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Service Delivery Innovation Profile

Urban Clinic Provides Free, Bilingual Primary and Specialty Care to the Uninsured and Underserved of Miami-Dade County


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Snapshot

Summary

The St. John Bosco Clinic provides free, bilingual medical services to underserved and uninsured children and adults living in Miami-Dade County. Clinic staff and volunteer physicians provide primary and specialty care, referrals, and patient education, with an emphasis on prevention and treatment of the most prevalent chronic diseases in the population served. Although the health outcomes of clinic patients have not been formally evaluated, data suggest that the program is enhancing access to needed medical care and education. Patients remain loyal to the clinic, and verbal feedback has been overwhelmingly positive; the clinic has become a medical home for many patients.

Evidence Rating (What is this?)

Suggestive: The evidence consists primarily of post-implementation data on patient volume and clinic visits along with verbal feedback from patients with the underlying assumption being that in the absence of the program, those served would not have had access to these services.
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Developing Organizations

Mercy Hospital of Miami
Mercy Hospital of Miami is the founding organization (1992-2011). According to information provided in June 2013, the clinic is now sponsored by the Sisters of St. Joseph of St. Augustine, FL  through the SSJ Health Foundation.end do

Date First Implemented

1992
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Patient Population

Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Immigrants; Impoverished; Medically uninsured; Non-english speaking/limited english proficiency; Urban populationsend pp

Problem Addressed

More than 60 percent of the population of Florida's Miami-Dade County is Hispanic, a group at increased risk of developing and dying from diabetes. However, many of these Hispanics are undocumented, underserved and uninsured, making it difficult for them to access needed medical care.
  • Less likely to be insured: Hispanics in Florida are less likely than members of any other racial group to have health insurance; over 46 percent Hispanics in Miami-Dade County lacked insurance in 2011 compared with 20 percent of non-Hispanic whites (updated June 2013).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: Diabetes is the seventh leading cause of death in the United States. Diabetes disproportionately affects minority populations and the elderly and its incidence is likely to increase as minority populations grow and the U.S. population ages. Missed work days, inability to support and maintain employment, and chronic and debilitating diseases that have significant personal and societal costs disproportionately affect low-income, underserved, and uninsured individuals. Significant prevalence for diabetes is seen in the St. John Bosco Clinic patient population—24 percent compared with the overall Miami-Dade rate of 9.3 percent for adults over the age of 18.
  • High hospitalization rates for uncontrolled diabetes: Hospital emergency department and admission rates for uncontrolled diabetes are high, causing financial stress for community hospitals, especially when caring for the uninsured. The Miami-Dade hospitalization rate for uncontrolled diabetes is 5.1/10,000. The rate for the ZIP codes in the primary service areas for the clinic average 8.26/10,000.

What They Did

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Description of the Innovative Activity

The St. John Bosco Clinic provides free, bilingual primary and specialty care services, medications, referrals, and patient education to underserved and uninsured children and adults living in Miami-Dade County. The clinic aims to improve access to care by providing comprehensive services in a welcoming, culturally sensitive environment, focusing in particular on those many individuals with diabetes and other related chronic conditions prevalent in the patient population. Key elements of the program include the following:
  • Target population: St. John Bosco Clinic serves uninsured patients with incomes below 200 percent of the Federal poverty level. Patients must live in Miami-Dade County and have no health care coverage. To receive services, patients need a picture identification, proof of address, and proof of income to verify that they meet eligibility requirements. Although services are not limited to any one racial or ethnic group, most 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. 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 Friday and one Saturday per month, including some early morning and evening hours to accommodate patients who work. Patients receive clinical services on site, delivered by one paid nurse practitioner and a core group of volunteer physicians that currently includes four primary care doctors, three pediatricians, one gynecologist, and one endocrinologist. Specialist services are available one evening per week, as the University of Miami DOCS Program holds an onsite clinic to train students and residents, bringing in different specialists on a rotating basis.
  • Referrals for advanced tests and specialty services: Patients in need of more advanced procedures (e.g., magnetic resonance imaging or computed tomography tests) may be 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 24 percent of St. John Bosco Clinic's patients are diagnosed with diabetes. As a result, the clinic focuses on diabetes screening and management, including the following:
    • 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: The clinic currently has two grants under review to implement an ongoing diabetes education program. Until 2007, the clinic offered free diabetes education classes two to four times each month; the clinic had to discontinue this program because of lack of funding. If approved, the clinic will implement a curriculum based on American Diabetes Association guidelines and the classes will be held at times that are accessible to the targeted patient population.
  • 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 has a dedicated volunteer to help patients navigate the process. For those clinic patients who are ineligible for such programs (i.e., lack established permanent resident status), the clinic maintains a pharmacy fund, created through a private foundation grant, to provide free medications. The clinic supplements this fund with discounted generic prescriptions available at large pharmacy chains such as Walmart and Target and with free pharmaceutical samples donated by doctors. Patients with diabetes are provided with a blood glucose monitor and strips to reinforce compliance with self-management.

