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					  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
   >100 clinics in 75 medical schools
   2-4 National Conferences/ year
    • Last year Savannah, Washington,
      Omaha
   National Organization Society of
    Student Run Free Clinics,
    http://www.studentrunfreeclinics.org
     National Meeting Jacksonville in
    Jan 30-31, 2010
         JayDoc 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…..
   The JayDoc Clinic is dedicated to
    providing:
    • Care to the underserved
    • Clinical medical education
        Student run free clinics
   Target population
   Spectrum/focus of services
   Funding
   Service volume (per patient visits)
   Relationships
Profile of Clinics-2005




                 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
   Vulnerable population
    • Homeless, immigrants, victims of abuse at
      other free clinics
    • JayDoc initially adolescents now,
      population at large
   Criteria
    • No visit criteria at JayDoc
    • 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
   Pop: 158,000
   17% uninsured,
    16.5 % in poverty
   Large Latino
    population- 20%
    Spanish at home,
    25% undocumented
                 Kansas* Wyandotte* JayDoc#
                         County     Clinic
%         10.4%                 16.4%   95%
Uninsured
Non-             8.7%           15.6%   49%
english
Non-white 10.9%                 31%     77%
ethnicity

*http://quickfacts.census.gov
#yearly clinic census
                 Level of Care
   Acute
    • ~Urgent care facility
   Chronic
    • Chronic disease management
         Smoking cessation, obesity, diabetes
    • Subspecialty
                 Jay Doc Clinic
   Walk-in urgent care (2 nights/wk)
    • Social Services for transition to care, specialty
      referral, and prescription assistance
   Specialty and Continuity Care (1 night/wk)
    •   Intermediate diabetes care
    •   Obstetrics and gynecology
    •   Physical Therapy
    •   Ophthalmology
    •   Neurology
    •   Legal Services
             JayDoc Clinic
   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
   Grants
    • AAMC
    • Local and national agencies
         JayDoc receives funding from Health Care Foundation
          of Kansas City (fund created from tranfer of non-
          profit hospital to corporation)
         Some clinics with faculty support have secured HRSA
          funding
    • University
    • Private donors
    • Fundraising
                 People and Place
   Volunteers (physicians, patient care, support
    positions)
    • Community vs University affiliation
          Patient care restricted to KUMC students and fully licensed
           physicians
          Social services, interpreter, and patient intake positions
           open to community
          Majority of physicians at JayDoc are KU faculty but
           community physicians are growing in number
    • >75% of 1st year students participated at JayDoc last
      year
   Site of operation
    • hospital, community clinic, shelter, mobile unit, and
      others
    • JayDoc operates at Southwest Blvd Family Health Care
           Who we are
   Volunteers
    • Faculty
    • Student
    • Community
   Executive Board
   Faculty mentors
   Southwest Family Health Care Clinic
         Leadership structure
   11 person board
    • 3 executive directors
    • 8 committee chairmen (finance,
      community relations, technology/
      supplies, volunteer, education,
      administration, research, and
      laboratory)
   Specialty Night Directors
                                    Advisors                                                                                     Board of Trustees
                                   Dr. Greiner                                                                                    Former Directors
                                  Dr. Freeman                                        Executive Co-                            Review of weekly
                              Provide advice and counsel                            Directors                                minutes
                              Signatories for financial and                         •External Relations                      Annual business
                              legal documents                                        •Clinic                                  review
                                                                                     Management
                                                                                     •Board Leadership

                                                                                                                       Specialty Night Liaison
                                                                                                                       Represents Specialty Night issues to the board
                                             Administrative Assistant
                                                                                                                       Communicates Board policies and processes to
                                                      Performs
                                                                                                                       Specialty Night Directors
                                                      administrative tasks
                                             Patient follow up



