages through the media, then the conversation is unlikely to be collaborative.

At this point, just like I’ve worked with other health system partners, it’s really about building personal relationships and in that process, being open to learning their perspectives and their pain points and challenges and bringing forward ours as well.

We are experts in serving a community that they may want to serve for different reasons. I have always believed that some of our power can come from the knowledge and connection that we have to a community.