crimson care collaborativefinal).pdf · crimson care collaborative: a student-faculty collaborative...

Crimson

Care

Collaborative™

A Guide for Establishing a Student-Faculty Collaborative Practice©

Crimson Care Collaborative: A Student-Faculty Collaborative Practice at Harvard Medical School 1

Crimson

Care

Collaborative™

A Guide for Establishing a Student-Faculty Collaborative Practice©


The Crimson Care Collaborative™

A Harvard Medical School Student-Faculty Collaborative Practice (SFCP) Copyright © 2011 The Crimson Care CollaborativeTM: A Guide for Establishing a Student-Faculty Collaborative Practice© was made possible with generous support from the Yawkey Foundations. The Crimson Care CollaborativeTM practice operates with continued support from Harvard Medical School, Massachusetts General Hospital (MGH), The John D. Stoeckle Center for Primary Care Innovation at MGH, and the Internal Medicine Associates practice at MGH. The guide was written by students at the Harvard Medical School who are involved with the Crimson Care Collaborative practice. The guide was edited by Harvard Medical students Albert Yeh (HMS 4), Luis Ticona (HMS 4), and Lindsay Cole (HMS 4), as well as staff members Rebecca Berman, MD (Crimson Care Collaborative Founder and Director), Elizabeth Kaplan, MPH (Stoeckle Center), and Julie Martin, MS (Stoeckle Center). Published by Massachusetts General Hospital First edition, second printing, April 2011


TABLE OF CONTENTS SECTION 1: OVERVIEW ................................................................... 4 SECTION 2: NEEDS ASSESSMENT ................................................... 6 SECTION 3: STAFFING AND RECRUITMENT..................................10 3-1 Institutional and Faculty Support ...................................10 3-2 Student Leadership and Organizational Structure ......... 12 3-3 Student Training and Orientation ................................... 15 3-4 Patient Recruitment.........................................................18 SECTION 4: RESOURCE IDENTIFICATION .................................... 20 4-1 Patient Resources............................................................ 20 4-2 Clinic Finance.................................................................. 23 SECTION 5: CLINIC OPERATIONS ................................................. 26 SECTION 6: RESEARCH AND QUALITY MEASURES...................... 34 APPENDIXES: .....................................................................................37 1 Selected Clinic Profiles.................................................... 38 2 Support Groups and Conferences....................................45 3 Financial Template ..........................................................47 4 Patient Criteria................................................................ 48 5 Brochures and Welcome Poster...................................... 49 6 Student Training Manual Outline .................................. 50 7 Patient Surveys.................................................................53 8 Curriculum Outline .........................................................61 9 Section Authors............................................................... 63


SECTION 1: Overview

In 2009, more than forty Harvard University Medical School (HMS) students collaborated with faculty from the Massachusetts General Hospital (MGH) in Boston, Massachusetts, to develop and launch the Crimson Care Collaborative (CCC), Harvard’s first student-faculty collaborative practice (SFCP). This clinic was created to address some of the challenges that exist in the post-healthcare-reform era. A significant amount of work went into starting this clinic, and many lessons emerged during the process. We hope that by compiling the experience into a comprehensive guide, we will inspire and empower other medical students and hospitals around the country to create their own SFCP. This guide is designed as a road-map for planning yours.

We will use our experiences as a backdrop for further discussion while focusing on five key elements: 1) Needs Assessment: Why should we start a clinic? 2) Staffing and Recruitment: Who can we partner with to make our clinic a reality? 3) Resource Identification: What can we use to maximize patient care? 4) Clinic Operations: How do we structure our clinic? 5) Research and Quality Measures: How do we know if we are doing a good job? During the development of our model, founding members gathered information about a number of other student clinics throughout the United States. This information influenced the structure of our SFCP, as we were able to choose the most relevant portions of various models for our clinic. We believe each clinic must serve the unique needs of its target population; learning from existing clinics is an effective way to incorporate current knowledge in innovative ways. As you begin to design your SFCP, please refer to Appendix 1, where we have compiled the information we gathered from other clinics so you can pick the components that fit your needs best. Structure of the Guide: Most sections begin by discussing the main concepts behind each theme and relevant events that occurred during the development of our clinic to illustrate these concepts. Significant challenges will be discussed followed by a listing of key learning points and a “to-do” checklist of action items. We have also included helpful references where relevant. These extra articles can serve as a jumping-off point for further research. Section Overviews: A. Needs Assessment What services should your SFCP provide? What is the healthcare landscape in your region? Is there a need to address particular ethnic groups or subpopulations in your area? In this section, we aim to provide guidance to answering the fundamental questions that are critical to guiding the development of your clinic. Having a thorough understanding of the specific patient needs that your SFCP will address is helpful when you recruit others to support your cause. B. Staffing and Recruitment This section covers faculty, student, and patient recruitment. Gaining support from key institutional and faculty members will facilitate the establishment of your SFCP. Increasing your chances of successfully navigating the political landscape is one theme in this section. With regards to recruiting students, we


discuss the organizational structure we used to delegate the numerous tasks. Finally, we talk about the patient population that CCC sees and how we find those patients. C. Resource Identification We designed this section to help answer two specific questions: 1) How do you most effectively use existing resources in your area to provide better care?; 2) How do you obtain financial resources to start and maintain your clinic? D. Clinic Operations How do you manage clinic flow? Are faculty volunteers or paid? Who does phlebotomy in your clinic? What happens if a patient needs to be seen between visits? This section will walk you through the nitty-gritty details of the CCC. Many other common logistical questions will be answered in this section. E. Research and Quality Measures Consistent evaluation and re-evaluation of your clinic’s performance is critical to its long-term growth and success. In this section we provide guidance for developing appropriate questions and tools to tackle this challenge. F. Appendixes The appendixes contain resources (including documents that CCC created) that may be useful as you build your clinic. We’ve included profiles for several other student-faculty clinics, as well as regional and national support groups and conferences to help jump start your initial research. Documents such as a budget template, patient brochures, and patient surveys are also included to aid your process.


SECTION 2: Needs Assessment

A. Introduction Before developing your Student-Faculty Collaborative Practice (SFCP) we suggest conducting a thorough needs assessment of your region’s healthcare climate and potential patient population. The needs assessment is, in many ways, the foundation of the clinic. The information you obtain here will guide the structure of the clinic, the outreach and other aspects of the operations. Moreover, it will serve as content that you present to potential donors, partners, and volunteers. It is the “case” for starting the clinic. Many SFCPs serve primarily uninsured patients, but these patient populations can vary significantly from region to region. Understanding the needs of the target population will allow you to develop the most appropriate services for your patients. For example, the ECHO (Einstein Community Health Outreach) clinic in the Bronx, New York, caters to a largely Spanish-speaking population. As such, their clinic has strong interpretation services that other clinics may not find necessary. We suggest investigating the population features that other student-run clinics or nearby community health centers have found to be important in developing and running their clinics. It is a good idea to determine what gaps these clinics have identified, as these gaps can be areas of focus for your SFCP. While it is vital to assess the needs of your patient population, it is equally important know the needs of your student volunteers. A core value of the Crimson Care Collaborative (CCC) was to design a clinic that would provide valuable experiences and education to our student volunteers, in order to encourage strong future leadership in primary care. Clinics that target specific populations (i.e., refugees, ethnic communities, specific diseases) yield unique experiences for their volunteer body. Thinking strategically about the value of the clinic for your students will be a great case when approaching your medical school, and likely increase institutional support. As you work through your needs assessment, try not to re-invent the wheel. If others have already determined optimal strategies, learn from them. However, keep in mind that every clinic is different. Clinics can differ based on patient populations, physical space, time of week/day, form of care offered, funding, local transportation, and many other factors. Thus, it can be helpful to take pieces from a number of different models to construct an SFCP that will best fit your patients’ needs. 1. The first step is to figure out what needs you can address. Consider the health care needs and access

issues in your region. Determine whether there is, in fact, a need for an SFCP in your region. For instance, are there already numerous SFCPs or other safety-net type practices in your area? If so, how can your clinic address a need that has not yet been filled by these other organizations. We developed a needs assessment committee very early on that was charged with collecting this information. A good start was to perform a simple Internet search to learn what types of clinics were already established in the area. Most student-run clinics have websites with contact information, and it was helpful to contact clinic leaders to learn about their clinics. Boston has many community health centers and a robust system for healthcare for the homeless, and we reached out to leaders of these programs to ask what health needs they felt still needed to be addressed. Once we connected with the community health centers, it became clear that they were operating at capacity and that we could provide a temporary medical home for patients who they were unable to accommodate.

2. The second step is to learn the structure of the healthcare system in your region. For this we used Pub med and Google Scholar to find peer-reviewed journal articles. We also used the local government


Health and Human Services department websites for information on demographics, health insurance, and health indices by region.

3. Study what other SFCPs in your region and nationwide found to be important. There are many such clinics across the country and it is helpful to learn about them. Begin locally because you may be able to visit these clinics and meet their staff. In the initial phase, make an outline of the critical components about which you would like to gather information and then compare it across clinics (see Appendix 1 for a list of clinics we reviewed and their profiles—note: this is by no means an exhaustive list; see Appendix 2 for support groups and conferences).

Many practices now have websites and you should visit these sites before contacting their leaders. If anyone at your school has ties to other clinics, ask them for information and to make an introduction. When you contact other sites, tell them you are very interested in their operations model (the way they run their clinic) and are seeking advice and wisdom from their staff. This can lead to fruitful relationships with leaders who can show you examples of their materials and give you tours of their operating practices. Recently there has been an effort on the East coast to bring students from many SFCPs together for regional conferences where students present information on their practices or areas of expertise. These are excellent opportunities to learn from others, share your own experiences, and to brainstorm ways to improve on commonly confronted issues.

B. Challenges i. Determine the healthcare insurance/access landscape in your region and how your clinic will fill critical gaps: The two predominant challenges facing patients in the United States are: 1) obtaining adequate healthcare insurance, and 2) accessing appropriate healthcare. The United States faces a severe shortage of primary care providers. The number of medical school graduates entering primary care training programs, and the number of internal medicine residents choosing primary care careers, continues to decrease. In Massachusetts, our primary care system has been recently strained following healthcare reform because the number of insured patients drastically increased but, due to the lack of primary care physicians, many are left without a primary care physician (PCP) [1, 2]. Thus, our experience at CCC may be of particular interest for SFCPs in the future as the nation begins to phase in large-scale health reform. Without access to primary care, patients turn to Emergency Departments (EDs) for their healthcare needs. A study of working-age Massachusetts adults found that, despite higher rates of health insurance post-health reform, ED use for non-urgent health problems is similar to what it was before Massachusetts health reform [3, 4]. Many patients cite the inability to obtain an appointment with a primary care provider as the reason that they are seeking ED care [5]. Given the data which showed both increased wait times for primary care physicians and ongoing ED use for non-emergent conditions due to a lack of access to PCPs, we determined that one of the primary needs we could address in CCC was providing access to primary care physicians. This example, from our own experience, illustrates the importance of delineating the major barriers to care (i.e., insurance coverage versus access to care) in order to incorporate solutions into your clinic design.

