Utilizing Studentrun Clinics to Foster Evaluation and Research

Utilizing Student-run Clinics to Foster Evaluation and Research Wanda Gonsalves, MD, MUSC Richard Usatine, MD, UTHSC Ellen Beck, MD, UCSD Cerrone Cohen, MS 2, MUSC Hallie Neal, MS 2, MUSC Daniel Cobb, MS 2, MUSC

Objectives Ø By the end of this session, participants will be able to: l l Describe the educational format of three student run clinics Describe how three institutions have incorporated research agendas into curricular activities, and how patient outcomes were improved Obtain ideas for research projects at their own institutions Generate activities that may be utilized at their own institutions to foster research

Medical University of South Carolina Wanda Gonsalves, MD Cerrone Cohen, MS 2 Hallie Neal, MS 2 Daniel Cobb, MS 2

Community. Aid. Relief. Education. Support Ø The CARES clinic opened in 2005 providing free primary care to individuals without insurance Ø Over 3 years the clinic has provided care to over 1000 patients Ø The clinic has now expanded from 2 nights/wk to 3 nights/wk and with plans to open a 4 th night at another site

Services Offered at CARES Primary care Ø OB/GYN services, including PAP smears Ø Physical Therapy Ø Psychiatry Ø Imaging services Ø Labs Ø Prescription assistance Ø

How the Clinic Operates Ø Student managed Ø Team teaching between clinical students and 1 st/2 nd year medical students Ø Attending physicians oversee process Ø Inter-professional collaboration between medical, pharmacy, physician assistant and physical therapy students

The CARES Elective Trains students in how the clinic operates and prepares them to step into a leadership role Ø Facilitates training in administrative and management roles of the clinic Ø Provides interdisciplinary approach to learning Ø Offers the opportunity to explore research through continuous quality improvement projects (CQI) Ø

Research at CARES Ø Understanding our patient population l l Ø Innovation and Efficiency l l Ø Patient Demographics Diagnosis and treatment statistics Better allocation of new funds Expansion of services to those in need Following patient outcomes

Early Research: Who CARES Caters To Ø Broad overview of our patient population including: l l Age Gender Patient Location Diagnosis Project by Cerrone Cohen, Jeannie Collins and Payal Patel, MUSC students

Improving Patient Research Project by Amanda Barnhorst, MUSC student

Sample results from a search for the chief complaint of depression

Improving Patient Research Improved patient database Ø research tool developed for improved patient outcomes Ø Better understanding of patient needs Ø Sample graph of diagnosis by patient zip code

Patient Satisfaction Study STUDY: Patient satisfaction survey results 1. 2. 3. 4. 5. 6. 7. Hours/Days of Operation Wait time Friendliness of staff Amount of time with student doctor Amount of time with supervising doctor Lab Services Meds provided (prescriptions or samples)

Patient Satisfaction Study STUDY: Patient Satisfaction survey results and recommendations l l Hours/days of operation and wait time had lower ratings but were satisfactory. Those that answered rated lab services and meds as satisfactory. A bilingual staff member is needed. Some specialty doctors may be needed.

FOCUS Free Outreach Clinics for the underserved in San Antonio Richard P. Usatine, MD FAAFP Professor, Dept. of Family and Community Medicine Faculty advisor, Student-run Clinics University of Texas HSC, San Antonio

Alpha Home & SAMM Student-Run Clinics San Antonio

Alpha Home Residential substance-abuse treatment program for women

Opening day at Alpha Home Clinic January 8, 2005

One exam room at Alpha Home

SAMM Transitional Living and Learning Center for 40 homeless families

Opening day at SAMM Clinic

The Babies We Care for at SAMM

Amy Cantor (student founder) with family at SAMM Clinic

What to Evaluate l Effect on students • Student satisfaction • Student outcomes l l l Change in attitudes, knowledge, behavior Future plans to give back to the community Effect on patients • Patient satisfaction • Health care outcomes l l Change in visits to ER Detecting and treating important conditions

How to evaluate Ø Surveys Ø EHR data Ø Track ER visits Ø Focus groups Ø Individual interviews

Evaluating the effect on the students Ø Survey Monkey for data collection l l Reflections Course evaluations Ø Quantitative and qualitative analysis

Reflections for qualitative analysis (themes from 22 students) What are the most important life lessons you have learned about caring for patients with addictions? Ø The most valuable thing you can provide is your time and understanding. Providing non-judgmental health care is especially important to this group. Sitting and spending time listening to their stories is meaningful for both the patient and the provider. Ø I was struck by the very real possibility that the roles could be reversed. It could be me. It doesn't take much to go down the path of substance abuse. Ø Addiction affects people of all backgrounds Ø There is always hope for recovery from addictions. Ø Health professionals often are the contributors to addiction. Ø Underneath an awful disease is a human being in need of compassion and kindness.

Evaluating the Clinics Patient demographics Ø Current health care needs Ø compared # ER visits before and after moving to SAMM or Alpha home. Ø access to health care before and after moving to SAMM or Alpha Home. Ø patient satisfaction with health care comparing care prior to student-run clinics and with the clinics Ø

Example of Demographics Ø Women at Alpha Home: l l l Mean age 34 years 27 out of 35 were uninsured Mean number of children was 2 Mean number of days sober was 40 21 out of 35 experienced domestic violence

Needs assessment Ø 26 out of 35 needed dental care Ø 3 out of 35 needed immunizations/shots Ø Average duration since last pap smear was 5 – 6 years ago

Patient Satisfaction Ø Clients reported overall satisfaction level with Alpha clinic was excellent in comparison to their last physician visits which were described as good. Ø The average response for the overall visit was “EXCELLENT”.

