Bridging gaps

(First published in the October 4, 2018 issue of City Pages)

Bridge Community Clinic is moving toward an integrative model that makes medical and mental health care a cooperative effort under one roof

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About a year ago, Marathon County Chief Deputy Chad Billeb encountered a man having a profanity-laced rant in the downtown area. The man had schizophrenia, Billeb says, and was loudly arguing with God and causing a disturbance punctuated by a few choice words.

Billeb asked more questions and found out the man suffered from a tooth that needed to be pulled and a urinary tract infection, which can be serious if untreated. Considering the combination of mental illness, a physical health problem and a dental issue, Bridge Community Clinic in Wausau was the first place Billeb could think to send him.

It’s unknown if he ever got there; the man distrusted law enforcement and wouldn’t allow Billeb to take him. But that incident illustrated to Billeb and others the need for more multi-pronged approaches to health care, especially for the area’s less financially secure population.

Bridge Clinic has been revamping its care model to be even more inclusive over the past few years. Assisted by a series of grants, the sliding fee-scale health service is turning toward an integrated health model where all aspects of treatment—dental, primary care, and behavioral issues health (which includes mental health and addiction as the two often go hand in hand) — are handled under one roof. A recent federal grant will help it move closer to that model.

Why does that matter? Because of the 12 issues that the Marathon County Board identified in its narrowly focused and results-oriented strategic plan, three of them are related to mental health and getting a handle on drug addiction. Though some might see county-level government as more about road maintenance, law enforcement and land planning, social and health services is a huge part of its responsibilities and budget. That’s why one fourth of the county’s core focuses through 2020 is related to those two issues.

They top the county’s Community Health priorities, which is diagramed as an inverted pyramid, with alcohol and other drugs at the top, and behavioral health right underneath. It’s important to note that childhood trauma takes the No. 3 spot, because of its link to mental health and drug addiction.

It’s not hard to see why those are the county’s priorities. While Marathon County’s drug overdose death rate is lower than the Wisconsin average, at 10.4 per 100,000 residents for 2014-2016 compared to the state’s total 16.3 per 100,000, the local rate seems to be increasing, despite a downward trend statewide. In 2016, the county’s overdose rate was 13.4 per 100,000, according to a report prepared by county health officer Joan Theurer, while the statewide rate was 18.5 that year. Theurer’s report concludes that Marathon County has been proactive in combating the opioid crisis but could do more to combat the drug crisis.

Integrative care models, where all aspects of health are addressed under one roof, is a step in the right direction. And because Bridge Clinic and other federally supported community health services already physically have those services in one place, they’re in a great position to fully transition to this model, and many have. “We’re perfectly poised to do this,” says Bridge Community Clinic Executive Director Jennifer Smith. “If not us, then who?”

A local priority


From left, Executive Director Jennifer Smith, Medical Director Ryan Gossett, therapist Ryan Jacobson and dentist Tessa Laber represent some of the fields that will work together to provide full patient services at Bridge Community Clinic.

An alarming trend in the past three years has been popping up in the medical examiners office. Drug overdose deaths has been through the roof. Up until about 2012, the county had been seeing about six overdose deaths every year—a disturbing number to be sure, but a number that more than doubled in recent years. According to recently updated data from the Medical Examiner Jessica Blahnik, Marathon County saw 15 overdose deaths in both 2016 and 2017.

And that’s with a county full of paramedics trained and experienced with handling overdoses, and armed with naloxone (also known by its brand name Narcan), which counteracts the effects of opioid drugs.

The impacts of drug abuse in Marathon County go far beyond those deaths. They’ve led to about $500,000 per year in additional money spent on housing children removed from their families, mostly because of drug abuse issues.

Paired with mental illness, it’s one of the driving forces behind why the jail is so overcrowded. Despite a capacity in the high 200s, the jail population has consistently been near or over 400, forcing the county to fund the transportation and housing of inmates in other county jails. Drug abuse even led Marathon County to join a multi-county lawsuit against pharmaceutical companies over their role in pushing pain medication without disclosing how addictive they are.

