At this clinic, the doctor is out

New clinic takes MD out of primary care equation
February 3rd, 2016

At the new CU Healthcare Partners @ Belleview Point clinic, the doctor is not in – and that’s the idea.

The University of Colorado College of Nursing (CON) clinic opened Jan. 19 in a bright second-floor space in a modern strip mall at Parker Road and Belleview Avenue in Aurora. It takes the proven notion that advanced practice nurses (APNs) can provide first-rate primary care at affordable prices to its logical conclusion.

HCP Belleview’s full-time staff includes a family nurse practitioner, a licensed clinical social worker to consult with patients on the behavioral aspects of whole-person care, a medical assistant/receptionist, and an office manager. It’s a lean operation, this gleaming clinic above the Chubby’s Fresh Mexican Grille, but it’s also innovative on the financial end. The clinic offers both low-cost fee-for-service as well as subscription-based direct primary care options. The latter involves a flat monthly fee ranging from $19 (for those ages 2-18) to $79 (50 and older) – with no co-pay.

The CON invested about $300,000 in launching the clinic, says Adrienne Wolf, MPH, the clinic’s operations manager; if it’s a clinical and financial success – it may take a year to 18 months to determine that – the plan is to open more clinics where the doctor is out.

From left, Adrienne Wolf, Kristen Petrelli and Carolyn Hughes at the CU Health Partners at Belleview Point clinic.

The new clinic was Amy Barton’s idea. Barton, RN, PhD, is chair of Rural Health Nursing at the CON and a longtime proponent of addressing the shortage of primary care physicians by having APNs work at the top of their games.

In Colorado, nurse practitioners (NPs) are allowed to diagnose, treat and prescribe medication without physician oversight. It’s hard to find a primary care clinic that doesn’t harness their talents to some degree. They are a mainstay of care for the underserved, and they’re the focus at CON’s Sheridan Health Services, whose establishment Barton also led. But it was a second APN-focused practice, the Center for Midwifery, that hinted at the potential for combining NP-based care with a direct primary care subscription approach, Barton said.

“The Center for Midwifery showed that there is a demand for advanced practice nursing services, and people are willing to pay for it,” Barton said.

Symbiosis

Not that the NP can do everything, said Kristen Petrelli, FNP, the board-certified family nurse practitioner who spearheads patient care at HCP Belleview. Petrelli took the job after a decade working as an oncology nurse, most recently with the multidisciplinary Lung Cancer Clinic at the University of Colorado Cancer Center at University of Colorado Hospital (UCH). She made the switch in part because she saw how improved access to primary care could have helped catch cancers sooner, she said.

“I thought it would be great to manage chronic needs and get to things earlier,” she said.

She says the clinic is establishing close relationships with UCHealth providers at the Anschutz Medical Campus, where she refers patients with complex, chronic or serious conditions. The referrals go both ways, adds Wolf: The UCH Emergency Department has referred patients to HCP Belleview for primary care follow-up. She views the relationship with UCHealth as symbiotic. They chose the clinic’s location because it was far from other UCHealth’s primary care clinics; going forward, she hopes to be referring patients to (and receiving referrals from) the nearby UCHealth ERs at Mississippi Ave. and Chambers Road and at E. Smoky Hill Road and E. Arapahoe Road.

That’s not happened just yet, Wolf said, because she’s been busy being what amounts to a health care startup entrepreneur. She took the job in March, just as Barton signed the lease, and spent the ensuing months helping to establish everything from décor to service delivery. The latter involved building a list of services –  relating to strep, blood sugar (there’s onsite HbA1c testing), sprains, skin conditions, stitches, smoking cessation and a raft of others – and then coming up with prices. She benchmarked to come up with the clinic’s retail prices (now posted on the website in a deliberate effort to be transparent, Wolf said) and then worked with Barton to come up with the monthly/annual direct primary care pricing.

“I had this big spreadsheet matrix, and from that, we narrowed it down to what was competitive,” Wolf said.

She also contracted with the Denver Health NurseLine for 24/7 phone consults for patients and with electronic health record provider Aprima, which interfaces well with UCHealth mainstay Epic but is less of an information behemoth.

“Epic would be like killing a flea with a sledgehammer,” Wolf said.

Start it up

She was also on the hook for publicizing the clinic’s opening. It attracted a deluge of attention: TV crews from FOX31, 9News, CBS4, and Channel 7 were all on hand when the doors opened on Jan. 19. A shower of email inquiries followed and continue to come in, Wolf said. About half the patients so far have been Medicare/Medicaid, she said, and while HCP Belleview accepts a growing list of insurance plans, many of the rest have been uninsured. For those with high-deductible insurance, she’s positioning the clinic – in particular the direct primary care option – as a way to address preventive and non-catastrophic care on a budget.

Colorado is among the top-10 states with people with high-deductible insurance plans, Barton said.

“The direct primary care approach allows them to pay for that membership fee and get primary care – we didn’t really think we were meeting an access need, but we are,” she said.

The goal is to see 4,000 patients the first year, and to introduce each of them to Carolyn Hughes, LCSW, on their first visit. The clinic has four consultation rooms – three outfitted as classic exam spaces and a fourth with a small couch and easy chair. This is Hughes’ domain, the physical expression of a belief in the inseparability of physical and mental health care.

“It is really our philosophy of care,” Barton said. And considering that two of the top five primary care diagnoses are anxiety and depression, she added, “How can you see that patient population and not provide behavioral health services?”

Patients in need of behavioral-health counseling (the initial, hour-long introductory session with Petrelli includes a short test for depression) will then work with Hughes, either as a warm hand-off or via a scheduled appointment. The counseling might involve tobacco cessation; it might revolve around grief and loss. Hughes takes all comers. She refers serious psychiatric cases to specialists.

“Right now, we’re just trying to engage,” said Hughes. “My job is to do brief, focused change interventions and engagement. I’m not going to have a caseload of 100 patients and see them for an hour laid out on the couch every week.”

For Hughes, the absence of a physician may be new, but it’s no surprise.

“Nurse practitioners are everywhere. Doing a stand-alone clinic like this was the next thing. It’s a fabulous model,” she said.

About the author

Since 2008, Todd Neff has written hundreds of stories for University of Colorado Hospital and UCHealth. He covered science and the environment for the Daily Camera in Boulder, Colorado, and has taught narrative nonfiction at the University of Colorado. He was a 2007-2008 Ted Scripps Fellowship recipient in Environmental Journalism at CU.

His latest book, "The Laser That’s Changing the World," tells the story of the inventors and innovators who saw, and ultimately realized, the potential of lidar to help solve problems ranging from smokestack-pollution detection, ice-sheet mapping, disaster recovery, and, ultimately, autonomous-vehicle guidance, among many other uses. His first book, "From Jars to the Stars," recounts how Ball Aerospace evolved from an Indiana jar company - and a group of students in a University of Colorado basement - to an organization that managed to blast a sizable crater in the comet 9P/Tempel 1. "Jars" won the Colorado Book Award for History in 2012.

Todd graduated with a business degree from the University of Michigan, where he played soccer, and with a master’s degree from the Fletcher School of Law and Diplomacy at Tufts University. Before becoming a journalist at the turn of the millennium, he was an IT and strategy consultant. He once spoke fluent Japanese and still speaks fluent German.

When not writing, he spends time with teenage daughters and wife Carol, plays soccer, and allows himself to be bullied by a puggle he outweighs by a factor of seven.