Evaluation of patient health outcomes of a student-run free clinic in East Harlem.

BACKGROUND: Most United States medical schools have affiliated student-run free clinics, but the quality of services provided in such contexts compared to national metrics is unknown. This study determines whether a student-run, attending-supervised free clinic servicing a low-income and minority race patient population in New York City can meet national metrics of care. METHODS: Through chart review from January 1, 2020 to December 31, 2020, patient outcomes and service utilization in the Healthcare Effectiveness Data and Information Set were examined and compared to national rates of patients using Medicaid HMO or Medicare. Patients are ≥ 21 years of age, residents of East Harlem, and ineligible for health insurance because of legal residency requirements. The majority identify as Hispanic and speak Spanish as their primary language. All patients who were seen in the clinic during the 2020 calendar year were included. The primary study outcome is the number of Healthcare Effectiveness Data and Information Set measures in which patients, seen in a student-run free clinic, meet or exceed national comparisons. RESULTS: The healthcare outcomes of 238 patients, mean age 47.8 years and 54.6% female, were examined in 18 Healthcare Effectiveness Data and Information Set measures. The student-run free clinic met or exceeded national metrics in 16 out of 18 categories. CONCLUSIONS: The student-run free clinic met or exceeded the national standard of care according to national metrics. Evidence-based priorities have been clarified for future improvement. Other student-run free clinics should similarly evaluate the quality of their services.

How Are We Doing? A Scoping Review of Published Patient-Centered Outcomes Research in United States Student-Run Free Clinics.

Phenomenon: Student-run free clinics (SRFCs) serve an integral role in most United States (US) medical schools and contribute substantially to literature on the quality of care to uninsured persons. There has been substantial growth over the past decade of scholarly work produced by SRFCs as they have increased in size and number. Research on patient care outcomes informs better care structures for patients, however there is no current synthesis of patient care outcomes research among SRFCs. This article provides an overview of SRFC research on patient outcomes to understand current research domains and to identify gaps in the literature. Approach: We completed a scoping review by searching Scopus, PubMed, and Journal of Student Run Clinics in June 2021. All peer-reviewed, English-language articles focused on patient-centered outcomes at SRFCs in the US were included. Two independent reviewers performed title, abstract, and full-text screening of relevant works, and eight reviewers conducted data extraction. Descriptive data analysis was performed along with relevant content analysis of patient-centered outcomes. Findings: The search strategy identified 784 studies, of which 87 met inclusion criteria. Most studies were published within the last six years (81.6%), located in California, New York, or Florida (43.7%), and intervention based (33.3%). Many studies (46.0%) had a specific disease of focus of which diabetes was the most researched(19.5%). Patient-centered studies were the leading focus of the study aims (40.2%), where key findings demonstrated primarily improved outcomes in clinic metrics post-intervention (36.8%) or equivalent/better clinical performance than national metrics (20.7%). Insights: This review brings to light gaps in the literature reporting research in SRFCs and can be applied to other low-resource settings. Future efforts to expand SRFC outcomes research should focus on community relationship building, understanding institutional support, and ensuring education on best practices for research within SRFCs. Doing so informs patient care improvement as SRFCs continue to operate as safety net clinics for marginalized populations.

Design of and outcomes in a student-run free mental health clinic serving the uninsured in East Harlem.

BACKGROUND: Safety-net clinics are an important source of low-cost or free mental healthcare to those with limited financial resources. Such clinics are often staffed by trainees in early stages of their career. Only limited data exist on best practices in treatment-implementation and on clinical outcomes attained in such clinics. The primary purpose of this article is to describe the design of an outpatient psychiatry student-run free clinic (SRFC) serving uninsured individuals in New York City's East Harlem neighborhood and to analyze the quality of services provided and the clinical outcomes attained. METHODS: The authors conducted a retrospective chart review of n = 69 patients treated in the EHHOP Mental Health Clinic (E-MHC) to describe the demographic and clinical characteristics of the study population. Utilizing Health Effectiveness Data and Information Set metrics, they estimated the likelihoods of patients meeting metric quality criteria compared to those in other New York State (NYS) insurance groups. The authors derived linear mixed effect and logistic regression models to ascertain factors associated with clinical outcomes. Finally, the authors collected patient feedback on the clinical services received using a customized survey. RESULTS: Almost all patients were of Hispanic ethnicity, and about half of patients had more than one psychiatric disorder. The clinical service performance of the E-MHC was non-inferior on most measures examined. Factors associated with symptom improvement were the number of treatment sessions and certain demographic and clinical variables. Patients provided highly positive feedback on the mental healthcare services they received. CONCLUSIONS: SRFCs can provide quality care to vulnerable patients that leads to clinically meaningful reductions in psychiatric symptoms and is well-received by patients.

