Promise Clinic  

Volunteer Manual   2013-2014  

“Isn’t it a bit unnerving that doctors call what they do ‘practice’” – George Carlin

Preclinical Student Doctor

General Information  

What makes us unique?

The Promise Clinic is a student-run organization that aims to provide free primary care to the clients of Elijah’s Promise Soup Kitchen in New Brunswick, NJ. Our patients are uninsured, and many are afflicted with chronic conditions.

The Promise Clinic is built upon a continuity of care model, where student doctor teams are assigned a patient and are responsible for the management of the patient’s primary care. We also have an Urgent Care component to serve our community with acute issues.

Under close supervision of volunteer attending physicians, medical students are committed to providing an encompassing range of care for our patients.

What care do we provide?

The Promise Clinic provides chronic and urgent health maintenance by offering primary care visits to members of the New Brunswick Community. We also provide vouchers for prescription medications, basic laboratory blood work, and vaccinations, all free of charge to patients.

We offer psychiatric care on site for non-emergent cases with the assistance of volunteer Psychiatry resident physicians from Robert Wood Johnson University Hospital. We also assist qualifying patients in applying for Charity Care so that they may meet Specialty Care needs such as Urology, Podiatry, Endocrinology, Cardiology, etc.

Our goals are aligned to the core missions of RWJMS:

Through Promise Clinic, the uninsured and underserved communities of New Brunswick, NJ have access to primary health care that they could not otherwise receive. The clinic also serves as an opportunity for early clinical exposure for medical students in their pre-clinical years. We provide both patient and peer education, as students in their clinical years teach pre-clinical students the basics of the physical exam and management of chronic and acute health conditions. We also c o l l e c t d a t a o n t h e characteristics of our patient population and use this research to optimize our service and care.

O u r f a c i l i t i e s a r e graciously loaned to us every week on Thursday evenings from the Eric B. Chandler Health Center.  

General Information  

Important Contacts Faculty Advisors

Dr. Karen Lin, Faculty Advisor for Promise Clinic Dr. Eric Jahn, Senior Associated Dean for Community Health Susan Giordano, HIPHOP Program Coordinator

Clinic Directors

Stephanie Oh Email: seo28@rwjms.rutgers.edu Rachit Vakil Email: vakilrm@rwjms.rutgers.edu Usha Rao Email: raou1@rwjms.rutgers.edu

Clinic Address

Eric B Chandler Health Center 277 George St. New Brunswick NJ 08901

Clinic Phone

(201) 452-6067 [For use by Patients to schedule appointments and contact the clinic]

Mailing Address

The Promise Clinic RWJMS Student Run Healthcare Clinic Robert Wood Johnson Medical School 675 Hoes Lane, Room N-100 & N-101A Piscataway, NJ 08854-5635

The Patients We Serve & Services We Provide Our patients are referred from Elijah’s Promise Soup Kitchen in New Brunswick, NJ. We provide the following services: •  Primary medical care for adults, including management of chronic

conditions, acute illnesses, preventative medicine and social support •  Vaccinations •  Patient Assistance Programs (PAP) for prescriptions •  Basic laboratory services including EKGs •  Referrals to specific specialty care services •  Psychiatry consults c/o Rutgers-RWJ Psychiatry Residents

Before You Volunteer: Background  

Statement of Need In the United States, it has been estimated that 671,000 adults are homeless in a given week, and an estimated 2.3 million adults are homeless over the course of a year. When children are included, these numbers increase to 842,000 and 3.5 million, respectively.

In January 2004, as part of a course in their curriculum, a group of students at Robert Wood Johnson Medical School (RWJMS) conducted a survey to determine the level of health care access for the clients of Elijah's Promise, a soup kitchen in downtown New Brunswick. The survey revealed substantial limitations to health care access, as well as the need for a consistent source of care. This is the premise on which the Promise Clinic began.

Relationship with Elijah’s Promise Soup Kitchen In partnership with Elijah's Promise, The Promise Clinic runs a weekly evening clinic, where teams of medical students from all 4 years supervised by physician preceptors serve selected clients of Elijah’s Promise.

