http://seattlecenter.org/skcclinic/
King County Washington is the 14th most populous county in the US with over 2 million people. King County represents 28.6% of Washington State’s population and is its largest population center. The County includes Seattle, 38 other incorporated cities, 19 school districts, and several cities and districts where racial minorities are the majority population. Immigrants and refugees from all over the world reside in King County, with over 150 languages spoken. 2010 Census data show more than 1 in 3 is a person of color, increasing to almost half among children. One out of every five residents lives below 200% of the federal poverty level. Twenty-three percent of residents speak a language other than English, and 19% are foreign-born.
Public Health – Seattle and King County provides a diverse mix of services and programs including jail health services, 10 public health clinics, King County Medic One and the King County Medical Examiner – in addition to more typical public health services staffed by 1311 FTEs.
The massive free healthcare clinic concept addressed and impacted three public health issues.
Access to care: The absence of universal access to basic medical care stresses King County, its residents, and safety net providers serving the uninsured. Within King County, wide disparities in insurance coverage exist by level of education, income, age and race.
Impact: 3,400 individuals received care in 2014 and 4,010 in 2015. $2.3 million in services were delivered in 2014 and $2.7 million in 2015. A very high percentage of patients were satisfied with the services they received and felt they received high quality care. 98% of patients felt they were treated with respect by clinic staff and volunteers. Over 60% of medical providers agreed that the patient’s primary complaint could be identified and treated on-site.
Emergency preparedness: Recent disasters, local and global, have highlighted the need for whole community emergency planning which leverages the public health system and partners to create a more resilient community able to recover more quickly from a disaster, and one in which no group is disproportionately impacted.
Impact: Members from six response teams helped staff the clinic, and participated in pre-clinic webinars where they received an overview of operations, role-based training, and context for how the clinic helped prepare them for similar roles during an emergency. Clinic operations were conducted consistent with regional emergency plans for capabilities such as medical materiel management, medical surge, emergency operations coordination, and public information. An exercise plan was developed for the clinic, activities were observed and evaluated according to objectives, and an after action report was written. Corrective actions will be incorporated into an improvement plan and tracked for resolution.
Workforce development: All standards and assessment frameworks to which public health is accountable stress the need to cultivate and maintain a skilled and productive workforce armed with the tools and resources to perform their roles.
Impact: 1,479 volunteers contributed time and expertise to produce the clinic. 34 of these volunteers were Public Health employees (3% of all employees), who worked a total of 1032 hours. 258 of the volunteers were MRC members (32% of all members), who donated a total of 7,704 hours. 87% of medical providers and 90% of support volunteers agreed they had the supplies to do their job. 90% felt the area in which they worked was well organized, and 98% felt they were treated well by clinic staff and volunteers. 96% of volunteers were satisfied with their roles in the clinic and 97% felt their experiences were worthwhile.
The goals of the clinic were:
1. Generate attendance of underserved populations
2. Recruit skilled volunteers to provide desired mix and volume of services, prioritizing volunteers who would participate in local Emergency Support Function 8 (ESF 8) response operations
3. Serve 4,000 patients in total each year
4. Provide approximately $3 million in medical care each year
5. Serve patients with more chronic health conditions than the general population
6. Provide appropriate referrals to health care providers, affordable care and other services
7. Assure volunteers find their involvement personally worthwhile, are comfortable with regard to role, and are willing to volunteer again
8. Test capabilities that would be used as part of the ESF 8 disaster response, including redundant communication systems, medical surge, and public information
9. Increase civic engagement through promoting ongoing volunteerism and support for community structures that support community needs. Serve as a point of entry to a more inclusive and compassionate society.
All goals listed above were met with the exception of goal 6 “provide appropriate referrals to health care providers and other services to attendees.” Although from the providers’ perspective, 88% of medical visits, 76% of dental visits, and 32% of vision visits will require follow up (an average of 70%), only one in five patients reported receiving a follow up referral to a medical provider.
As stated above, three public health issues were addressed by the clinic. First, the absence of universal access to basic medical care and wide disparities in insurance coverage. Second, the importance of creating a more resilient community able to recover from a disaster. Third, the need to cultivate and maintain a skilled and productive workforce armed with the tools and resources to perform their roles.