Ophthalmology Services at Student-Run Free Clinics: A National Survey.

IMPORTANCE: Student-run free clinics (SRFCs) primarily service the uninsured and are a unique way for medical students to gain hands-on exposure to ophthalmology. The free clinic model takes many different forms- some with episodic and longitudinal models-- and this is mirrored in corresponding eye services. OBJECTIVE: To describe SRFC ophthalmology services nationwide. DESIGN: This was a telephone survey study administered from June through July of 2018. SETTING: This study surveyed medical school SRFC clinics across the United States. PARTICIPANTS: Survey request was sent to 19 SRFCs previously identified as having ophthalmology services via internet search. Fourteen SRFCs (73%) participated; participants were either student clinic leaders or medical directors. One respondent no longer had a distinct eye clinic so was excluded from relevant results. MAIN OUTCOME AND MEASURE: Characteristics of ophthalmology SRFCs including participants, frequency of sessions, common diagnoses treated, and challenges encountered were assessed through this survey. RESULTS: On average, each SRFC provided 5.15 hours per month of ophthalmology services. The mean number of medical students involved per session was 8.7. Lack of infrastructure to ensure adequate patient follow-up and faculty recruiting were cited as the main challenges in providing ophthalmology services. Most SRFC leaders indicated exposure to ophthalmology and practice with the exam as the main experiences that students sought and achieved. The most common conditions treated were refractive error (92.3%) and diabetic retinopathy (69.2%). CONCLUSION: There are a small number of SRFCs that have ophthalmology services, and they share common features in terms of participants, staffing, and, barriers to sustainability. Ophthalmology services at SRFCs offer a unique venue for medical students to gain exposure to an under-represented field in medical school curricula. The growth of this critical venue for medical student training could be enhanced by recruitment strategies aimed at ophthalmology faculty with a strong interest in service and teaching.

On-Site Prescription Dispensing Improves Antidepressant Adherence among Uninsured Depressed Patients.

The successful treatment of depressive disorders critically depends on adherence to prescribed treatment regimens. Despite increasing rates of antidepressant medication prescription, adherence to the full treatment course remains poor. Rates of antidepressant non-adherence are higher for uninsured patients and members of some marginalized racial and ethnic communities due to factors such as inequities in healthcare and access to insurance. Among patients treated in a free, student-run and faculty-supervised clinic serving uninsured patients in a majority Hispanic community in East Harlem, adherence rates are lower than those observed in patients with private or public New York State health insurance coverage. A prior study of adherence in these patients revealed that difficulty in obtaining medications from an off-site hospital pharmacy was a leading factor that patients cited for non-adherence. To alleviate this barrier to obtaining prescriptions, we tested the effectiveness of on-site, in-clinic medication dispensing for improving antidepressant medication adherence rates among uninsured patients. We found that dispensing medications directly to patients in clinic was associated with increased visits at which patients self-reported proper adherence and increased overall adherence rates. Furthermore, we found evidence that higher rates of antidepressant medication adherence were associated with more favorable treatment outcomes. All patients interviewed reported increased satisfaction with on-site dispensing. Overall, this study provides promising evidence that on-site antidepressant dispensing in a resource-limited setting improves medication adherence rates and leads to more favorable treatment outcomes with enhanced patient satisfaction.

Exploring Antidepressant Adherence at a Student-Run Free Mental Health Clinic.

Minority groups experience higher depression but lower treatment rates. Student-run free mental health (MH) clinics, such as the East Harlem Health Outreach Partnership (EHHOP) MH clinic, address this disparity. This study scrutinized EHHOP MH's depression treatment by measuring adherence to antidepressants. Pharmacy data from seventy-nine patients were reviewed according to HEDIS criteria. Results compare EHHOP MH to New York State (NYS) Medicaid and NYS commercial insurance providers. In the acute treatment phase, EHHOP MH performed similarly to NYS Medicaid. In all other comparisons, EHHOP MH had lower adherence rates. Physician notes were reviewed to identify reasons for low adherence.