Clinic Structure

Continuity of Care

Each new patient is paired with a team of medical students from all levels of training. The assigned student doctor team will be responsible for the patient’s care throughout the patient’s stay with the clinic, ensuring continuity that is characteristic of primary care.

Urgent Care

Urgent Care sees patients who are new to clinic and have not yet been assigned a Continuity team. This team sees patients with more acute issues. With the changing landscape of American health care, the Urgent Care model will become crucial to our clinic structure.

Promise Clinic Steering Committee  

Student Directors

Rachit Vakil Stephanie Oh Usha Rao

Managers

Kristin Bonello Ramya Krishnan Lindsay Volk

Education

Bryan Botti Afua Takyi Hannah Simon Jeffrey Desilets

Finance

Sana Ahmad Andrew Orr Sakina Attar

Specialty Care

Stephanie Peters Rachel Rosenblum Helen Mac Alyssa Schochet Karl Chamberlin

Laboratory

Angel Lee Derek Rudge Bekah Gensure Jenna Presto Laura Pierce Gaby Ghobrial Debby Chen

Pharmacy

Bahareh Shanehsaz Katherine Fu Angela Rugino Azad Hirpara Devon O’Brien

Community Outreach

Michael Serzan Sophia Sequeira Elizabeth Shteyn Carolyn Na Lisa Gabor Andrea Poon Suzanne Elshafey Anousheh Shafa Jonathan Tsui Oby Ibe Jacob Jaslove

Quality Improvement

Vidya Puthenpura Hannah Xu Kiersten Frenchu Lesley Portugal Chase Hulderman Stephanie Mischell Gloria Gerber Nikhil Yegya-Raman

Grants Rachit Vakil Lindsay Volk Andrew Orr Matthew Cichocki

Communications

Pallabi Guha Kerly Guerrero Anna Rose Johnson Tito Mantilla

Schedulers

Sanjay Jumani Christine Tolias Jimmy Lin

M1 Representatives

Alexa Melucci Niall Buckley Ila Nimgaonkar Marissa Falkiewicz

Interpreter

German Bayas

The Promise Clinic operates with the assistance of the steering committee, which is made up of various subcommittees.

Clinic Policies  

Role of a Student Doctor Care is delivered using a team approach. Each patient will be paired with a group of four or more student doctors, each from various years in medical school. The student doctor team will work with the patient to come up with an assessment and plan, and the team will present the patient’s case to the attending physician. The attending physician will then see the patient to confirm the assessment and prescribe medication, if necessary. The student doctor teams will help the patient navigate any social services, including specialty care and inpatient services.

Attendance Policy Serving as a Promise Clinic Student Doctor requires a four (4) year commitment to your assigned patient(s). In order to maximize the continuity experience of the clinic, attendance by all team members at every visit is required. Excused absences will be given according to the circumstances below:

•  M1: the Thursday night before an exam, the summer months preceding second year, confirmed illness, and any absence excused by the Student Affairs office.

•  M2: the Thursday night before an exam, the months of May and June preceding third year, confirmed illness, and any absence excused by the Student Affairs office.

•  M3: confirmed illness, and any absence excused by the Student Affairs office.

•  M4: confirmed illness, and any absence excused by the Student Affairs office. Due to the unique nature of rotations during fourth year, the attendance committee will give latitude to students who have demonstrated commitment to their patients for such events as away rotations and residency interviews.

The attendance policy will consist of the following: Any student who accumulates three absences (excused or unexcused) will have their specific attendance situation reviewed by the education committee. The committee will weigh the student’s contribution to his/her team and the detrimental effect of his/her absences to determine appropriate action, if it should be required.

Student doctors must dress in a Business Casual style and wear a White Coat. Women must wear a blouse with slacks or an appropriate-length skirt, or a professional dress with closed toed shoes. Men must wear slacks, a button-down shirt, a tie, and professionals shoes. Student doctors must also bring their stethoscopes, any relevant medical equipment, and a pen.

