Problem Addressed

• Failure to receive needed services: Low-income individuals often cannot access needed health care and social services, for several reasons:
  • Systemic barriers: Disadvantaged individuals often cannot access appropriate health care and social services, primarily due to systemic barriers, such as difficulties finding a job, obtaining housing, or securing health insurance.¹ Such problems tend to be most acute among the homeless and those at-risk of homelessness.²
  • Lack of trust: Even when adequate community services and resources are available, many at-risk residents do not trust health care providers and lack the patience or life skills to navigate the health care system. Lack of trust may arise when clients have their social service applications denied, experience discrimination from front-desk staff, or are unable to submit appropriate documentation. In such circumstances, clients often become discouraged and stop seeking services.
  • Lack of coordination: On their own, health care providers serving at-risk residents often lack the systems and workforce needed to coordinate with other organizations to ensure that clients receive needed services. Coordinating care to the homeless and those at-risk of homelessness is especially difficult, because separate agencies, with separate funding streams, tend to serve this population. When homeless individuals do receive care, they typically are treated for a single, acute problem, with little or no attempt to deal with the multiple, ongoing conditions that they face.²
• Increased likelihood of untreated medical conditions and uncompensated care: At-risk individuals unable to access needed services face an increased risk of untreated chronic health conditions.¹ These individuals frequently end up requiring expensive, uncompensated inpatient and ED care. This problem is particularly acute for homeless individuals, for whom the lack of preventive and primary care leads to increased risk of poorly controlled diabetes, heart and lung disease, sexually transmitted diseases, untreated wounds, and a range of psychiatric and substance abuse problems.

Description of the Innovative Activity

• Clinic logistics: The Promise Clinic operates inside of the St. John's Family Health Center, a larger health clinic run by Catholic Charities-Diocese of Metuchen. Key logistical details are described below:
  • Convenient location, regular hours: Promise Clinic is located across the street from Elijah's Promise, a large soup kitchen, and next door to Catholic Charities-Diocese of Metchen-Ozanam Inn, (Men's Shelter for the Homeless). The homeless men who reside at the shelter eat meals at Elijah's Promise and most are patients of UMDNJ-RWJMS/Homeless and Indigent Population Health Outreach Project (HIPHOP)—Promise Clinic. Medical students see patients at the clinic on Thursday nights from 6 to 9 p.m. In addition, every evening one resident is available at the center to provide health information and schedule appointments for individuals from the soup kitchen.
  • Team-based care: The students are organized into four-person teams. Each team consists of one medical student from each year of training, with the third-year student serving as team leader, the fourth-year student as an adviser, and the first- and second-year students as patient advocates and assistants to the team leader. Each team works with one or two patients at a time and with three to five over the course of a year (since patients are drawn from a highly transient population and some drop out of the program). As much as possible, teams stay together from one year to the next, with a first-year student added to the team when the fourth-year student graduates.
  • Faculty physician preceptor oversight: A physician preceptor from the faculty of the medical school is on duty at the clinic each Thursday night to oversee the medical students. Preceptors observe the care provided by students and take an active role in that care. Preceptors also routinely review patient charts with students to ensure high-quality care.
  • Referrals from soup kitchen: The staff social worker at Elijah's Promise asks new visitors to the soup kitchen about their health and access to medical services. In cases where an individual needs medical care and is not likely to pursue it independently, the social worker explains how the clinic works and encourages him or her to make an appointment for an initial screening. Many visitors to the soup kitchen are skeptical about health care and have not seen a doctor in years, so overcoming their doubts often takes multiple conversations.
• Initial and ongoing care: The clinic offers an initial screening and diagnosis and ongoing care based on a customized care plan, as outlined below:
  • Screening and diagnosis, supported by onsite laboratory and pharmacy: At the patient's first visit, he or she is introduced to the assigned student medical team and the physician preceptor on duty that evening. The team takes the patient's medical history and performs a physical examination and basic diagnostic tests (e.g., body mass index, blood pressure, cholesterol, and glucose). The clinic has an onsite laboratory, also staffed by student volunteers with supervision from medical school faculty. For many patients, this initial screen leads to the diagnosis of one or more chronic conditions, such as diabetes, asthma, hypertension, obesity, high cholesterol, and heart disease. In these instances, the team may prescribe medications, which can be obtained at the onsite pharmacy (also run by students). In 2012, the clinic plans to replace the onsite pharmacy with a prescription voucher system that will allow patients to pick up free or low-cost medication at nearby pharmacies.
  • Team-developed care plan: After the screening, team members develop a long-term care plan for the patient, which they subsequently discuss with a faculty physician preceptor. In many cases, patients' illnesses are already severe, leading the team to implement an intensive plan.
  • Ongoing care: Going forward, the team provides comprehensive primary care for the patient's acute and chronic conditions, with care based on the established plan. Patients typically have one or two clinic appointments each month, with two to four team members present during each appointment. Patients can also call a designated team member any time they have questions.
  • Specialized care: As necessary, the team arranges for the patient to see a specialist. Mental health needs can be addressed onsite by a psychiatry resident who volunteers at the clinic every other Thursday, with oversight from a faculty member. For other specialized needs (e.g., surgery, cancer treatment), the medical team sets up appointments with relevant providers familiar with the clinic.
• Additional educational opportunities for students: In addition to learning as they provide care at the clinic, students regularly attend lectures at the medical school on topics relevant to underserved patients, and they are required to write a short paper about an individual patient's circumstances and progress. Students may also volunteer to serve on any of several student-run committees on clinic-related issues, such as clinic management, specialty care, laboratory, public health, and patient recruitment. Based on an annual application process reviewed by the physician preceptors, some students receive elective credit toward their medical degree for their participation in the program. (The medical school can offer only a limited number of elective credits each year, so not all volunteers receive them.)