ii. Determine how your clinic can provide the best educational experience to students to reinforce or create new interest in primary care: Studies have shown that early exposure to primary care careers and mentorship, [6-8] along with meaningful longitudinal experiences, make students more likely to pursue a career in primary care. SFCPs, where medical students help design the practice and see patients under the supervision of primary care attending physicians, can foster interest in


primary care. At Harvard Medical School (HMS), there were no opportunities for students to have early exposure and hands-on experience to the joys of taking care of primary care patients. Instead, their exposure to medicine came primarily from the hospital wards. Thus, we built the CCC to provide medical students with early exposure to primary care, with the goal of increasing the number of students who choose and become leaders in the primary care field. To encourage these outcomes, we designed multiple student-run committees to enable students to be intimately involved in building the CCC. For instance, many students are interested in research and systems improvement; therefore, we created a research team that designs research studies and surveys to analyze our operations and guide our innovation efforts. We believe that building an interdisciplinary model will help students learn how to practice real-world healthcare delivery. We have encouraged students from many other professional schools including the Harvard School of Dental Medicine, the Harvard Business School, the Harvard School of Public Health, and the Massachusetts College of Pharmacy to join our collaborative. We are planning to reach out to Nurse Practitioner (NP) and Physician Assistant (PA) school students, as has been done successfully at other SFCPs (such as Yale’s HAVEN Free Clinic). Fostering an environment that encourages innovation and collaboration gives students exciting first-hand exposure to systems-based primary care delivery. iii. Determine your own model by learning from existing SFCPs and other outpatient practices: There are many ways to run an outpatient practice, and creative students all over the country have developed their own recipes for success. While each practice is unique, there are many common issues and themes. We used our needs assessment to determine which clinics we would study when planning our SFCP. We engaged our junior students in this “clinic case studies” project and had each student pick one clinic to investigate. We generated a list of categories that we compared across clinics, and we organized several site visits (see Appendix 1). In every case it was important to do the following:

a. Reach out to clinic leaders to arrange the visits b. Have multiple students go to each visit c. Visit when the clinic was open and operating d. Take detailed notes e. Debrief after each visit to discuss key elements of the clinic that were attractive and

appropriate for building into our own model. After all of the clinic case studies were complete, we met as a large group to discuss key attributes of each clinic and to decide which of those attributes we would try to model or avoid. Our initial needs assessment evaluated other community organizations and local resources that could inform our model. Massachusetts has a robust network of Community Health Centers (CHC). CHCs were created in 1965 by the federal government as a way to provide health and social services access points in poor and medically underserved communities and to promote community empowerment. We carefully examined the local CHCs that were serving to communities and patients with many of the same needs that we planned to serve. We defined how we differed from these organizations and whether there remained a need for our model of care [9]. We contacted area CHC directors and it became apparent that many of their sites were at capacity and many patients could benefit from additional service organizations. Furthermore, we laid the initial foundation upon which to build possible future partnerships (such as bridging patients to CHCs for long-term care). We also learned about some of the particular challenges of serving these demographics—and some of the solutions. In particular, we learned that coordination of care and robust social services are critical for ensuring high-quality care. From these


lessons and partnerships with our community allies, we refined our model of care and began building a referral network and foundation for our own organization. C. Key Points / Action Items

Learn about the health care insurance and access landscape in your region and try to anticipate how you can address relevant needs.

Investigate the local patient populations you will likely serve to predict their specific needs Engage other professional schools as early as possible to create an interdisciplinary and

collaborative practice. Build student groups that encourage research, process/systems analysis, and innovation. Perform case studies of other SFCPs (Appendix 1) and go on site visits to learn their successes and

failures and to build alliances. Contact local organizations (e.g. CHCs, Healthcare for the Homeless) offering similar services

and/or working with patients and communities with needs similar to the ones you will likely serve to learn, share resources, and build potential partnerships/referral networks.

D. Resources [1] Massachusetts Medical Society Physician Workforce Study 2009. [2] Massachusetts Division of Health Care Finance and Policy. Access to Health Care in

Massachusetts: Estimates from the 2008 Massachusetts Health Insurance Survey. March 2009. [3] Long SK, Masi PB. Access and Affordability: An Update on Health Reform in Massachusetts, Fall

2008. Health Aff (Millwood) 2009 Jul-Aug;28(4):w578-87. [4] Osborn EH. Factors influencing students' choices of primary care or other specialties. Acad Med

1993 Jul;68(7):572-4. [5] Fincher RM, Lewis LA, Rogers LQ. Classification model that predicts medical students' choices of

primary care or non-primary care specialties. Acad Med 1992 May;67(5):324-7. [6] Kassebaum DG, Szenas PL, Schuchert MK. Determinants of the generalist career intentions of

1995 graduating medical students. Acad Med 1996 Feb;71(2):198-209. [7] Beck E. The UCSD Student-Run Free Clinic Project: Transdisciplinary Health Professional

Education. Journal of Health Care for the Poor and Underserved 2005;16:207–219. [8] Simpson SA, Long J, Medical Student-Run Health Clinics: Important Contributors to Patient

Care and Medical Education. Society of General Internal Medicine 2007;22:352–356. [9] Massachusetts League of Community Health Centers. http://www.massleague.org/CHC/Overview.php. Accessed January 10, 2011. E. Additional Readings: [10] Meah YS, Smith EL, Thomas DC. Student-run health clinic: novel arena to educated medical

students on systems-based practice. Mount Sinai Journal of Medicine. 2009;76:344-356. [11] Focus on Health Reform: Consumers' Experience in Massachusetts: Lessons for National Health

Reform, September 2009 (Carol Pryor and Andrew Cohen) The Access Project: Kaiser Family Foundation.

[12] Jessamy, T. The Fundamentals of Community Health Centers. National Health Policy Forum. August 31, 2004.

[13] Community Health Centers Strained By Recession, Face Bigger Caseloads Under Reform. http://www.kaiserhealthnews.org/Stories/2009/August/07/Community-health-centers.aspx. Accessed January 10, 2011.


SECTION 3: Staffing and Recruitment

SECTION 3-1: Institutional and Faculty Support A. Introduction In order to start your student-faculty collaborative practice (SFCP) you will need to get permission from your medical school and ideally from a host clinic. Institutional support not only increases your legitimacy, but will help you obtain malpractice coverage for the students and physicians in your practice. Our clinic’s founder, Dr. Rebecca Berman, is a practicing primary care physician in the Internal Medicine Associates (IMA) practice at the Massachusetts General Hospital (MGH), in Boston, Massachusetts. Thus, we decided to approach the IMA with the idea of the clinic before presenting to Harvard Medical School (HMS). The idea of CCC generated a lot of excitement in the IMA, our eventual host clinic, and we met with its director to brainstorm which leaders at MGH needed to be on-board with us before we proceeded. This led us to meet with the Vice President for Quality and the Vice President of Primary Care to address their concerns about malpractice and the legal ramifications of an SFCP. Once MGH was enthusiastic about the project, we sought the blessing of HMS’s Dean of Student Affairs. Once accomplished, we moved forward with student recruitment efforts. B. Challenges i. Finding a clinical champion and recruiting faculty: Finding committed faculty can be challenging due to the time commitment involved with clinic operations and general advising. Ideally, your champion already works at your host clinic, is enthusiastic about the project, and believes in the mission of your SFCP. In our case, Dr. Berman saw the great need to increase access for patients and to improve primary care education and opportunities for medical students. Your champion must have the time to dedicate to the development of the clinic. In the CCC, physician faculty are only partially compensated for their time. Some of the cases we see are urgent-care visits from IMA patients and most of our “bridge-to-care” patients have insurance. Nevertheless, compensation is only a fraction of what they would make in a routine clinic day, so faculty are volunteering some of their time. This point reiterates the importance of recruiting those who are passionate about the clinic’s mission. ii. Obtaining participation from the practice director: Since starting a SFCP will involve using space at your host clinic, it is important to gain the support of the practice director. In our case, we negotiated a situation where we would use the IMA clinic facilities to see “bridge-to-care” patients, as well as urgent-care patients who are part of the IMA, thus generating a small amount of revenue for the host clinic. The clinic director was able to dedicate a small amount of administrative time to our clinic to help us schedule patients and to enter our patients into the hospital’s electronic medical record. In addition, the clinic altered the hours of a medical secretary and a phlebotomist so that they could be available to us for about two hours each week (these staff members come late in the morning and stay through our evening clinic).

iii. Determining key players who need to buy in and anticipating the issues they may have with the clinic: These key players include practice directors, hospital administrators, and where


applicable, medical school deans. When meeting with the IMA director, the MGH Vice Presidents, and the HMS Dean of Students, the following issues arose:

a. Concern about giving sub-par care to disadvantaged patients: To address this concern, rather than calling this a “student-run clinic” we renamed it a “student-faculty collaborative practice” to highlight that all patients would be seen by faculty members as well as medical students. In addition, by incorporating attending physician’s urgent-care patients into the patient mix, we re-billed our clinic from one for “disadvantaged people” to a clinic for “all people.” These strategic changes ultimately placed “quality of care” high on our list of priorities.

b. Importance of not competing with existing clinics or Community Health Centers: We were concerned that the CHCs in our area would object to our practice. We approached the Massachusetts League of Community Health Centers during our initial planning stages to obtain their buy-in. They were able to give input into how the practice should be run and became early supporters!

c. Need to insure good long-term follow-up for patients: While this is an ongoing challenge, a large component of our clinic mission is to help patients who do not have a PCP find a long-term physician. We utilize publically available resources (See Section 4-1, Resource Identification) to assist our patients. In addition, we try to schedule student clinician teams to return together on a monthly basis to increase patient continuity while patients are being taken care of at our clinic.

iv. Strategically building alliances to create a powerful network: With support from the HMS Dean of Students, the CCC achieved full institutional support for student volunteers. Although this took some negotiation and politicking, garnering this support became a critical asset for the CCC. At the University of California-San Diego, for example, the students found value in developing a “community of deans” who supported them. This way, during leadership changes, the clinic’s remaining administrative supporters could help promote the SFCP to the next dean [Ellen Beck, personal communication]. This also illustrates the importance of institutional support for the continuity of your SFCP. v. Eliciting administrative support to assist patient scheduling: If your clinic adopts a model of working alongside professional staff, it is critical to determine which roles medical students can perform. For example, who books patients into the schedule? Is special computer knowledge required for this? In our case, the scheduling system required training so the task remained with our professional staff; students were not able to volunteer for this specific task. C. Key Points / Action Items

Find a clinical champion: recruit faculty members who are enthusiastic about your mission and have time to dedicate to the clinic’s development.

Meet with known allies early: think about how to win over potential doubters and turn your potential detractors in to allies by being flexible and addressing concerns up front!

Identify key players (practice directors, hospital administrators, medical school deans) who can assist you and try to anticipate their concerns.

Anticipate others concerns and carefully design the practice to address them on many levels. Obtaining practice and hospital support early in the process made approaching the medical

school very straightforward. Make finding supporters for your clinic a top priority. Try hard to get administrative support to assist with patient scheduling and other tasks.


SECTION 3-2: Student Leadership and Organizational Structure A. Introduction A project of this magnitude requires dedicated students (the “board”) who can meet regularly to initiate and maintain its development. It is important to designate a few committed students to serve as board directors. They are responsible for overseeing projects, running regular board meetings, and creating meeting agendas. Initially, the directors for our clinic met on a near-weekly basis to coordinate the numerous tasks at the start of the clinic. We also organized several subcommittees (discussed below) that met on a regular basis with one or more of the directors. Once the clinic opened, we were able to plan and troubleshoot with monthly one- to two-hour board meetings and through communication via a board e-mail list. This highlights the importance of delegating tasks and of accountability in your new clinic. B. Challenges i. Forming useful subcommittees: We found it useful to divide clinic responsibilities into subcommittees where most of the “doing” takes place. Leaders of each subcommittee gave reports at the main board meetings. Our subcommittees included the following:

a. Staffing b. Community Outreach c. Resource Center d. Hospital Liaison e. Fundraising f. Patient Education g. Student Education h. Research i. Labs

While the exact organization of your institution’s subcommittees may vary, we provide a succinct description of each of our subcommittees to outline important items under each role that should be addressed in one manner or another. ii. Staffing subcommittee:

a. Organize the recruitment and assignment of student volunteers to clinic positions. b. Set up schedule for all student volunteers c. Maintain and distribute current student contact information d. Organize team-building events for students e. Work with Student Education to integrate other professional schools into CCC.