Dress Code

Clinic Policies  

Staffing Policy On each clinic night the clinic will be staffed by: a student director, a scheduling coordinator, a pharmacy coordinator, one or more attending physician(s), a First Year Representative, a Lab coordinator, a Specialty Care coordinator, and Student Doctor Teams.

Student teams will be assigned their first date with a new patient, and can schedule subsequent follow-ups. Reminders are sent on Sunday night prior to the appointment. Urgent Care teams have specific dates where they are scheduled, and they will also be reminded via email regarding these dates.

Confidentiality The Rutgers-RWJMS policy on Confidentiality is described in the Code of Professional Conduct and is adapted from the AAMC’s Recommendations and Guidelines for the Students of the Organization of Student Representatives. It states the following:

The Patient’s right to confidentiality of his or her medical record is a fundamental tenet of medical care. The discussion of the problems or diagnoses of an identified (or potentially identifiable) patient by professional staff or medical students in public places (for example in elevators or in cafeterias) violates patient confidentiality and is unethical. Under no circumstances can any medical record be removed from the institution, nor is photocopying of the record permitted. For presentations or rounds, students are permitted to extract information but not copy wholesale parts of the chart.

All Promise Clinic paper charts will be kept in a separate filing cabinet in Eric B. Chandler, which will be locked when the clinic is not in session. Under no circumstances may a chart be removed from the clinic. It is essential that all students maintain the confidentiality guidelines outlined in the University’s Code of Professional Conduct and in the HIPAA (Health Insurance Portability and Accountability Act) guidelines. For more information about HIPAA guidelines, please see the following website: https://ethics.rbhs.rutgers.edu/

Clinic Policies  

Patient Phone Communication Policy A student will be managing patient phone calls. The scheduled on-

call hours will be from 5-9 pm daily, during which time the cell phone will be on and patients should expect their call to be answered. If a patient leaves a message at any time, the call will be returned as soon as possible after 5 PM or at earliest convenience for the patient.

Information from each patient contact will be sent in an e-mail to the student doctor team and PC steering committee, which includes the following information: Name, Date of call, Chief Complaint/Patient Question, and if an appointment is scheduled the appointment date and time will also be included.

Communications coordinators will make reminder phone calls to patients who have an appointment the upcoming Thursday on Monday or Tuesday night. For any patients who are unable to be reached personally, follow-up phone calls will be tried on Wednesday.

Any phone calls between the patient and the student doctor team must be recorded in the Communications Committee Database.

Interpretation Services Policy We have tried to include one Spanish speaker on each student doctor team, although this was not always possible. Our translator will be available at the clinic. Be aware of the appropriate protocol that one puts in use when utilizing a medical interpreter.

EMR is maintained on a RWJMS secure server. EMR is a central hub, where patients are scheduled for visits, clinic encounters are documented, and patient health information is stored. Safeguards have been put in place to ensure patient confidentiality of sensitive patient health information. EMR can be accessed at: http://promiseclinic.rwjms.rutgers.edu. To access the websites, users must have a RWJMS Core account and be approved by Promise Clinic Student Directors.

Electronic Medical Records (EMR)

Remember your ABCs Before your patient arrives

q Arrive to clinic 5:15-5:30 q Discuss the patient history with your team

Admit the Patient

q Bring your Patient to the Intake Room and take vitals q Move to the exam room and complete HPI/ROS q Write your time of entry on the Post-It on the door q Complete the Physical Exam q Compete any labs, if necessary.

Bring to Presentation

q Wait in line for the attending q While you wait, complete your note in EMR q Present your patient to the attending q Bring the attending to the room to visit the patient q Create any prescriptions, if necessary q Make any charity/specialty care referrals, if necessary

Close the Visit

q Finish the note in EMR q Ask the attending to sign your note electronically q Counsel your patient, if necessary q Schedule your patient for the next appointment q Deliver your summary to the scheduler q Wrap-up discussion with your team

A

B

C

Things to remember:

•  Arrive 15-30 minutes early •  Bring your white coat, stethoscope, other relevant

medical equipment, and your RWJMS ID •  Do not park in the Eric B. Chandler Parking Lot.

