December 4, 2012Michael Toboni and Brian Chou with Dr. Brian Prestwich

Executive Board Members: Emily Levy, Joseph Li, Natane Runningfox, Sadia Quidwai, Megan Chen, Yvonne Hoang, Mena Alrais

Who We Are

200+ Student Volunteers25+ Preceptors

4 Health ProfessionsMedicineOccupational TherapyPharmacyPhysician Assistant

2 Clinic SitesLAC + USC Urgent CareEisner + USC Med Center

Who We AreWe are students working

together in interprofessional care

teams to help deliver comprehensive care to the chronically ill and underserved population

of Los Angeles.

Care Team1 Clinic Coordinator2 Medical Students2 Pharmacy Students1 OT Student1 PA StudentSupervising Faculty

Patient ServicesPreventative ScreeningLifestyle ModificationMedical AssessmentMedication Therapy MgmtMedical Home Linkage

Cycle Time70 Min per Patient

What We Do

Primary Care Project at USC+ Eisner Family Medicine Center

Urgent Care Project at LAC+USC Urgent Care Center

The Clinic Protocol

Medicine

Pre-Clinical Medical StudentsVital SignsPreventative ServicesPatient EducationMedical HistoryPhysical Exam

Clinical Medical StudentsAssessment & PlanningTeaching and SupervisionCharting

Physician Assistant

Medical HistoryPhysical Exam

Treatment PlanningPatient Education

Verbal Case ReportsCharting

Pharmacy

Medication Therapy ManagementMedication HistoryMedication ReconciliationDrug Assessment

Appropriateness

Effectiveness Safety

Design new medication regimen Patient Education

Occupational Therapy

Increase patient engagement in chronic condition self-management and preventative health behaviors.Collaborate with team to create an individualized wellness action plan.

The Lifestyle Redesign® Approach.The process of acquiring health-promoting habits and routines in daily life. Patient education Daily activity analysis Goal setting

Students are exposed to other

disciplines, work as a clinical team, and adopt an analytical, case-based approach to

patient care…as early as their first

year of school.

All Participants

Clinical TrainingChartingCase PresentationProcedural SkillsInterviewing SkillsCultural Sensitivity

Policy TrainingMedical Home ModelChallenges to AccessCollaborative Solutions

Other Projects

Inter-Professional Health Symposium

Inter-Professional Health Fairs

Research

Questions?uscstudentrunclinic@gmail.com

Michael Toboni, Co-PresidentBrian Chou, Co-President

Brian Prestwich, Medical Director

The Phillips Neighborhood Clinic

Brian Sick, MD – Medical DirectorAnna Berglund, MS2 – Board Co-ChairAutumn Chmielewski, MHA2 – Board Co-Chair

Where are we? - The Phillips Neighborhood

• South Minneapolis

• Urban

• Diverse - 31.3% foreign

born residents

• Impoverished - 34.4% below

poverty level

• Accessible - metro transit

buses - lightrail system

• Active Neighborhood

- many non-profits - large employers

Where are we? – The Phillips Neighborhood Clinic (PNC)

PNC is located in the heart of the Phillips Neighborhood and operates from the basement of Oliver Presbyterian Church.Picture is of: 2647 Bloomington Avenue SouthMinneapolis, MN 55407

2647 Bloomington Avenue SouthMinneapolis, MN 55407

PNC is located in the heart of the Phillips Neighborhood and operates

from the basement of Oliver Presbyterian Church.

Who are we? – Our Two-part

Mission

Patient Centered

To provide accessible, culturally appropriate,

interdisciplinary health care services and education in

order to reduce the burdens of poor medical access and raise the quality of life for

our patients.

Who are we? Our Two-part

Mission

Student Centered

To provide health professional students with

the skills they need to effectively and

compassionately serve people who are

underinsured and/or unstably housed.

Who do we serve? – Our Patients

• Approximately 1,200 patient visits annually• All services are free and provided to anyone in need

• Patients are served on a first-come-first-served basis two nights per week

Uninsured 77%

Public16% Private

7%

0%10%20%30%40%50%60%70%80%90%

Type of Insurance

Who do we serve? – Our Patients

38%

21%13%

9%

8%8% 2% 1%

PNC Patient Ethnicity

Hispanic or LatinoUnknown/Choose not to answerWhite/CaucasianAsianAfrican African AmericanOtherAmerican Inidan

What services do we offer?