iii. Community Outreach subcommittee: a. Promote awareness of potential Bridge-to-Care patients by working with members of the

community and the MGH ED staff b. Orient new patients to the practice c Build relationships with community organizations and providers to facilitate referrals d Create community advisory board

iv. Hospital Liaison subcommittee: a. Serve as the primary point person(s) for all communication between our clinic and our

host clinic


c Work with hospital administration who are in charge of patient scheduling d Work with Community Outreach to ensure the entry of patients into the care of CCC from

the ED and other points of referral e. Trouble-shoot any issues related to practice-flow, follow-up

v. Resource Center subcommittee: a. Train help desk volunteers b. Oversee help desk operations c. Maintain up-to-date resources at help desk d. Oversee the documentation and summary of all patient encounters e. Oversee bridging of patients to community primary care providers f. Ensure that assistance with all of the following services is available to patients:

i. Housing (finding housing, infested/unsafe housing, evictions, landlord disputes) ii. Health insurance and medical debt relief iii. Low-cost medication iv. Utilities (stopping shut-offs, paying for utilities) v. Food (food pantries, food stamps, WIC) vi. Cash assistance/income security (TAFDC - "welfare") vii. Childcare (childcare subsidies) viii. Education (ESL, job training) ix. Job search x. Legal issues (immigration, etc.) xi. Clothing, furniture, baby needs (diapers, etc.), car seats, safety equipment xii. Dental care referrals

vi. Fundraising committee:

a. Coordinate grant applications and grant awards b. Establish and nurture relationships with donors and prospective donors c Work with the MGH’s primary care administration on financial planning d Promote awareness of CCC's growth and accomplishments e Arrange events, merchandise sales, etc. as necessary to generate additional funds

vii Patient Education subcommittee:

a. Supervise patient education volunteers b. Ensure that the patient education department runs smoothly c. Update/develop information to help clinic volunteers learn how to best educate patients

about their health issues d. Develop, staff, and supervise group education modules e. Develop, staff, and supervise patient education community outreach program f. Ensure that patient education materials are multilingual and at an appropriate health

literacy level viii. Student Education subcommittee:

a. Update and maintain student training manual prior to current semester’s training b. Coordinate and supervise student volunteer CCC training each semester c. Coordinate and organize resident teaching sessions at post-clinic meetings (including

setting residents’ teaching calendar)


d. Maintain, contribute to, and continue the Social Justice in Primary Care & Community Medicine (CCC course) in the HMS curriculum; explore other ways in which CCC can be integrated into the HMS curriculum

e. Work with the Staffing Subcommittee to integrate other professional schools (nursing, physical therapy, etc) into CCC

ix. Research subcommittee:

a. Oversee data collection and analysis b. Communicate results of performance measures to the CCC volunteers (in the form of a

written report or presentation) c. Lead the creation of evidence-based CCC guidelines d. Accept proposals from CCC members for research studies e. Work with the rest of the CCC volunteers to ensure comprehensive data collection is

integrated into the practice flow f. Oversee publication processes, including IRB approval g Collect information on patient satisfaction

x. Lab subcommittee: a. Supervise the ordering and logging of patient laboratory studies b. One lab director is present at each CCC session to guide the clinical teams in the process

of ordering patient labs c. Trained by MGH staff to conduct the following point-of-care tests as requested by clinical

teams for their patients: i. Fecal Occult Blood Test ii. Urine Pregnancy Test iii. Urine Dipstick Testing iv. Glucose Finger Stick Testing v. Rapid Strep

xi. Transitioning leadership: One of the most difficult challenges that you will likely face as you maintain your clinic is recruiting motivated and energetic students every year, as student volunteers transition to the wards or become busy with exams. A few important points that guided us were:

a. Start early and transition slowly: This was especially important for the student director position. We began to seek interest in this position four to five months prior to our official transition and invited potential candidates to shadow current directors. b. Create an application: By having students apply to specific board positions, we can ensure that each student is invested and interested in the position. If a position is under-filled or not filled, we contact individual students based on their application to ask if they would be interested in taking on the role.

C. Key Points / Action Items

Recruit dedicated core of student directors who are willing to devote a significant amount of time to start and maintain the clinic.

Decide on a regular time (and place) to hold routine board meetings—expect more frequent meetings in the beginning

Create subcommittees to enhance your ability to complete certain sets of tasks


SECTION 3-3: Student Training and Orientation A. Introduction

We required every student to attend a mandatory training session prior to the start of clinic each semester. The student training sessions have a few key goals: 1) The sessions must convey the mission of the clinic 2) Each student should be aware of the patient population the clinic serves and the goals for each patient

encounter 3) Orientation is a crucial platform for discussion of clinic organization; each student should be aware of

the overall clinic flow and how their role fits into the model. It is important that there is a general education component with information that all members know. There should also be specific breakout sessions or individual meetings to discuss more directed training about the various roles within the clinic.

4) Lastly, orientation should be an opportunity to familiarize students with the clinic’s physical layout, location of materials, and any special situations that may arise during a patient encounter.

We designed a student training manual to formally introduce new volunteers to the clinic; it also serves as a reference document for existing volunteers. Each clinic’s training manual should be tailored specifically to the needs and unique design of that clinic’s operations. In our training manual, there is a focus on clinical roles, flow, and services, as these areas were considered to be the most intricate and confusing. Key pieces that we included into our training session were: i. Brief overview of the clinic mission and clinic history ii. Clinic tours:

a. There were multiple iterations of a tour throughout the trainings, both in a guided tour led by the attending physician, as well as during a mock clinical encounter

b. We stressed the location of practical things and did the tour from the patient perspective: waiting room, check in, vitals, exam room (and the location of all the materials therein), attending physician’s location, labs, checkout.

c. We made sure to stress “special situations,” such as imaging

iii. Review of training manual: Each student was given a training manual prior to the training sessions (See Appendix 6 for an outline of the manual). They were expected to be familiar with the content that would be covered during particular trainings sessions:

a. Clinic flow: addressed as a talk through, then walk through tour, then mock patient b. Roles and responsibilities: given in lecture format, then during the mock patient each

student was in their appropriate clinical role c. “Special situations” and key safety information: for example, emergency numbers, how to

send someone to the ED, security issues, how to call a code iv. Discussion of the details of the clinical encounter, including forms, patient encounter, and follow-up protocols: These points were addressed in the mock patient sessions. v. Mock-patient encounter: We highlighted the importance of letting the attending physician know early about abnormal vitals, how to order radiology and referrals, and how to check out a patient.


vi. Break out sessions: Each session was led by a board member in order to give more focused training for each clinical role. vii. Clinical pearls: We spent some time reviewing how to do a focused interview, take vitals, and use the machines, as well as red flags that require immediate attention from the attending physician. viii. Post-training quiz: We felt that a quiz helped to place value on key pieces of training, as well as to ensure that students paid attention during training sessions. B. Challenges i. Timing: It is difficult to get a large number of medical students to be available at the same times in order to run a training session. Therefore, we ran our training sessions twice; students had to attend both part I and part II, but could choose between two dates for either session. Each subcommittee held more focused individualized trainings that were more easily scheduled among smaller groups of students. ii. Distilling down the relevant material: This was by far the most difficult task in preparing our trainings. There will always be more information that could be useful to volunteers, but we felt that keeping trainings relatively short and succinct was more important than conveying all the details. Handing out the manuals prior to trainings ensured a baseline of knowledge. iii. Identify what needs to be included in a manual: The manual can quickly become extensive, turning into something that no one reads. Every effort was made to make the manual as concise as possible and to provide more information on areas that could lead to confusion. Student feedback was crucial to determining what should be included in the manual. iv. Ensure that individuals read the manual: Another challenge was that individuals might opt not to review the manual, given its length. This was problematic because the student training sessions (see below) relied on students being acquainted with its contents, as not everything that was important to understanding clinic flow and roles was covered in the training sessions due to time constraints. The solution was to create a post-training online quiz, which all students were required to pass, to ensure that they had read through the most important parts of the training manual.

v. Obtaining student feedback: In order to assess the effectiveness of the student training process, it is important to receive feedback from student participants. We felt that this was most effectively done after students had seen patients in clinic, so that they might be able to point out areas where they felt unsure or needed more training, as well as areas that were not as relevant to their role within the clinic. We received feedback in three main areas: student education, patient satisfaction, and student satisfaction.

a. Student education: This involved questions regarding the training sessions, which allowed us to assess not only what information was most crucial and what felt unnecessary, but also to gain insight into the structure of trainings (e.g., length of time for each session, didactic teaching versus smaller groups). In response to this feedback, we modified our trainings to include hands-on walk through and a simulated patient experience.

b. Patient satisfaction: This section asked for the student’s opinion on any areas they felt were problems or successes of patient care. Being at the “front lines” gave students a better


understanding of timing bottlenecks, patient frustrations, and revealed areas that could be modified to create a more streamlined clinic flow and patient experience. In response to the critiques during the pilot, we established an easy-to-use white board system to notify the attending physician about timing and status of patient appointments. c. Student satisfaction: This was aimed at evaluating how we could improve the student experience. Areas for improvement included the teaching component of the clinic, the interaction among the clinical team, the exposure to primary care, and the student’s assessment of their overall happiness with the clinic and its contribution to their medical education.


Start early to plan your trainings in order to accommodate residents/physicians who run parts of the training, and to line up logistics such as food and location.

Decide how long the training should be and what it should cover. Remember to keep materials and length of trainings minimal to ensure that students aren’t overwhelmed with information.

Identify the most important aspects of the clinic that incoming volunteers need to know. Have the board work together in assembling different parts of the manual to ensure that those

with expertise are writing and explaining appropriate areas. Design a training follow-up to ensure that all volunteers are acquainted with the training manual

contents (ex: post-training quiz). Training will be a continuous process since new students will be recruited each year, and it is

important to receive formal feedback about your training sessions so that you can continue to make them more useful and streamlined.

D. Resources [1] See Appendix 6 for an outline of our Student Training Manual


SECTION 3-4: Patient Recruitment A. Introduction Our goal is to create a patient pool that fulfills our mission of serving people who are without a primary care physician and who could benefit from the social resources we provide. From the outset, we decided to exclude any patients for whom we would be duplicating services (i.e., pregnant women seeing an obstetrician, homeless patients who have excellent services through the MGH Health Care for the Homeless program), so as to reach as many people as possible and to avoid alienating our counterparts in the community. We created a template of the type of patients we provide care for to present to community liaisons who help us recruit patients to the clinic (See Appendix 4 for our patient criteria). Because we were not sure what the interest in the community would be, and we did not want to overload the clinic with more patients than it could handle, we built our recruiting process one group at a time. First we met with the MGH Emergency Department (ED) liaison, hoping to relieve some of the burden on the ED by recruiting patients who were using it for primary care-related visits. Next, we collaborated with MGH Medical Walk-in to recruit a similar group of patients. The major challenge to this point was figuring out how to balance a steady flow of patients without overbooking the clinic at an early stage. As part of the patient recruitment process, the outreach coordinators created brochures and a welcome sign to inform patients about the main goals of the clinic (See Appendix 5). This required a new understanding of health literacy and how to create low health-literacy-level documents. We found it important to inform our patients early on about the clinic’s goals and processes, in order to eliminate confusion. In addition to brochures and a welcome poster, a “bridge-to-care” discussion was built into the patient visit to assess the patient’s goals for care at the clinic and beyond. We plan to continue to develop these materials and add to our recruitment process as the clinic grows. B. Challenges i. Building relationships with patient referral agents: Establishing contacts for patient recruitment purposes should occur several months prior to opening the clinic. Such collaboration can be found within your own institution (e.g., ED administration) or in the community (e.g., city or county public health agency, churches, community centers, community health fairs). Obtaining the buy-in of potential partners is crucial and can be facilitated by the following:

a. Understanding the goals of potential partners and assessing their compatibility with your own. b. Clearly communicating your clinic mission statement: Clearly demonstrate the need that will be fulfilled by your operations and how your clinic is uniquely positioned to succeed in these areas. c. Stressing the benefits of forging these partnerships: Reassure potential partners that collaboration is advantageous for all and that your clinic is in no way threatening to their activities.

ii. Determining the patient volume your clinic can accommodate: A valid concern for patient recruitment is that you attract more patients than your clinic cannot handle. Since such a patient backlog is contrary to increasing patient access to medical appointments, we approached patient recruitment by establishing a handful of patient referral sources (i.e., ED and Medical Walk-in) along with plans to expand recruitment in the face of insufficient patient demand. Regardless of your initial approach


to patient recruitment, the demand for appointments should regularly guide ongoing patient recruitment efforts. In order to titrate patient recruitment efforts to meet the capacity of your clinic, we recommend the following considerations for two likely scenarios:

a. Excess patient demand: Maintain constant contact with your referral sources to communicate the scarcity of appointment availability and the consequent need to decrease patient outreach. b. Insufficient patient demand: Have a number of referral sources on reserve that can be engaged and recruited to assist in patient outreach.