Using Nurse Practitioner Co-Management to Reduce Hospitalizations and Readmissions Within a Home-Based Primary Care Program.

Nurse practitioner (NP) co-management involves an NP and physician sharing responsibility for the care of a patient. This study evaluates the impact of NP co-management for clinically complex patients in a home-based primary care program on hospitalizations, 30-day hospital readmissions, and provider satisfaction. We compared preenrollment and postenrollment hospitalization and 30-day readmission rates of home-bound patients active in the Nurse Practitioner Co-Management Program within the Mount Sinai Visiting Doctors Program (MSVD) (n = 87) between January 1, 2012, and July 1, 2013. Data were collected from electronic medical records. An anonymous online survey was administered to all physicians active in the MSVD in July 2013 (n = 13).After enrollment in co-management, patients have lower annual hospitalization rates (1.26 vs. 2.27, p = .005) and fewer patients have 30-day readmissions (5.8% vs. 17.2%, p = .004). Eight of 13 physicians feel "much" or "somewhat" less burned out by their work after implementation of co-management. The high level of provider satisfaction and reductions in annual hospitalization and readmission rates among high-risk home-bound patients associated with NP co-management may yield not only benefits for patients, caregivers, and providers but also cost savings for institutions.

Interpreter training for medical students: pilot implementation and assessment in a student-run clinic.

BACKGROUND: Trained medical interpreters are instrumental to patient satisfaction and quality of care. They are especially important in student-run clinics, where many patients have limited English proficiency. Because student-run clinics have ties to their medical schools, they have access to bilingual students who may volunteer to interpret, but are not necessarily formally trained. METHODS: To study the feasibility and efficacy of leveraging medical student volunteers to improve interpretation services, we performed a pilot study at the student-run clinic at the Icahn School of Medicine at Mount Sinai. In each fall semester in 2012-2015, we implemented a 6-h course providing didactic and interactive training on medical Spanish interpreting techniques and language skills to bilingual students. We then assessed the impact of the course on interpreter abilities. RESULTS: Participants' comfort levels, understanding of their roles, and understanding of terminology significantly increased after the course (p < 0.05), and these gains remained several months later (p < 0.05) and were repeated in an independent cohort. Patients and student clinicians also rated participants highly (averages above 4.5 out of 5) on these measures in real clinical encounters. CONCLUSIONS: These findings suggest that a formal interpreter training course tailored for medical students in the setting of a student-run clinic is feasible and effective. This program for training qualified student interpreters can serve as a model for other settings where medical students serve as interpreters.

A user-editable web-based platform to streamline clinical information flow.

Frequent turnover of staff in medical clinics creates challenges in the maintenance of clinical protocols, workflows, and information management. Care coordination between providers in such a setting can be complex; disruptions in communication may lead to poorer health outcomes and patient satisfaction. Furthermore, protocols change frequently in response to new guidelines, which demands rapid updates to maintain compliance. To address these challenges, we developed an intuitive, end-user editable web-based knowledge management system optimized for use on mobile devices. The resulting system served as a point of care information storage and retrieval tool that providers can reference quickly for operational tasks. Since launch, the platform has allowed our clinic to consolidate knowledge banks, standardize staff training, and streamline information flow during clinic, and is now used extensively by clinic staff. During a one-year period, 175 new pages have been created and 1686 edits have been submitted by users. We posit that a mobile platform for clinical information flow management has significant potential to improve information maintenance and facilitate transfer of up-to-date clinical protocols to new personnel.

Quality of mental health care at a student-run clinic: care for the uninsured exceeds that of publicly and privately insured populations.

