Student- Run Free Clinics A model for indigent

Student- Run Free Clinics: A model for indigent health care and medical education T. Ryan Smith Janell Jones Nick Stucky 100’s of others August 1, 2009 AAFP Student Resident Conference Kansas City, MO Available at http: //www. fmdrl. org

Network of clinics and collaboration n n >100 clinics in 75 medical schools 2 -4 National Conferences/ year • Last year Savannah, Washington, Omaha n National Organization Society of Student Run Free Clinics, http: //www. studentrunfreeclinics. org National Meeting Jacksonville in Jan 30 -31, 2010

Jay. Doc Mission • To provide opportunities for medical students of the University Of Kansas Medical Center, and ultimately students of the multi-disciplinary field of health care, to aid in narrowing the health disparities and concerns found within the target population. Students will also gain experiences in establishing and operating a free clinic.

In our words…. . n The Jay. Doc Clinic is dedicated to providing: • Care to the underserved • Clinical medical education

Student run free clinics n n n Target population Spectrum/focus of services Funding Service volume (per patient visits) Relationships

Profile of Clinics-2005 n Simpson SA, Long JA. ”Medical Student run clinics: important contributers to patient care and medical education. ” J Gen Intern Med. 2007 March; 22(3): 352– 356

Target population n Vulnerable population • Homeless, immigrants, victims of abuse at other free clinics • Jay. Doc initially adolescents now, population at large n Criteria • • • n No visit criteria at Jay. Doc Ensure target population by yearly census Income/insurance restrictions at other clinics Point of Access only nighttime ambulatory clinic in Wyandotte County Safety Net

Community profile- Wyandotte County n n n Pop: 158, 000 17% uninsured, 16. 5 % in poverty Large Latino population- 20% Spanish at home, 25% undocumented

Kansas* Wyandotte* Jay. Doc# County Clinic % 10. 4% Uninsured Non 8. 7% english 16. 4% 95% 15. 6% 49% Non-white 10. 9% ethnicity 31% 77% *http: //quickfacts. census. gov #yearly clinic census

Level of Care n Acute • ~Urgent care facility n Chronic • Chronic disease management n Smoking cessation, obesity, diabetes • Subspecialty

Jay Doc Clinic n Walk-in urgent care (2 nights/wk) • Social Services for transition to care, specialty referral, and prescription assistance n Specialty and Continuity Care (1 night/wk) • • • Intermediate diabetes care Obstetrics and gynecology Physical Therapy Ophthalmology Neurology Legal Services

Jay. Doc Clinic n n Founded in 2003 - 1 night/ wk 2004 - expanded to 2 nights/ wk 2007 - expanded to 3 nights/wk 15 -20 patients/ clinic night 1700 patient visits/ yr serving 1000 different individuals

Funding n Grants • AAMC • Local and national agencies n n • • • Jay. Doc receives funding from Health Care Foundation of Kansas City (fund created from tranfer of nonprofit hospital to corporation) Some clinics with faculty support have secured HRSA funding University Private donors Fundraising

People and Place n Volunteers (physicians, patient care, support positions) • Community vs University affiliation n Patient care restricted to KUMC students and fully licensed physicians Social services, interpreter, and patient intake positions open to community Majority of physicians at Jay. Doc are KU faculty but community physicians are growing in number • >75% of 1 st year students participated at Jay. Doc last year n Site of operation • hospital, community clinic, shelter, mobile unit, and others • Jay. Doc operates at Southwest Blvd Family Health Care

Who we are n Volunteers • Faculty • Student • Community n n n Executive Board Faculty mentors Southwest Family Health Care Clinic

Leadership structure n 11 person board • 3 executive directors • 8 committee chairmen (finance, community relations, technology/ supplies, volunteer, education, administration, research, and laboratory) n Specialty Night Directors

Advisors Dr. Greiner Dr. Freeman ·Provide advice and counsel ·Signatories for financial and legal documents Executive Co. Directors • External Relations • Clinic Management • Board Leadership Specialty Night Liaison ·Represents Specialty Night issues to the board ·Communicates Board policies and processes to Specialty Night Directors Administrative Assistant ·Performs administrative tasks ·Patient follow up Director, Finance ·Grants ·Budgets and Finances ·Fundraising Director, Social Services ·Safety Net Clinic Liaison ·Patient Referrals and Follow up ·Drug Assistance Program Director, Volunteers ·Volunteer Recruitment and Staffing ·Volunteer Training Board of Trustees Former Directors ·Review of weekly minutes ·Annual business review Director, Physician and Community Relations ·Physican Recruitment, Scheduling, and Retention ·Communiation Material Development ·Community Event Coordiantion Director, Technology and Supplies ·Development and maintence of clinic software and hardware ·Maintaining inventory pharmacy and supplies Director, Lab ·Recruit, schedule and train lab volunteers ·Act as liaison to external organizations re: lab Director, Administration ·Maintain records of board meetings ·Maintain, in print and intranet, clinic documentation Director, Research ·Collects data and performs analysis on clinic operations ·Coordinates research done at clinic ·Coordinates educational forums for students

