A Free Clinic Can Make a Difference

Free clinics provide free, high quality, empowering health care to people who do not qualify for and/or cannot afford any form of health insurance. At the same time, they train the next generation of health professionals to provide humanistic, transdisciplinary, empowering health care to underserved individuals.

In our own clinic, we practice and implement a comprehensive empowerment model that encourages people to achieve and maintain employment, addresses social or economic barriers to health, and provides comprehensive high quality healthcare.

Health-professional volunteers and donated or low-cost services make it possible to serve 2,000 patients per year, for 1,000 of whom we provide comprehensive medical care (including medications, labs, etc.) at a cost of $1000 per patient. Our healthcare outcomes are similar or better than the VA, known for its quality.

Although we were not the first student-run free clinic, because of the needs of our community and the passion among our students, and the support of our institution, we are one of the largest student-run free clinics in the country. We train faculty, students, and teams from around the country. Our clinic model has been recognized nationally, has been replicated in more than 15 communities across the U.S., and has won awards both for service and innovation.

The purpose of this page is to help others start, maintain, troubleshoot, and grow free clinics of their own. Click on the subjects below to learn more. Please feel free to contact us if you need additional help setting up your own free clinic project. Below, we outline How to Start and Strengthen a Free Clinic and How to Set Up a Patient Assistance Free Medication Program. In addition, you can find relevant, useful forms and files, such as our consent forms, in our Useful Files & Forms folder.

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1. Student Recruitment

Identify a core group of interested students.

2. Faculty Recruitment

Identify a faculty advisor/champion who will help to build credibility and support from your institution and help to ensure adequate clinical supervision for all activities.

3. Find a community partner...

Find a community partner who is already serving the underserved in a community setting - e.g. school, church, neighborhood program, meal program. Meet with the partner and begin to establish a trusted relationship. From the beginning, help your fellow health professional students and team understand that we, as health professionals, are guests in the community partner's setting. Thus, if something is needed, whether an electrical outlet, or a copy machine, or keys to a certain door, that we are in this long term partnership together and the elements of trust and mutual respect are essential to a successful long-term project.

4. Establish a legal relationship with the university...

Establish a legal relationship between the university and the site so that for the purpose of health professional education, the site becomes an extension of the university. Complete a memorandum of understanding and/or affiliation agreement. This may take several months and will involve the legal/contracting team from both partners. The legal contracting team at your university will know how to set these up. Your faculty champion can help you with this step.

5. Identify what permits you will need...

Identify what permits you will need for certain activities and arrange for County or state permits as needed including environmental waste hauling (how you will get rid of your medical waste), CLIA waiver (so you can do simple on-site labs), and others, e.g. a permit to use an x-ray unit for dental services, etc.

6. Contact local preceptors, community faculty, and faculty...

Contact local preceptors, community faculty, and faculty if they would be willing to volunteer (from once a month to once every 3 months), in addition to the core faculty advisor(s). It is important to establish liability and malpractice coverage for all aspects of your free clinic project. Community physicians who would like to volunteer will be appointed as community/voluntary faculty at your health professions school. Refer to Item 4.

7. Establish your risk management plan...

Establish your risk management plan. You'll need to ensure that all your health professional student and community volunteers have a legal status at your program. Thus, if a medical student is enrolled, they will be covered because they are supervised by a member of faculty and there is an affiliation agreement in place. If you have a community member who would like to volunteer their services, they can sign up as a free clinic project volunteer and complete your paperwork for volunteering, you never want to burden your community partner. Ensuring that liability structures are established is key. It may feel onerous, but in the long run, there is a feeling of safety and both community partner and institutional trust that is established because it is recognized that these structures are in place. See steps 4, 5, and 6.

8. Start small...

Start small, perhaps one evening a week at a local community program.

9. Arrange for elective credit...

If possible, arrange for elective credit for the medical/health professional students. At UCSD, first and second year medical students who want to work in the free clinic must take a required elective course, Community Advocacy, which introduces them to the free clinic project, and includes philosophy, approach, skills, and opportunities for reflection as well as their first clinical experiences. Students who continue to be involved receive further elective credit. Fourth year medical students can complete a clerkship in underserved or family medicine that gives them extensive experience at the free clinic project and, with supervision, the opportunity to learn to be clinical coaches/teachers to the first and second years.

