In Orlando, Florida Free Walk-In Primary Care Clinics Add Services, Capacity
Shepherd's Hope, a faith-based, nonprofit organization in Orlando, Fla., that operates free walk-in primary care clinics staffed by volunteers, expanded the capability of four clinics and opened four new ones.
Local Funding Partnerships is a national matching grants program that seeks to stimulate innovative, community-based projects to improve the health and health care of underserved and vulnerable populations.
- Shepherd's Hope increased the capacity of their four health care centers and expanded the services they offered to patients.
- Some health centers opened two nights per week, or two nights every other week as the project staff recruited new volunteers.
- In addition to giving out pharmaceutical samples from physicians, Shepherd's Hope became a wholesale distributor of generic drugs in 2004. Clinics gave out about 14 standard generic medications, such as antibiotics, basic diabetes medications and drugs for hypertension.
- Shepherd's Hope opened four new clinics by the end of 2004, enabling it to increase the number of patients served by more than 5,000.
- Licensed medical and lay volunteers for Shepherd's Hope provided primary care during 35,766 patient visits from 2000 to 2004. Some 15,437 of these visits were from new patients.
RWJF supported this project with a $441,140 grant from August 2000 through January 2005.
A Large Uninsured and Low-Income Population in Orange County, Fla.
Orange County has one of the highest percentages of residents without medical insurance in Florida and the nation. In 1998, more than 21 percent of the county's population under 65 about 176,000 residents had no medical insurance. This compared with Florida's average of 19 percent and the national average of 16 percent, the Florida Agency for Health Care Administration estimated.
Some 46 percent of the uninsured in Orange County earned less than 150 percent of the federal poverty guideline, at the time $12,075 for an individual, $16,275 for a couple and $24,675 for a family of four. The agency estimated that this group would grow at a rate of 4.7 percent annually.
Within the population earning less than 150 percent of the federal poverty guideline, many needed ambulatory medical care. Those who sought medical care in emergency departments incurred bills for the most expensive health care available and possibly lost work time.
The county health department and its clinics served those who earned less than 125 percent of the federal poverty guideline, but only during work hours. For uninsured people who earned above this level, even only a little bit more, their income level disqualified them from government-assisted health programs but generally did not enable them to afford private health insurance.
Shepherd's Hope Provides Free Medical Care to Low-Income, Uninsured People
In 1996, Bill Barnes, senior pastor of St. Luke's United Methodist Church in Orlando, shared with his congregation the idea that a volunteer effort could help more uninsured people receive the health care they need.
Shepherd's Hope began in 1997 by setting up a clinic in a public school's family service center. Staffed by volunteer physicians, other licensed medical personnel and administrators, the Westside Shepherd's Hope Health Center opened one and then two evenings a week, providing primary care to uninsured people who earn less than 150 percent of the federal poverty guideline.
From 1997 through 1998, the Westside center provided free medical care for nearly 2,700 patient visits. Health Central, the center's partner hospital, contributed more than 500 free radiology and laboratory procedures. In 1998, Special Care, a program of the Orange County Medical Society, began to donate cardiology, gynecology, orthopedic and other specialty care.
Shepherd's Hope expanded its partnerships to open three new evening clinics in 1999. Each clinic was supported by:
- A school, which offered free clinic space.
- A sponsoring church for stability, financial support and as a primary resource for volunteers.
- A community hospital, which provided free diagnostic testing services and, frequently, volunteer physicians and nurses.
Also in 1999, Shepherd's Hope proposed to replicate this model of volunteer-based primary care by opening another four health centers in the Orlando area with funding from local donors and RWJF's national Local Funding Partnerships program.
This project was funded within RWJF's Local Funding Partnerships program. Local communities identify a pressing local health need of vulnerable populations, design the strategy for addressing it and put together a funding package that provides at least one dollar of outside support for every dollar of RWJF grant money. This bottom-up strategy is the program's guiding philosophy.
Shepherd's Hope is a faith-based, nonprofit organization in Orlando, Fla., that operates free walk-in primary care clinics staffed by volunteers. With a $441,140 RWJF grant, Shepherd's Hope expanded the capability of four clinics and opened four new ones from August 2000 through January 2005.