Access to Care
Washington State has approximately 7 million residents. In 2014, 10.7% of Washington State residents were uninsured (16% of adults and 6% of children). 65% of patients at the 2014 clinic had no health insurance. 26.1% of families in Washington earn less than 200% of the federal poverty level. 73% of patients at the clinic resided in households earning less than 200% of the federal poverty level. 5.5 % of Washington State residents are unemployed; 49% of clinic patients reported being unemployed.
There are widespread perceptions that the Affordable Care Act has increased the strength of the medical safety net such that mass free clinics like this are not needed. However, based on self-reported data from patients at the clinic, many have health insurance but cannot afford to use it due to high deductibles and co-pays, and many lack dental or vision insurance. Nationally, a third of Americans lack dental coverage, and there is no requirement for states to provide Medicaid dental coverage for adults. Data from the CDC’s BRFSS shows that among Americans aged 40 and over with moderate-to-severe visual impairment, 39.8% said they had skipped seeking eye care in the past year because of costs or lack of insurance.
Large scale free medical clinics are not new to the field of public health, but the Seattle / King County Clinic represents a creative use of this existing practice. First, the range and volume of services provided on site is unsurpassed anywhere in the country, according to Remote Area Medical who stages these clinics across the nation. For example, dental extractions and root canals were performed and crowns were placed on-site. Lab work was done on–site. Prescriptions for commonly needed medications were dispensed on-site with coupons for low-cost refills. Chiropractic, acupuncture, and osteopath services were available on-site.
In the area of access to care, Public Health – Seattle and King County has historically implemented both systems approaches and one-time events to address coverage gaps. Systems approaches have involved: outreach to enroll individuals in insurance via the Affordable Care Act; services through the Healthcare for the Homeless Network; the operation of Public Health clinics; and programs aimed at linking individuals to a medical and dental home. One-time or recurring special events providing free healthcare services have included the Stand Down (an annual event targeted at homeless veterans); weekly health screenings and medical referrals provided at food banks, low income housing communities, and homeless shelters; health clinics for homeless individuals operated by United Way; and mass vaccination clinics for flu, Tdap and measles. The Seattle / King County Clinic was a more effective practice than supporting multiple free healthcare events serving limited populations due to:
1. Economies of scale. The clinic was able to serve more individuals at a lower per person cost than the individual events.
2. The massive community event focused media and policymaker attention on issues related to access to care, and rallied people to action in a way that the small individual events could not.
Emergency Preparedness
The use of the clinic as an emergency preparedness exercise is also innovative. Clinic operations were designed to test functions which would be used during a public health emergency. Among the specific objectives tested and evaluated through the clinic were:
1. Provide, coordinate, and recover supplies and equipment to help the clinic deliver healthcare to underserved individuals.
2. Test and evaluate security procedures which would be used during a medical countermeasure incident, such as securing medications, on-scene security, and security in transport.
PHSKC produced an exercise plan for the exercise, observed and evaluated clinic activities, and produced an after action report. Staff were placed in roles similar to those they would fulfill during an emergency. Corrective actions generated by the clinic -- which will be incorporated into PHSKC’s emergency preparedness improvement plan and tracked through to completion -- touch on redundant communication systems, security procedures, inventory management systems, chain of custody for pharmaceuticals, intelligence and information sharing.
In emergency preparedness, previous strategies to improve competencies and test capabilities have included classroom and web-based training, tabletop exercises, functional drills, and full scale exercises. Real world events also present opportunities to train and test emergency response capabilities, but Public Health has not mobilized a large scale, complex emergency response extending for multiple operational periods since the H1N1 influenza outbreak of 2009.
Operating the clinic created an innovative opportunity to provide training and test capabilities. Whereas past emergency preparedness exercises were simulated scenarios in sterile training environments involving numerous artificialities, the four day clinic required volunteers to respond to dynamic situations and solve real problems.
Workforce Development
Approximately 292 individuals from Public Health – Seattle & King County and the Public Health Reserve Corps helped staff the clinic, representing 14 % of the entire Public Health workforce (defined as all PHSKC employees plus all PHRC volunteers). These individuals received webinar briefings by their team leads ahead of time explaining how their role at the clinic would help prepare them to perform similar roles following a disaster.