10. Consider how to get labs, medications, and tests...

Consider how to get labs, medications, and tests. Initial basic supplies can usually be donated from a local practice, or the faculty practice. Pharmaceuticals initially can be donated, and also one can use the Patient Assistance Programs which provide free prescription medications for specific patients. The $4 programs at many stores, such as Target, can also be used. Beginning to provide medications this way requires no additional input of funds. Soon, develop a basic formulary using generics, and a mechanism to use the Patient Assistance Programs, and a wish list formulary for samples and purchased medications, so that patients are not being constantly switched from medicine to medicine. Approach your university, local labs, purchasing cooperatives such as Council Connections, and other resources to achieve affordable lab services. Medical specialty clinics can be developed as well by involving medical students as specialty managers and specialist faculty as attendings.

11. Plan to write grants and fundraise...

Plan to write grants and fundraise. Develop a basic budget. Faculty may consider writing a HRSA medical student education grant to fund some faculty teaching time, especially for program supervision. AAMC grants for student community service grants, and other small grants can also be written. Local foundations may be interested in your project. Over time, approach your university for core infrastructure funding as foundations prefer to match core funding.

12. Empower your students...

Empower your students, encouraging them, with guidance and supervision, to develop patient charts, history forms, data collection methods, an intake system, environmental waste permits, lab arrangements, social resource consultations, health education, fund-raising..."whatever it takes" to provide excellent, high quality care.

13. Allow some of these questions to surface over time...

Allow some of these questions to surface over time, as the clinic evolves, questions and issues will emerge, that the students will then address, e.g. patient flow, quality assurance. Develop a mechanism to follow up during the week, to check lab results, etc. It is essential to have patient contact information for each patient, even it is the street corner where a patient usually sleeps, and/or their best friend's cell phone. Explain to patients that labs can only be drawn, if you have a way to find them if needed. Reinforce the approach that high quality care, one patient at a time, is the most important role you can play. Given that the need in the nation is almost infinite, student-run free clinic projects cannot address this larger need. But, one patient at a time, you can provide safe, legal, high quality thorough integrated health care.

14. Develop a mission statement and a clinic philosophy...

Develop a mission statement and a clinic philosophy, that is reinforced and adhered to, e.g. our approach includes showing respect to all patients, taking time with them and establishing trust, so over time, some of their deeper problems and issues can be addressed. Always show respect to all patients, colleagues, fellow students, custodians. Our philosophy consists of four tenets: Empowerment, a Humanistic approach, a Transdisciplinary Model, and the Community as Teacher.

15. Patient Visits and Clinic Flow

In our program, patients are seen by a pair of medical students, preclinical and clinical. Other students, including pharmacy students, social work interns, acupuncture students, and interpreters may also participate; the clinical student acts as the coach. The students then present to the attending and the attending comes to see the patient, then the chart is written and signed off by both students and the attending. All patient care must be directly supervised by clinical attendings.

16. Develop strong social resource and case-management activities...

Develop strong social resource and case management activities at the clinic so that those patients who are eligible for access through Medi-Cal, Medicare, Medicaid, County Programs, or SCHIP/Healthy Families are assisted with access and are able to have a medical home. Develop an approach that integrates assessment for the Social Determinants of Health (SDH) into your history, essentially evolving the Social history into a Social Determinants of Health history. Encourage and reinforce thorough social histories and treatment/intervention Plans that include addressing the SDH. In our setting, all patients who are eligible for government supported programs are referred for care. Free clinic projects should serve people who are not eligible for any access or who are unable to achieve access, thus, those "who fall through the cracks". Your program can become part of the "safety net" for the safety net.

17. Develop mechanisms to follow outcomes...

Develop mechanisms to follow outcomes. A clinical database and/or Electronic Health Record can be developed to measure patient outcomes and compile patient statistics. The Quality of Well Being Scale is used to measure outcomes. Other measures are the SF-12, SF-36, SF-1, and the PHQ-9 (which is used for depression).

18. In the summer...

In the summer, students can also volunteer and receive credit and, with funding, several students can be hired to help build the infrastructure of the clinic. These students can work on improving the clinic infrastructure, look at the clinic as a whole, brainstorm its current needs, then set goals, assign tasks, and meet weekly to review objectives and achievements.

19. Students may do community projects and occasional research projects...

Students may do community projects and occasional research projects. One must be careful of research in a free clinic setting- patients are very grateful and are a "vulnerable population". Also, trust building is very important. If your clinic is seen too much as all about research, it may be hard to build trust. Nonetheless, research which helps to address the needs of the community and the clinic, and uses a Community Oriented Primary Care Research model, which involves the community at ALL steps.

20. As each site grows and becomes stronger...

As each site grows and becomes stronger, new sites are developed or new resources at existing sites are developed. Overall, growing deeper and stronger in terms of quality at one site is more important than developing many sites.