The organization raised more than $700,000 in matching funds from foundations and other sources, and received in-kind donations of volunteer time and diagnostic procedures valued at more than $4 million. (For the list of donors, see Appendix 1; for in-kind donations, see Appendix 2.)
Shepherd's Hope hired four staff people, including a project director. They undertook activities to:
- Expand medical services to the full extent of volunteer capabilities in each existing health center and establish four new health centers.
- Provide 12,000 patient visits in 2004 at an average cost of $33.33, based on clinic performance through 2000.
- Create an environment within each health center that would be comfortable for patients and free of administrative hassles for medical professionals.
- Develop a model of access to health care, using faith-community sponsorship with hospital partnership, which could be replicated in areas of similar need throughout the United States.
Annual Patient and Provider Surveys
Beginning in 2003, the Shepherd's Hope board of directors used results from a patient satisfaction survey and a volunteer survey to achieve the kind of "user-friendly" environment they wanted at the health centers. Shepherd's Hope staff with help from volunteers at each clinic surveyed the patients and volunteers annually, collecting data from 10 percent of patients, based on projected numbers, and from 25 to 35 percent of the volunteers.
- The patient survey asked about demographic information and such questions as: where patients previously got medical care, whether the clinic was easy to use, how they experienced working with the staff and what the high and low points of their visits were.
- The volunteer survey asked respondents how often they volunteered, whether Shepherd's Hope provided the right training and resources for their work, how well volunteer coordination worked, how well other aspects of the clinics worked and whether respondents found their tasks rewarding.
In 2002, project staff produced an operations manual for their model of care delivery and updated it regularly. (See the Bibliography for details.) Shepherd's Hope staff answered 25 requests for their manual.
They also held workshops with other Florida groups upon request to acquaint them with Shepherd's Hope's approach to health care and made presentations to state and local conferences and meetings.
Web Site and Fund Raising
In 2003, project staff launched a Web site that included information about Shepherd's Hope health care services. The Orlando Sentinel, Florida Golf Central magazine and the evening news of all local television channels covered the clinics and several special events mounted by Shepherd's Hope for fund raising.
Several events affected the volume of patient visits the clinics could achieve during the grant period.
- One clinic fell below capacity for a time due to inadequate staffing. A new clinic manager recruited new volunteers.
- In 2001, negotiations with the sponsoring faith community of a proposed clinic took four months longer than anticipated because of the sponsor's concerns about liability.
- In 2003, the renovation of a high school that housed a clinic forced the closing of that clinic for six months. Since volunteers dispersed while the clinic was closed, the clinic was short of staff when it reopened and did not operate at its full capacity.
The project accomplished the following:
- Shepherd's Hope increased the capacity of its existing health care centers and expanded the services offered to patients.
- Some health centers opened two nights per week, or two nights every other week as project staff and collaborating partners recruited new volunteers.
- In addition to giving out pharmaceutical samples from physicians, Shepherd's Hope obtained a permit to become a wholesale distributor of generic drugs in 2004 to give their patients better access to medications. Clinics usually have about 14 standard generic medications on hand, such as antibiotics, basic diabetes medications and drugs for hypertension. They give out the medications for free.
- By the end of 2001, staff at Shepherd's Hope had instituted and documented:
- An orientation program for general volunteers.
- A clinical orientation for health care volunteers.
- Volunteers and project staff developed a pilot chronic care program that Shepherd's Hope implemented at the Health Alliance Family Health Center beginning in 2003. This program educates patients about their chronic disease, gives them support in coping with it and meets some of their pharmaceutical needs.
- Shepherd's Hope opened four new clinics by the end of 2004, enabling them to increase the number of patients they served by more than 5,000. These clinics' partners include 11 faith communities, 11 hospitals and radiology centers, four county and state entities, six health care centers or provider groups and three volunteer organizations focused on medical care (see Appendix 2 for a list of partners).
Shepherd's Hope Clinics and Patients/Patient Visits
|Year Started||Patient Visits||Annual Patient Visits||Total Patients|
(Highlighted areas represent the four centers set up during the project and the pilot chronic care project.)
