A small clinic’s big task

Dr. Dimitri Sirakoff is less harried these days. The general medicine doctor and founder of the aptly named Serve the People Community Health Center still dons his white lab coat 90 hours a week. But thanks to small foundation grants and local business support, the industrious physician has been able to hire a small staff to help him as he whips around his clinic providing services for a flood of poor, uninsured Santa Ana residents making their way to his waiting room.

The clinic, which opened its doors in 2009 and became a certified health center in 2010, offers the gamut of clinic services — all for about $15. Diabetes screenings, mammograms, and pap smears are all free. Dr. Sirakoff, who estimates that he now serves about 500 patients a month including walk-ins, said the clinic is likely only reaching one quarter of the local population who require medical care, but can’t afford it. He wants to make a bigger dent in the medical desperation he sees around him in his community.

Dr. Sirakoff’s lean new, professional crew — a physician’s assistant, patient navigator and office manager — have a collective goal: to earn certification to become a Patient Centered Medical Home which will allow them to serve even more people.

Under the federal Affordable Care Act or health care reform, clinics that win that PCMH certification would be in line to receive more patients. California supports implementing models for more comprehensive and coordinated care for the state’s most vulnerable residents to prepare for the additional people who will have access to health care.

One of the certification requirements is for each clinic to have a baseline assessment of their services and systems. Serve the People, as one of the health clinics in the Orange County Health Home Innovation Partnership, recently completed its initial evaluation conducted by the consulting group Health Team Works. The assessment measured everything from quality improvement to hypertension control, and focused on how each clinic addresses both chronic and common diseases. The smallest of the five clinics, Serve the People had the highest score in the categories of “information systems,” “patient-centered care,” and “coordinating care.”

“The consultants looked at where we need help, what we need to modify, and how to serve the population with more efficient, effective health care,” Dr. Sirakoff said. “This is far more stringent than any private practice goes through.”

On a recent Saturday, several dozen people, mostly Latino, are either waiting patiently in the cheery waiting room area or in one of the small exam rooms. Dr. Sirakoff donated the space in the two-story modest Spanish-style building, which he owns and where he operates his own private practice. One of his goals is to reduce the amount of time his patients, many of them walk-ins, spend in the waiting room. He recently made a big purchase: a medical records system, which will help clinic staff keep track of the voluminous piles of essential information, from a patient’s demeanor to their diagnosis and treatment history. The records system will put essential patient details at their disposal, so that the staff can schedule follow up appointments and make referrals. The clinic offers panoply of services including pediatrics, gynecology, asthma, diabetes, high blood pressure, ulcers, back pain and other areas of specialty care.

“We are trying to serve indigent people, but we are getting buried in all this criteria we have to keep up with,” Dr. Sirakoff said. “It’s a challenge.” The records system, once up and running, should help, he said.

The clinic’s new physician’s assistant, Esther Guardado, is also easing the administrative burden. Guardado came from the world of private practice medicine, where ordering an MRI or providing a patient with samples of a drug was commonplace. For her, the community clinic world is a big contrast. “The little things you can do — if I can get samples for a patient — it’s so much more appreciated,” she said. “So we are just trying to help the people that need it the most.” The clinic also has a new Patient Navigator, a recent college graduate and a certified health education specialist, whose job it is to help answer patients’ questions and review the doctor’s recommendations before and after exams.

David Silveira, a 43, is one patient with questions.

In one of the exam rooms, Silveira, who is unemployed and has no health insurance, has a host of medical conditions. With a thick chart in hand, Guardado ticks through the issues. They discuss how Silveira is managing his diabetes with his diet choices, how his sleep apnea has persisted, the nerve problems in arms and hands, his breathing difficulties, and his worsening eyesight. Thorough and efficient, Guardado makes dietary recommendations and refers him to a pulmonologist and an ophthalmologist for his outstanding complaints.

“You are really thorough with explaining everything and I really appreciate it,” Silveira said as he lifted himself off the examination table. “The good thing is I am keeping my blood sugar under control.”

What Silveira and other patients don’t know is that the clinic staff’s job doesn’t end there. They are constantly negotiating with dozens of doctors in the area to get a reduction in fees for tests or procedures that patients need.

On a recent summer afternoon, Dr. Sirakoff, had just seen a 47-year-old woman who came in for a follow up appointment. The woman had come to the clinic complaining of constipation and rectal bleeding. The treatments did not fix the problem, however, so they referred her to a gastroenterologist, where she was recently diagnosed with colon cancer.

“Now she has no money, what do you do with her? Where do you send her?” said Dr. Sirakoff, who plans to call doctors he knows and hospitals he works with to see if they can treat her patient pro bono. “That’s a big challenge. What are you going to tell that person, go home and die? That is what I have to work on this week.”

Isela Soriano, a medical assistant who was recently hired at the clinic, said she admires her boss. “I don’t think he sleeps or eats,” she said. “He is always running around helping people.”

Soriano also feels lucky to have landed a position herself, especially in this challenging job market. “Economically people are going through very hard times,” she said, as a patient handed over a $20 bill for services. “They don’t have good insurance so it’s a good thing we’re here.”

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