Addressing the Health Needs of the Uninsured: One Community’s Solution



 

Lynne M Hutchison, DNP, FNP-BC1; Raymond L Cox, MD, MBA2

Perm J 2020;24:19.022 [Full Citation]

https://doi.org/10.7812/TPP/19.022
E-pub: 03/13/2020

Editor’s note: Please also see: Let’s Care for Those in Need—Today: Collaborating to Solve the Uninsured Crisis in America, by Lee Jacobs, MD (page 106); and Fostering Partnerships with the Safety Net: An Evaluation of Kaiser Permanente’s Community Ambassador Program in the Mid-Atlantic States, by Lorella Palazzo, PhD; Juno Matthys; Craig Sewald, MPA; et al. (page 35)

ABSTRACT

Introduction: Providing high-quality health care to poor and uninsured individuals has been a challenge to the US health care system for decades. Often, patients do not seek care until they are in a crisis, or they seek care at a health care system while not addressing their primary care needs.
Objective: To report on a community that has sought to change this dynamic with the development of an all-volunteer practitioner-run clinic model.
Methods: Perspective on a successful volunteer-run safety-net clinic.
Results: Volunteers in Medicine on Hilton Head Island, SC, provides free health care, with more than 28,000 eligible patient visits annually, for the underserved population. This clinic is self-funded through donations and charity events and accepts no federal money. The patients are not asked to pay a fee for service. Most medical specialties are represented at the clinic, and many partnerships are in place for referrals for more advanced procedures such as surgery. All health care clinicians are volunteers, including physicians, nurses, dentists, and mental health professionals.
Discussion: The quality of care meets or exceeds national recommendations on many measurements, including mammography and Papanicolaou test screening rates.
Conclusion: Safety-net clinics such as Volunteers in Medicine are a needed and viable option to the provision of health care to the vulnerable, often unseen members of society.

INTRODUCTION

Hidden among the beauty and affluence of the resort beach community of Hilton Head Island, located just off the southeast coast of South Carolina in the US, is the subpopulation of service workers who provide the labor to maintain the quality of life and vacation experience that people have come to expect. Although the average income of residents on Hilton Head Island is $72,509, approximately 10.9% of the population lives at or below the poverty level.1 The uninsured population is estimated to be 1:5 persons.2 This high rate of poverty and uninsured status has created a health care equity and access problem.

HISTORY OF VOLUNTEERS IN MEDICINE

A chance encounter in 1993 between Jack McConnell, MD, and a hitchhiker created the knowledge of the health access gaps and sparked the vision for the establishment of a volunteer-run clinic on Hilton Head Island, SC.3 The original Volunteers in Medicine (VIM) Clinic building was built on land the town of Hilton Head Island leased to VIM for $1 per year. The initial clinic consisted of 5 paid staff members, 48 retired physicians, 74 retired nurses, and 3 dentists. The focus was primary health care. Since 1993, the clinic has experienced tremendous growth. There are now 22 full-time equivalent employees who operate the clinic with the help of 650 retired and professional volunteers. As a team, the staff and volunteers serve in excess of 3500 individual patients annually, providing more than 22,000 medical visits and 6000 dental visits. This equates to $13 million in health care provided. VIM conservatively saves the local hospitals more than $2.5 million in uncompensated Emergency Department visits.3 

MISSION AND QUALITY MEASURES

The primary mission of VIM at this location is “to understand and serve the health and wellness needs of the medically underserved population and their households who live or work on Hilton Head and Daufuskie Islands.”4p1 The focus is on maintaining the health of these individuals, so they remain productive members of the community. The clinic is funded through generous community donors and volunteers. The clinic does not accept any government funding. The clinic has been awarded 4-star status through Charity Navigator 5 years in a row, with 91.87% of funds going directly to patient care.5 The clinic is committed to providing high-quality health care to those it serves.

Improve the Patient Experience

The clinic is open 5 days a week with scheduled and walk-in appointments available. The care provided is holistic. Services available include primary care, dental care, vision care, and the specialties of general surgery, otolaryngology, neurology, orthopedics, endocrinology, urology, infectious diseases, gynecology, cardiology, chiropractic medicine, dermatology, gastroenterology, pediatrics, podiatry, psychiatry, mental health, pulmonology, rheumatology, imaging (radiology/ultrasonography), occupational therapy, and physical therapy. Laboratory services are available on-site and include point-of-care testing for streptococcal infection, influenza, hemoglobin A1C, international normalized ratio, urinalysis, electrocardiography, and pregnancy testing. The newest service to be provided is telepsychiatry in cooperation with the Medical University of South Carolina in Charleston (unpublished data).

Patients consistently share their gratefulness for the clinic. Some of the comments include the following6:

•  “They really demonstrate a level of caring that goes above what you would expect from anybody.”