21. Reach out to other professions...

Reach out to other professions, lawyers, pharmacists, social workers, acupuncturists, nurses, dentists, and other integrative health professionals to develop collaborations to create a transdisicplinary model to address patient needs. Eventually, pharmacy faculty and students, dental faculty and students, social work faculty and students, law school faculty and students, acupuncture faculty and students, nursing faculty and students, and others, all will work side by side with the patient at the center.

22. Involve community members as much as you can...

Involve community members as much as you can, roles include liaison, outreach, promotoras, teachers for the students. Have the student see the community as their teacher and learn from community members how best to address concerns or take the next step. Consider starting empowerment groups for the patients/clients, and involve them in creating and receiving health education and health maintenance activities. The concept of the promotora, the wise woman (person) from the community, who helps build trust to the community and brings wisdom from the community is key to the success of these projects.

23. Maintain very high professional standards, confidentiality, quality of care, and safety...

Maintain very high professional standards, confidentiality, quality of care, and safety, not "poverty" or "half-care" because it's the "free clinic". As a society, we are underserving this population, thus inherent in the term underserved is a "right to health care".

24. Avoid hierarchical structures among the student leaders...

Avoid hierarchical structures among the student leaders. Everyone has a leadership role; everyone works both administratively and clinically, expect a high level of maturity, responsibility, and ownership and most of all, humility. No task is too small. The clinic leaders are the ones who also take out the garbage.

25. Practice regular reflection activities

Practice regular reflection activities, "learning circles", build community among everyone at the sites, learn from our mistakes, follow up, and model respectful communication, empathy, congruence, and positive regard. Practice thoroughness, conscientiousness, and compassion.

1. Overview

Use of Patient Assistance Programs must be part of your overall Pharmacy Plan.

This plan should take into account how you will provide or help provide medications for all your patients-you have to think about their acute medication needs, their chronic medication needs, education about their meds, continuity, follow up, and tracking.

2. Acute vs. Chronic Meds

Patient Assistance Programs work best for chronic meds, since it takes two-three weeks once all the paperwork is completed, for the medications to arrive. Thus, for acute infections, e.g. antibiotics for infections, other methods, either Government 340 B pricing, a purchased general formulary that your clinic dispenses, or an arrangement with the $4 generic programs, such as the Costco, Walmart or Target program must be set up.

3. Pharmaceutical Patient Assistance Program Volunteer Team

This team of volunteers is charge of ordering medications for clinic patients from pharmaceutical patient assistance programs offered by various companies. Each program has different forms, and different rules. Follow the rules carefully, and make sure that all forms are filled out completely. All of these volunteers must have completed HIPAA training as well as full training in the different aspects of the program.

4. New Patients

When a new individual requiring medications offered through the PAP program joins the clinic, the following information must be gathered: patient's full name, date of birth, social security number (if any), phone number, address, residency status, citizenship status, gender, insurance info (if any), household size, number of dependents in household, household income, tax information (if any), employment status, and financial documentation (if any). If one or more of the requirements are not met, a supplemental letter may be substituted in its place. This will be discussed in more detail later. Many pharmaceutical companies require financial documentation beyond the “low-income letter” (discussed later), so ask the patient to bring copies of pay stubs, bank statements, or an employer letter stating amount paid in cash if applicable. This information must be kept confidential. The material listed above is necessary in order to order medications from the pharmaceutical companies and must be explained to the patient in this way, that you are not trying to intrude, but that in order to apply for these medications, you need this information. You can also ask the MD, pharmacist, or health promoter who already knows the patient to help with explaining why you are asking these questions and to be a “trust bridge” to the patient. The process is described below.

5. Patient Assistance Program Steps at the Free Clinic Project

The clinic physician attending or medical student with MD supervision “checks in” with the PAP team and requests a specific medication. At this time the PAP representative will check whether that medication or similar medications will be ordered based on which medications are available based on patient eligibility and available equivalent medications. It is possible that clinic patients will not qualify for patient assistance at all or may not receive all their medications from patient assistance programs. Drugs that cannot be obtained from patient assistance, such as generic drugs, vitamins and supplements, can oftentimes be ordered through the clinic pharmacy that supplies many generic drugs (but entails a cost to the clinic). Other possibilities include the low-cost Walmart, CVS, generic drug programs where medications may be $4 a person per med. We have established a contract with Target to occasionally purchase low cost meds for our patients.

If a doctor or student with MD supervision submits a medication order request, the PAP representative must fill out a patient application and include the drug order, doctor's DEA number, clinic address, patient signature, and any additional information.