Identify patient population served by the mission statement and determine exclusion criteria. Make sure that your goals for the clinic and patient population are clear from the outset to

prevent miscommunication with potential allies and referral sources. Be prepared to adjust your clinic goals based on the feedback received from the community and

recruiting partners. Be flexible when it comes to your clinic goals, recognizing that your plans for patient population

and recruitment may change based on the needs of the community you are serving. Create patient and provider friendly clinic materials early in the process to distribute to referral

sources and potential patients. Establish patient referral intake process with clinic administration Monitor appointment demand and incomplete appointments.


SECTION 4: Resource Identification

SECTION 4-1: Resource Identification – Patient Resources A. Introduction Socioeconomic factors are crucial determinants of health that are rarely effectively addressed within a clinical encounter. To address these issues, the Resource Center at CCC has two central goals: 1) connect patients who do not currently have a PCP and/or do not have health insurance to a long-term primary care physician and an affordable insurance plan; and 2) provide connections to any social service resources necessary to improve the patients’ or families’ health, including housing assistance, job search assistance, job training or ESL programs, affordable childcare, food and cash assistance, utilities assistance, domestic violence resources, affordable medications, free legal assistance, and many others. For us, the most important part of building a comprehensive social services program was to identify key partners in the community who already had databases or lists of those resources who we could depend on to provide the majority of the resources we planned to provide. Another important aspect of establishing a resource center within the clinic was to work closely with the other founding committees to integrate the Resource Center into the workflow of the clinic in a way that would be efficient for us and respectful of patients’ time and privacy. We set up the Resource Center in two small nursing rooms adjacent to the waiting area which ensured patient privacy but was visible to patients at the end of their visit. Two student volunteers staff the Resource Center at CCC. The student volunteer who does patient intake becomes responsible for that patient and provides long-term follow-up. Resource Center volunteers continue to follow-up with their patients, usually via phone, for as long as necessary until their resource needs have been met or nothing more can be done on the part of the volunteers. Social service information on each patient is made accessible to the physician and student clinical team by whomever the patient is seen. B. Challenges i. Finding a comprehensive set of community resources through partnerships with existing organizations: Begin early by identifying local programs that already work to provide individuals and families with the types of resources you plan to offer. They will likely be happy to share their resources and community connections, as you will be helping them reach more people by providing resources to the patient population at your clinic. Examples of such organizations include existing NGOs or student groups such as Health Leads (formerly Project Health), local Community Action Programs, services offered by the local Public Health Department or Department of Human Services, social workers, hospital-based insurance assistance programs, hospital-based domestic violence programs, and many others. Many service-oriented clinics and hospitals are happy to share their materials with a student-driven organization. We found a great database through the Boston Children’s Hospital, called the On-line Advocate which was willing to provide us with their database free of charge, in exchange for help updating the database. In addition, the Boston Mayor’s Health Line, which is designed to help patients find new PCPs, has been incredibly helpful to our organization. Meet with the representatives of these programs to establish personal connections and discuss how their resources would be useful in your clinic.


ii. Identifying patients with needs that can be addressed at the Resource Center: Work closely with the committee writing the intake surveys at your clinic to incorporate questions that will screen patients for social service needs. Carefully consider the wording of the questions to make sure that you cast as wide a net as possible. Consider including questions on patient demographics, such as income range, education, and number of children in the family, which can help you in the preliminary identification of appropriate resources.

iii. Integrating the Resource Center into the clinic workflow: Make sure everybody involved in your clinic understands what aspect of the clinic mission the Resource Center fills and how it works. This will help clinical and administrative teams identify patients with social service needs; clinical teams will better prepare patients for what to expect at the Resource Center and will help everyone else understand how and why to integrate the Resource Center into the clinic workflow. Work closely with the operations committee to determine when patients should be screened for social service needs, when they will visit the Resource Center if needed, and how communication between clinical teams, clinical directors, and the Resource Center will function. If documents that pass through the Resource Center ultimately need to go to the research or administrative teams, make sure to establish a system to ensure proper handoffs. To entice patients to come to our Resource Center, we developed a system where Resource Center volunteers read the patient intake surveys and provide written resource materials for a patients stated needs (example: child care, housing etc). These are left in a box outside the patient’s clinic room and delivered to the patient by the clinical team which then directs patients to our Resource Center for further information.

iv. Defining boundaries: Do not attempt to provide help on issues that are outside of the scope of your clinic, and establish specific guidelines for how to address these issues when they arise. Know where to refer a patient with those needs. The most important examples from our experience are mental health and domestic violence. v. Efficient data storage system: Resource Center volunteers will need their own method of recording, storing, and accessing patient information, since their interaction and follow-up with the patient will be separate from that of the clinical team. Follow-up phone calls will be frequent and should be recorded. There are many existing companies and organizations that provide secure databases, such as Social Solutions, Webexone, Community TechKnowledge, and others, or one could be developed by a volunteer or individual with computer programming experience.

vi. Follow-up system: For a clinic that is far from the student campus, a system that allows students to access patient social service information remotely and to make calls via a non-personal phone line will be needed. This could be in the form of an office with a landline, remote access to a secure database, and/or an online phone account such as Skype or Google Phone. C. Key Points / Action Items

Establish community partnerships early to find existing resources that can assist you. Define boundaries and develop protocols for situations outside the scope of the Resource Center. Educate other clinic volunteers and staff about your mission and services provided. Determine efficient operational model and work with operations and administrative committees

to effectively integrate the Resource Center into the workflow of the clinic. Establish an efficient system of data storage and follow-up.


D. Resources Examples of CCC Resource Center community partners: i. Health Leads (Project Health) model used to design our Resource Center: http://www.healthleadsusa.org/our-model/family-help-desk/.

Accessed January 11, 2011. ii. Boston Public Health Commission service used to connect patients to new primary care

physicians and health insurance: http://www.bphc.org/programs/cib/civicengagement/mhl/Pages/Home.aspx. Accessed January 11, 2011.

iii. Interactive resource database: https://www.onlineadvocate.org/index.htm. Accessed January 11, 2011.


SECTION 4-2: Resource Identification – Clinic Finance A. Introduction Student-faculty collaborative practices (SFCP) are at a distinct advantage when it comes to covering the core costs of providing health care services. CCC was able to minimize start-up costs and spring from idea to open doors in a matter of months because much of the necessary infrastructure—exam rooms, medical supplies, an electronic health record—was provided by our host clinic, Internal Medicine Associates (IMA) at the Massachusetts General Hospital (MGH).

Beyond bricks and mortar, the IMA also staffs a Patient Care Coordinator and a Medical Assistant during our clinic hours. One of the reasons the IMA is so invested in our success is that, in addition to our “bridge-to-care” services for patients without a PCP, we also see members of its patient panel for urgent-care complaints, which keeps patients out of the ED. The requirement that all residents in Massachusetts have health insurance ensures that we can bill for the majority of care that we render, and our Resource Center team enrolls any uninsured patients in a plan that works for them. Again, the patient mix of our host clinic distributes the financial risk posed by any single patient. Fund-raising is essential for two reasons: to fund many of the additional programs (e.g., patient education, social services) that we believe constitute effective, personalized, high-quality health care, and to expand our roster of clinical staff in order to take on more patients in the future. We have applied for grants ranging from $5,000 to $50,000 from major community foundations that are committed to improving health care access or transforming primary care as a profession. Given our affiliation with Harvard University, we also try to tap into funding sources available through HMS or the university at large. Since students from the Harvard School of Public Health, Harvard School of Dental Medicine, and Harvard Business Schools also participate in the clinic, we are eligible for a broader pool of funds from their respective institutions. Remember that a university’s primary mission is education, so be sure to explain how students will acquire skills and knowledge, and refine their core values as a professional by participating in your clinic.

When it is time to apply for a grant, we assemble a team of writers to draft specific portions of the proposal; we always include members of the finance committee, as well as those who will implement the project or program for which we are applying for funding, The application goes through several revisions, and then we ask our medical director and other experienced, professional grant writers from the Stoeckle Center at MGH to provide us with critical feedback. Down the road, the parent hospital helps us administer the funds and compile final reports for our funders. The next step of our fund-raising strategy is to build a network of individual donors. While grant money is often tied to particular activities, there is often more leeway with private donations. The MGH Development Office is a key advisor as we identify supporters to pursue, design ways to engage them in a personally compelling aspect of the clinic, and establish an infrastructure for receiving and managing donations. B. Challenges i. Going out-of-network for advanced care: The SFCP financial model of being housed within a host clinic (see first paragraph) and the legislated health insurance requirement in Massachusetts make it possible to cover the costs of preventive care, outpatient sick visits, and outpatient management of chronic illnesses. However, in the event that a patient needs care from a provider outside of our clinic, we


are still committed to making sure that the patient has access to the care she or he needs. Should financial concerns pose an obstacle, it may be necessary to set aside a pool of funds to help subsidize the treatment or procedure, or to establish a network of preferred providers who can offer the service at a more affordable rate. This has not been an issue in our clinic so far as we have been able to obtain health insurance, with help from our partners at MGH patient financial services, for all of our patients. ii. Finding fast cash: Through grants and donations, one can acquire sizeable sums of money for a reasonable investment of time and energy. However, the timelines can be unpredictable. The clinic has much more control over the timing of small-scale fundraising activity like merchandise sales, or events, like walks, auctions, concerts, comedy shows, and parties. While these tactics have the added benefit of promoting your organization, bear in mind that they can become extremely time-consuming and require the commitment of your entire leadership board to maximize return. iii. Applying for grants: While this is a massive topic in and of its own and this section is not an attempt to comprehensively address this topic, we provide a couple of pointers we have found useful.

a. Research. Research the funding opportunities within your city/community, school, and professional/pre-professional organizations. Set up an introductory meeting with your parent hospital’s development office to get advice about funding in your area. Try searching the Internet and email listserves, but also ask your student volunteers to serve as your eyes and ears—word-of-mouth will help you find less well-known, less competitive funding sources. b. Know thy funder. If you want any chance of winning a grant, make that foundation your new best friend. Leave no page of its website unturned, read recent annual reports, look at whom and what they’ve funded in the past, and be sure to speak explicitly to their mission statement in your application. Don’t assume that this alignment of values can magically be inferred from your organization’s mission statement. You’ll probably have more luck by choosing a specific program or project that exemplifies why your clinic and this foundation are a good match and making it the thrust of your proposal. The “overall awesomeness” of your clinic is unlikely to win you many of the major community foundation grants (although it might work for start-up grants, grants for organizational development, etc.) Similar logic applies to courting private donors. c. Know thyself. Don’t fall into the trap of chasing grants and losing yourself in the process. If it feels like a forced fit or if you’re inventing programs so that you are eligible to apply for a certain grant, you probably don’t have a great chance of winning it, and if you do, the funds will be restricted for items you never intended to purchase in the first place.

iv. Grant funding cycles vs. the academic calendar: At HMS, it can be difficult for third-year medical students to hold leadership positions in the SFCP while completing their rotations. This means that many of the grants that we won will be received, administered, and reported on by people who weren’t the authors. It is imperative that our organization stay in the good graces of our funders—there can be NO fumbles in this handoff between regimes. Create a “reporting contract” that details each reporting requirement, the responsible party within your organization, and a deadline for submitting that information that still gives the grant coordinator enough time to compile the final report for which foundations often ask. This is no substitute for talking through the grant and introducing your successor to important contacts, but at least you have centralized the tasks and translated them into action items.


v. Create “cultural” sustainability as well as financial sustainability: The IMA wants us to exist because we see their patients and keep some of their urgent-care patients out of the ED. HMS wants us to exist because we are part of the new primary care offering that students and the nation are calling for. The backing of our host clinic, parent hospital, and medical school means that we will have allies in poor economic times. C. Key Points / Action Items

Define and evolve your relationship with your host clinic and parent hospital. Understand the nature of insurance coverage in your state. Identify funding priorities for your clinic on a regular basis. Update your communications strategy (e.g., web, print, local news, ads at the bus stop, annual

report, etc…). Research funding opportunities and consider getting advice from your parent hospital’s

development office. Write grants collaboratively and put them through several rounds of revision; include your

development office allies in this process. Collect individual donations (e.g. pledge drives, automatically recurring gifts). Find new donors. Appreciate your donors with an event or small gift, but always write a personalized thank you.