Context of the Innovation

St. John Bosco Clinic is a program of Mercy Mission Services, the charitable arm of the Sisters of St. Joseph of St. Augustine, Florida outreach mission and ministry in Miami-Dade County; it was originally sponsored by Mercy Hospital. As of 2011, Mercy Hospital was sold and is no longer a sponsoring entity. St. John Bosco Clinic continues to be an outreach ministry of the Sisters of St. Joseph of St. Augustine, Florida under Mercy Mission Services and the philanthropic fundraising mission of SSJ Health Foundation. Dr. Pedro "Joe" Greer launched the clinic in 1991 after noticing that the county's public hospital often refused to treat undocumented individuals referred by Camillus Health Concern, a clinic run by Dr. Greer since 1984 to serve the county's homeless population. The hospital's refusal to serve these individuals created an environment in which undocumented patients felt unwelcome, leaving them unable to access needed services. In response, Dr. Greer collaborated with Mercy Hospital to establish a clinic in the back of St. John Bosco Catholic Church, hoping that the parish-based location would encourage undocumented patients to feel comfortable seeking care.

Did It Work?

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Results

Although the health outcomes of clinic patients have not been formally evaluated, data suggest that the program is enhancing access to needed medical care and education. Patients remain loyal to the clinic, and verbal feedback has been overwhelmingly positive; the clinic has become a medical home for many patients.
  • Facilitating access to services: According to information provided in June 2013, the clinic has a patient census of more than 1,700. In 2012, the clinic saw almost 700 patients and provided more than 5,000 visits. The total number of new registered patients increased by 30 percent. The clinic is now open to all residents of Miami-Dade County who meet the eligibility criteria. 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: Verbal feedback from patients is overwhelmingly positive, and word-of-mouth referrals are the main referral source for the clinic. Patients continued to access the clinic after the 2007 move to its new location, even though the new location meant significantly longer travel times for many patients.

Evidence Rating (What is this?)

Suggestive: The evidence consists primarily of post-implementation data on patient volume and clinic visits along with verbal feedback from patients with the underlying assumption being that in the absence of the program, those served would not have had access to these services.

How They Did It

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Planning and Development Process

Key steps in the planning and developing process include the following:
  • 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 as a volunteer agent for the Florida Department of Health, meaning that the health care provider, for the purpose of improving access to health care for indigent individuals, is afforded liability protection as agents of the state while acting within the scope of their duties as a volunteer physician.
  • 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 supervisor, one receptionist (who works 32 hours per week), one medical assistant (who works 32 hours per week), and one full-time nurse practitioner. In addition, the clinic relies on volunteers to provide clinical services and perform clerical tasks. Currently, a core group of four 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 15 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 2012, St. John Bosco Clinic's operating expenses were $472,000.
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Funding Sources

American Academy of Family Physicians; Florida Department of Health; Allegany Franciscan Ministries; Susan G. Komen for the Cure (Miami/Ft. Lauderdale Affiliate)
The organizations listed above were active funders during 2012. Funders from previous years include: Mercy Hospital of Miami, American Cancer Society, American Heart Association, Deering Foundation, Dr. John T. MacDonald Foundation, Blue Foundation for a Healthy Florida, and Jesse Ball Dupont Foundation.end fs

Adoption Considerations

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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 and underserved individuals 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.

More Information

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Contact the Innovator

Pedro "Joe" Greer, Jr., MD
Assistant Dean of Academic Affairs
Florida International University College of Medicine
11200 SW 8th Street, AHC II 693
Miami, FL 33199
Phone: (305) 348-0570
Fax: (305) 348-0123
E-mail: greerp@fiu.edu

Berta Cabrera, MS
Executive Director
SSJ Health Foundation
3661 South Miami Avenue, Suite 103
Miami, FL 33133
Phone: (305) 854-0533
Fax: (305) 854-0559
E-mail: berta.cabrera@ssjhealthfoundation.org

Innovator Disclosures

Dr. Greer and Ms. Cabrera have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

Footnotes

1 American Community Survey. Adults with health insurance. Miami-Dade Matters Health Council of South Florida [Web site]. Available at: http://www.miamidadematters.org/modules.php?op=modload&name=NS-Indicator&file=indicator&iid=785550.
2 Ortega AN, Fang H, Perez VH, et al. Health care access, use of services, and experiences among undocumented Mexicans and other Latinos. Arch Intern Med. 2007;167(21):2354-60. [PubMed]
3 Diabetes and Hispanic Americans Web site. U.S. Department of Health and Human Services. The Office of Minority Health. Available at: http://minorityhealth.hhs.gov/templates/content.aspx?ID=3324.
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Original publication: February 16, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 23, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.