How to start your own free clinic.
Liability is the biggest anxiety for physicians who want to volunteer, but the idea that patients served by clinics sue more than other patients is a myth, said Dr. Nadkarni of the department of internal medicine at the University of Virginia, and founder of the Charlottesville (Va.) Free Clinic.
In a 2003 national survey of 153 free clinics, the National Association of Free Clinics (NAFC) found that patients who visit free clinics sue less often than those of higher socioeconomic status. Of seven claims brought against the clinics surveyed, three were eventually dropped and two are pending. The other two settled for about $67,000, "well below the average payout for settlement," he said.
When establishing a free clinic, mechanisms are available to protect physicians and staff from liability. Many states have extensions of "Good Samaritan" laws that protect emergency personnel. "If you're working at a free clinic, you can gain that sort of coverage," Dr. Nadkarni said.
Most states that offer coverage raise the bar for what someone can sue for, he noted. "Rather than sue for simple negligence, you have to get up to the level of proof of gross negligence, or recklessness, or wanton disregard. So that really stems the possibilities for suits."
Other states let free clinics buy into a state risk pool to get a better deal on malpractice insurance. A few states, such as Kentucky, reimburse free clinics for the cost of their malpractice insurance.
Clinics that don't charge patients can register with the Federal Tort and Claims Act; its defense fund provides malpractice coverage for volunteers. The clinic's board members, as nonphysicians making decisions, also need liability insurance.
Free clinics served 3.5 million patients and received $300 million in donations in 2003, according to the NAFC, which estimates there are at least 800 free clinics nationwide.
Conducting a needs assessment and targeting the area's patient population are some initial steps to establishing a clinic. Physicians should decide what type of model they want, and where it should be located. "You may have a hospital-based, church-based, or freestanding clinic," he said. Then there's the "clinic without walls" model, a clearinghouse that sends patients to participating doctors in the community.
Decide what types of services will be offered, and whether clinic staff will refer to private offices for subspecialty care. Dr. Nadkarni's clinic hired care coordinators to ensure continuity of care, which is something that free clinics always struggle with.
Other services to consider include social work, dentistry, psychiatry, and inpatient care. "You may be able to do it all, or you may only be able to do a small part of it, but decide in advance what you want to do," he said. Otherwise, "you can go down a road where you destroy the clinic if you use up lots of resources you don't have."
Clinics can get funding from government, businesses, churches, or philanthropies. Dr. Nadkarni said his clinic received small grants from the county council and county board of supervisors. Many banks are chartered to give back certain amounts of their capital to local resources. "If you can get on their docket, they generally support lots of local institutions."
If a clinic stays around long enough and grows in size. Dr. Nadkarni suggested hiring other health care providers such as nurse-practitioners and dentists. The clinic may need local grants to help support those extra salaries.
"You really want the community you're serving to have input on this," he said. This means building public-private partnerships and interacting with the health care community. To accommodate patients, "you should make sure the clinic is on bus lines."
Gain publicity by asking local media to make public service announcements. Another approach is to follow local populations. "You can target local restaurants that don't [offer] health insurance to their staff," he said. His clinic took this approach, and contacted major companies in the area that lacked good health insurance plans.
A clinic's board of directors should reflect "work, wisdom, or wealth," to represent a variety of contributory sources, Dr. Nadkarni added.
RELATED ARTICLE: Charlottesville's Free Clinic Has Ties to 150 Physician Volunteers in Community
Dr. Nadkarni's clinic started in 1992 with two residents carrying beepers as the administrative support. A grant made it possible to hire an executive director, he said, "and that made things move along much more quickly."
The Charlottesville (Va.) Free Clinic now sees more than 3,000 visits per year. "We are open three nights per week for clinical work, each night seeing 35 patients," he said. The volunteers include more than 150 primary care physicians and ob.gyns, Residents from the University of Virginia, Charlottesville, also participate.
"We have a special diabetes clinic staffed by endocrinologists and certified diabetes educators and we also provide limited psychiatric services," Dr. Nadkarni said. The clinic makes referrals to community specialists who provide free or discounted care, and has an acute dentistry program, with local dentists volunteering at their own office sites.
Patients qualify for care at the clinic if they're uninsured or do not qualify for free care elsewhere in the community. "We also hook patients up with various Medicaid/FAMIS [Family Access to Medical Insurance Security Plan] programs if they qualify," he said.
The clinic receives donations of laboratories, x-rays, and funds from University of Virginia Health Systems and Martha Jefferson Hospital in Charlottesville. "However, we are a separate, nonprofit entity," he noted.
Regarding liability, Virginia is "very free-clinic friendly," Dr. Nadkarni said. "We have never been sued."
BY JENNIFER SILVERMAN
Associate Editor, Practice Trends