With regard to existing practices in workforce development, Public Health employees and volunteers have the ability to take separate management and emergency response classes in topics including incident command, de-escalation techniques, safety and infection control, triage and mass care, but this clinic provided an opportunity to learn and apply these skills in a real world environment.
Training and organizational development literature asserts that after three days of training, people remember:
10% of what they read
20% of what they hear
30% of what they see
50% of what they see and hear
70% of what they say
90% of what they say and do
The Seattle / King County clinic provided a unique and effective opportunity to train individuals in emergency response skills and other competencies in a manner which reinforces skill development by giving them a chance to act out job functions ("say and do") in a real world environment.
The clinic also enhances Reserve Corps recruitment and retention efforts, and is an effective method of marketing the Corps. At the first volunteer orientation following the clinic, more than twice the usual number of potential volunteers attended, and 54% of the attendees found out about the PHRC for the first time at the clinic. Engaged volunteers are also more likely to remain active with the PHRC for longer; many volunteers cite the clinic event as a highlight on annual volunteer satisfaction surveys.
As stated above, the goals and objectives of the Seattle / King County Clinic were:
1. Generate attendance of underserved populations
2. Recruit skilled volunteers to provide desired mix and volume of services, prioritizing volunteers who would participate in local Emergency Support Function 8 (ESF 8) response operations
3. Serve 4,000 patients in total each year
4. Provide approximately $3 million in medical care each year
5. Serve patients with more chronic health conditions than the general population
6. Provide appropriate referrals to health care providers, affordable care and other services
7. Assure volunteers find their involvement personally worthwhile, are comfortable with regard to role, and are willing to volunteer again
8. Test capabilities that would be used as part of the ESF 8 disaster response, including redundant communication systems, medical surge, and public information
9. Increase civic engagement through promoting ongoing volunteerism and support for community structures that support community needs. Serve as a point of entry to a more inclusive and compassionate society.
The clinic followed a similar planning and implementation process in both years, and involved the following activities taking place in the 12 – 14 months leading up to each clinic:
The local health officer assessed healthcare access data, determined that a large free medical clinic could help fill holes in the safety net, and approved the planning and implementation of the clinic – which would operate under the authority of the local health officer.
Once it was decided that the clinic was moving forward, directors were appointed for each department: Medical, Primary Care, Triage, Dental, Logistics, Infection Prevention/Safety, and the Project Director.
Public Health staffed the director positions in Logistics, Triage, and Infection Prevention/Safety, to assure plans were developed in alignment with public health goals, to place a public health face on the event and to enable Public Health to shape operations as a test of regional emergency response procedures.
A campaign was launched to procure cash and in-kind donations
A kick off meeting was convened with the directors to define roles and responsibilities and create a host community workplan
As part of the workplan, directors developed detailed plans for operations within their area
Directors participated in monthly calls to update each other on progress and troubleshoot issues
Outreach was conducted to prospective volunteers and the community at large
Directors developed common guidelines for volunteers (such as rules, parking, what to expect, maps), then directors used the guidelines to customize and send welcome letters to volunteers for their area
Outreach was conducted to targeted patient populations, especially ethnic communities, by using trusted and accessible sources for each respective target community
Implementation activities conducted at the clinic itself included:
Operating medical, dental, and vision clinics
Providing free, respectful, quality clinical services
Guiding and supporting attendees throughout clinic
In addition to Public Health – Seattle & King County, the primary organizations involved in planning the clinic were:
Ballmer Family Giving
Bill and Melinda Gates Foundation
Brooks
Essilor Vision Foundation
Group Health
The Norcliffe Foundation
Patterson Dental
Philips
Seattle Center
Seattle Center Foundation
AHEC Volunteer Retired Providers Program
Representatives from the 12 partner agencies listed above served on a Host Community Workgroup over a period of 14 months to plan and implement each event. Each representative’s role was to coordinate their organization’s involvement, serve a leadership role in clinic planning, encourage peer organizations to support the clinic, recruit volunteers from their organization, serve as an ambassador promoting awareness and enthusiasm about the clinic, and facilitate cash and/or in-kind donations from their organization.
