Problem Addressed

• Less likely to be insured: Hispanics in Florida are less likely than members of any other racial group to have health insurance, with 31.8 percent of Florida's Hispanics lacking insurance in 2004 compared with 14.3 percent of non-Hispanic Whites. Miami-Dade County has the highest percentage of uninsured residents in the state (28.7 percent in 2004).¹
• Less access to care: Undocumented Hispanics are less likely to use health care services and more likely to report poor experiences with the health care system than are U.S.-born Hispanics.²
• Higher rates of diabetes, its associated complications, and death: According to the Centers for Disease Control and Prevention and the National Health and Nutrition Examination Survey, more than 12 percent of Mexican Americans age 20 years and older have been diagnosed with diabetes. In 2006, Hispanics were 1.7 times more likely to start treatment for end-stage renal disease related to diabetes than were non-Hispanic White men. In 2006, Hispanics were 1.5 times more likely than non-Hispanic Whites to die from diabetes.³

Description of the Innovative Activity

• Target population: St. John Bosco Clinic serves uninsured patients with incomes below 200 percent of the Federal poverty level. Adult patients must live in 1 of 13 zip codes within the Little Havana and Allapattah neighborhoods of Miami and must either be undocumented or have a worker's permit or status as a legal resident. Children receive care regardless of where they live. To receive services, adult patients are asked to show identification and proof of income to verify that they meet eligibility requirements. Although services are not limited to any one racial or ethnic group, nearly all of the clinic’s patients are Hispanic. Individuals who are not eligible for services receive limited case management assistance from clinic staff and are referred to Jackson Memorial Hospital and/or to other appropriate social service or health care providers in the area.
• Welcoming, culturally competent environment: Originally housed in a renovated car dealership across the parking lot from St. John Bosco Catholic Church in East Little Havana, the clinic moved in early 2007 to a new building owned by the Corpus Christi parish in Allapattah. In both locations, the clinic's church-based setting has helped its primarily Hispanic patient base feel comfortable and safe. All clinic staff and volunteers, including volunteer physicians, are bilingual in Spanish and English.
• Free, onsite clinical services: St. John Bosco Clinic is open Monday through Thursday, including some early morning and evening hours to accommodate patients who work. Patients receive clinical services on site, delivered by two paid nurse practitioners and a core group of volunteer physicians that currently includes two primary care doctors, three pediatricians, one gynecologist, and one endocrinologist. Specialist services are available one evening per week, as the University of Miami holds an onsite clinic to train students and residents, bringing in different specialists on a rotating basis. Mercy Hospital provides free laboratory tests, x-rays, and other diagnostic services to clinic patients.
• Referrals for advanced tests and specialty services: Patients in need of more advanced procedures (e.g., magnetic resonance imaging or computed tomography tests) are referred to Jackson Memorial Hospital, the county's only public hospital. For patients who require specialty services not otherwise available, the clinic maintains a roster of approximately 20 physicians who volunteer to see clinic patients in their offices for free.
• Emphasis on diabetes: Approximately 20 percent of St. John Bosco Clinic's patients are diagnosed with diabetes. As a result, the clinic expanded its services to focus on diabetes screening and management, including the following:
  • Diabetes educator on staff: One of the clinic's two nurse practitioners specializes in diabetes. She trains patients on the use of blood glucose meters and counsels them on physical activity, diet, and nutrition.
  • Ongoing screening: Clinic staff and volunteer physicians routinely screen nearly all adult patients for diabetes, using a combination of interview questions focusing on lifestyle and family history and, if deemed appropriate, laboratory testing of blood glucose levels.
  • Diabetes education classes: Until 2007, the clinic offered free diabetes education classes two to four times each month. Using a curriculum adapted from the American Diabetes Association, the nurse practitioner taught sessions for up to 10 patients on various diabetes-related topics including understanding the diagnosis, making healthy food choices, dieting, physical activity, and using blood glucose meters. After completing a series of sessions, patients received a $20 grocery store voucher (provided through private donations) that could be used during an educational grocery story tour led by the nurse practitioner. During the tour, the nurse practitioner pointed out nutritious foods and demonstrated how to understand the nutrition charts printed on the packaging of many food products. Although funding for these classes ran out in early 2007, the clinic is hoping to secure additional grant money that will allow the classes to be reinstated in the future.
• Medication assistance: The clinic assists patients in obtaining free medications through various patient assistance programs (PAPs) sponsored by pharmaceutical companies. Because qualifying for these programs often requires the completion of an overwhelming amount of paperwork, the clinic employs a full-time staff member to help patients navigate the process. For those clinic patients who are ineligible for such programs (because most programs require a Social Security number, something that many clinic patients lack), the clinic maintains a pharmacy fund, created through private donations, to provide free medications dispensed through Mercy Hospital. The clinic supplements this fund with discounted generic prescriptions available at large pharmacy chains like Walmart and Target and with free pharmaceutical samples donated by doctors.