- Licensed medical and lay volunteers provided primary care during 35,766 patient visits from 2000 through 2004. New patients accounted for 15,437 of these visits. More than 10,300 patient visits took place at the clinics in 2004.
- Shepherd's Hope recruited more than 900 new volunteers during the grant period, increasing their volunteer staff to 1,051 by the end of 2004.
- Shepherd's Hope staff adapted the clinic environment to meet patient and volunteer needs. Results from the 2004 patient satisfaction survey showed that overall satisfaction among patients averaged 4.63 on a scale of 1 to 5, with five as the best possible score. Using a similar scale, those responding to the volunteer survey reported that their experience had been positive (4.32) and rewarding (4.46).
- Clinics changed from an appointment system to walk-in clinics.
- Project staff trained bilingual volunteers to serve as interpreters.
- Clinics used patients' own statements of income eligibility rather than requiring them to provide extensive documentation of their income.
- Clinics did not require licensed medical volunteers to record patient insurance-related codes and statistics that other physician practices usually require. Volunteers charted only the patient's medical history and treatment information.
- A nurse mentor program helped new volunteer nurses learn how the clinics worked.
- The average cost per patient visit reached $50.83 in 2004, rather than leveling off at $33.33 as projected. With only four clinics and no central office, the cost per visit in 2000 averaged $34.90. The 2004 average included the cost of personnel, a new central office, generic medications, pharmaceutical permits and evening security service for the clinics.
- Shepherd's Hope became an interim source of health care for the uninsured who had not found a place in federally qualified health centers, taking some patient burden away from local emergency rooms. The project director explained that waiting lists for federally qualified health centers an appropriate medical home for uninsured patients were often months long. Results from the patient satisfaction survey indicated that 5 percent of the patients surveyed in 2003 and 9 percent in 2004 previously went to an emergency room or hospital for care.
- The staff at Shepherd's Hope created an operating manual so that others could replicate this model of health care delivery. Following a general introduction, the manual offered sections on:
- How to open a new health center.
- Volunteers: codes of ethics, application forms, job descriptions, Florida department of health policy document on immunity from liability, etc.
- Patient eligibility forms.
- Scheduling procedures.
- Medical records: consent and release forms, etc.
- Policies and procedures for clinical services.
- Orientation packages for clinical and lay volunteers.
- Copies of licenses and permits, letters of agreement with partners, etc.
- Examples of forms.
The People Who Used the Clinics
A volunteer board member of Shepherd's Hope, Carrie Ferenac, wrote about the experiences of several people who came to Shepherd's Hope during the course of the project and how Shepherd's Hope clinics helped them get care. Here are four examples of people helped by the clinic:
Charles lost his job as a gardener when he got sick with complications from diabetes. Along with his job, he lost his health insurance. Some time later, Charles showed up at Shepherd Hope's Hungerford Health Center with a gangrened foot wrapped in a plastic garbage bag. One of the volunteer nurses drove Charles, who was without transportation and resources, to an emergency room, where he was admitted. Doctors amputated two of his toes. The same nurse visited him in the hospital, and supported him through his recovery. After that, Charles regularly visited the health center and volunteers continued to help him. One volunteer provided him with a bicycle and another helped him apply for Social Security Disability support.
Keith had a torn retina and needed specialized surgery within two weeks to avoid going blind in that eye. Keith was working part time, but did not have health insurance and could not afford the surgery. He spent three days on the telephone calling agencies and doctors looking for help. A friend told him about Shepherd's Hope and he called. Within two days, Shepherd's Hope volunteers had Keith scheduled to see an eye surgeon who specialized in retinal care. The surgery saved Keith's vision in that eye.
Valerie came to a Shepherd's Hope health center because her son was sick and needed antibiotics. While she was there, she heard there was a gynecologist on staff and asked if she could see him. The volunteer doctor was able to squeeze her in. While she was talking with the doctor, Valerie revealed that she had not had a pelvic exam in 18 years. The doctor performed a Pap smear, and the results were positive for potentially deadly cancer. The doctor referred her for immediate follow-up care and made sure she got the treatment she needed.
