HAVEN Free Clinic: Studentrun primary care for the uninsured

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HAVEN Free Clinic Student-run primary care for
the uninsured
Medical Student Council Lecture Series

• Nancy Angoff, MD, MPH, MEd
• Sara Whetstone, Director HFC
• Emma Barber, Associate Director HFC
• Ryan Schwarz, Associate Director HFC

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Outline of presentation

• HAVENs history (Dean Angoff)
• Free Clinics in the US
• HAVEN Free Clinic
• Model of Care Provided to Patients
• Administration and Operating Structure
• Patient Data and Demographics
• Challenges
• Future Directions

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Definition of Free Clinic

• Free Clinics are private, non-profit, community
  based organizations that provide medical, dental,
  pharmaceutical and/or mental health services at
  little or no cost to low-income, uninsured and
  underinsured people.

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Free Clinic Movement

• Haight Ashbury Free Clinics founded in 1967 and
  represented the initiation of the free clinic
  movement
• Central philosophy health care is a right, not
  a privilege
• Free Clinics were founded as alternative forms
  of practice and an outlet for community service

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Fair Haven Community Health Center

• Opened in 1971 under the leader-ship of the
  Alliance for Latin American Progress
• With a budget of 5,000, the clinic saw 500
  patients in first year
• In 1970s, the clinic expanded to provide more
  comprehensive primary care
• In 1980s, the clinic changed its name to the Fair
  Haven Community Health Center (FHCHC) to reflect
  its broader range of services

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FHCHC Mission

• To provide comprehensive primary healthcare,
  particularly to the residents of Fair Haven  
• To serve as the central focus for health and
  safety issues in Fair Haven and enlist local
  support in an effort to solve these challenges
•  
• To keep policy-making decision power within the
  Fair Haven community.

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HAVEN Free Clinic

• Partnered with Fair Haven Community Health Center
  since 11/2005
• Open Saturdays from 9AM to 2PM
• Mission
• To serve as a sustainable free clinic that
  provides, at no cost, primary care, wellness
  education and assistance in securing healthcare
  coverage to uninsured adult residents of Fair
  Haven.
• To introduce students to the challenge of
  managing patient care with limited resources.

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Patient Anecdote

• 42 year old Ecuadorian woman who presented to the
  clinic with a history of headaches of increasing
  intensity x 2 weeks
• -Her mother died from ruptured aneurysm years
  prior
• -Fearful of obtaining care at the hospital
  because of her undocumented status
• -Had not had routine health care in over 5 years
• -Multiple stressors including separation from
  her family, food insecurity, and safety concerns

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Patient Care Concerns
Medical Evaluation
42 year old Ecuadorian woman
Socio-Economic and Political Concerns
Access to Care
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HAVEN Model of Care

• Medical
• Comprehensive Primary Care
• Referral specialty services
• Access to Care
• Free medical visits and medications
• Assist patients in obtaining medical coverage
• Socio-Economic and Political Concerns
• Robust social service and education department
• Interpreter services for all facets of the clinic

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Services

• Primary Care
• Eligibility Screening for Title 19 and other
  federal, state, and medical debt relief.
• Needs Assessment of food security, housing
  stability, safety and social support structures.
• Health Education -- one on one wellness,
  diagnostic, nutrition counseling.
• Referrals to volunteer specialty care providers
  and diagnostic centers.
• Pharmacy distribution of no cost medications.
• Laboratory Services
• Spanish Translation

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Patient Services(aka Front Desk)
Triage
Clinical Visit

• Treatment Plan
• Lab tests needed
• Imaging
• Referrals (as needed)
• Medications
• Addtl support services
• Appropriate follow-up

Pharmacy
Referrals
Schedule Follow-Up
Lab
Social Services
Education
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Typical Day

• 8.30am Morning Meeting
• Students work with attending physicians to
  develop appropriate and focused plans for patient
  visits.
• 9am 130pm Patient visits
• Junior Clinical Team member triages patient
  obtain vitals and chief complaint.
• Senior Clinical Team member performs history and
  physical
• Senior Clinical Team member presents H P to
  attending as well as their management plants
• Attending clinician briefly sees patients and
  assists with revision and implementation of plan
  of care
• Patient can obtain additional services at clinic
  as needed
• 130pm 2pm Wrap-Up Meeting
• Students and Faculty assemble to discuss
  management of typical presentations (i.e. the
  appropriate work-up for a patient who presents
  with palpitations)

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Interdisciplinary Education and Model of Care

• Student volunteers from all four health
  professional schools Medical, Nursing, EPH and
  PA Programs and some undergraduates.
• Clinician volunteers physicians and nurse
  practitioners from Yale, FHCHC, and the
  community.