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Results

• Facilitating access to services: The clinic serves roughly 1,200 individuals each year, handling approximately 11,000 visits from these patients. (Visit figures include those individuals who do not qualify for clinical services but receive case management and/or referrals to outside agencies.) In 2007, the clinic provided 448 referrals to volunteer specialty physicians and enrolled 70 individuals in PAPs that provide free medications. In the absence of the program, it is highly unlikely that clinic patients would have had access to any of these services.
• Highly loyal, satisfied patients: For most patients, the clinic's 2007 move from Little Havana to Allapattah meant significantly longer travel times, because no efficient bus route exists between the two neighborhoods and many patients do not own cars. In spite of this, the clinic's patient volume remained steady after the move. In addition, anecdotal, verbal feedback from patients has been overwhelmingly positive.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Securing the initial facility: Dr. Greer approached the pastor of St. John Bosco Catholic Church with the clinic's proposed mission to provide free medical services to the community. The church agreed to provide the space free of charge, requiring payment only for utilities.
• Establishing partnerships: Drawing on his existing reputation and prior record of community outreach through Camillus Health Concern, Dr. Greer collaborated with Mercy Hospital's chief executive officer, staff, physicians, and nurses to cement interest in the project and establish key roles related to the delivery of patient services.
• Recruiting volunteer physicians: Dr. Greer and founding partners recruited the clinic's initial group of volunteer physicians by capitalizing on existing professional relationships; the recruitment of physicians continues on an ongoing basis. To protect participating physicians and make them feel safe in volunteering, the clinic requires that volunteer physicians apply for and receive sovereign immunity from the state of Florida, meaning that the state assumes responsibility for any litigation or disbursement of funds should a physician get sued while performing charity work.
• Training: Clerical volunteers were provided with a basic orientation by Mercy Hospital’s volunteer resources department.

Resources Used and Skills Needed

• Staffing: The clinic employs one full-time administrator, one full-time PAP manager, one receptionist (who works 32 hours per week), one medical assistant (who works 32 hours per week), and two nurse practitioners (one who works full-time; one who works 32 hours per week). In addition, the clinic relies on volunteers to provide clinical services and perform clerical tasks. Currently, a core group of two primary care physicians, three pediatricians, one gynecologist, and one endocrinologist volunteer their services onsite at the clinic on an ongoing basis. In addition, approximately 20 specialty physicians volunteer to see patients in their offices on an as-needed basis. Clerical volunteers serve as greeters at the clinic, welcoming patients and assisting them with registration and orientation. Currently, the clinic maintains a roster of 17 clerical volunteers, with an average of 3 volunteers working each day. All clinical and clerical volunteers must be able to speak both Spanish and English.
• Costs: In 2007, St. John Bosco Clinic's operating expenses were $397,000.

Funding Sources

Getting Started with This Innovation

• Seek out and cultivate partnerships: Relationships with established health care organizations and/or hospitals can help in securing funding, sharing resources, and increasing capacity to provide services.
• Get buy-in from key stakeholders: Ensure that all stakeholders embrace the program’s mission and understand the community need being addressed.
• Choose a welcoming location: Fear and distrust of the medical system prevents many undocumented immigrants from accessing care. Providing services in a familiar, welcoming setting, such as a church, can help these individuals feel more comfortable and safe when seeking care.
• Hire and retain a culturally competent staff: Ensure that all staff are bilingual in Spanish and English and are able to communicate effectively with patients.

Sustaining This Innovation

• Grow volunteer base through professional networking: Encourage existing volunteer physicians to recruit their colleagues to build and maintain a strong corps of participants.
• Search broadly for resources: Seek large foundation grants as well as individual and in-kind donations. Nonmonetary contributions such as pharmaceutical samples and medical supplies can also be helpful.
• Give staff and volunteers the opportunity to try their ideas: Capitalize on the skills and talents of participating providers by allowing them to share their expertise and talents with patients. For example, allowing staff and volunteers to experiment with new patient education programs can benefit patients while keeping providers engaged.
• Continually promote services: Use word-of-mouth and other promotional programs to encourage patients to seek care and build community interest in the program.