D. Resources All politics are local. You must understand the fund-raising climate in your community and the particular strengths of your fund-raising team to set a strategy and discover the tactics that work well for you. That being said, it still pays to read widely for new ideas and to build your own fund-raising philosophy. Here is my favorite: [1] Crutchfield, LR and McLeod Grant, H. (2008) Forces for good: The six practices of high-impact nonprofits. San Francisco. *Especially Chapters 2-6!* [2] See Appendix 7-3 for a sample budget.


SECTION 5: Clinic Operations A. Introduction In order to staff a student-faculty collaborative practice (SFCP), you should have an idea about how your practice will run. This will inform how many student volunteers you will need, how you will recruit and select them, and how you will coordinate scheduling. We based the structure of our clinic operations on the successful Yale HAVEN Free Clinic (see Appendix 1), which has been running since 2004. HAVEN Free Clinic based their model on the ECHO (Einstein Community Health Outreach) clinic, one of the first successful student clinics, established in 1999 (See Appendix 1). It was helpful to carefully examine both of these clinics while we were creating our own. Our clinic runs every Tuesday evening from 5:00pm to 9:00pm (chosen for site and attending physician availability). We started with two core clinical structures, each consisting of one attending physician and three teams—each team has one junior (MS 1, 2) and one senior (MS 3, 4) medical student.


Below is a basic flow chart for each patient encounter. We follow a hierarchical system, where the patient is seen first by the most junior team member. We budget one hour of face time for each patient in order to give the junior and senior student sufficient time to see the patient prior to the attending physician visit. More details about each key player will be discussed in the next section.

In an effort to maximize student learning, we set aside 30 minutes each clinic night for resident teaching sessions. These are case-report type conferences where a student presents a clinical case seen that evening and a resident leads the discussion about the case. B. Challenges i. Figuring out how many student volunteers your practice will need: This is based on the following factors that can be addressed by your SFCP board. How many patients will be seen? How many attending physicians will there be? How many days per month will each student volunteer need to commit to? How many students will see each patient? The CCC board decided that we would start with a 14-week session (10/05/10 to 01/25/11), and would see 12 patients/night with two attending physicians, each seeing six patients/night. We also decided that all


volunteers would have to commit to an average of at least one clinic night a month. This ensured that all volunteers would stay connected to the clinic, but none would be overly committed. In order to ensure this arrangement, we recruited 24 junior clinic members and 12 senior clinic members. ii. Determining what student roles need to be filled: How you run your clinic will directly inform the roles for which you need to recruit. Our clinical roles were as follows:

a. Student Director: oversees the operations of the clinic and works with the hospital administrator in charge of scheduling patients to ensure that patients are appropriately assigned to each team (e.g., a patient’s subsequent visits are scheduled with the same team). He or she works closely with the attending physician to ensure efficient flow of the clinic.

b. Senior Clinicians: assists the clinical team in providing high-quality, patient-centered, primary care services. The senior student will mentor a junior student be and assigned patients to evaluate. We determined that senior students must fall into one of three categories: be an MS-III participating in CCC as part of their Primary Care Clerkship (a longitudinal, year-long course), be an MS -III who has completed an internal medicine rotation including the ambulatory month, or be an MS-IV.

c. Junior Clinicians: assists the clinical team in providing high-quality, patient-centered, primary care services to each patient. The junior student will be assigned patients to accompany throughout their entire CCC experience, from waiting room to examination room to the final exit at the end of the visit. Priority for the junior clinical student position will be given to second-semester MS-I and MS-II students.

d. Administrative Coordinator: maintains the practice's flow and provides continuity for following up with patients. He/she will create patient packets with a face sheet, any notes from the ED or medical walk-in unit in our system, as well as the new patient survey and a check-out form. He/she will be responsible for ensuring that all necessary follow-up for each patient is successfully completed. He/she will also help the practice run smoothly by coordinating care across social services, education, and clinical teams. e. Laboratory Director: assists clinical teams with ordering appropriate labs, including all point-of-care testing. In our case, student volunteers are supervised by a medical assistant (MA) who is licensed in phlebotomy. Hospital lab services trains and certifies students to do point-of-care testing. The professional MA performs all phlebotomy and EKG services, and is assisted by the lab volunteers. We are currently exploring the possibility of certifying student volunteers to perform phlebotomy and EKGs under MA supervision. f. Resource Center volunteers: assist with the social service needs of the patient, including follow-up and making sure that patients who do not have a primary care physician are put in touch with the appropriate resources to expedite the process. (See Section 4-1, Patient Resources, for a more in-depth explanation of the Resource Center.)

iii. Determining the dates for which you are recruiting student volunteers: Look at academic calendars and figure out what days you may have to close your clinic based on student schedules. All the volunteers are students, and they should not have to drop out of school due to clinic


commitments! Note public holidays, as well. If possible, put student test days on your calendar, as it may be harder to recruit volunteers for days leading up to tests. These may be unpopular sign-up dates and some sort of incentive or restrictions may need to be made to insure volunteer commitment on these days. We chose to run our first session from October 5, 2010 to January 25, 2011. This gave us enough time to recruit, appoint, and train students in the beginning of the school year, before opening our SFCP. Ending in January gave us time to transition first-year students into clinical roles, while transitioning second-years out, as they began to focus on USMLE Step 1 preparation. iv. Ensuring that there are enough senior clinicians: As 3rd- and 4th-year medical students tend to be less accessible, it is important to reach out to medical students who have clinical experience to serve as senior clinicians. Target medical students taking a year off to do research or get a master’s degree; they tend to have more flexible schedules, but also have the necessary clinical experience. One of our 4th-year board of directors reached out to her class to personally recruit interested students . We also took advantage of the 3rd-year format at HMS, where MS-IIIs spend their entire third year at one hospital. We were able to recruit some students who were already housed at the hospital where our clinic is located, and they participated in our clinic as their longitudinal primary care clerkship. v. Creating an application: Online applications make organizing and decision-making easier, since you don’t have to rifle through a hundred paper applications (and it saves trees!) . We used a Google form to make our application. All students noted their class year and prior student clinic experience (both with our SFCP and otherwise). They also ranked each volunteer position in order of their interest. To make scheduling simple, we asked each applicant to tell us which days they would attend training, which days they were unavailable, and what other obligations they held. We also asked them to write a short paragraph on why they wanted to be a part of our SFCP. vi. Advertising and recruiting: Send out emails to your school’s all-student e-mail lists. Make sure to poster well-trafficked areas. Hold information sessions so students can learn about all the positions and ask questions. We emailed the application and position descriptions to our medical student e-mail lists. We also held an information session, hosted a table at the school’s annual Involvement Fair, and were very big on word-of-mouth! Reach out to other schools! We needed more research coordinator volunteers, so our Head of Research sent an email to the Harvard School of Public Health and recruited some highly qualified students. vii. Assigning roles and notifying applicants: Decide how you will assign roles before sending out the application, and stick with this decision throughout the process. This ensures a fair and painless selection process. Create a simple system for assigning roles that gives students priority based on the qualifications you decide are most important. As a board, we decided that all board members would get priority for positions. Students who had volunteered in CCC during the pilot were given next priority. Since first-years did not have any experience with interviewing patients, second-years were given priority over them for Junior Clinical Staff member positions. We also chose volunteers based on how much free time they had, as indicated on their application. Using all this info, we ranked students in tiers (e.g. Tier 1 = students with clinical experience and no conflicts; Tier 2 = students with no experience and no conflicts, Tier 3 = no experience and 1 conflict, etc.). We assigned each student in each tier a number, and using an online random number generator, we assigned roles. This way, we were impartial and gave everyone a fair chance. In retrospect,


we wish that we had asked about “interest in pursuing a primary care career” and have changed our application to reflect this. We want students who want to go in to primary care to have a higher priority than those who simply want more patient contact. We decided we wanted to be as inclusive as possible, and created additional committee positions, offering them to the applicants we did not take initially. We encouraged them to apply again for the next session, as more positions would open up as the second-years stepped down. To further encourage these students, we gave them priority when filling open slots the next semester.

viii. Scheduling: Now that you have a full staff, it’s time to create a schedule. Based on talks with the board, we had a basic framework for each position. Everyone is required to work one night/month, except for our 3rd-year Primary Care Clerkship students, who must work at least three times/month. For non-clinical roles, we did the following (note: These numbers do not include committee heads):

a. Administrative Coordinators (AC) (four volunteers total) - Each volunteer worked four weeks straight, with the last day of one AC being the first day of the next, which allows for better transition of the role.

b. Laboratory Director (five total) - For the first three weeks, we had two volunteers to make things less overwhelming, and to increase each volunteer’s exposure to the clinic. After that, one student came each week.

c. Research Coordinator (ten total) - two volunteers each week to enter patient information into a database.

d. Patient Education (nine total) - Came into clinic, as needed; determined by committee heads. e. Resource Center (ten total) - two volunteers each week.

Create a document (Google spreadsheets work well) so that everyone has access to volunteers’ emails and phone numbers in case of emergency.

In order to make scheduling easy for everyone, we assigned “schedule leaders.” Board members served as schedule leaders for their respective committees. We also assigned one senior clinician from each clinical team to be a schedule leader. (We chose a senior who was not on the board to be the leader so as not to overwhelmed board members with CCC commitments.) Every CCC member could view the CCC Scheduling GoogleDocs, but only the schedule leader could make changes. That way, 100 students weren’t making changes, but also, one the staff coordinator was not responsible for scheduling everyone. ix. Staff Coordination: Even after volunteer recruitment and staff scheduling is completed, the job of staff coordination continues. It’s your job to make sure that staffing for each clinic session runs smoothly. Send a reminder email to volunteers one to two days before their session. We created a sign-in sheet with the names and phone numbers of everyone who is expected to be at your SFCP on a given night, so that student volunteers can sign-in and we could easily identify and call patients who did not show up on time. In case a student is unable to make it on his or her scheduled date, always have a back-up plan! Make sure you know what you will do if someone calls in sick. Every clinic volunteer has access to the scheduling document and can see who holds their same position, but is off duty. If a volunteer can’t make it, it is his or her responsibility to contact one of these off-duty volunteers to replace them, and to let their schedule leader know about the switch.


x. Ensuring adequate clinic flow: From our visits to other student clinics, we know that the most common bottleneck for clinic flow is waiting for the attending physician. To reduce these wait times, we limited the number of teams working with each attending (three teams, each of which sees two patients). We also staggered appointment start times so that an attending physician's three teams start 15 minutes apart; this builds attending physician teaching time into each patient visit (see diagram below). In addition, we used white boards where teams could note what time they entered their room so that the attending physician could provide a reminder (gentle knock on the door) at 30 minutes if the team had not yet wrapped up. In addition, we enlisted a team of Harvard Business School students to conduct a time-tracking study during our initial weeks to help us determine other hold-ups in the patient clinic visit (such as paperwork at the beginning of the visit, communication with labs team, etc…). In order to give patients a sense of the clinic structure, we also designed a welcome poster that explained what to expect in our clinic (See Appendix 5).

xi. Emphasis on teaching within the clinical team: Each clinical team is the root of our educational model; each team contains both a senior student (MS3, MS4) and a junior student (MS1, MS2). With each clinical encounter, there are multiple opportunities for teaching. The students start by going through the patient chart, they discuss key points in the history and the senior student uses this


time to teach any clinical information that will be relevant in the interview. After the interview and initial physical examination, but before the attending physician arrives, there is another opportunity for the junior student to ask questions about what was done and the pertinent findings. It is very important to stress that asking questions is part of the purpose of a SFCP and to make sure that this becomes a cultural norm. Lastly, at the end of the encounter, as the senior student writes the note, the junior student should be present to both contribute additional findings and discuss the thought process behind the treatment plan.