6. Where to Find Application Forms Online

The application forms can be found online through the pharmaceutical companies' websites and then navigating to their patient assistance page. Instructions specific to each company can be found on this page (e.g. Is the social security number required or is a clinic letter acceptable; does a prescription need to be included; what financial documentation is acceptable?) Several application forms can be printed out at one time and saved as hard copies at the clinic.

7. Specific Company Examples and Links

GSK: For example, for Glaxo Smith Kline, the webpage is called GSK For You, and the link is the following:
http://www.gskforyou.com/patient-assistance-programs/drugslist.html

From GSK, many medications such as Advair, Bactroban cream, Coreg, Imitrex and Ventolin may be available for your patients.

MERCK: The link for Merck patient assistance program is as follows:
http://www.merck.com/merckhelps/patientassistance/

Merck also has a program for ordering adult vaccines in which vaccines must be purchased in advance and then Merck will reimburse the vaccine cost for qualifying patients.
http://www.merck.com/merckhelps/vaccines/home.html

PFIZER: The link for Pfizer Patient Assistance Programs is
http://www.phahelps.com/pages/Find/FindAll.aspx

To find other companies, simply Google the name of the pharmaceutical company and the words "Patient Assistance".

8. Additional Information Needed/Explanatory Letters

To reiterate, each program has different forms, and different rules. Follow the rules carefully, and make sure that all forms are filled out completely. If there is no or limited information for a particular answer, you can add an explanatory letter, as described above, or fill in true responses (as suggested below) but don't leave blank spaces.

As stated above, in addition to filling out the application and the drug order form, other information is oftentimes required by the pharmaceutical company, such as proof of income, social security number, etc. Low-income and/or no-social-security-number letters can sometimes be used in lieu of such documents. The clinic's PAP personnel draft these letters and state”the patient's information has been verified and they qualify for the company's program.” They might also include a sentence such as “However, the patient cannot provide “proof of income because they are paid in cash or due to an unusual circumstance.” It is essential to include as much of the required information as possible to prevent the application from being rejected and mailed back.

9. Physician Signature

Once the applications are filled out they are given to the clinic doctor to sign and authorize.

10. Administrative Office Volunteer Procedures

Once the physician has signed the application and if necessary, has included a signed prescription, the completed forms are sent to the clinic administrative office to be mailed out. A record is kept of all applications and their date, and a copy of the application is kept at the office. Follow up of these applications is important. After a designated period of time, approximately three=four weeks, if no response has been received from the company, the PAP office volunteer will follow up with the company to make sure that the application has been received and is being processed.

11. Pharmaceutical Company Replies

If an application is reviewed and approved by the company, the company mails an acceptance letter with the patient's identification number and medication. While a patient is enrolled in the company, refills can be oftentimes ordered online or by phone. The enrollment period lasts between six months and one year at which time the patient will need to be reenrolled. However, if an application is rejected, due to missing information or signatures, it will be sent back to the clinic and the drug order will not be processed by the pharmaceutical company. If the pharmaceutical company calls back, or sends a letter that there is missing information, the PAP volunteers at the administrative office call back to the pharmaceutical companies and/or complete the additional information required and resubmit the information.

The process described above is the general procedure for enrolling patients in pharmaceutical company patient assistance programs and ordering medications. However, there are sometimes special or unusual cases that prevent the application from being filled normally. Such cases are when a patient is homeless, paid in cash, does not work regularly (cash gigs), or really needs a medication offered by a company but does not qualify for their program. These applications must have an original letter addressing the situation and any alternative information that the company may be able to accept in lieu of the required documents.

12. Dispensing Medications

We have chosen to have the meds delivered to the admin office and distributed to the clinics where they are dispensed to the patients. This allows to follow the patients, and that the patient comes for med refill visits when we can check BP, diabetes symptoms, LDL, liver enzymes etc. Having to come to us for their medications, we believe, has helped with our ability to help patients achieve excellent clinical outcomes. The other option is for the meds to be delivered directly to the patient's home, usually a three month supply. We have not chosen this approach for the reasons mentioned above. Dispensing the meds at the clinic allows for thorough patient education including teach back re their meds, to do our best to ensure patient safety and reduce patient error.

13. Conclusion

Every patient is important and it is the duty of the clinic PAP representatives to do everything possible to provide for the patient medication requirements. Qualifications include courtesy, respect, thoroughness, attention to detail, and language skills, and commitment to follow up.

When we first began using the Patient Assistance Programs, it was very challenging. It took a long time, many forms would be returned, and follow up would not always occur. Now we have a cadre of volunteers at each site and at our admin office, committed to this program and willing to follow all the steps. Now, we receive more than 1.7 million dollars a year in Patient Assistance Meds. We wish you luck and are happy to help you make this work.