Health system outcome Ø Total number of ER visits BEFORE SAMM for self was 45 and for children was 98 Ø Total number of ER visits AFTER entering SAMM for self was 6 and children was 27

*Lack of access during the year before coming to Alpha Home or SAMM

Mining data from your EHR

UCSD Student-Run Free Clinic Project Founded in 1997 Three Sites: Community Partners( 2 churches and inner city school) Ø Transdisciplinary Model: Pharmacy, Dental, Acupuncture, Law, Social Work, Mental Health, Primary Care, Specialties Ø 1000 ongoing medical patients, over 5000 medical visits a year, 900 dental, 700 acupuncture patients Ø Students, with supervision, manage all core aspects of the clinic project Ø Ø

Research Guidelines and Teaching Principles Ø Minimize research at the free clinic project, no “guinea pigs” Ø Teach concept of “vulnerable populations” Ø Research that serves the community that the free clinic project serves and/or improves the quality of service we provide

Microcosm of Health Care System/Institution Outcomes Measurement: QWB Ø Clinical Database Ø Chronic Disease Model Quality Indicators Ø Cost-savings Ø Patient Satisfaction Ø Error Reduction Ø Quality Assurance Models Ø

Medical Education Studies Ø Long term impact of experiences at the free clinic project on: Ø Career choice Ø Transdisciplinary practice Ø Humanistic Attitudes Ø Teaching Skills Ø Work with the underserved Ø Policy Attitudes

Clinical studies Free Clinic Project Faculty and student committee to decide what studies are appropriate and why Does the study serve the population? What are the burden/benefits to the clinic? E. g. Additional staff needed, waiting time, patient fears Examples: Pulmonary specialist looking for people of color for his clinical study but not interested in contributing time or services or coming to the clinic to build patient relationships NO GI/Hepatitis specialist who volunteers at free clinic arranges for Hepatitis C patients to receive treatment by joining his VA clinical study YES

Independent Study Projects Students at UCSD have to complete an extensive Independent Study Project which may be: Ø bench or community based research, or Ø community service or educational project with evaluation. Ø 25 related to free clinic project since 1999, frequent prize-winners, Stokes award for community based research project Ø Examples: Ø

Ø 2000 Orientation to and Participation in a Student Run Free Clinic: Effect on Medical Students' Attitudes Regarding the Medically Underserved

2004 Quality of Wellbeing Scale use 2007 Systematizing QWB-SA Use and Score Analysis at the UCSD Student-Run Free Clinic Project Ø Ø Ø Ø Validated outcomes measure to measure change over time in continuity patients at the UCSD Student-Run Free Clinic Project Patients sign a consent form to participate, not required to attend the clinic Are followed at regular intervals over the year in English and Spanish Increase in all sites in QWB SA score but not yet significant Increase in score greatest in families and working adults ineligible for access to care, and smaller increase in patients who are street homeless Challenges in data collection and quality Two abstracts have been presented and published though the International Society of Quality of Life Research

Hypertension Flowchart and Registry Ø Ø Ø Ø UCSD Student-Run Free Clinic Hypertension Management Log and Lab Schedule Patient ID: ___________ Patient Name: ______________ Birthdate: ___________ Age: ____ Date of Hypertension Dx: __________ Classification of BP Category SBP mm. Hg DBP mm. Hg Normal<120 and <80 Prehypertension 120 -139 or 80 -89 Hypertension, Stage 1140 -159 or 90 -99 Hypertension, Stage 2 160 or 100 Hypertensive Urgency>220 or >125 without symptoms. Hypertensive Emergency>220 or >125 WITH symptoms* *symptoms include: headache, irritability, confusion, altered mental status, hematuria, proteinuria, progressive renal dysfunction, intracranial hemorrhagem aortic dissection, preeclampsia-eclampsia, pulmonary edema, unstable angina, or MI. Medications: ___________________________________ Date prescribed: ___________________________________________________ Date prescribed: _________________ Laboratory Exams: Basic Metabolic Panel (including Na+, K+, Cr)Diuretic&Aldo. Ant: BMP; ACE-I/ARB: Cr; BB&CCB: N/ADate of BMP: Na+ result. K+ result. Cr result. Other results 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Co-morbidities: Cardiac: __________________________ when Dx: ____________ Eyes: ___________________________ when Dx: ____________ Renal: ___________________________ when Dx: ____________ Nervous

Identifying and Addressing Barriers to Healthy Families Registration In the Baker Free Clinic Patient Population: The Barriers Underserved Latino Families Face When Trying to Access Healthcare for Their Children

In depth interviews with 22/25 parents/grandparents at the Baker Site of the UCSD Student-Run Free Clinic Project Eighty-seven percent (19/22) reported that people in their community are scared of trying to get health insurance for their children/grandchildren, with 82% (18/22) citing fear of INS investigation and 73% (16/22) citing fear of risking citizenship status. After hearing a description of Healthy Families, 59% (13/22) of participants were interested in trying to enroll their children/grandchildren in Healthy Families.

Folic Acid Education

Current Directions Ø Long term follow-up study for students Ø Database and flowcharts, continued analysis and link with outcomes Ø Providing dental care for uninsured patients with diabetes-impact on diabetes and cardiovascular health Ø Toothlessness leads to joblessness

Learnings Vulnerable Populations True consent Opportunity to dispel stereotypes through research Opportunity to contribute to policy discussions Do research that is useful and has a minimal burden Research to aid Practice Management Explore educational outcomes Thinking about issues of quality of life, outcomes, data, safety, health promotion, best practices, ethical issues, Ø How does a clinical practice become involved in research, what are the ethical standards and appropriate criteria Ø Ø Ø Ø