xii. Resident teaching sessions: We felt that it was important to have a wrap-up after each clinic session, when students of all levels could gather, in order to promote both education and group camaraderie. These sessions are lead by a medical resident who receives information about scheduled patients on the day before the clinic session. They choose an interesting patient or topic, and prepare for discussion. During the teaching session, a student presents the selected case as it presented in the clinic. The resident then leads discussion, beginning with basic questions aimed at first-year medical student knowledge, then building through more complex questions and lines of thought to involve students in higher levels of medical education. We usually focus on a differential, go over key physiology and clinical concepts, and discuss any test results. These sessions have been incredibly well-received by students. In the assessment of the pilot, the resident teaching sessions were a very popular part of clinic, and most students stated that these sessions were highly beneficial to their learning. xiii. Community-building events: In order to accommodate as many students as possible, given the overwhelming interest, we created a number of extra positions by increasing the size of research, labs, the Resource Center, and patient education subcommittees. In retrospect, we should have had monthly CCC activities or meetings to make everyone feel included in the clinic, particularly those whose roles did not involve a frequent presence at the clinic. From now on, we will invite all interested students to our monthly board meetings to learn about what’s going on with CCC. We are also planning to hold one or two social events per semester to increase a sense of cohesion among volunteers. xiv. Incorporating patient education into the clinic flow: You don’t want patient education to be a random “extra,” but rather, an integral part of the patient’s experience and clinic visit, regardless of whether the education takes place between junior clinician and patient in the exam room, or the patient comes to an educator before or after their visit for more help in a specific area (e.g., diabetes, asthma control). We are exploring other ideas on how to incorporate patient education into the clinic flow, but a preliminary list is to educate patients during their initial wait time, hold mini-classes with the focus on broad health topics (e.g., nutrition, exercise, supplements) that take place each clinic, or create easy-to-read brochures that patients can take home. C. Key Points / Action Items

Determine what roles need to be filled and how many students you need to recruit. Anticipate possible problems with scheduling and figure out creative ways to prevent them Create an application with descriptions for each role. Advertise and recruit! Set up the schedule and make sure to share it with all volunteers. Send out weekly reminders/update emails to all volunteers one day prior to clinic session Make teaching an integral part of the culture of your clinic by emphasize the role of the senior

clinician as a teacher, and allot time in the clinic schedule to allow for student education.


Work with residents and faculty to plan educational sessions that are interest to all students. Make sure to schedule residents and faculty far in advance and have back-up options ready. Make sure all student volunteers feel engaged – consider community building events or optional

monthly meetings Brainstorm your vision of patient education at your clinic. Will you have “educators” on site?

Classes? Waiting-room teaching sessions? Brochures? This will drive what you need to do next. Create easy-to-read, low-literacy, attractive handouts on the issues that you believe your

population will need most. Don’t reinvent the wheel – find out what resources exist and edit them to fit your goals and clinic.

Find someone who can translate materials into the most common languages you will encounter. Rather than starting from scratch, partner with clinics that already use a coaching model and

adopt their training materials to your needs.


SECTION 6: Research and Quality Measures A. Introduction Plan your SFCP research agenda like you would any significant research endeavor. For the CCC, we asked, “What are the questions we want to answer?” The answers guide all of your research efforts, so answer carefully. In our case, as a new SFCP, we had a set of straight-forward questions:

1) Who are our patients? 2) What care do our patients ask for and what are we providing for them? 3) Are our patients satisfied with their care? 4) Does enrollment in CCC impact patients’ use of ED services?

From this set of questions, a plan for a research infrastructure emerged. For instance, we needed to know our patients’ age, race, gender and socioeconomic status to answer question #1, and our patients’ chief complaints and range of clinical services received to answer question #2.

Once the research questions were clearly formed and we understood what data we needed, we created survey instruments to collect that information and recruited a team of students to administer the surveys and analyze data. Designing surveys is challenging and requires the help of a dedicated faculty mentor, as described below. In addition, we prepared an IRB application for institutional support of our research project. And lastly, we formed a research advisory board of faculty researchers in the fields of health services research, primary care, and quality-of-care to guide our team. With all of these steps in place, we had a functioning team ready to implement an ambitious research agenda.

B. Challenges i. Choosing the right platform for data collection: We thought carefully about the right software to collect our data—a decision that could have a big impact on future research if we needed to change our minds. We decided to use REDCap (project-redcap.org), a flexible, secure, web-based database application that suited our needs perfectly. Using software that isn’t designed for large-scale data entry, like Excel, can have major ramifications down the line if you need to transfer data into another format or realize that a mistake has been made.

ii. Designing surveys: Survey design is quite subjective and very challenging. Part of the challenge is that it seems deceptively simple, but it can create very surprising obstacles. To deal with this difficult task, it is essential to enlist the help of researchers with experience in survey implementation. In our case, student volunteers had access to several faculty members who were willing to help and give feedback on survey design. Generally, faculty members are interested and excited when students take the initiative to design a solid survey for a well-thought-out project. We asked a group of respected faculty at our parent hospital to meet with us twice annually to serve as a “research advisory committee” and were overwhelmed by their response and willingness to help. Please see Appendix 7 for sample patient intake and satisfaction surveys. iii. Assembling a research team: Learning about survey design, statistics, quality assessment, and patient data collection can be daunting. Before diving in, have some team members do clear, focused literature reviews about the topics on which you need help. Some of the issues that we needed to research in depth were quality measurement, medical coding, and health literacy.


It is crucial to find a team of students with enthusiasm for, or better yet, experience with, survey research. Data collection is time-consuming and laborious, but the pay-off is very satisfying when you can analyze results and make informed decisions.

iv. IRB applications: If you plan on doing anything related to publishing or communicating your research beyond your clinic walls, you must get IRB approval. Get the IRB application process at your institution started as soon as possible. Any faculty researcher will have extensive experience with this process and can help guide your team. v. Planning for the future: Like all SFCPs, we would like to show quality patient outcomes. Setting up a patient registry is critical to being able to track outcomes. We update our database weekly. Once we have compiled a group of patients, we plan to use chart reviews from our electronic medical record to compare our clinic on the HEDIS measures used to measure quality in primary care clinics across the state. C. Key Points / Action Items

Find someone with significant health services research experience to be a mentor in this process. Recruit a team of research coordinators to aid in data collection, analysis, and future research

leadership Start with a set of clear research questions to answer. Decide what data will be necessary to answer these questions. Obtain IRB approval for each project. Design a survey with professional help. Create a clear process for data collection. Do background research when issues are unclear, and back decisions with evidence in the

literature. Develop a patient registry to be used for QI projects in the future.

D. Resources [1] REDCap: www.project-redcap.org


SECTION 7: Appendixes


SECTION 7-1: Selected Clinic Profiles Information about each clinic presented was obtained from the Society of Student Run Free Clinic Website (http://www.studentrunfreeclinics.org/) under “Clinic Profiles.” We then sent out the information to respective clinics for approval. A. The Sharewood Project, Tufts University School of Medicine

*Approved by student group i. General Information:

a. Address: 184 Pleasant Street, Malden, MA. b. Website: http://www.sharewood.info/index.php c. Hours: Tuesdays, 6:30pm-9:00pm

ii. History: Founded under the guidance of Dr. Brian Lisse, an Associate Professor at TUSM. iii. Patient population: 43% from Malden. 76% are uninsured; 70-75% are employed. 82% are 20-65 years old, with median age around 40; 14% over 65. 70% are new patients, 30% are returning. Usually see 15-30 patients/night. iv. Patient recruitment: Advertisements are put up in the subway system for 10 weeks (~$7000). Undergraduates disseminate flyers. Table at health fairs. Visits to local churches/social facilities v. Structure of clinic: Undergraduates work the triage desk, have patient point to signs (general, STI, flu clinic, dental, vision, case management) for desired services. Patients are given a number - first come, first serve. Are trained to take vitals, height, and weight. Give patient consent form. Less experienced medical student pairs up with a more experienced member and both go in together to do the H&P. Present the case to an attending physician or resident in pairs.

There are weekly board meetings of 23 members (1 administrative director, 2 clinic coordinators, 1 clinic administrator, 5 case managers, 1 IT manager, 2 publicity chairs, 1 equipment/pharmacy manager, 2 fundraising coordinators, 1 grant writer, 1 finance coordinator, 1 physician coordinator, 1 data analyst, 5 sexual health counselors). vi. Core services: Provide laboratory tests including blood glucose and pregnancy testing. Have Hepatitis B and C, HIV and STI testing (anonymous). Work with Quest diagnostics that processes all their labs. There is a clinic steering committee member in charge of follow-up on these labs to see that the patients are given their results. Patients are asked to return to clinic for follow-up on their lab results. HIV counseling available, 5 members of the steering committee are trained in HIV counseling. MassHealth signup on-site. No formal translators on duty.

vii. Pharmacy: Clinic has a list of 30 prescription drugs for which the local pharmacy will provide significant discount. Direct patients to Costco/Target. viii. Finances: Yearly operating budget: $35,000. Funds come from grants, donations, auctions, other student events, and revenue generated from a deal with Amazon.com.


B. Columbia Student Medical Outreach (CoSMO) *Approved by student group

i. General Information:

a. Address: 21 Audubon Avenue, New York, NY 10032 b. Website: www.cosmoprimarycare.org c. Hours: Saturdays, 8:30am to 1:30pm; second Thursday of the month, 5:30pm-8:30pm

ii. History: CosMO began in 2000 when a group of first year medical students started to work on establishing a primary care center in the community designed to serve the uninsured in the area. They did a lot of research on student run clinics in the NY area and asked for the involvement of attending physicians, administration, and the support of NY Presbyterian Hospital. The clinic was opened four years later. iii. Patient population: Uninsured of Washington Heights, NY. iv. Patient recruitment: Designated person helps recruit and enroll patients who qualify for public assistance insurance by having a community worker on site every Saturday to screen CoSMO patients for eligibility. Word-of-mouth; referrals from inpatient discharge, community health fairs, and ED. i. Structure of clinic: Volunteers from schools of public health (mainly administrative and data management), physical therapy and nutrition students (for patient education).

a. First Visit: Enrollment

1) Screening to determine eligibility for medical coverage through government programs 2) Social work and health education services 3) Duration: 1 hour.

b. Second Visit: Clinical Appointment 1) A complete medical evaluation 2) Appropriate testing and referrals 3) Health education on topics relevant to patient’s health, i.e., exercise, diet, new diagnoses. 4) Duration: 1 to 2 hours.

c. Future Appointments 1) Scheduled as needed to ensure high quality continuity of care. 2) Evaluation of new or continuing healthcare needs. 3) Health education and social work services when appropriate 4) Duration: 1 hour.

vi. Core services: Provides primary medical care and social services. Multidisciplinary, including medical students, nursing students, and social work students.

vii. Pharmacy: Primarily pay for patient medications. Have accounts with 2 pharmacies (Target and Theresa’s, a local pharmacy). For brand name drugs that are not available generically or still expensive (e.g. Flonase, Nexium), patients are registered with the “Pharmacy Assist Program” (PAP), which provides free meds through pharmaceutical companies.

viii. Finances: The majority of the budget (~$20,000 annually) is spent on medications (>97%). Fundraising is done with several cultural events (recent events featuring author Junot Diaz and Martin Espada), direct mailer, and Amazon link. Also receive generous in-kind donations for space, labs, supplies, and EMR, as well as some admin services at the clinical space occupied.