Seattle Center Foundation served as the non-profit fiscal agent for the Seattle/King County Clinic, raising funds and paying for operations. Staging the clinic involved both start-up and in-kind costs. $300,000 in cash was raised by Seattle Center Foundation and used to leverage in–kind donations to deliver almost $3,000,000 in services. Of the $300,000 in cash, nearly 1/3 went to food (feeding volunteers 3 meals a day for 7 days), with another large portion paying for medical equipment rentals. Almost $1 million was raised in in-kind donations. 25.1% of contributions came in the form of cash, while 74.9% were in-kind donations (physical resources, not inclusive volunteer time)
The cash and in-kind resources addressed a wide array of needs. Clinic partner Remote Area Medical contributed dental and vision equipment and supplies, patient and volunteer registration equipment, select medical supplies, and covered the cost of transportation for their equipment and key staff. The Host Community supplemented RAM’s dental infrastructure in order to provide x-rays, root canals, crowns and flippers, and was responsible for covering all other operating costs for the clinic including those of the medical clinic, facility, parking, food and beverage, volunteer and patient outreach, among others.
The Corporation for National and Community Service values volunteer time in Washington State at $26.72/hour. With upwards of 25,000 hours recorded during the week of the clinic, this results in a minimum of $668,000 in donated time. However, given the professional rates of over 800 healthcare volunteers, as well as the untallied hours that went into planning the clinic, a figure of more than $2 million can be easily assumed.
The clinic was evaluated and results showed the clinic met or exceeded identified goals. The clinic was evaluated by the Center for Community Health and Evaluation (CCHE) at Group Health Research Institute. The CCHE developed the evaluation plan and logic model, designed data collection tools, recruited evaluation volunteers, oversaw data collection efforts, administered a survey, and analyzed survey and clinic data. Primary data sources included patient surveys, volunteer surveys, and a web application that tracked services access and patient and volunteer numbers. Evaluation activities focused on two main aspects of the clinic due to limited resources: the patient experience and the volunteer experience. Overall 98% of patients surveyed were satisfied with the care they received and 96% of volunteers were satisfied with their experience.
The following discussion references data from 2014 only, as the evaluation of the 2015 clinic has not yet been completed. Clinic achievements as reflected in the 2014 clinic data:
3,400 served
$2.3+ million in services provided at $0 cost to patients
Over 1,500 volunteers
25,000+ volunteer hours
100+ partner organizations engaged in clinic planning, recruitment, operations, and in-kind assistance
Served 2,687 unique patients
67 dental operatories
15 vision lanes for complete dilated eye exams
45 hours of clinic operations
Over 1100 eye glasses dispensed
$500,000 in vision care provided
Over 1800 dental images taken
Nearly 4000 pairs of new shoes provided to patients
Approximately 100 root canals performed and 95 dental flippers made onsite
125 CEREC crowns made onsite
65% of patients had no health insurance
73% of patients were below 200% of the federal poverty level
49% of patients reported they were unemployed
31 languages interpreted
230 unique zip codes represented among primary residences
Primary data sources
Patient clinic data (n=3386 registrations for 2,867 people)
Survey of volunteers (n=938)
Exit survey of patients (administered at clinic exit in English and Spanish) (n=528)
Secondary data sources
Interviews with 23 representatives of organizations involved with the project
Interview notes from 32 patient shadows
Semi-structured interviews with six key informants
Over 80 person-hours of clinic observation by evaluation team members
Performance measures
1. Outreach generates attendance of the targeted populations, and recruitment of appropriately skilled volunteers to provide services to patients who attended
2. Number of patients seen in each clinical area, number and value of services provided
3. Population profile of patients seen in the clinic (e.g. rates of chronic illness, BMI)
4. Number and type of referrals to health care providers and other services provided to attendees
5. Identify and quantify areas of unmet need in the patient population
6. Extent to which volunteers found their involvement personally worthwhile, satisfying, comfortable with regard to role, and willingness to volunteer again
Methodology/ Analysis of Results
Patient data was analyzed by race/ethnicity, primary language, geographic distribution, socio-economic status, time since receiving services, employment status, and insurance coverage. Evaluators reviewed qualitative data from interviews with patients and volunteer area leads after the clinic and analyzed these to identify challenges, compile lessons learned, and offer suggestions to improve clinic outcomes in several areas of interest.