Six-year-old Juan should have been playing in the Little League and working on his spelling. Instead, he was dealing with pain. Juan's kidneys had not functioned properly for more than two years, and he now needed extensive treatment. Although his Mexican immigrant father worked in construction, the family had no health insurance and could not afford treatment for Juan. A Shepherd's Hope volunteer doctor who had been treating Juan at Shepherd's Hope for two years worked with the Orlando Regional Medical Center and arranged for the boy to be hospitalized at no cost. Juan spent 15 days in the hospital where doctors determined he needed dialysis. The Shepherd's Hope doctor arranged for him to receive that treatment. Later, Juan returned to Shepherd's Hope for continued care.
- Set up access to free or affordable prescription medications when operating a free clinic. Patients cannot comply with doctors' orders if they have no money for prescriptions. (Project Director)
- Look for opportunities to form partnerships with other faith congregations in your own community. You will not reinvent the wheel and you will have partners within your own community. This enhances your ability to meet your goals and to answer the needs of the community. (Project Director)
- Invest in good training for volunteers. Do not expect perfection when working with an all-volunteer staff, but realize that solid training leads to better outcomes. (Project Director)
- Target volunteer recruitment efforts toward finding volunteers that reflect the cultural, linguistic and ethnic backgrounds of patients. This helps patients understand and comply with their treatment and improves patient satisfaction. (Project Director)
- Limit paperwork and bureaucracy when working with volunteers. Each volunteer may work only one evening a month for three hours; as much volunteer time as possible should go to patient care. (Project Director)
- Redeploy volunteers to other clinics or tasks if a facility has to close its doors temporarily. The renovation of a high school resulted in a clinic closing for six months, during which volunteers drifted away from the organization. Quickly moving volunteers to other clinics or program activities might have helped keep them involved. (Project Director)
- Use simple methods for volunteer medical professionals to document patient information. Having a single form where volunteer physicians can check boxes and sign their name is what they want. (Project Director)
- Exercise patience when collaborating with other agencies. Find a pace that supports partners but also encourages forward movement to accomplish goals. (Project Director)
- Find large faith communities to support health ministries. A health center the size of those started by Shepherd's Hope requires the determination and work of many volunteers. (Project Director)
AFTER THE GRANT
Shepherd's Hope volunteers served their 50,000th patient in 2005. By January 2006, Shepherd's Hope had 1,261 volunteers; more than 500 of those were licensed health care professionals.
With a $48,000 grant from the Winter Park Health Foundation, Shepherd's Hope hired a full- time, bilingual case manager. She guided people with complex cases through the health care system and ensured that volunteer medical staff could track the highest-risk patients.
Project staff planned to expand the chronic care program as additional health educators volunteered.
CVS/pharmacy Charitable Trust awarded $10,000 to Shepherd's Hope in March 2005 to help pay for generic medications.
In September 2005, Shepherd's Hope patients became co-beneficiaries of a two-year, $582,240 grant to the community from Florida Hospital. This grant, administered by Orange County Health and Family Services, funded medications to the indigent through the Central Florida Pharmacy Co-op, an initiative based in the Orange County Medical Clinic.
GRANT DETAILS & CONTACT INFORMATION
Free Medical Care for the Working Uninsured and Their Families
Shepherd's Hope (Orlando, FL)
Dates: August 2000 to January 2005
- Blue Foundation for a Healthy Florida, $85,000
- Dr. P. Phillips Foundation, $143,148
- Edyth Bush Charitable Foundation, $126,300
- McCormick Tribune Foundation, $211,805
- N. Donald Diebel, Jr., M.D., Good Samaritan Fund, $50,000
- Walt Disney World Helping Kids Shine, $50,000
The following organizations each made contributions of less than $50,000:
- Bob & Cheri Vander Weide Foundation
- Central Florida Women's League
- Charles and Mary Grant Foundation
- City of Orlando
- Community Foundation of Central Florida
- Eckerd Foundation
- Eckerd Youth Alternatives
- Father's Table Foundation
- Femmes De Coeur
- First Presbyterian Church of Orlando 'Branches class'
- Florida Hospital Seventh-day Adventist Church
- Friends Foundation Trust
- John H. Sykes Charitable Foundation
- Manhattan Institute for Social Policy
- Northland Community Church
- Orlando Sentinel Family Fund
- Pascal International, Inc.