You must use street parking to save the few available parking lot spots for the patients

•  Enter through the front door, show your badge to the security guard, and proceed to the back of the waiting area

•  Review your patient’s chart on EMR with your team in the break room

Standard Clinic Visit  

M3 Responsibilities Objective: Learn to coordinate care for your patient and lead a team of student doctors •  Coordinate care for the patient according to national health guidelines •  Present case and write notes •  Make and explain action plan to team •  Teach M1/M2 Physical Exam Skills, as well as presentation skills •  Draw labs with guidance of M4/Lab

M4 Responsibilities Objective: Guide the M1, M2, and M3 in their care of patients •  Ensure correct measurement of vitals by M1 •  Ensure/confirm physical exam by M2 •  Correct/confirm note in EMR by M3 •  Discuss prognosis and treatment with your team •  Assist team in presenting to the attending

As a M3/M4, you serve as the Team Leaders. This means that you are the primary physician for your patient. This allows you to demonstrate leadership skills to M1/M2s. The commitment that you show to your patients will serve as an example for students in their initial stages of training. M3/M4s are expected to teach M1/M2s basic physical diagnosis skills and clinical pearls as they arise during clinic visits. M3s are expected to lead patient visits and present to the attending with the guidance of M4s. Discussion regarding patient diagnosis and management is greatly encouraged among student doctor teams, as the Promise Clinic environment can greatly prepare M4s for residencies.

Student Doctor Responsibilities  

Once the patient has arrived, a First Year Representative will

notify your team. Greet the patient in the

waiting area.

Bring the patient into the Vitals Intake

Room. The M1/M2 shall take the vitals and the M3/M4 shall record them in EMR.

Move the patient to an exam room and have the M1 write the time

you enter on the Post-It attached to your door.

Ascertain the chief complaint.

Work together to create a differential diagnosis and management plan. Record all findings

in EMR.

Admit the Patient

(35 Minutes)

Bring to Presentation

(10-15 Minutes)

Wait in line to see the attending preceptor.

Update the patient’s contact information. Conduct a H&P. M3/M4 should teach M1/

M2 key points.

Present the patient to the attending in the

attending office. Discuss your

assessment and plan.

Accompany the attending as s/he sees

the patient.

Once the attending has confirmed the

diagnosis, arrange for any labs, prescriptions,

referrals or social services.

Close the visit (25 Minutes)

Ensure that all patient questions have been addressed. Counsel

your patient, if necessary.

One of the team members should

accompany the patient and make a follow-up appointment with the scheduler. Give him/her an reminder card

Deliver your summary to the scheduler on

duty.

Complete your note in EMR and have the

physician electronically sign it.

Conclude the visit with your team. Make sure all teaching points are

discussed.

If your patient needs a Public Health referral,

search for the appropriate resource in the Public Health box.

Patient Flow Process

Clinic Procedures

Medical Supplies Each patient room will have: band-aids, otoscope tips, tongue depressors, gauze, gloves, etc. Do not use supplies from the cabinets in the clinic. If you need something not found in room, please ask the student director.

Before beginning to perform a diagnostic test, such as an EKG, blood draw, or PAP smear, please consult with the student director present at the clinic for the evening. Make sure that you have presented to the attending physician prior to conducting any diagnostic procedures!

Labs PC laboratory coordinators will direct student doctor teams toward the laboratory testing area(s), will gather necessary collection supplies for the team, and will help in processing the specimen(s).

Labs and tests are needed (approved by preceptor)

Tests available at clinic (in-house)?