According to statistics from Melissa Moore, Marathon County Drug Free Communities coordinator, 90% of inmates at most prisons abuse drugs or alcohol, and nearly half are clinically addicted.

County Health Officer Joan Theurer found herself about a month ago fending off a suggestion the county cut $200,000 from its funding of StartRight, a program that sends health department workers to the homes of babies and young children to help provide the tools, information and resources for new parents. Those visits also serve as a window into the lives of the county’s young children, and can help prevent the kind of early childhood trauma that can later lead to drug abuse or mental illness.

In light of the county’s priorities, Bridge’s plan to integrate health care services, including in-house addiction treatment, fits with the county’s plan perfectly, Theurer says. She also cites the school-based Youth Counseling Consortium, a partnership of several organizations, including Bridge Clinic, as another example of that coordination. “There is an agreement across all sectors that we need to create opportunities to help people understand that one’s mental health is just as important as one’s physical well-being,” Theurer says.

Office Changes


AODA and mental health top Marathon County’s identified health priorities for good reason: They’re driving forces behind a maxed out jail population.

Under the integrative model, mental health and addiction treatments will be addressed just like medical care, Smith says. If someone comes in with a foot problem, that person is X-rayed, and maybe sent to a specialist in the building. The hand off for mental health and addiction services should be just that easy, Smith and others says.

Bridge received a $175,000 federal grant last year to facilitate this change, which included funding a part time psychiatric nurse practitioner. This year the clinic received roughly $285,000, and that will include hiring a full-time psychiatric nurse practitioner. That will allow Bridge Clinic to more fully address mental health; the part-time psychiatric nurse right now can only keep up with managing meds for existing patients.

The new grant also will allow Bridge to better address AODA counseling. The clinic now can perform assessments but must refer patients elsewhere for any treatment. Soon Bridge will be stepping into the role of AODA counseling and addressing the opioid epidemic directly.

Transitioning into a new model of care that includes integrating behavior and physical health is not as easy as it might sound, even if all the different providers are under one roof. Becoming a team-based model means a lot of workplace changes, training and different workflows, Smith says.

All those daily systematic changes matter, because mental, physical and dental issues often don’t fit into nicely made silos, Smith says. “Is there past trauma that’s fueling mental health, which is fueling stress, which is fueling physical health, and potentially driving self-medicating behavior and addictions?”

The next steps are training: Staff will work with a clinic in Tennessee that’s known for its integrated care model, as well as two similar clinics in Wisconsin. There are several different models to this type of care, Smith says, and Bridge leaders will need to evaluate in the next several months which model will work best for the Wausau area. At some point, a building update to better accommodate the integrated model will be considered, Smith says. That’s a few years down the road.

And then there’s the public education. For example, anyone can use Bridge Community Clinic, even those covered by traditional health insurance. Billing is determined on a sliding fee scale. It’s a fully operational, modern clinic, with the high-tech medical and dental equipment one would expect of any health care office. Smith says there are a lot of misconceptions about the clinic to be overcome.

Bridge Community Clinic isn’t pursuing an integrative, collaborative approach alone. Smith points to the school-based Youth Counseling Consortium as a good example of how Bridge partnered with other organizations to provide more mental health services at schools in the Wausau area. When she presented at a conference in Sheboygan about the consortium, people asked, “How did that happen?” “I told them, ‘this is how our community is built. Collaboration is strong here’,” Smith says.

Billeb agrees with that assessment, and says it will take all community elements working together to effectively tackle drug and mental health issues. Bridge Community Clinic already is a key partner for the Marathon County Sheriff’s Office, Billeb says. Bridge sends advocates a few times a month to the jail to help inmates reconnect with benefits so they can receive the care they need after being release. Those benefits, such as mental health care, might be a critical factor in whether or not they return to jail—most are more likely to reoffend if they no longer can afford medication or counseling, for example.

Medical organizations that can change how they operate, like Bridge Community Clinic, will be critical in the overall effort to reduce problems stemming from untreated mental health concerns, says Laura Scudiere, an executive at North Central Health Care in Wausau. “Bridge and other [community medical providers] are key partners that want to be part of the solution, and have that vision,” Scudiere says.