•  “The doctors who are volunteers really took an interest in my son and his case and came up with a diagnosis.”

•  “Volunteers in Medicine makes a meaningful difference in people’s lives. Without VIM’s surgical program, I probably would have been in a wheelchair for the rest of my life.”

VIM continuously gathers patient satisfaction data through focus groups and patient satisfaction survey cards.

Improve the Health of Populations

VIM is committed to improving the health of populations as well as individuals. Intake screening questions include food security, domestic abuse and safety screening, and smoking status. Resources are available to address positive answers to these questions, including an on-site food pantry, on-site counseling and social work services, and information about smoking cessation. VIM also strives to improve the health of populations through disease management clinics. The Wellness Program focuses on healthy lifestyle choices by offering weight management programs, free group exercise programs, cooking classes, and access to health monitoring devices such as the Fitbit (Fitbit Inc, San Francisco, CA). Other clinics include Diabetes, Hypertension, Pulmonary (sleep apnea), and Women’s Wellness. There are also a variety of complementary services such as physical therapy, chiropractic care, exercise programs, healthy eating classes, and stress management classes. With a recent upgrade to the electronic health record, implementation of a voice recording documentation system, and the employment of a full-time medical records manager, the clinic has begun collecting data on key clinical indicators to demonstrate the quality of care being provided (see Sidebar: Proposed Key Clinical Indicators, 2019, with Benchmark Sources).

VIM provides full-service immunizations for children and has a robust influenza vaccination program. Through a partnership with Walgreens, VIM provided influenza vaccines to the adult population of the clinic. In addition, through a community partnership grant with Access Health Lowcountry in Beaufort, SC, VIM is able to provide fecal immunochemical testing to adults for colon cancer screening.7 Additionally, more than 700 screening mammograms were provided, free of charge, within the Women’s Health program in 2017.

Reduce per Capita Cost of Health care

By using a volunteer provider model of care, VIM provides more than $13 million in health care on a $2.3 million budget. This is accomplished in many ways. The on-site pharmacy receives discounted medications from Nashville, TN-headquartered Dispensary of Hope and other donors at a cost of approximately $40,000, with a value of $6.7 million in pharmaceuticals dispensed.8 The Surgical Donation program, through partnership with local hospitals, has provided care to more than 200 patients, with a value exceeding $800,000, at a cost to VIM of $74,000, resulting in a 10-fold cost-saving factor (Table 1).

Improve the Work Life of Clinicians and Staff

Often, the focus in health care is on the patient experience, but more recently the literature cites an additional focus toward “Improving the work life of clinicians and staff.”9 This is an inherent part of the VIM philosophy. Everyone who works or volunteers at this clinic does so out of a desire to serve others. The clinic strives to provide the clinicians with support to provide high-quality care. Support includes subscriptions to UpToDate for online access to the most recent health care guidelines, on-site technical support for the electronic health record, daily team huddles to keep everyone informed of policy and care changes, interpreters to facilitate conversations with non-English-speaking patients, and support staff who are always ready and able to provide assistance. The daily huddle ends with the medical director issuing a call to action: “Have some fun, do some good.” That one statement describes the atmosphere of the clinic. Volunteers have described working at the clinic in the following ways: “It’s a support group. It’s like family”; “I volunteer to not let years of learning and practicing go to waste and to interact with a talented group of peers”; and “This is my happy place. Everyone wants to be here; the patients, the staff, the volunteers. It brings joy back to work.” There are many long-term volunteers at VIM, with greater than 200 having volunteered for more than 10 years (unpublished data). The Volunteer Satisfaction Survey of 214 volunteers reports that 98.1% of respondents would definitely recommend VIM to friends and others as a great place to volunteer.10 The volunteer program has seen a growth in younger volunteers, many of whom are students or are still working, which aids in the sustainability of the volunteer workforce.

CONTINUOUS QUALITY IMPROVEMENT PROCESSES

Although the care is free, the quality is not subpar. The clinic is continuously monitoring quality health outcomes such as percentage of eligible patients receiving mammograms (80%),3 the number of patients with diabetes screened with hemoglobin A1C and a vision test, or the percentage of charts in which the medication list was reconciled at the time of service. There is an effort to streamline the documentation process to ensure that medication lists are up to date, documentation of immunizations in the state health department system occurs, and patients are contacted with abnormal laboratory results. There is a documentation scribe program in development to assist clinicians in the use of the electronic health record as well as the use of a voice recognition dictation system. These are all patient care activities one would expect in state-of-the-art health care systems, yet they are being offered in this free clinic.