C. HAVEN Free Clinic, Yale School of Medicine i. General Information:

a. Address: Fair Haven Community Health Center; 374 Grand Avenue, New Haven, CT 06513 b. Website: http://havenfreeclinic.org/wp/index.php/haven/welcome/ c. Hours: Saturdays, 9:00am-12:30pm; staff are present from 8:30am-2:00pm.

ii. History: The clinic was started in 2004 and operates out of the Fair Haven Community Health Center. It was initially set up for comprehensive primary care and is now transitioning to a “bridge-to-care” model with a 1-year target-goal to refer patients to establish formal care. The original goal was unsustainable with a growing panel of patients with significantly greater healthcare needs than originally envisioned (chronically ill, medically complicated, etc.). New model aims to triage, stabilize and provide as many free/low-cost services before transitioning them to more permanent care. The university administration gave a lot of support initially (20K from medical school, 5K from nursing school etc, 5K from PA program). The extensive free referral service network was established mostly through personal relationships between medical students and attending physicians at Yale whole offered to volunteer their services. iii. Patient population: Majority Spanish-speaking patients, undocumented immigrants. iv. Patient recruitment: Word-of -mouth. The clinic is currently full and has a wait list. v. Structure of clinic: Clinical students (MD, PA,NP) complete clinical work (i.e.: taking pts into examination rooms and doing H&P). All other students all together run all other departments. The 1-2 yr med students (or equivalent NP/PA) complete vital signs and obtain chief complaint. The 3-4 yr students (or 2nd year PA, 3rd year NP) take most of the medical history and complete the physical exam. This clinical student team presents the patient to the attending. Then the whole team sees the patient. There are usually at least two attending physicians on a given clinic day. One of them must be a Fair Haven clinic attending. School of Public Health students perform much of the patient education, research, and grant writing. There are meetings held before the start of the clinic day (i.e.: assigning students to teams for cases, assigning translators, etc) and one at the end of the clinic where two cases are presented (one clinical, and one psychosocial). The departments that function during clinic times include Patient Services, Laboratory, Interpreters, Education, Social Services, Clinical, and Pharmacy. After hours, patients have access to a phone number that connects them to a cell phone held by a student for appointments, basic questions, etc. Clinical questions are directed to clinical advisors (4th year medical students), who have ready access to faculty advisors. Referrals: patients are referred back to clinic so they can come back to get blood draws in the lab at the free clinic. Normal results are given over the phone. However, patients are always given a follow-up appointment to come in to go over lab results. Lab results are always sorted into 3 piles (Normal, Slightly abnormal, and abnormal). Patients with slightly abnormal results are encouraged to come in to their follow-up apt for education, and patients with abnormal results are encouraged to come in to go over the results and plan accordingly. If a lab value is very abnormal, the patient is called and told to go to the ED. Labs that are drawn are sent to Quest labs under the Yale/Quest contract. vi. Core services: The clinic serves as bridge to care for patients without a primary care physician. The general rule is that patients must be transitioned to the Fair Haven clinic within one year. The clinic provides basic primary care services. In addition, it has a women’s health clinic every other week with Certified Nurse Midwife preceptor; the team can provide STI evaluation, pap smears, and IUD placements. Mental health care is limited to patients with depression who respond to initial SSRI trial; otherwise patients are referred to a


specialist. There is a latent TB treatment program where patients on treatment regimens are scheduled for regular follow up appointments with the same medical student. Pediatric patients, pregnant patients, patients with poorly controlled chronic disease (i.e. HbA1c >8), HIV patients, patients with cancer are referred elsewhere. Undergraduate students who are trained and evaluated for medical interpretation proficiency provide interpreter services. Depending on their proficiency, interpreters are assigned to different departments (conversational Spanish = pharmacy services; native speaker fully proficient in medical Spanish = direct interpretation)

vii. Pharmacy: All medications are free. Attending prescribe medications and patients go to an internal pharmacy within the clinic. About 50% of medications in the formulary are generic medications regularly filled in the pharmacy. If a medication is not stocked in the pharmacy, the clinic has an arrangement with a local Rite Aid in which patients may pick up free medications, after which Rite Aid sends the clinic the bill. The clinic does not prescribe narcotics. All medication-related activities (including pill counting) are overseen by an attending physician. viii. Finances: Initial funding: Yale University Medical School gifted $20,000. School of Nursing and PA School each gave $5000. The current budget is $110,000. Public Health students lead grant-writing initiatives.


D. ECHO (Einstein Community Health Outreach) Clinic i. General Information:

a. Address: 1300 Morris Park Avenue Bronx, NY 10461 b. Website: http://www.einstein.yu.edu/echo/default.aspx?id=19924 c. Hours: Saturdays, 9:00am-3:00pm

ii. History: Established in 1999; Einstein students collaborated with Institute for Family Health (IFH) to launch ECHO clinic in conjunction with its already operating community health centers. iii. Patient population: Uninsured adults. Patients are primarily African American, Hispanic. iv. Patient recruitment: Initially recruited by going to local community groups. Now has steady patient flow. v. Structure of clinic: Staff required per clinic day: attending physicians 1 health education specialists 4-5 1st-year medical students 5-6 3rd-year students 1 student working in the laboratory 3-4 4th-year students (overseeing 3rd years) 1 student working in referrals 1-2 Social workers 2 front desk receptionists 1-2 nursing assistants Services are provided by social workers, nurses, and physicians from the IFH, and by medical students from the Albert Einstein College of Medicine, under the supervision of the licensed physicians. Two or three students serve as Spanish-speaking interpreters at the clinic. 1st- & 2nd-year medical students complete administrative work. Their duties include patient registration, medical chart organization, referrals and medications, lab work, health education, translation, nursing, and clinical shadowing. 3rd- & 4th-year medical students see patients and present patients to attending physicians to decide on treatment plans. Attending physicians: Must be board certified in family or internal medicine, or a licensed family nurse practitioner. They are encouraged to volunteer once every few months with an open commitment. A recruiter sends out email every ~3 months asking volunteer MDs which Saturdays they will cover. vi. Core services: Provides primary care services. Routine medical exams, physicals, vaccinations, prescriptions, women’s health visits (including gynecology exams), social services, counseling by appointment.

vii. Pharmacy: No pharmacy on site. viii. Finances: The IFH covers clinic-related costs (medical supplies, utilities, pay for non-volunteer personnel). The Einstein Student Activities office covers student costs (transportation, training, food).


E. Equal Access Clinic, University of Florida *Approved by student group

i. General Information:

a. Address: UFHSC Box 100211; Gainesville, Florida 32610-0211 b. Website: equalaccess.med.ufl.edu c. Hours:

1) Medical clinic: Thursdays, 6:00pm and Tuesdays 5:30pm 2) Mobile medical clinic: Mondays, 6:30pm 3) Women’s Clinic: first Thursday of every month, 5:30pm

ii. History: EAC opened its doors in 1992, four years after the initial idea was generated by a group of motivated medical students. Health professional students from UF undergraduate and UF Colleges of Medicine, Dentistry, and Public Health volunteer at the EAC under the supervision of UF faculty. iii. Patient population: Medically underserved in the Gainesville community. iv. Patient recruitment: Not described v. Structure of clinic: Pre-medical students run patient intake and chart organization. First year medical students are paired up with a senior medical student to conduct the initial history and physical until they have all of the examination skills necessary (about 2/3 of the way through first year) at which point they are able to interview and examine the patient alone. 2nd-4th year med students may interview and perform the exam alone. Based on volume of patients and turnout of students at our clinic, this model can be adjusted. An attending physician supervises every case. The case is written up for presentation to resident/attending. After presentation, student and physician discuss plan with patient. vi. Core services: Primary care, follow-up care, social work and psychological consultations, administration of medications (over-the-counter and prescription – no controlled substances), blood pressure and blood sugar monitoring, confidential HIV testing and counseling, referrals to WE CARE network specialists, emergency dental referrals to UF dental clinic. Multidisciplinary, including health professional student volunteers from UF undergraduate and UF Colleges of Medicine, Dentistry, Pharmacy, and Public Health.

Donations, UF Student Government, UF College of Medicine Alumni Association, AHEC, Alachua County, AAMC, AMA, Equal Access 5K Run (biggest fundraiser) vii. Pharmacy: Pharmacy students rotate through the clinic as well as volunteer at the clinic. The Pharmacy team must be consulted before a medication can be prescribed for multiple reasons: to establish the most effective usage of resources (between donated medications, generic programs, and costly medications), to ensure the optimal drug administration for patients, and to teach the students about pharmacology. viii. Finances: Donations, UF Student Government, UF College of Medicine Alumni Association, AHEC, Alachua County, AAMC, AMA, Equal Access 5K Run (biggest fundraiser).


F. United Community Clinics of the University of Pennsylvania i. General Information:

a. Address: First African Presbyterian Church, 4159 Girard Avenue, Philadelphia, PA 19104 b. Website: http://www.med.upenn.edu/ucclinic/index.html c. Hours: Mondays, 6:00pm-9:00pm

ii. History: Two students decided to open a free clinic to serve West Philadelphia. Wrote proposals and received funding from The Philadelphia Foundation and the Bryn Mawr Presbyterian Church. Fundraised at undergraduate organizations. Initial steering committee consisted of students from dental, medical, nursing, and law schools who drafted a mission statement, planned services that would be offered, needs assessment, etc. The First African Presbyterian Church had a willing Reverend. Students were trained and the clinic opened in Fall 1996. iii. Patient population: West Philadelphia community. Over two-thirds of patients are uninsured. iv. Patient recruitment: Centers around the church. Huge community buy-in as their opinions and needs are taken seriously by clinic board. Community members consulted at start of clinic and also serve on advisory boards. v. Structure of clinic: Walk-ins welcome. Patients can guarantee a spot by signing up at the church between 8am & 4pm the day they wish to be seen. Patients who visit the clinic are first greeted by a social work student. This student offers patients various resources to help with many aspects of life and health. Patients are then seen by a medical or nursing student who takes a medical history and performs a physical exam. A physician then reviews this information with the student to decide on an appropriate treatment plan for the patient. vi. Core services: Physical Exams, diagnostic Services including rapid (20-minute) HIV testing, PPD placement for tuberculosis screening, glucose testing, cholesterol testing, administration of flu shots, EKG analysis. Hypertension Program: free anti-hypertensive medications and lifestyle counseling. They do not treat: bus driver’s license physicals, City of Philadelphia School District physicals for teachers, physicals for disability declarations (Employment Assessment Forms, etc.), certain blood-work (cholesterol, lead, toxicology screening, etc.), immunizations other than flu shots, x-rays, gynecological exams, STI tests. vii. Pharmacy: If patient needs medication, it is either offered to the patient from the med box at the clinic free of charge, if available, or a prescription is written which can be filled at a local pharmacy. Vitamins are often dispensed to patients when requested. viii. Finances: Grants written by students. Now currently supported by three benefactors (Bryn Mawr Presbyterian Church, University of Pennsylvania School of Social Work, Graduate and Professional Student Assembly of the University of Pennsylvania).