Physical Exams Pediatrics Well Child Visits Sports Physicals Women’s Health

Dermatology Foot Care Contraception /Birth Control

Dispensing Pharmacy Pharmacy Care

Diabetic Treatment Physical Therapy Nutrition Mental Health

Counseling Lab Tests

Blood Pressure Checks

Cholesterol, Blood, and Urine

TestsPregnancy Tests

and ReferralsSTI & HIV

Testing and Counseling

Health Insurance Application Assistance

How do we do it? – Our Structure

How do we do it? – Our Volunteers

328 Student Volunteers100 Medical72 Pharmacy

55 Public Health*40 Nursing

38 Physical Therapy15 Social Work

8 Undergraduate

* Includes Nutrition & Master of Healthcare

Administration

How do we do it? – Volunteer Commitment328 Student Volunteers

•Sign contract for 2 years of 2 semesters per year (summer optional)•Hours per semester = 35•3-4 clinic shifts x 5 hours each = 20 hours•3 outreach activities x 3 hours each = 9 hours•4 meetings x 1 hour each = 4 hours•1 cultural awareness event = 2 hours

Value of time student volunteers commit to the clinic per year = $496,395

How do we do it? – Our Preceptors

86 Volunteer Preceptors

MedicalNursingNutrition

Physical TherapyPharmacy

ResidentsMed/Ped’s

Family Medicine

How do we do it? – Our Expenses

• Total annual operating expenses are approximately $40,000• Includes the cost to provide free labs & medications for 1,200+ patient visits

per year, building rent, utilities, training materials, & fundraising costs• The average cost to serve each patient = $31.00

How do we do it? – Our Income & SupportUniversity of Minnesota Physicians: UMP helps manage clinic operations by working with PNC leadership to determine medical supplies, computers, EMR, and sign facility leaseUniversity of Minnesota: Medical school administration develops an annual budget with PNC officials with the understanding that PNC raises funds to cover as much of the budget as possibleMinnesota Medical Foundation: UMN approved foundation for Health Sciences. PNC can receive donations and gifts through the foundation, which is a 501 (c) 3 organizationPhillips Neighborhood Clinic: PNC is classified as a campus life program. All financial transactions are processed through the University.

• Income comes from a variety of sources including fundraising, donations, & grants

• Significant in-kind support is provided by supporting organizations

University of Minnesota Physicians

UMP helps manage clinic operations by working with PNC

leadership to determine medical

supplies, computers, EMR, and sign facility

lease

University of Minnesota

Medical school administration

develops an annual budget with PNC officials with the

understanding that PNC raises funds to cover as much of the budget as possible

Minnesota Medical FoundationUMN approved foundation for

Health Sciences. PNC can receive

donations and gifts through the

foundation, which is a 501 (c) 3

organization

Phillips Neighborhood Clinic

PNC is classified as a campus life program. All financial transactions

are processed through the University.

What else makes us unique? –

Community Outreach

• Student volunteers commit to 6 community outreach activities per year• Activities include tutoring, diabetes education, blood pressure & blood sugar checks,

health fairs, legislative advocacy, meal service, etc…• We can only see so many patients in clinic, but we can help many more outside of the clinic

Community

Outreach

Understand where our patients

come from

Connect with the

community

Create partnerships with other organization

s

Increase awareness of the PNC as a health resource

What else makes us unique? –

Interdisciplinary Approach

• 6 different schools are represented at PNC (medical, nursing, pharmacy, physical therapy, public health, & social work)

• Clinic “huddles” draw on insights and expertise from each profession to diagnose patients and create care plans

• Students learn firsthand that collaborative care is best for the patients

Neighborhood Phillips Neighborhood Clinic: Providing culturally

competent care and cultivating caring future

healthcare leaders

Crimson Care Collaboratives (CCC)

Harvard Medical School Student-Faculty

Collaborative Practices

Presented by Rebecca Berman MD, Juwarat Kadiri & Jessica O’Brien

CCC – Overview5 Evening Clinics, planning began fall of 2009

• CCC- MGH Internal Medicine Associates (CCC-IMA), October 2010

• CCC- MGH Chelsea, October 2011• CCC- Beth Israel Deaconess (CCC-BIDMC), January 2012• CCC- MGH Revere, October 2012• CCC- Cambridge,  November 2011

