>>WILLIAM WARNING: The Center for Family Health in Springfield is an outpatient clinic of
Crozer Chester Medical Center.
The community is generally middle class, working class population.
We have a big influx of immigrants and refugees in certain parts of the county that we see
as well, so it's more of a global health feel to the office.
We are a family medicine practice so we literally take care of women when they are pregnant
and delivery their babies and we go all the way through pediatrics, adolescent, up to
geriatric care and end of life care.
>>BARRY JACOBS: This is a level 3 patient center medical home.
In our center here we have not just the family physicians, but we have nurse case managers,
we have a social work student, we have myself and 3 doctorate level psychology students,
we have pharmacists who come for our super utilizer team.
The super utilizer concept was developed by Dr. Jeff Brenner, a family physician in Camden,
New Jersey.
>>WILLIAM WARNING: They're really highly complex medical illness with overutilization.
So that means that these are patients who are going to the emergency room, to the hospital,
to a lot of offices, a lot of testing.
We have to have a very intense coordinated team to handle these patients.
So we actually kind of dial up services to what we call the super utilizer level.
Which means they get highly coordinated, highly concentrated care with the right person who
can manage that.
>>WILLIAM WARNING: Integrated care is really key for family medicine.
So we need a team to handle all the integration of care, and that team has to be really in
one place.
>>BARRY JACOBS: This is the primary training site for our family medicine residents.
I'm responsible for teaching them about the behavioral aspects of family medicine.
Many patients who have problems with depression or anxiety or psycho-social issues, poverty,
difficulty with transportation, marital issues – they don’t readily bring these things
up to physicians.
And so, by having our psychology students screen many of the patients who walk into
the office they are getting much more comprehensive service than most primary care offices can
possibly offer.
>>JOSEPH QUINTILANI JR: Mark will come up to me and say “you're seeing someone this
afternoon who I know or that I saw has this diagnosis and I think that it would be beneficial
for me to speak with them..
What do you think about that?”
and we will kind of discuss it and it's a great way to have the patient see both the
physician and a psychologist here at the office in one shot.
>>MARK CASSANO: To come into this practice and to be around physicians who are very open,
very accepting, very interested in the behavioral health component to their patients’ needs
has been really refreshing for me as a provider because I can feel comfortable approaching
him and saying “Hey, I’m concerned about this in your patient.
Let's have a discussion about it”
>>PATIENT: That’s why it's nice for me especially because I have this one this place where I
come for my primary care, and I can see Barry Jacobs and I know he is always there and I
can get to the other doctors if I need to.
>>TAMAR HALPERN: Doctor Jacobs kind of takes the list of patients every morning and circles
all the patients who may have some kind of psychology or mental health issue that he
wants us to try to go and get to see.
>>WILLIAM WARNING: A lot of these patients have very complex chronic medical diseases,
and you can't separate the mental from the medical.
It's a piece of the care that we just can't ignore.
>>BARRY JACOBS: The folks who become family doctors are those with a very strong interest
in psychology already but what I'm trying to do is broaden their perspectives from narrowly
focusing on the bio-medical aspects of patients.
To really see them in their entirety, take into account where they live, the families
that they live with,, the communities that support them, and how it affects their health.
>>WILLIAM WARNING: We find that we have to be in their home, we have to actually go the
homes many time.
Home visit is a component of the super utilizer work, you can't do it from an office.
>>PATIENT: The program with my mother, where they come and talk to my mother in my mother’s
house.
And they sit and they talk to her and they listen to her.
That couldn’t be more wonderful and it takes the stigma away from going into – like a
building that says “mental health”.
>>BARRY JACOBS: There is lots of good that can be done bringing different professionals
together, by working closely in partnership with patients and their families, by getting
out of the office and going to the home setting, and then by actually better coordinating care
across health care settings.
We have improved the quality of the patients’ lives and we keep them out of the hospital.
>>MARK CASSANO: What we’re doing is we are empowering patients to become more active
participants in the treatment that they are being provided versus us saying this is what
I want you to do, go do it.
>>PATIENT: It’s just amazing because I never thought I would ever see my mother ask for
help from anybody and she does.