FUNDING

It is no small endeavor to keep a clinic such as the VIM Clinic Hilton Head Island in operation. Unlike many businesses, growth at VIM costs money. It costs $9000 each day to operate the clinic, which is more than $2.3 million per year. This budget is accomplished through 52,000 volunteer clinician hours10; donated pharmaceuticals; health care community donations; and donated maintenance, construction, landscape, and technology support. The Development Office, with a combination of paid and volunteer staff, works year-round to solicit funds to keep the clinic operating. Activities such as an annual gala, letter fundraising appeal, food festivals, silent auctions, community grant applications, and the Vehicle Donation Program are just a few examples of the fund-raising efforts.11 The financial report for the fiscal year ending June 2018 can be found on the VIM Clinic Hilton Head Island Web site.12 We must not forget our patients, who volunteer to clean the clinic, perform maintenance, and hold fundraising activities for the clinic. Patients are eligible for care at the clinic if the household income is less than 200% of the Federal Poverty Guidelines and they are not eligible for other medical insurance.4p3,4 The patients do not pay a fee for service; the care is free.

Many ask why the Affordable Care Act (ACA)13 does not solve our patients’ health care needs. As a safety-net clinic, VIM plays an important role in the health care of the working poor people on Hilton Head Island. South Carolina did not participate in the Medicaid Expansion offered through the ACA, making many of our patients ineligible for insurance. Even with subsidies, insurance premiums and out-of-pocket costs are expensive, and out of reach for many of our patients. In addition, there is a health care clinician shortage in Beaufort County, SC, meaning there are not enough physicians and dentists to serve the population, making access an issue. Furthermore, there is only 1 insurance company offering an ACA health insurance plan in South Carolina.14

The hotel and hospitality industry has direct benefit from this clinic by means of keeping its workforce healthy. A partnership is in development between the University of South Carolina Beaufort and VIM Clinic Hilton Head Island to create a comprehensive communication plan that will demonstrate the value provided by the clinic to this industry.15 The goal is to obtain some financial support from the organizations that directly benefit from the services provided at the clinic.

FACILITATING THE VOLUNTEER PROCESS

Volunteering in a free health care clinic is a rewarding service. To make the volunteer role attractive, the VIM organization has created a streamlined onboarding process. All volunteers must16

•  attend an orientation offered monthly

•  provide a curriculum vitae, driver’s license, social security card, and any medical/professional license

•  receive an annual tuberculosis test provided by VIM

•  sign and complete a confidentiality statement and code of conduct agreement.

Retired volunteers can work under a special license established for physicians volunteering in not-for-profit clinics (legislation passed by request from VIM Clinic Hilton Head Island in 1993).17 All health care clinicians receive full malpractice coverage from the South Carolina Joint Underwriting Association.18

There is no minimum number of volunteer hours required. Some volunteers are seasonal (snowbirds), and others volunteer on a weekly basis.

CONCLUSION

Safety-net clinics, such as VIM Clinic Hilton Head Island, are a feasible way to provide access to high-quality, cost-efficient health care to those in need. While serving the mission of VIM, the volunteer health care clinicians also experience a renewed satisfaction in their chosen professions. Bridging the gap between provision of care and joy in work is accomplished at VIM. Other communities can use VIM Clinic Hilton Head Island as an example to develop their own unique models of health care. More information is available through the national VIM Web site (http://volunteersinmedicine.org). The national office, which developed from the original clinic on Hilton Head Island, is dedicated to assisting individuals, groups, and local communities who want to develop a free health care clinic for people without access to health care. The organization provides direction, inspiration, and support in the process of developing a clinic through training, resource materials, and consulting services. Volunteerism is alive and well in the health care community, as demonstrated by the 88 VIM Alliance member clinics, the 20 clinics under development, the 343,00 patient visits in 2017, and the 10,400 volunteers working to improve the health of those in need.19 What are you waiting for?

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copy edit.

Author Affiliations

1 University of South Carolina Beaufort
2 Volunteers in Medicine, Hilton Head, SC

Corresponding Author

Lynne M Hutchison, DNP, FNP-BC ()

How to Cite this Article

Hutchison LM, Cox RL. Addressing the health needs of the uninsured: One community’s solution. Perm J 2020;24:19.022. DOI: https://doi.org/10.7812/TPP/19.022

References
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    8.    Locations [Internet]. Nashville, TN: Dispensary of Hope [cited 2019 Jan 2]. Available from: www.dispensaryofhope.org/access-site-finder?locsearch=29906&loccountry=US&locdistance=25&sortdir=distance-asc.
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    13.    The Patient Protection and Affordable Care Act of 2010. Public Law 111-148, 111th Congress, 124 Stat 119, HR 3590, enacted 2010 Mar 23.
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    15.    Community partnered courses [Internet]. Beaufort, SC: University of South Carolina Beaufort; [cited 2019 Mar 30]. Available from: www.uscb.edu/studentsconnected/students-connected-projects/community-partnered-courses/index.html.
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Keywords: patient access, quality, safety-net clinic, volunteer health care workers

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