Patients were surveyed to learn: 1) which services they came to the clinic hoping to receive; 2) which services they received; and 3) which services they came hoping to receive, but did not get. Volunteer providers were asked to rate their agreement with several questions related to patient needs. We asked them if they thought: 1) there was a great need for a free clinic like this; 2) did they discover many conditions that could not be treated on site; 3) whether the patients they treated would require follow up; and, 4) if they thought a similar clinic should be held again.
Event planners redesigned several aspects of clinic operations from 2014 to 2015 based on findings from the evaluation. Some of the specific changes implemented are described below.
Waiting area: A patient tracking mobile phone app was developed and used to measure wait times in different clinical areas. This information was communicated to patients to set realistic expectations around wait times and the time required for services to be provided. Waiting area volunteers communicated an overview of the clinic area and the process patients would follow to receive their care.
Registration: Interpretation capacity was increased at registration. Computer access and the wireless network was improved. A community services / social work intake form was developed and used.
Getting around: Color coding was implemented for clinic areas. Escorts were used to move patients between areas (such as medical discharge to dental waiting.) A system was developed to enable patients to come and go from the facility.
Within clinic: A triage station assessed patient status and helped patients prioritize the services they would receive at the clinic. 40% more dental chairs were added.
Discharge: Interpretation capacity, a navigator/expeditor role, and social workers were added at the discharge station. Referral systems were improved between year one and year two.
Volunteers: A new volunteer registration system was implemented. Orientation was revised to include big picture in addition to job specific information. Volunteer confirmation systems were improved to reduce the rate of no-shows. A volunteer waitlist was established to help fill emergent staffing gaps.
Data related to patients came from patient charts, exit surveys, and patient interviews. Three fifths of patients came seeking dental care. Registration records show the greatest number of people seeking dental services, followed by vision and medical care. Most had not seen a doctor within the two years prior to this clinic, had not received dental services in the past 4 years, and had not received vision services in 4 ½ years. Four-fifths of the people had delayed or avoided dental care in the past year, and all but one of them identified the cost of care/no insurance as the reason.
Data regarding the volunteer and patient experience included surveys and in-person interviews. Volunteer providers and patients believed the clinic was exceptionally well organized. The flexibility “to fix it as we went along” was seen by providers as an organizational strength and attributed to the competence and experience of the clinic organizers, as was the very clear chain of command within each clinical area and the support areas. More than 250 volunteers commented about the exceptional organizational effort. Patients also, for the most part, were impressed by the organization of such a large clinic. Four times as many patients commented about the organization and flow of the clinic positively than mentioned it as a challenge.
According to volunteers, the clinic created an invaluable opportunity for networking across healthcare workers, human service providers, emergency managers, and first responders. Relationships were strengthened and Public Health and other agencies built or updated lists of contacts which will be needed during a catastrophic disasters.
There was a high rate of late cancellations and no shows among general support volunteers. Roughly 50% of general support volunteers, or approximately 100 people per day, did not participate as anticipated which greatly impacted operations.
Patient recruitment and outreach was evaluated and changes were made from the 2014 to 2015 as a result. The clinic’s communications team made a concerted effort to connect with underserved and vulnerable populations, especially ethnic communities, by utilizing trusted and accessible sources for each respective target community. The outreach campaign conducted to draw patients to the clinic was successful as measured by the total number of patients, their health needs, the diversity of the patients who attended, and how well they aligned with the intended audience. The most common ways patients reported hearing about the clinic were newspaper/television news, friend/family/healthcare provider, flyers, word of mouth, and radio.
Referrals and advice for follow-up care were provided throughout the clinic in each area as care was provided. Social worker volunteers, providing patients access to a range of community resources including local Community Health Centers, were stationed near the clinic exit as were in-person assisters tasked with providing information about Medicaid enrollment and state-sponsored health insurance programs. One in five patients (21%) reported having received a follow up referral to a medical provider. There was a relatively even split between the types of referrals given, including dental (44%), vision (27%), and medical (37%). When asked how likely they were to follow-up, 58% of patients said it was likely they would/could follow-up with their referral instructions versus 19% who thought they would not. The most common reason for not seeking follow up was the perceived cost.