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HAVEN Free Clinic Structure
Clinic Director Associate Directors
Steering Committee Professional Members -FHCHC
Medical Director - HAVEN Free Clinic Medical
Directors -Legal Counsel -Deans of Yale Health
Professional Schools -Representatives for YNHH
and Yale Medical Group

• Student Board
• Health Professional Students
• -Oversee all operating components of the free
  clinic Saturday operation, finance, research,
  volunteer faculty and student recruitment
• -Represent all 4 health professional schools
• 20 students sit on the board

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Student Board 2007
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Student-Run Health Clinics

• Time of avg operation 7.4 years
• Common site of clinic operations homeless
  shelter or other community agency
• Most clinics saw uninsured patients and never
  accepted payment from patients
• Total of 37,000 annual patient visits a year at
  all reporting student-run clinics (n92 avg403)
• Majority of clinics have infrastructure to
  address acute and chronic complaints

Simpson SA et al. Journal of General Internal
Medicine, 2007 352-356.
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Who are our patients?

• Primary Language
• 84 Spanish, 14 English
• Legal Status
• 69 undocumented, 21 citizens
• Ethnicity
• 86 Latino, 6 African American, 4 White
• Gender
• 61 male, 39 female
• Medical debt
• Of those pts who present to SS, 1/3 have
  significant debt
• Average among this cohort is 1948 (an
  underestimate for our patients globally)

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Who are our patients? Age
N 229 73 of our patients are under the age of
50
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Who are our patients? Country of origin
N 137 includes Dominican Republic,
Honduras, Colombia, Trinidad, China, Dem.
Republic of Congo, Afganistan, Australia, India,
Mali, and Portugal
How long have our patients been in the US? Of
those pts who emigrated, 78 have come since 2000
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Who are our patients? Food Security Status

• Of 111 social services charts reviewed, food
  security status was known for 67 patients (60).
  60 are food secure 19 are food insecure 21
  are food insecure with hunger

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Who are our patients?Occupation Status

• N 113
• There may be some overlap between part-time and
  seasonal, causing an underestimate for number of
  seasonal workers.

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Patient clinical visits at HAVEN
Avg of pt visits/SaturdayNov 05-May 06 6.7
vs. May 07-current 17.2
visits

• To date, HAVEN has conducted 1100 clinical
  visitsavg pt visits/12 months 550

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Common Chief Complaints
N 99 Other includes routine health
maintenance, mental health, ophtho, ENT, flu
shots, HIV tests, pregnancy tests, trauma
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Pharmacy Costs
In 12 months cost/Rx has decreased 20 cost/pt
has decreased 42 Commonly prescribed meds Oral
hypoglycemics, H2 blockers, anti-hypertensives,
antibiotics, statins, NSAIDs
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Continuity of care

• We are a primary-care clinic, but are we the
  best source of care for our patients?
• Patients rarely see any provider more than a
  couple times (at best)
• Student-run, student-facilitated
• A need for strategies to ensure patients more
  continuity in their care
• Differential volunteer requirements?
• Model of clinic?

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Reaching capacity

• Current waiting time for an appt is 4 wks
• Average waiting time for FHCHC is 6 wks
• At some point in the future our clinic will be
  operating at similar capacity
• Ability to care for our patients longitudinally?
• Need for more regular transfer process?

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Community involvement

• A need for an institutionalized, integrated
  patient and community perspective
• Patient surveys
• Patient focus groups
• Alliances/collaborations w/ community based
  organizations
• they know our pts better than we do
• they are able to better identify our patients
  needs
• mental health/social isolation What is the
  need? What can we provide?
• housing/ job needs/ legal representation
• Are we best suited to handle this?
• The ability of working together to develop
  solutions for our patients needs

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Expansion of provider network

• Continual need for more volunteer attendings for
  Saturday clinic sessions
• Need for enhanced specialty provider network
• Federal malpractice insurance (FTCA)
• Federal insurance that would enable a wider
  volunteer pool for providers
• Application in June, 2007 pending

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Electronic Medical Records

• Many providers seeing patients over time
• Several departments offering different services
  to each patient
• A need to integrate and simplify record-keeping
• - continuity of care (of sorts)
• - difficulty integrating and normalizing provider
  notes and
• - loss of records

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Veterans Health Information Systems and
Technology Architecture (VistA)
Free and open source (customizable) User-friendly
Ability to document clinic-wide services in one
centralized database
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VistA implementation

• Funds secured through The Community Foundation of
  New Haven (2006-2008)
• Physicians Innovations LLC private consulting
  company to provide setup and training
• A team of IT-savvy volunteers to provide
  tech-support longitudinally
• Coming in 2008

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Acknowledgements

• FHCHC
• Medical Director, Laurie Bridger MD
• Mary Bartlett APRN
• Elizabeth Maggenheimer FNP
• Katrina Clark, and the FHCHC Staff
• Yale University
• Yale Office of Development
• HAVEN Steering Committee
• HAVEN Student Board
• The Community Foundation
• Rite Aid, Pharmacy Express
• Our volunteers