Student-Faculty Collaborative practicesHMS MD, DMD students• MGH Institute for Health Professions – NP students

– clinical and nonclinical roles since summer 2011• Harvard Undergraduates

– nonclinical roles since summer 2010• HMS faculty

Needs Assessment Post Massachusetts Health-

Reform• Long wait times for new PCP

appointments

• Only 44% of IM practices accepting new patients (down from 66% pre-Health reform)

• 45% of adults using the ER for non-emergent reasons unable to get a PCP appointment

MMS Physician Workforce Study 2009,2008 Massachusetts Health Reform Survey (Long and Masi, Health Affairs 28 May 2009)

Needs & Ethical Concerns• Need for acute access to primary care

services

• Need for meaningful student experiences in primary care

• Ethical concerns met by:– Faculty partnership, supervision, and

mentorship– High quality benchmarks– Student-faculty collaborative practices

• Student-driven initiative w/close faculty support

• Student exposure to & participation in primary care in a multidisciplinary approach

• Strong social mission by increasing access to care or addressing social needs

• Commitment to quality through stringent attending-level supervision

• Development of innovative solutions to community or organizational problems

Overriding Themes

CCC – MGH IMA• Primary care and urgent care services, social services,

embedded research team

• 50% Bridge-to-Care Patients– Do not have PCP, frequent fliers to ER (MGH primary care

closed to new patients otherwise)– Patients transitioned to a long-term PCP through social

service center

• 50% Urgent Care Patients– Urgent care visits from patients who have a PCP at MGH

Internal Medicine Associates– Addresses Ethical Concerns

• 2012: Inter-professional teams of medical and NP students, interchangeable roles

CCC – MGH CHELSEA• Primary care services, social services, mental health

services, embedded research team

• Patients who have just been released from prison– Highly vulnerable population

• Patients frequently seeking care at Chelsea HealthCare Center’s Urgent Care Clinic– Predominantly immigrants/refugees– Lack access to primary care

• 2012: Interprofessional teams of medical and NP students, interchangeable roles

CCC – BIDMC• Needs assessment revealed BIDMC had access

available in their resident clinic, need for chronic disease management

• Chronic Disease Co-Management Model– Diabetes, hypertension, COPD– Focus on motivational interviewing, patient education– Titrate meds, check labs as indicated– Embedded research team

• Urgent Care

• Future direction of more team-based care– Non-physician health professionals – have run into

political difficulties getting NP/PA students involved 2/2 multiple different NP programs at BIDMC

CCC – MGH Revere (pediatrics)

• Needs assessment– Pediatricians have openings– Need for expanded hours and obesity co-

management– Difficult for students to get exposure to pediatrics

• Pediatric patients– Well child and after hours urgent care– Group visit model being piloted surrounding healthy

eating/weight management in obese patients not eligible for other services

• Inter-professional team of medical and NP students, interchangeable roles

• Community health center– Ethnically diverse, predominantly low SES

CCC – Cambridge• Located in YWCA• Women in transitional housing (residents have

history of physical, psychosocial or financial trauma)

• Initial plan was monthly outreach to bridge patients to a PCP

• Many residents have PCPs but don’t go to them due to multiple psycho-social barriers

• Students as patient navigators– Health screening, including mental health and

social services needs, help make PCP appointments and go with patients

Statistics• Each clinic sees between 6-12 patients per night,

total monthly capacity ~ 100 patients

• Clinic lasts ~3 hours, volunteers must come at least monthly

• Board members work ~ 5-10 hours per week on CCC-related planning

• 473 student volunteers to date

• This semester: 180 HMS/HSDM, 24 NP, 32 Harvard College, 3 post-baccalaureate/graduate students

Clinic Sustainability• Average annual cost to operate a clinic =

100K

• Funding Sources– Insurance accepted post health reform (wRVUs)– In-kind support from participating practices– Teaching dollars from Harvard Medical School– Grants including MGH Stoeckle Center for Primary

Care Innovation, Yawkey II Foundation, HMS Center for Primary Care

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