Relationships n University relationship • Supported (financial and/or staff) n n Educational (part of clerkship, supplementary activity) formal activity allows for reflection Outreach • Independent relationship exists but financial autonomy • Fosters/ legitimizes clinic n Over time (in the case of Jay. Doc, ) focus shifts to relationships in community

Clinic partnerships Endowment Department KUMC Governmen t Agencies SWB FHC School of Medicine KU Hospital Safety Net Clinics Jay. Doc Free Clinic KUMC Physicians Community Groups Grant Agencies KUMC Students Community Volunteers Community Physicians

Our community n Jay. Doc representatives participated in coalitions, task forces, and other planning organizations including: • Regional indigent planning commission • Coalition of county indigent care clinics

n n Technical/ legal issues Legal • Consultation with university counsel office guides physician and student qualification for participation full -time faculty vs community physicians vs exempt license • Good Samaritan laws in many states provide malpractice insurance for indigent care no case precedent for use • Outside physicians encouraged to contact administration at hospital of employment Organizational • Independent designation of 501. 3 c or designation through university as subsidiary or university or other organization as fiscal agent

Medical Education n n n Core competencies Career Choice Clinical Skills Research Innovation Administrative Experience

Core competencies n n To guide medical education, ACGME identified competencies in patient care, medical knowledge, practice- based learning, communication skills, professionalism, systems based practice E. g. • Include organizational, financial, and health systems issues in clinical decision making • Appropriately adapt to participate in patient care in a variety of settings each with different priorities • Integrate altruism, respect, duty, honor, integrity, and commitment to excellence in clinical settings • Conduct a culturally competent clinical encounter including the use of interpreters

Career Choice n n 1985 study at UCD found 96. 5% of student run clinic participants elected primary care, 55. 2% family practice Current study at University of Florida/ South Florida/ George Washington determined preference for primary care but not family practice, in particular Current studies clouded by confounding variables National studies with representative sample from 5 -10 year time period needed for determination

Research n n Pubmed research revealed 18 peer- reviewed articles on student run clinics Current national collaboration should create standardized tools for collection of data and establish research priorities

n n n n n 1: Rosenbaum BP, Patel SG, Guyer DL, Dunn SR, Herceg ME, Knox CK, Miller RF. The pharmaceutical management system at Shade Tree Family Clinic: a medical student-run free clinic's experience. Inform Health Soc Care. 2008 Sep; 33(3): 151 -7. 2: Hastings J, Zulman D, Wali S. UCLA mobile clinic project. J Health Care Poor Underserved. 2007 Nov; 18(4): 744 -8. 3: Cadzow RB, Servoss TJ, Fox CH. The health status of patients of a student-run free medical clinic in inner-city Buffalo, NY. J Am Board Fam Med. 2007 Nov-Dec; 20(6): 572 -80. 4: Simpson SA, Long JA. Medical student-run health clinics: important contributors to patient care and medical education. J Gen Intern Med. 2007 Mar; 22(3): 352 -6. Pub. Med PMID: 17356967; Pub. Med Central 5: Buchanan D, Witlen R. Balancing service and education: ethical management of student-run clinics. J Health Care Poor Underserved. 2006 Aug; 17(3): 477 -85. Pub. Med PMID: 16960315. 6: Moskowitz D, Glasco J, Johnson B, Wang G. Students in the community: an interprofessional student-run free clinic. J Interprof Care. 2006 Jun; 20(3): 254 -9. Erratum in: J Interprof Care. 2006 Dec; 20(6): 692. Pub. Med PMID: 16777793. 7: Niescierenko ML, Cadzow RB, Fox CH. Insuring the uninsured: A student-run initiative to improve access to care in an urban community. J Natl Med Assoc. 2006 Jun; 98(6): 906 -11. 8: Beck E. Stymied. J Health Care Poor Underserved. 2005 Nov; 16(4): 612 -4. 9: Beck E. The UCSD Student-Run Free Clinic Project: transdisciplinary health professional education. J Health Care Poor Underserved. 2005 May; 16(2): 207 -19. 10: Bennard B, Wilson JL, Ferguson KP, Sliger C. A student-run outreach clinic for rural communities in Appalachia. Acad Med. 2004 Jul; 79(7): 666 -71. 11: Clark DL, Melillo A, Wallace D, Pierrel S, Buck DS. A multidisciplinary, learner-centered, student-run clinic for the homeless. Fam Med. 2003 Jun; 35(6): 394 -7. 12: Der DE, You YQ, Wolter TD, Bowen DA, Dale LC. A free smoking intervention clinic initiated by medical students. Mayo Clin Proc. 2001 Feb; 76(2): 144 -51. 13: Weiner S, Dischler J, Horvitz C. Beyond pharmaceutical manufacturer assistance: broadening the scope of an indigent drug program. Am J Health Syst Pharm. 2001 Jan 15; 58(2): 146 -50. 14: Davenport BA. Witnessing and the medical gaze: how medical students learn to see at a free clinic for the homeless. Med Anthropol Q. 2000 Sep; 14(3): 310 -27. 15: Cohen J. Eight steps for starting a student-run clinic. JAMA. 1995 Feb 1; 273(5): 434 -5. Pub. Med PMID: 7823393. 16: Kenney AM. School-based clinics: a national conference. Fam Plann Perspect. 1986 Jan-Feb; 18(1): 44 -6. 17: Campos-Outcalt DE. Specialties chosen by medical students who participated in a student-run, community-based free clinic. Am J Prev Med. 1985 Jul-Aug; 1(4): 50 -1. 18: Elmore JG. How students are incorporated into the health care team: an example of a student-funded, student-run, self-help clinic. J Am Coll Health Assoc. 1980 Oct; 29(2): 92.

