Beyond medicine: Primary care clinics heighten attention to patients’ social needs

A.F. Williams, Lowry clinics add outpatient social worker
Feb. 3, 2016

At first glance, Pornpimol Sanitkhum and Tony Dotson have little, if anything in common. Sanitkhum (aka Lang) is a slightly built 60-year-old native of Thailand. Dotson, 38, is a burly African-American originally from Chicago. If they met, they would understand little of what the other said without an interpreter.

Social worker Autumn Kuehl, MSW, helps providers at AF Williams Family Medicine and University Medicine – Lowry who have patients with issues such as housing, transportation, and employment that can interfere with their medical care.

But in at least one important way, Lang and Dotson are united in their experience. They both have serious medical issues complicated by poverty, isolation and other barriers to care. Both understand what it is to be without a home. Lang only recently acquired stable housing in an assisted-living facility. Dotson has lived in his car for the past two years.

Lang and Dotson are among those who sail without a rudder through the twisting channels of the social services and health care systems in Colorado. Their clinical needs are routine for many people: medications for high blood pressure, appointments for new glasses, a CPAP for sleep apnea, for example. But meeting those needs is an uphill struggle because they and many patients like them lack the basic stability in their lives that many of us take for granted.

More than medicine

At University of Colorado Hospital, two clinics, A.F. Williams Family Medicine and University Medicine – Lowry, have taken steps to meet that challenge by adding a social worker, Autumn Kuehl, MSW, onto their teams. Having a social worker on their teams is a first for A.F. Williams and Lowry. Social workers also provide help at the hospital’s specialty clinics; Kuehl is working to coordinate patient care with them (see box).

Their broad goal is to help people with limited resources manage their own health care, avoid unnecessary trips to the emergency department and hospital admissions, and maintain regular contact with their primary care providers.

“My job is to connect patients with the needed resources at the right time to provide patient centered care,” Kuehl said.

To make that happen, she works with providers at the two clinics to address patients’ often complex social needs. She makes phone calls to appropriate agencies, helps with paperwork, looks for insurance coverage, finds clothing and other basic supplies, and generally connects patients and families to resources they would have great trouble finding on their own.

The number of referrals is growing. Kuehl said she averaged about 40 referrals per month between the two clinics in the first couple of months after she joined UCH in March 2015. Today, the combined number is 70 to 80. The populations and challenges at the two clinics differ. A.F. Williams serves a large Medicaid population; a significant number are homeless. Patients referred at Lowry are generally much older. They frequently need home care and adult day services as well as help with insurance questions, Kuehl said. Mental health is a “huge referral need” for both clinics, Kuehl added.

It’s work that requires patience and an extensive network of community and government contacts. Kuehl developed both while working for the Colorado Coalition for the Homeless, where she saw close up people struggling to find housing in a tight market while also dealing with a meshwork of mental health issues, substance abuse disorders, and medical problems.

That experience equipped her for the challenges at A.F. Williams and Lowry. “I know what to expect,” Kuehl said. A helping hand brings breakthroughs that go beyond meeting material needs, she added.

“For a lot of the patients, the feedback I’ve gotten is that a physician listened, and someone called to help,” she said. “They have someone to talk to and someone to listen to their needs.”

Beyond the exam room

Providers have benefited from Kuehl’s help as well, said Corey Lyon, DO, medical director for AF Williams.

“As providers, we’ve always known that we need to help many of our patients with more than medications,” he said. “The problem is that meeting those needs has fallen to physicians or nurses who have no training or knowledge about finding the resources that are available.” As a result, Lyon said, providers often don’t ask patients questions about their social situations, like what might make it difficult for them to get their medications and stick to taking them.

With Kuehl on board, providers are asking patients those questions, knowing that they have someone who can help, Lyon said.

“It’s opened my eyes to how many patients we have who face significant barriers to improving their health,” he said. “The truth is we have to deal with the social determinants of health, and then we can focus more clearly on medical issues,” he said. “For years, we’ve been frustrated as providers when we make no progress at getting patients healthy. We know now that we have to look at their social situations and mental health issues.”

The addition of Kuehl is another step in the long-running effort by UCH and the CU School of Medicine to build patient-centered medical homes that offer a continuum of care and services under a single roof. She focuses on patients’ most pressing immediate needs, while care managers at A.F. Williams and Lowry coordinate their medical care. A care manager, for example, might set up a patient’s dialysis treatments, while Kuehl makes sure he or she has transportation to get there.

Together, Lyon said, the sharper focus on treating the whole patient has helped to create a new “clinic-wide culture.” Binders holding information about community resources for patients are now readily available and providers and staff are aware of them, he said.

Broad barriers

The cases of Lang and Dotson simultaneously illustrate  the help Kuehl can provide patients and the challenges to doing so. In both cases, housing, or the lack of it, was a major problem.

Speaking through an interpreter during a recent visit to the UCHealth Eye Center, where she is receiving treatment for cataracts, Lang said she came to the United States from Thailand 40 years ago. She lost her apartment after her husband of 38 years died in 2012. She bounced between friends’ apartments, surviving on Social Security retirement checks. Lang said she has a son and daughter in the area, but they “have families of their own and don’t take much notice.” An uncle is her primary source of help.