                                                                               Director,
                                                                             Physician and           Director,                                                           Director,
                     Director, Social                                         Community           Technology and                                                         Research
                                                      Director,                Relations                                   Director, Lab             Director,
Director, Finance       Services                                                                     Supplies            Recruit, schedule                              Collects data and
                                                                        Physican                                                                  Administration
Grants             Safety Net Clinic               Volunteers                                  Development and                                                        performs analysis on
                                                                                                                         and train lab            Maintain records of
Budgets and        Liaison                      Volunteer             Recruitment,             maintence of clinic     volunteers                                      clinic operations
                                                                                                                                                  board meetings
                    Patient Referrals and       Recruitment and        Scheduling, and          software and            Act as liaison to                              Coordinates research
Finances                                                                Retention                                                                 Maintain, in print
Fundraising        Follow up                    Staffing                                        hardware                external organizations                          done at clinic
                    Drug Assistance              Volunteer Training   Communiation            Maintaining
                                                                                                                                                  and intranet, clinic
                                                                                                                                                                         Coordinates
                                                                        Material                                         re: lab                  documentation
                    Program                                                                      inventory pharmacy                                                      educational forums
                                                                        Development              and supplies                                                            for students
                                                                        Community Event
                                                                        Coordiantion
                   Relationships
   University relationship
    • Supported (financial and/or staff)
          Educational (part of clerkship, supplementary
           activity)  formal activity allows for reflection
          Outreach
    • Independent relationship exists but financial
      autonomy
    • Fosters/ legitimizes clinic
   Over time (in the case of JayDoc,) focus
    shifts to relationships in community
    Clinic partnerships
                                          Endowment
                                          Department
                                                                 Governmen
                          KUMC                                   t Agencies




       School of                                                              SWB
       Medicine                                                               FHC



                                                                                      Safety
KU
                                                                                      Net
Hospital                                      JayDoc                                  Clinics
                                                Free
                                               Clinic


  KUMC                                                                              Community
  Physicians                                                                        Groups




               KUMC                                                       Grant
               Students                                                  Agencies

                                 Community              Community
                                 Volunteers             Physicians
             Our community
   JayDoc representatives participated
    in coalitions, task forces, and other
    planning organizations including:
    • Regional indigent planning commission
    • Coalition of county indigent care clinics
        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 501.3c or designation
      through university as subsidiary or university or other
      organization as fiscal agent
          Medical Education
   Core competencies
   Career Choice
   Clinical Skills
   Research
   Innovation
   Administrative Experience
              Core competencies
   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
   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
   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
   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. PubMed PMID: 17356967; PubMed 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. PubMed 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. PubMed 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. PubMed 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
   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
          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
   Provides opportunity for 1st and 2nd to
    practice clinical skills
   Fewer time constraints than clerkship or
    preceptor setting
   Environment promotes teaching
    • 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
   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, non-
      for-profits, governmental agencies
Question and Answer
Growing a student-run free clinic
   Fundraising
   Planning
               Fundraising
   Administrative Structure
   Events
    • Student organization events
    • JayDoc 5K
    • Physician and past donor mailing
    • Benefit Concert
    • Mustache
       Administrative Structure
   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
                  JayRock
   Benefit Concert entering its fourth year
   1st year @ bar w/ ~50 people 2nd year @
    event space w/ >400 attendees 3rd @
    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
   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
   University of Nebraska benefit golf
    tournament
   UC-San Diego gala dinner
            Planning Activities
   Biannual planning meeting (~4hrs)
    • Review mission statement
    • Selected 4-5 priorities out of 30
    • Calendar of event for succeeding months
   Bimonthly director and committee
    meetings (1-2hr)
   Weekly board meetings (1 hr)
    • Operational issues
    • Committee reports
    • New business/ initiatives
   Annual transition meetings and orientation
      Board Meeting Worksheet

   Sent by email before board
    meeting
   Posted to intranet
   2-3 items/ committee
   Reviewed by directors bimonthly
Board Meeting Worksheet
     Strategic planning schedule
   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
   Financial Autonomy
   Specialty Care
   Medical Education
   Patient Education
   Physician recruitment
           Financial autonomy
   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
   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
   Initiated and led by students
    • Relationship with academic medical center
   Recruit faculty liaison
   Create yearly strategic and operational
    plan
    • Mission (targeted population & services)
    • Clinic logistics
          Budget (funding drawn from general clinic)
          Staffing/ training
          Sustainability/ transition/ scheduling
               Boundaries
   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
   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
   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)

				
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