SECTION 7-2: Support Groups and Conferences A. Support Groups i. Society of Student-Run Free Clinics (SSRFC) www.studentrunfreeclinics.org SSRFC is a national organization aiming to maintain communication, collaboration, and resources to support the growth of new and existing student clinics. This site provides a database of student clinics, a forum for discussion, resources, links, newsletters, and conference information. ii. National Association of Free Clinics (NAFC) www.freeclinics.us NAFC is a nonprofit organization that supports the needs and issues of free clinics and the patients they serve. This site provides resources for starting a free clinic, how to find a free clinic, information on issues of free clinics, and more. iii. Association of the Clinicians for the Underserved (ACU) www.clinicians.org ACU is a nonprofit organization that serves and supports health care development in underserved populations. This site has resources on clinical tools, access to pharmaceuticals, patient education, etc. iv. Community Voices: Healthcare for the Underserved www.communityvoices.org Community Voices works to increase access to quality health care among underserved and uninsured people. This site provides helpful links and resources. v. Institute for Healthcare Improvement (IHI) www.ihi.org IHI aims to increase the quality of health care through innovative change. This site provides links, resources, ideas, models, programs, and more. vi. Kaiser Family Foundation: Health Coverage & the Uninsured www.kff.org/uninsured/ The Kaiser Family Foundation provides up-to-date data, facts, and figures on our healthcare system and health coverage. This site offers fact sheets, resources, news releases, reports, presentations, etc. vii. Cover The Uninsured covertheuninsured.org/ Cover The Uninsured is leading a national effort to enroll the uninsured in available programs. This site provides information and research by state, as well as links to available coverage options. viii. National Association of Community Health Centers (NACHC) www.nachc.org NACHC supports of network of community health centers through research, advocacy, and education. This site provides tools on policy and clinical issues, and more.


ix. National Coalition on Health Care (NCHC) nchc.org/ NCHC strives for comprehensive health care reform. This site provides information on key issues, facts, and resources. x. National Health Law Program (NHeLP) www.healthlaw.org NHeLP is a public interest law firm that aims to improve health care for the working and unemployed poor, minorities, the elderly and people with disabilities. This site offers insight on key issues. xi. HealthCare.Gov www.healthcare.gov HeathCare.Gov is the official government site on the US healthcare system. This site provides information on finding insurance options, prevention, comparing care quality and understanding the new legislature on healthcare. xii. University of Maryland Health Sciences & Human Services Library Health Policy Links http://guides.hshsl.umaryland.edu/policy University of Maryland Health Sciences and Human Services Library provides numerous health policy links from academic and research institutions and associations, and federal and state resources. xiii. American Academy of Family Physicians (AAFP) www.aafp.org AAFP is a national medical association, comprised of family medicine physicians, residents, and medical students, dedicated to improving health care to achieve optimal health for everyone. xiv. American College of Physicians (ACP) www.acponline.org ACP is a national medical association, comprised of internists, internal medicine subspecialists, medical students, residents, and fellows. xv. Society of General Internal Medicine (SGIM) www.sgim.org SGIM is national medical association of general internists, dedicated to promoting improved patient care, research, and education in primary care and general internal medicine. B. Conferences and Meetings i. Society for Student-Run Free Clinics – annually, at the national and regional levels ii. National Association of Free Clinics – annually, at the national level iii. American Academy of Family Physicians – annually, at the national level iv. American College of Physicians – at the national and regional levels v. Society of General Internal Medicine – at the national and regional levels


SECTION 7-3: Financial Template


SECTION 7-4: Patient Criteria A. Patients Not Seen

i. Pregnant (for prenatal care) ii. Age <18 iii. Emergencies

B. Accelerated Transfer

i. Uncontrolled Chronic Conditions (e.g., HgbA1C>9%) ii. HIV/AIDS iii. Uncontrolled psychiatric disease iv. Homeless (Bridge to Healthcare for the Homeless) v. Cancer patients


SECTION 7-5: Student Training Manual Outline TABLE OF CONTENTS A. Clinical Encounter Flow Charts B. Clinical Roles And Responsibilities C. Basic Clinical Unit Structure & Schedule D. CCC & MGH Contact Numbers E. Research And Outcomes F. Laboratory Testing G. Social Services H. Domestic Violence I. Translation J. Patient Education K. Emergency Plans/Protocols L. Appendix A (Clinical Templates / Guidelines)

I. Junior Clinical Assessment Template Ii. Senior Clinical Assessment Template Iii. Physical Exam Guide Iv. Sore Throat Assessment & Treatment Guidelines V. Clinical Information On Commonly Seen Illnesses

M. Appendix B (Forms) I. Junior Clinical Time Tracking Form Ii. Crimson Care Check-Out Order Form Iii. Intake Survey Form

* The complete student training guide is available upon request


SECTION 7-6: Brochures and Welcome Poster

A. Welcome Poster


B. Brochure (Outside page)


C. Brochure (Inside Page)


SECTION 7-7: Patient Surveys

A. Patient Intake Survey (page 1 of 3)


Patient Intake Survey (page 2 of 3)


Patient Intake Survey (page 3 of 3)


B. Patient Satisfaction Survey (page 1 of 5)


Patient Satisfaction Survey (page 2 of 5)


SECTION 7-8: Curriculum Outline A. Introduction Most students volunteer for SFCPs to further develop their own skills in clinical medicine and to better serve their community. For these reasons, medical education is an essential component of SFCPs. Students should be instructed on clinical medicine, peer education, and the unique aspects of the population served by their clinic. Strengthened by such an education, students may improve the quality of care delivered and the outcomes achieved in their respective clinics. CCC incorporates these fundamentals of medical education into the backbone of the clinic through student training sessions, weekly resident teaching conferences, and a six-week course designed for students seeking to delve further into scholarly work related to the clinic. We developed a six-week-long course entitled Social Justice Through Primary Care And Community Medicine to aid students in the development of scholarly projects for the improvement of CCC. We chose to open the course to students participating in Family Van, the Harvard-based mobile clinic, which has many of the same ideals as CCC. The format of the course is six journal club sessions during which a guest speaker introduces a topic and the remaining time is used for discussion of that topic and the weekly assigned readings. Topics are both general to the development of scholarly work within student-run and mobile clinics and delve more specifically into the unique challenges posed by the social infrastructure in Boston. The final project for the course is a project proposal. The best projects will be implemented. Funding for the projects is possible through the Office of Enrichment Programs at HMS.

B. Course Title: Social Justice Through Primary Care And Community Medicine The course is designed for students participating in either the CCC or Family Van with a special interest in social justice in healthcare delivery. Broadly, the course will cover the current role of community medicine physicians and how that role is shaped by healthcare reform and specific patient populations. The course will focus specifically on understanding the unique characteristics of the patient populations served by these groups. The lectures will focus on broad topics as they pertain to health care in Boston. The goal of the course is to inspire students to develop new ways to overcome the current barriers to care specific to the patients they see in their respective Boston-based clinics.

C. Specific Objectives i. Underline current gaps in the medical care system with a specific focus on patients who have

limited access to care ii. Understand the role of primary care and community medicine physicians today and in the setting

of healthcare reform iii. Explore the role of the physician as an advocate for social justice iv. Explore new models for healthcare delivery through either the CCC or Family Van v. Recognize the importance of community-based care, such as that through CCC or Family Van, as

a key component of the healthcare system D. Course Requirements All students must participate in the CCC or the Family Van to enroll in the course. Attendance at four out of the six classes is required for course credit. Weekly readings are strongly recommended for full participation in discussion. Students will work individually or in pairs on a final project focused on health


delivery in the community, as described below. The students will develop these projects under the guidance of the course faculty.

E. Final Project i. Basics

a Propose project for improvement of CCC or Family Van operation b. Propose research project for CCC or Family Van that would measure patient outcomes,

quality of care, cost-effectiveness, etc. c. Does not necessarily need to be implemented, but must be feasible within reason d. The best projects may be implemented in the CCC or the Family Van. e. Students may work in groups or individually

ii. Requirements a. Brief 1-page proposal for the final project will be due halfway through the course. b. 5-page paper of proposed project

1. Format will be similar to a mock grant proposal with an introduction to the topic, prior data on the subject (if it exists), project design, and methods for how project will be implemented

2. Due the last day of the course c. 15-minute presentation of the proposed project

1. Presentations will be given on the last day of the course. iii. Mentorship

a. Students are encouraged to seek out mentors for their projects. The course directors are happy to facilitate this process.

iv. Feedback a. Students will receive feedback on their presentations from a panel of mentors, and from

Family Van, CCC, and other Boston-based community health organizations b. Formal written feedback from the course directors will be given on the project proposals

F. Grading The course will be graded Pass/Fail. G. Course Evaluation The course directors will evaluate the course in several ways: i. Course evaluations at the midpoint and endpoint of the course ii. Evaluations of each lecture completed by both the students and faculty immediately following

each session iii. Pre-course and six-month-post-course follow-up survey to assess change in attitudes,

perceptions, and success of implemented projects iv. Pre- and post-course survey focusing on insight into social justice issues in community medicine.

The purpose of the survey is for the instructors to evaluate the success of the course. H. Course Format The course pilot is a six-week course that will meet weekly for two hours. The ideal course structure would meet for 12 weeks, every other week for two hours.


SECTION 7-9: Authors A. Student Editors:

Albert Yeh, Luis Ticona, and Linsday Cole are fourth-year medical students who serve as senior clinicians and student directors for CCC. B. Section 2: Needs Assessment

Julia Carnevale, Andrew Chao, and Camille Powe are fifth-year medical students and were three of the founding student directors CCC. They worked closely with Dr. Berman to imagine, build, and launch the CCC within one year’s time. They will all enter internal medicine residency in summer 2011. C. Section 3-1: Institutional and Faculty Support

Dr. Rebecca Berman is an internist and medical educator who joined the John D. Stoeckle Center for Primary Care Innovation (Stoeckle Center) in 2009, where she spearheads efforts to encourage medical student interest in primary care. She is the founder and director of CCC, and directs the Stoeckle Primary Care Scholars summer internship program. D. Section 3-2: Student Leadership and Organizational Structure

Albert Yeh is a fourth-year medical student and serves as one of the senior clinicians and student directors for CCC. E. Section 3-3: Student Training and Orientation

Emily Hinchcliff and Jimmy Yang are second-year medical students. As board members of the CCC, they were in charge of student education, from inception to assessment. F. Section 3-4 : Patient Recruitment

Susan Miranowski is a second-year medical student who served as a Community Outreach Coordinator in 2010. Susan became involved in the CCC as a first year helping to found the clinic and develop its goals and mission. Jesús Treviño is a second-year medical student who served as Community Outreach Co-Coordinator in 2010. He joined the CCC because of the opportunity to pair his interests in innovative primary care delivery methods with the CCC’s Bridge-to-Care model. G. Section 4-1: Patient Resources

Jana Jarolimova became involved with the CCC during her first year of medical school. She has worked to establish and develop the clinic’s Resource Center, which provides social services to patients. From contributing research and organizational efforts to the clinic’s Social Services Committee throughout her first year, she moved on to become one of the clinic’s founding board members and co-coordinator of the Patient Resource Center during her second year. H. Section 4-2: Clinic Finance

Amanda Johnson (MD/MBA candidate) became involved with the CCC in 2009 as a member of the Scheduling and Administration Committee. The following year she served as the Funding Coordinator, directing fund-raising efforts and coordinating active grants. In addition to primary care, her passions include medical language training and smart use of technology in health care systems, locally and globally.


I. Section 5: Clinic Operations

Adeola Oni-Orisan was involved with the HAVEN Free Clinic at Yale as an undergraduate, and she was initially disappointed to learn there wasn’t something similar at Harvard. She worked in the Operations Committee when CCC was a distant dream, then as an administrative coordinator and junior clinician during the pilot phase. Mekeme Utuk is a first-year medical student and got involved with CCC working with the Social Services committee, focusing on Domestic Violence screening. During the pilot, she volunteered as a Junior Clinician, on the Patient Resources team, and with Labs. Emily Morell is a first-year medical student who found CCC when looked for an opportunity to work with patients early on in medical school. She is committed to improving access and care for those who don’t have it and feels CCC provides students with an invaluable opportunity to become part of a patient’s clinical team, even at the earliest stages of medical training. Hannah Jackson became involved with CCC within the first month of being a medical student at Harvard. She was impressed by student clinics during her medical school interviewing process, and found like-minded first-year students at Harvard who connected with senior HMS students already working to establish a clinic. Juwarat Kadiri became involved in CCC during its early stages in her first month of medical school. During the pilot she served on the community outreach committee and later transitioned to the patient education department where she combines her interest with outreach and patient education. J. Section 6: Research and Quality Measures

Michael Barnett is a fifth-year medical student and was a Doris Duke Charitable Foundation clinical research fellow in 2009-2010, where he did research on physician referral networks. He is applying for residency positions and hopes to be an academic health policy researcher and primary care physician. K. Section 7: Appendixes

Karolina Brook is a first-year medical student who graduated from Princeton University '10. She is currently exploring all fields of medicine and has a strong interest in global health. Sheena Chew is a fourth-year student and worked as a senior clinician at CCC during its first year. She has worked on getting primary care to homeless patients and did research for the Boston Healthcare for the Homeless Program. McKenzie Koss is a fourth-year medical student. She currently serves as a member of the CCC Finance and Fundraising Committee. Michelle Fox is a fourth-year medical student applying to internal medicine. She was one of the initial co-founders of CCC and spearheaded the development of this course due to her interest in medical education.


Crimson Care Collaborative™ A Harvard Medical School

Student-Faculty Collaborative Practice (SFCP)

www.massgeneral.org/ccc