An island of stability for Lang is A.F. Williams, where she has received care from physician assistant Julie Przekwas, PA-C. Przekwas helped Lang manage her high blood pressure, cholesterol, and diabetes and connected her with the UCHealth Eye Center. Kuehl, meanwhile, set up a dental appointment for Lang to get dentures. With Kuehl’s assistance, Lang also completed the paperwork for a Direct Express debit card for her Social Security payments. That eliminated cashing a paper check – an invitation for theft and abuse – and helped her get her money quicker.

The major breakthrough, however, was securing housing for Lang, which took months. Kuehl worked through Home and Community Based Services (HCBS) to complete an application for Lang and set up an appointment with an interpreter with Colorado Access, which is the single entry point connecting Colorado Medicaid patients to services. After a long waiting period, Lang was approved for HCBS services. With help from All About Seniors, Inc., a free service, she found a spot in an assisted-living facility in Littleton. Transportation to her appointments is still a challenge, but Kuehl connected her with Total Transit for assistance. The Littleton facility is farther away from her family, but the owner of the facility has another one in Aurora, closer to where they live. When there is an opening, she can move there.

“She’s been helping me a long time,” Lang said of Kuehl. “She is taking good care of me.”

Without a home

Dotson’s turbulent path began a couple of years ago after his vision deteriorated from what turned out to be fluid in his brain. That cost him his warehouse job with Petco in Aurora. He said he received a stent to relieve the pressure, but still suffers from chronic, painful headaches. He takes pain and blood pressure medications and needs a CPAP mask because of sleep apnea.

The mask is not a possibility at this point because Dotson lives in a banged-up car his brother gave him two years ago. He runs the engine off and on to stay warm when the temperature drops, and picks up a little money driving friends who need a lift. That and periodic temporary jobs pay for his phone, his lifeline to Kuehl and the everyday world.

Kuehl with Pornpimol Sanitkhum
Kuehl with Pornpimol Sanitkhum, a native of Thailand and long-time patient at A.F. Williams.

With Kuehl’s help, Dotson recently got on a waiting list for Section 8 low-income housing. The available units are so tight that communities hold lotteries to choose individuals for vouchers they can apply toward housing payments. Dotson was chosen in the Jefferson County lottery, an event Kuehl likened to winning the real lottery. She helped Dotson fill out the paperwork to complete the process so he could begin looking for a landlord willing to accept the vouchers.

His fortunes also seemed to be looking up on the employment front. Dotson found a warehouse job that didn’t require a great deal of exertion, and there was a chance that it could go full-time. It was a promising development because his medical conditions make it difficult to find and hold a job.

“I take pain medications every day,” he said. “They help me manage it, but I can’t bend over quickly or laugh too hard.”

But problems cropped up. To use the voucher, Dotson needed a Jefferson County address – a tall order for a homeless person with no contacts in the county. Kuehl suggested getting a post-office box, but that required a matching address on another piece of documentation. They met that challenge by updating his voter registration card online, but he wasn’t able to find a unit in the month allotted him to use the voucher.

“It all fell through,” Dotson said.

Meanwhile, Dotson lost his job because he had too many absences for medical appointments. He said he’s in a tough position. If he tells a prospective employer he has serious medical conditions, he’s afraid he won’t get hired. If he doesn’t discuss it and has to miss time for appointments – his medical record over several years at A.F. Williams and other UCH facilities fills several pages on a computer screen – he knows he risks losing the job anyway.

But with Kuehl’s help he carries on. She’s working with him to apply for Social Security disability and unemployment benefits and food stamps. During a recent visit to the clinic she gave him a few blankets AF Williams collects to help patients like him through tough times.

“With the paperwork for food stamps and unemployment and pillows and blankets, she’s given me a lot of help,” Dotson said.

Long road

Tony Dotson receives blankets
Tony Dotson receives blankets A.F. Williams collects to help patients in need.

The problems that Lang, Dotson and many other patients face are complex, but Kuehl takes them one at a time. She also informs providers about the issues patients face and what she can do to address them.

“The reality in Denver, for example, is that for many patients, finding housing is not realistic. The waiting lists are years long. I tell them there are problems I can’t solve, but this is what I can do to help,” Kuehl said. “I feel that if we can help patients meet some of their everyday needs, a lot of these medical issues would go away.”

That’s a goal that can’t be ignored, particularly as UCH and UCHealth expand their footholds in metro Denver and the rest of Colorado, Lyon said.

“As we grow, there will be more and more patients with social needs,” he said. “Right now, we are only scratching the surface. Unless we jump out front, we will not be tackling the population health issue that it is.”

The many helping hands of social workers

Social workers help patients and providers in many of UCH’s outpatient specialty clinics. Autumn Kuehl is helping to coordinate care with many of them, including:

  • Endocrinology
  • Gastroenterology
  • High-risk OB
  • Neurology
  • Plastic Surgery
  • Women’s Integrated Services in Health
  • Wound Care

About the author

Tyler Smith has been a health care writer, with a focus on hospitals, since 1996. He served as a writer and editor for the Marketing and Communications team at University of Colorado Hospital and UCHealth from 2007 to 2017. More recently, he has reported for and contributed stories to the University of Colorado School of Medicine, the Colorado School of Public Health and the Colorado Bioscience Association.