Innovation n Student run free clinic hold numerous advantages over traditional outpatient clinics • Dedicated/passionate students, faculty, and volunteers • No billing no restriction on spectrum of care n Difficulty is integrating complicated health models in setting of limited resources and frequent leadership transitions • Abstracts and conference presentations on such clinics have examined models for diabetes, obesity, and smoking cessation

Clinical Skills n n n Provides opportunity for 1 st and 2 nd to practice clinical skills Fewer time constraints than clerkship or preceptor setting Environment promotes teaching • • • n Senior students to junior students Residents to senior/ junior students Attending to all volunteers Anecdotal evidence from faculty indicates advantage to students before entering clerkships but documented research is still pending

Administrative experience n Student board members responsible for • Daily tasks for managing clinic affairs lab results, follow-up, and answering queries from patients and • Developing clinical protocols with assistance of faculty • Practice management • Communication with community, nonfor-profits, governmental agencies

Question and Answer

Growing a student-run free clinic n n Fundraising Planning

Fundraising n n Administrative Structure Events • Student organization events • Jay. Doc 5 K • Physician and past donor mailing • Benefit Concert • Mustache

Administrative Structure n n n Open dedicated account for fundraising Clinic board limited to 2 fundraising events/ year Created mailing lists and marketing materials for physicians, community partners, and donors Other events may be organized by individual or group of students GOAL funding general clinic expenses with endowment

Jay. Rock n n n Benefit Concert entering its fourth year 1 st year @ bar w/ ~50 people 2 nd year @ event space w/ >400 attendees 3 rd @ theater w/ ~1000 concertgoers Collaboration w/ marketing form yielded professional materials for event and clinic Forged relationships with local/ national businesses and private donors established mailing list Growth into signature fundraising event for clinic

Stache for Cash n n Participants could not shave above upper lip for 30 days Organized by Andy Jurgensmeier without assistance from board • Raised $3000

Models of success by $$$$ and longevity n n University of Nebraska benefit golf tournament UC-San Diego gala dinner

Planning Activities n Biannual planning meeting (~4 hrs) • Review mission statement • Selected 4 -5 priorities out of 30 • Calendar of event for succeeding months n n Bimonthly director and committee meetings (1 -2 hr) Weekly board meetings (1 hr) • • • n Operational issues Committee reports New business/ initiatives Annual transition meetings and orientation

Board Meeting Worksheet n n Sent by email before board meeting Posted to intranet 2 -3 items/ committee Reviewed by directors bimonthly

Board Meeting Worksheet

Strategic planning schedule n n n Days to months – operational decisions 2 -3 years- development and management of new and existing programs 5 -10 years- large capital expenses and campaigns

Planning Priorities n n n Financial Autonomy Specialty Care Medical Education Patient Education Physician recruitment

Financial autonomy n Establish an endowment and fundraising structure to, ultimately, pay operating expenses and allow for capital investment • Open a dedicated fundraising account with tax exempt status • Create fundraising and management boards for administration of endowment • Create fundraising base by extending community and physician outreach and expanding current fundraising activities • Upgrade jaydoc “brand” with development of professional grade marketing materials

n The clinic will undertake an ambitious fundraising effort designed to create an endowment with sufficient capital to sustain annual operating costs and support future expansions • Open a dedicated fundraising account with tax exempt status • Create fundraising and management boards for administration of endowment • Create fundraising base by extending community and physician outreach and expanding current fundraising activities • Upgrade Jaydoc “brand” with development of professional grade marketing materials

Outcomes

Specialty Care Program n Initiated and led by students • Relationship with academic medical center n n Recruit faculty liaison Create yearly strategic and operational plan • Mission (targeted population & services) • Clinic logistics n n n Budget (funding drawn from general clinic) Staffing/ training Sustainability/ transition/ scheduling

Boundaries n Progress in strategic planning permitted by restriction of other activities • 3 community events/ year • Research and educational activities limited to those with minimal affect on clinical encounter • Limit initiatives to defined priorities • Staff member to manage administrative tasks

Further Information n n If you would like a copy of resources described or have questions, please email me at tsmith@kumc. edu This presentation is posted online on the family medicine digital resource library, http: //www. fmdrl. org

Thank you n n n n Nick Stucky Janell Jones Adam Obley Dr. Sharon Lee Beth, Parker, Sush, Kristin, Nathan, Andy, and Alan Drs. Josh Freeman and Allen Greiner EVERY VOLUNTEER (student, faculty, and community)