See lab staff for instructions and to get set up in one of the intake rooms

Labs will be processed same day

Labs will be sent out to RWJUH lab

services

NOYES

See lab staff with patient info to get patient entered in system

Speak to attending to get signed PC lab request form with tests indicated

Bring patient to laboratory front room (entrance adjacent to waiting area)

Draw labs and label all tubes (name, PC-ID, DOB, date & time)

Draw labs and label all specimens (name, PC-ID, DOB, date & time)

Lab staff will run tests and return results to you same day

Review results and add to patient’s chart

Follow-up on results after receiving email from lab team

Lab staff will send tests out for processing

Bring patient to laboratory front room (entrance adjacent to waiting area)

Drawing Labs Tips to Keep in Mind • Check whether fasting is required before drawing (lipid profile, glucose). • After drawing blood, invert tubes several times gently but thoroughly. Avoid vigorous shaking, which may cause hemolysis. • Proper label ing is key! S p e c i m e n s w i l l n o t b e p r o c e s s e d i f t h e y a r e mislabeled. • Always observe universal precautions in collecting blood specimens (wear gloves when handling tubes, exercise proper sharps handling, do not transport specimens across the waiting room). • HIV testing: We currently do n o t o f f e r r o u t i n e H I V screening because we do not have access to the medication needed to treat it. However, this service is provided by E l i j a h ’ s P r o m i s e S o u p Kitchen. Please refer the patient to Mr. Robert Mason for further follow up.

Clinic Procedures

Specimen Preparation 1.  Teams wishing to order laboratory tests will complete a brief PC Lab request form (see

below) and bring completed form signed by the attending preceptor to the lab coordinator. 2.  Blood draws must not be done in patient rooms. 3.  Senior team members (M3s / M4s) can perform phlebotomy on their patient, or teams can

request assistance from the PC lab coordinator.

Labs will be picked up by RWJUH courier at 8:30 pm. This means that if your team needs to draw blood, it needs to be done by 8 pm (to allow the PC lab coordinator enough time to prepare the sample & paperwork).

Laboratory Follow-Up Results PC Laboratory staff will notify involved teams that their laboratory results are complete and will print out a copy of the laboratory results to be placed in the results folder at Promise Clinic. Normal lab retrieval by student doctor teams: •  The M2 must see the lab

coordinator at the next Promise Clinic session to retrieve lab results from the lab folder and initial & date the lab log sheet

•  Review lab results with your student doctor team. Discuss r e s u l t s w i t h t h e a t t e n d i n g physician on duty. Physician must sign the lab sheet.

•  The M2 must input results into EMR, including any change in plans. Note: Physician must sign this addendum.

Other Diagnostic Tests Available In-House

•  Urine Dipstick

•  Hemoglobin A1C

•  Random fingerstick glucose: •  EKG •  Rapid streptococcal antigen testing •  Urine pregnancy testing •  Fecal occult blood testing (stool guaiac test) note: this test should only be done using a

home kit with specific instructions that will be sent home with the patient.

•  Cancer Screening: Patients of The Promise Clinic who are residents of Middlesex County and who meet combined family income eligibility criteria will be able to obtain free screenings for the following: Prostate, breast, cervical, and colorectal cancer.

  Other testing: If you require other tests, discuss with the lab staff. They will be happy to determine if a lab can be done either at EBCHC or sent out through RWJUH. If the labs you need can’t be processed through any of those places, they will try to find out where to refer you so that it can be done.

Pharmacy Pharmacy serves as the liaison between patients and Ultracare Pharmacy in New Brunswick. The Pharmacy strives to assist patients within a limited budget by distributing vouchers for necessary medications. We advocate the use of the $4 Prescriptions list, and help to facilitate Patient Assistance Program (PAP) applications for medications that are not otherwise included in this list. If your patient requires medication: 1.  Have the attending on duty survey the need for the medication and write a prescription

for this medication – if this medication can be found on the $4 list, please make sure that the attending is writing a prescription for the brand on the list. Be sure only to fill out one prescription for all medications.

2.  Bring this prescription to the Pharmacy staff. If the prescription exists on the $4 list, Pharmacy will assist you in writing a voucher, which can be handed to the patient at the end of the visit. If it is not on the $4 list, Pharmacy staff will assist student doctors in filling out a PAP application to reduce the cost of this medication.