Clinic records were not available to assess levels of disease or specific diagnoses received at the clinic. Although we did not ask specifically about patients’ health status, all patients were asked to provide data to calculate their body mass index, a measure of cardiac disease and diabetes risk used here as a proxy for health status. The clinic met its goal of serving a sicker mix of patients than the general population. The mean BMI for patients who self-reported this information was 27.00, which is classified as overweight; 62% of the patients in the sample were overweight or obese, with a BMI in excess of 25.0. Overall in Washington State, the mean BMI is 26.31; with about 61% of adults thought to be overweight or obese.
Emergency preparedness functions were evaluated using objectives and an after action report process. From an emergency preparedness perspective, the big lesson learned was that establishing a pop-up medical clinic (such as an alternate care facility) will be a larger and more complex operation than previously understood. The clinic also validated many preparedness approaches pursued in recent years, such as recruiting medical reserve corps volunteers, obtaining agreements with hospitals on background check/credentialing/badging procedures, collecting images of healthcare facility ID cards so staff can be rapidly identified during in an emergency, developing triage protocols, and building relationships with vulnerable and underserved populations. The clinic illuminated that an insufficient proportion of local medical providers are registered in ESAR VHP (the emergency system for the advanced registration of voluntary health professionals) which helps Public Health verify identity and medical licensure during an emergency.
A cost/benefit analysis was not performed.
There are widespread perceptions that the Affordable Care Act has increased the strength of the medical safety net such that massive free clinics like this are not needed. However, based on self-reported data from patients at the clinic, many have health insurance but cannot afford to use it due to high deductibles and co-pays, or lack dental or vision insurance.
There is sufficient stakeholder commitment to sustain the massive free clinic year after year, but there is anecdotal evidence that donors may be reluctant to provide the necessary cash and in-kind donations to mount the clinic in the Seattle area for a third year in a row. The anecdotal evidence ties this reluctance to two factors. First, there is a perception that the clinic is delivering services to the same group of people each year, rather than reaching an expanded proportion of the population. Second, there is a perception that the clinic’s effectiveness in filling holes in the healthcare safety net may reduce policymaker’s willingness to implement needed systemic healthcare reforms.
Sufficient patient demand and volunteer engagement also exists to support another clinic. Almost all (95.7%) 2014 patients responding to the survey agreed or strongly agreed that they would attend the clinic if it were held again, and the total number of patients seeking care grew by 18% from 2014 to 2015. Volunteer participation more than doubled between 2014 and 2015, and almost all (99%) 2015 volunteers agreed they would be interested in volunteering again and would recommend volunteering at the clinic to colleagues and friends.
There is stakeholder commitment to explore sustaining or modifying this practice, as well as improving access to care outside of a stand-alone clinic event. A task force has been formed, co-chaired by Tao Sheng Kwan-Gett MD, MPH and Christine Lindquist MPH, to explore some of the larger questions that are emanating from this initiative, including what needs to happen to make events like this unnecessary. Clinic directors and policymakers agree that this should not become an annualized event, and are focused on seizing the opportunity to address system gaps while there is attention and energy focused in this direction. Group Health Research Institute and the Northwest Center for Public Health Practice will collaborate with the task force to help develop and promote policy recommendations which will improve access to care.
One option which will be explored by the task force is keeping the clinic an annual event, but moving it around to different regions of Washington State each year. Representatives from the cities of Yakima and Spokane toured this year’s clinic and received briefings from clinic management as a first step towards exploring that strategy.
The intent of the SKC clinic, besides providing care to people who are in need and trying to get them connected to resources for on-going care, is to use the clinic as a platform to help illustrate the real and perceived barriers to both receiving and delivering care. Hopefully the clinic will help to spark further conversations and associations within our State that can reap benefits beyond the life of the clinic itself.
In the absence of the clinic, access to care will continue to be sustained through a combination of system approaches and special events as described in the "responsiveness and innovation" section.
Whether or not the clinic is staged in the Seattle area for a third year in a row, regional emergency preparedness efforts will be sustained by to the proven methods of planning, training, exercising, and testing capabilities / tracking lessons learned from exercises and real world events via an improvement plan. Workforce development efforts will be sustained by reverting to the previous methods of stand alone training courses and development opportunities in management and emergency response skills. Recruitment and retention for the Public Health Reserve Corps will be sustained through outreach to schools and professional organizations, as well as the program's robust slate of trainings, recurring pop up clinics serving vulnerable populations, and real world events and emergency responses.
Colleague in my LHD|E-Mail from NACCHO|NACCHO website