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Results

• Vital experience for medical students: From the clinic's inception in 2005 through 2011, approximately 600 student doctors participated in the program, providing them with their first experience serving low-income patients. Many former students report that clinic work sensitized them to the needs of low-income patients and influenced how they practice medicine and the direction of their careers.
• Enhanced access to care: Since the clinic opened in 2005, the number of patients served has consistently grown from 15 in 2005 to 65 in 2011. As of April 2012, 80 patients were being served. In the absence of this program, many of these patients likely would not have had access to medical care.
• Anecdotal reports of health improvements: Although the program's impact on patient outcomes has not been formally evaluated, staff frequently report cases in which the clinic's care enabled patients to avoid imminent health crises. For example, students have detected cancerous tumors that could then be treated and have helped those with extremely high cholesterol and/or uncontrolled diabetes get their condition(s) under control.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Initial planning: In 2004, HIPHOP leaders approached the dean of the medical school and the director of Elijah's Promise about setting up a student-run health clinic. Both were amenable to the idea. They also contacted the director of St. John's, who offered to donate space to house the clinic. During subsequent meetings and phone calls, key program details began to take shape, such as the four-person teams, Thursday evening hours, elective credit for some participants, and onsite pharmacy and laboratory services.
• Recruiting and training student volunteers and faculty: In the months leading up to the planned opening, HIPHOP publicized the clinic on-campus via e-mail and informational meetings. This effort led to the signing up of roughly 60 students who formed 15 medical teams. In addition, several faculty members agreed to serve as physician preceptors. The students attended several training sessions to learn about the clinic's operations and their role in providing care.
• Expanding and enhancing program: Following the model's initial success, the clinic gradually expanded to allow more student involvement and serve more patients, reaching its present contingent of 160 volunteer students (organized into 40 teams) and 11 physician preceptors. To better address patients' mental health needs, the clinic added the psychiatric component in 2009.

Resources Used and Skills Needed

• Staffing: Approximately 160 students and 11 physician preceptors volunteer their time at the clinic. Of these, between 10 and 15 students and several preceptors handle various administrative duties along with clinical work. The program has several paid part-time staff, including a nurse (who is employed by St. John's but receives a portion of her salary from HIPHOP), the medical school's program coordinator, and a secretary.
• Costs: Data on program costs are unavailable. Costs tend to be relatively low, since volunteers provide care and the clinic space has been donated. Expenses include laboratory tests, medications, and salaries and benefits for paid staff.

Funding Sources

Getting Started with This Innovation

• Focus on community needs: Consult with community health leaders to identify those who could benefit most from a clinic. Although this program targets low-income (often homeless) adults, the same approach could work with older patients, low-income families, immigrants, or other underserved populations.
• Start small: Make sure the size of the potential target population is appropriate for the number of available student volunteers and physician preceptors. Trying to serve too many patients can overwhelm program resources, leading to staff burnout and low-quality care.
• Find strong community partners: The program's success depends in large part on having community partners who share similar ideals and goals. In this case, staff at Elijah's Promise support the program enthusiastically and play a critical role in identifying potential patients and convincing them they will benefit from seeking care at the clinic.

Sustaining This Innovation

• Maintain strong institutional support: Although the program is run primarily by students, the medical school plays an important role in sustaining it. Ongoing support from the dean's office and key faculty members, for example, helps to ensure the program's long-term survival.
• Look for ways to enhance care: Physician preceptors and third- and fourth-year students often identify innovative ways to enhance program services. For example, after recognizing that many patients had significant mental health needs, they recommended incorporating psychiatric residents into the program.