3.  Remind your patient to bring voucher to Ultracare Pharmacy, across the street from Eric B. Chandler, where they will be able to obtain their medications.

Clinic Procedures

Specialty Care Referral Procedure: A referral form should be completed for any patient sent to a specialist and the student doctors should accompany the patient when possible and if appropriate. Make three copies of the referral form and keep one copy with the Specialty Care Team, fax one copy to the specialist and give one copy to the patient. Have all referral forms signed by the attending physician.

Inform the patient that they will be contacted with a date for their referral appointment within a couple weeks. If the patient has not heard from the clinic regarding the referral in two weeks, he/she should call the Promise Clinic to find out about the appointment.

To obtain Optometry, Radiology, Cardiology, Physical Therapy, Orthopedics, Neurology, Nephrology, Dental, Audiology, GI, Dermatology, Urology, Ophthalmology consultations, teams should speak to a specialty care representative. The general process for obtaining specialty care is as follows:

1. Obtain a prescription signed by the attending 2. Have the patient sign a release of medical information 3. Schedule a time to meet with the patient at the charity care office (In order to see the above specialties, patients will generally need to apply for charity care through Robert Wood Johnson). 4. Schedule an appointment for the patient 5. Meet the patient at the charity care office and help them apply for charity care 6. Make sure the patient is aware of any fees/special considerations

PC/Elective Requirements What does it mean to ‘remain in good standing as a student doctor’ in Promise Clinic?    For M1 student doctors: Attendance at all patient appointments unless excused (Thursday prior to exam or Student Affairs approved absence) or June/July prior to M2 year. Participation at one Blood Pressure Screening at Elijah’s Promise. Attendance at a minimum of one Public Health workshop. Attendance at a minimum of two student-doctor teaching sessions. Attendance at the clinic-wide orientation.   For M2 student doctors: Attendance at all patient appointments unless excused (Thursday prior to exam or Student Affairs approved absence) or June/July prior to M2 year. Attendance at a minimum of one Public Health workshop. Attendance at a minimum of two student-doctor teaching sessions. Attendance at the clinic-wide orientation.   For M3 student doctors: Attendance at all patient appointments unless excused (Student Affairs approved absence). Please note, that if absent, the M3 must arrange for a substitute to be present during the appointment. Attendance at the annual clinic-wide orientation.   For M4 student doctors: Attendance at all patient appointments unless excused (Student Affairs approved absence), on away rotations, or for residency interviews. Attendance at the annual clinic-wide orientation. M1 PCM Requirements: Attend 6 PC appointments 4 Patient write ups (modified “history and physical” or SOAP note) 1 project on a patient whose presentation interests you (see syllabus for details) 9 reflections on visits addressing the core competencies (see syllabus for details)   Promise Clinic Electives   M3 year - MDC 8806 Promise Clinic Continuity Elective Part III Attend training session (AKA clinic-wide orientation). Attend a minimum of 4 patient visits over the course of the year. (Patient visits counted towards the elective may not be used towards fulfillment of PCM requirements.) Teach two student-doctor teaching sessions for 1st and 2nd year students at clinic. Teach one Public Health workshop. Hand in a 1-2 page paper about your patient’s story or your experience in Promise Clinic. Remain in good standing as a student doctor.   M4 year - MDC 9006 Promise Clinic Continuity Elective Part IV Attend training session (AKA clinic-wide orientation). Attend a minimum of 3 patient visits over the course of the year. Teach two student-doctor teaching sessions for 1st and 2nd year students at clinic. Teach one Public Health workshop. Hand in a 1-2 page paper about your patient’s story or your experience in Promise Clinic. Promise Clinic Administrative Elective Attend 75% of all Steering Committee Wide meetings and sub committee meetings. Follow the guidelines outlined by your committee chair and manager/director pair. Submit a one paragraph description of your individual achievements each year to the Education committee. Complete a Peer-Evaluation for all members of your team.