(photo above: Americares Free Clinic-Stamford; credit: Mike Demas)
Even in the midst of the COVID-19 pandemic, the clinicians who are dedicated to serving underserved populations, are continuing serve those populations. How the leaders of those patient care organizations are making it all work—including through the intelligent leveraging of technology—could be useful for providers of all types nationwide.
Among the patient care organizations successfully serving underserved communities, including, primarily, communities of color, is the network of Americares Free Clinics, based in Stamford, Connecticut. Americares Free Clinics is the largest free-clinic organization in Connecticut, with four locations serving more than 2,000 low-income, uninsured adults, 85-90-percent of them Latino, in Connecticut, with the four clinics in Stamford, where the organization is headquartered, as well as Norwalk, Bridgeport, and Danbury. The staff numbers 33, including two physicians and three nurse practitioners, and is supplemented by 75 volunteers; 56 percent of visits are conducted via telehealth.
Patients seen at the Americares Free Clinics receive primary care consultations, laboratory and diagnostic testing, medications, and health education, all at no cost. The focus of the clinic organization’s work is on treating patients with chronic disease, especially hypertension, diabetes, high cholesterol, and other diseases.
As the organization’s website notes, “Over the years, our program has grown to become the largest free clinic network in the state with four locations serving 2,500 patients annually. Today, our clinics in Bridgeport, Danbury, Norwalk and Stamford are a lifeline for low-income uninsured residents from across Fairfield County. We care for patients with diabetes, hypertension, asthma and other chronic conditions, as well as provide treatment for minor injuries and sudden illnesses like the flu. Without our services, many would rely on emergency rooms for primary care services – or worse – delay care until they have a medical emergency. Over the years, 28,000 of our neighbors in need have received free health care services valued at $129 million from our clinics and community partners. Supported by local philanthropy, our clinics are an example of a community coming together to help patients in need.”
Further, the website explains, “Our clinics are supported by volunteer doctors, nurses, interpreters and administrative help, and draw on the resources of community hospitals, laboratories, specialists and pharmacies to ensure comprehensive outpatient care. Patients receive essential prescription medications at little or no charge through Patient Assistance Programs, donated medicines and our relationships with local pharmacies. Americares Free Clinics is a member of the National Association of Free & Charitable Clinics and licensed by the Connecticut Department of Public Health.”
What’s more, the clinicians are using the UpToDate clinical decision support platform, sometimes referred to informally as “Google for doctors,” donated to all the sites by Wolters Kluwer. The donation is part of a broader initiative to empower optimal care delivery and health equity on the part of Wolters Kluwer leaders. The Society of General Internal Medicine (SGIM) offers a donated one-year subscription of UpToDate in Internal Medicine to up to twenty domestic hospitals/clinics/individuals who work in medically underserved areas, and who could benefit from access to UpToDate, but who do not currently have funding to subscribe. A description of the solution states that “UpToDate is a clinical resource for physicians and patients that provides the most current evidence-based information and over 9,500 recommendations to over two million clinicians worldwide. It is the only resource of its kind ghat is proven to be associated with improved outcomes. Using this tool, providers are able to look up clinically-validated recommendations at the point of care – which ultimately helps them reduce the reliance on specialty care when possible.”
Recently, Healthcare Innovation Editor-in-Chief Mark Hagland spoke with Karen Gottlieb, executive director of Americares Free Clinics, regarding the ongoing work that the clinicians and staff at Americares Free Clinics continue to provide to those in need in Connecticut. Below are excerpts from that interview.
Can you elaborate a bit on the population that you’re serving in Connecticut? All of your patients are uninsured individuals, correct?
That’s correct; these are folks who fall through the cracks of the system. Criteria: They must be residents in our service area; they must make less than 250 percent of the federal poverty level; and must be uninsured. They don’t have catastrophic insurance or Medicare, and don’t qualify for Medicaid.
What is the poverty level for income in Connecticut?
It’s a federal number: the current number: 250 percent of the federal poverty level. A family of one can make up to $32,200 a year; a family of four, $66,250. Those levels are based on the guidelines that the federal government puts out every year.
How many physicians and other clinicians are involved in working in the clinics?
Unfortunately, COVID-19 has wreaked havoc with our volunteer base. To put it into perspective, in 1994 when the program started, our goal was to use volunteer doctors, nurses, interpreters and admins. As the program has grown and the needs have increased and the patients have become more complex, we’ve anchored our staff with a salaried doctor or nurse practitioner at each clinic. The volunteers provide both primary and specialty care.
So, now, we are primarily staffed by paid staff: doctors, nurses, nurse practitioners, and admins. We have five different providers working in the four clinics. Our volunteer base of doctors—I would have told you our volunteers in 2020 before COVID struck were about 220 people. Now we’re down to a fall smaller number.
What does the typical patient look like?