- Publix Supermarkets Charities
- St. James Cathedral Church
- St. Luke's United Methodist Church
- Susan G. Komen Breast Cancer Foundation
- Universal Studios Escape
- University Carillon Church
- VNA Foundation
- Wheat Ridge Ministries
Shepherd's Hope Partners
- Blessed Trinity Catholic Church
- First Presbyterian Church of Orlando
- Florida Hospital Seventh-day Adventist Church
- Forest Lake Seventh-day Adventist Church
- Macedonia Missionary Baptist Church
- Northland Community Church
- Ococee United Methodist Church
- St. John Vianney Catholic Church
- St. Luke's Lutheran Church
- St. Luke's United Methodist Church
- St. Margaret Mary Catholic Church
Hospitals and Radiology Groups:
- Florida Hospital Altamonte
- Florida Hospital Apopka
- Florida Hospital East
- Florida Hospital Orlando
- Florida Radiology Associates
- Health Central
- Medical Center Radiology
- Orlando Regional Lucerne Hospital
- Orlando Regional Medical Center
- Sand Lake Hospital
- South Seminole Hospital
Local and State Entities:
- Florida Volunteer Health Care Provider Program
- Orange County Government
- Orange County Health Department
- Orange County Public Schools
Health Care Centers and Providers:
- Central Florida Family Health Centers
- Christian Service Center for Central Florida
- Community Health Centers, Inc.
- Health Alliance Family Health Center
- Orange Blossom Family Health Center
- West Orange Alternative Resource Center
- Central Florida Health Care Coalition
- Primary Care Access Network
- Special Care, Inc. (Orange County Medical Society)
Volunteer Medical and Administrative Personnel Services Conservatively Valued at More Than $3,500,000
|Central Florida Health Care Coalition||Training and donated medical equipment|
|Christian Service Center||Social needs referrals|
|Eckerd (pharmacy) Corp.||Discounted prescriptions|
|Florida Volunteer Health Care Provider Program||Medical and income compliance forms|
|Florida Hospital Altamonte||Lab and radiology services|
|Florida Hospital Apopka||Lab and radiology services|
|Florida Hospital East||Lab and radiology services|
|Florida Hospital Orlando||Lab and radiology services|
|Florida Radiology Associates||Radiology services|
|Health Alliance Family Care Center||Facility for chronic care program|
|Health Central||Lab and radiology services|
|Medical Center Radiology||Radiology services|
|Orange County Government, Secondary Care||Specialty care services|
|Orange County Health Department||Referrals for prenatal and obstetric care|
|Orange County Public Schools||Access to in-school family health centers|
|Orlando Regional Lucerne Hospital||Lab and radiology services|
|Orlando Regional Medical Center||Lab and radiology services|
|Sand Lake Hospital||Lab and radiology services|
|South Seminole Hospital||Lab and radiology services|
|Special Care, Inc. (Orange County Medical Society)||Specialty care services|
|West Orange Alternative Resource Center||Counseling and other needs|
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Shepherd's Hope Operations Manual. The manual includes sections on how to open a new health center, volunteers, patient eligibility and scheduling, medical records, clinical services, orientation manuals, licenses and permits, forms and orientation packages for clinical and lay volunteers. Orlando, Fla.: Shepherd's Hope, 2002.
"Patient Satisfaction Survey," Shepherd's Hope, fielded Winter 2003 and 2004.
"Volunteer Survey," Shepherd's Hope, fielded Winter 2004.
World Wide Web Sites
www.shepherdshope.org. Provides information about Shepherd's Hope health centers in Orlando and surrounding communities for patients, volunteers, case managers and donors. Orlando, Fla.: Shepherd's Hope, 2003.
Report prepared by: Antonia Sunderland
Reviewed by: Janet Heroux
Reviewed by: Molly McKaughan
Program Officer: Jane Isaacs Lowe