Our focus is on adults with chronic disease; those are the folks who really fall through the cracks. There are types of care out there for their children; but our typical patient would often be a Spanish-speaking immigrant working two or three part-time jobs, such as landscaping, snow removal, working in a factory, working in a restaurant, providing child care, in settings where there is no health insurance, or where they might not qualify. Some are undocumented. We care that they live in this area, and they’re working to make Connecticut a better place. The chronic disease is really important, because there are so many things that are needed, whether laboratory tests, hospital tests, medications, specialty care, they’re all important for people with chronic disease.
How are those who are insulin-dependent accessing insulin supplies?
We take care of about 400 diabetics. And long-acting insulin is very expensive. We are fortunate that because of the Americares Foundation, we receive donated insulin, and so our providers have access to just about all the medications they need to manage diabetes. It would be an exercise in futility if we didn’t have the medications. We get the medicines many different ways: some medicine is donated, some purchased; and we make use of the drug manufacturers’ Patient Assistance Program. Each drug company has their own version of it, so when you have a patient on many different medicines, you have to go to many different companies. But we get hundreds of thousands of dollars of medication donations, including for medications like the bronchodilator Advair, which can cost hundreds of dollars a month.
What are the biggest challenges in keeping everything running?
Staff, staff, and staff. We are a non-profit, so fundraising that allows us to grow and do more, is a challenge. But probably our biggest challenge is not only recruiting volunteer staff, but even paid staff. Even two years ago, there was a shortage of physicians, nurses, and nurse practitioners. So even if we have the funding, we can’t find someone to fill the position. The COVID-19 pandemic has impacted us tremendously. All medical facilities are struggling this week. But we’ve done quite well. On March 13, 2020, we were prepared for the pandemic; we had set ourselves up so that we could switch to telehealth; we did all of our care from march to August via telehealth; we had employed staff in the clinic, and all our interactions with patients were via telehealth; they would pick up medications, masks, gloves, hand sanitizers, in person. We stayed in touch constantly with them, because everyone was afraid; who wasn’t afraid in March 2020? But I’m very proud of our response to COVID. We did look back and do some quality improvement studies to see if there was a disruption in primary care, and it was not. We were pleased with that. Now, we’re doing a hybrid model as most people are. We’re doing telehealth and also face to face. Some clinics are at about 50/50, some are doing more face to face, because of their preference.
Have you been experiencing any shortage of volunteer interpreters?
We’re very fortunate; in two of our clinics, 100 percent of the staff are bilingual, and many are bicultural. That instantly helps. We still use interpreters, because we have volunteers and paid staff who don’t speak Spanish. And interpretation is as important in some case as medical care. And in our Danbury clinic, we have a big Brazilian population, so we have both Spanish and Portuguese interpreters. Everything we do is to try to support the patients and meet them where they are. This is a group that from a health equity standpoint, has struggled in the past; we’re trying to give them a level playing field?
What about the electronic health record? Do you use an EHR?
Yes, we have an EHR in each of our clinics; we’ve just finished the final implementation in our fourth clinic. We’re totally electronic. And there’s a telehealth component integrated into our electronic health record.
What is the outlook for the next few years for your organization?
Strategically, we have some very clearcut plans. To increase the depth and breadth of what we offer has been a strategic goal for awhile. Do we have access to cardiologists, podiatrists, ophthalmologists? That is important to us. Health coaching is important: we are very big on health education, and on trying to help our patients engage in better self-management for diabetes. If we can teach them how to eat better, how to exercise, how to make lifestyle changes, they can begin to control their destiny. It’s a population that really wants to take care of themselves; the idea that they aren’t interested is just so wrong. But they look to us for the support. And sometimes, it involves baby steps; so whether it’s deciding to walk around the block once a week or better monitor their blood sugars… And a lot of folks aren’t working, so we’re involved in food cards, rental assistance, keeping their phones running, all those things are a part of health equity, to give them a chance, to equalize the playing field.
We’re very, very fortunate: quality care is a big bucket, and chronic disease management is a big bucket. And we can do what we do because we have partnerships with our local hospitals and laboratories, so we can do bloodwork and determine their a1c regularly. And we’re able to access all diagnostic imaging services. Each of the hospitals in all four service areas are partners, and we can get our patients CT scans and chest x-rays just like regular patients. We and the hospitals have a mutual goal, to keep these folks healthy. They’re going to see the patients in the ED, if we don’t keep them healthy.
And besides telehealth and our electronic health record, sometimes, our patients have challenges with technology themselves. But we have access to UpToDate, an online encyclopedia. And so when our doctors are seeing our patients, they can access the most current guidelines. A free clinic is as good as all the resources we can pull together: that means volunteers, partners, laboratory services, UpToDate, all the things we can pull together for our patients.
Is there anything you’d like to add?
The services we provide are similar to those provided in a typical doctor’s office. They’re very comprehensive. But that care navigation is extraordinarily important. Our population often doesn’t speak the language, and they don’t always have the wherewithal to manage the healthcare system; so we do a lot of that for our patients; it’s all about equity and giving them a good shot at healthcare. But we also listen to our patients. We’re putting together focus groups to find out what we can do better for our patients.