Diagnosing and treating depression in a primary care practice is an important, yet difficult task, especially for safety-net practices serving the uninsured. In the United States healthcare system, there is a mismatch between the need for mental health care and access to services. This disparity is most striking among the uninsured. Mental health disorders are more prevalent among the uninsured, and even when diagnosed with mental illness, they are less likely to obtain necessary treatment than insured patients. Given the increasing burden of depression on society, growing numbers of uninsured and negative repercussions of untreated mental illness, improvements in screening and management protocols are becoming more important in primary care practices serving this population. The quality of depression treatment at commercial and public insurance plans in New York City (NYC) and New York State (NYS) were compared to that of the East Harlem Health Outreach Partnership (EHHOP), the student-run clinic of the Mount Sinai School of Medicine. Based on the comparison, the study made recommendations for an integrated, on-site mental health service program at the community health clinic. A cohort of 49 depressed patients were evaluated and treated at the EHHOP clinic. The quality of the mental health care was evaluated according to variables from the Healthcare Effectiveness Data and Information Set (HEDIS). Indicators of quality included demographics, method of diagnosis, type of pharmacological treatment, referral to specialty care, patient adherence to follow-up care and adherence to pharmacologic treatment. When compared to insured patients in NYS, more EHHOP patients had the appropriate number of physician contacts after being diagnosed with depression than patients with commercial health plans (P = 0.008) and Medicaid (P = 0.09). Similarly, a greater number of EHHOP patients had better acute phase (P = 0.001; P = 0.096) and continuous phase (P = 0.049; P = 0.88) pharmacologic treatment than patients with commercial health plans and Medicaid, respectively. EHHOP meets and, in some areas, exceeds the quality of depression treatment when compared to insured populations. Even though EHHOP already surpasses these indicators, the clinic can improve its diagnostic capabilities, prescription medication adherence, and referral care follow-through by creating an on-site mental health clinic.

Student-run health clinic: novel arena to educate medical students on systems-based practice.

In recent decades, the United States has experienced substantial growth in the number of student-run clinics for the indigent. Today, over 49 medical schools across the country operate over 110 student-run outreach clinics that provide primary care services to the poor and uninsured. Despite this development, little research has been published on the educational value of such student-led endeavors. Although much has been surmised, no general methodology for categorizing the learning experience in these clinics has been established. This article represents the first literature review of the novel method of educating students through the operation of a clinic for the underserved. It highlights the student-run clinic as a unique enhancement of medical education that may supplant current curricular arenas in teaching students about systems-based practice principles such as cost containment and financing, resource allocation, interdisciplinary collaboration, patient advocacy, and monitoring and delivery of quality care. The novelty of the student-run clinic is that students place themselves at the forefront of problem solving and system navigation to effectively care for severely disadvantaged populations. This article underscores the student-run clinic as a potentially ideal experiential learning method for preparing young physicians to confront a US healthcare system currently facing crises in cost, quality of care, and high rates of uninsurance. The article stresses the need for outcomes research on the long-term effectiveness of the student-run clinic experience in affecting medical student practice behaviors and attitudes in patient care settings that extend beyond the student-run clinic.

Quality of diabetes care at a student-run free clinic.

Student-run clinics are emerging safety-net practices for the uninsured; despite the over 110 clinics that currently operate across the United States, however, no data exist on the quality of care being delivered at such sites. The East Harlem Health Outreach Partnership (EHHOP) of the Mount Sinai School of Medicine in New York is a medical student-run, attending-supervised free clinic that offers primary care to the uninsured of surrounding East Harlem. The aim of this study was to evaluate diabetes care quality at the EHHOP clinic. Diabetes management was assessed using common quality-of-care indicators such as glycosylated hemoglobin level and blood pressure control. Clinic rates of such diabetes quality-of-care indicators ranged from 12% to 96%, and in most areas was comparable to or better than averages previously reported for uninsured populations.

Resident as teacher: the Mount Sinai experience and a review of the literature.

Residents play a pivotal role in the education of medical students and junior house staff but are rarely provided with the tools to help them teach effectively. Residents value their roles as teachers and desire training programs in teaching skills. Teaching skills courses for residents have been shown to improve residents' self-confidence and self-assessed use of effective teaching behaviors. They have also been shown to improve residents' evaluations by students. The Institute for Medical Education at the Mount Sinai School of Medicine has developed a successful, multidisciplinary curriculum to improve the teaching and leadership skills of all of our residents at the Mount Sinai Hospital and its affiliate institutions. The Resident Teaching Development Program (RTDP) has already been implemented in the departments of Medicine, Surgery, Pediatrics, Psychiatry, and Obstetrics and Gynecology. This adaptable, seven-hour curriculum has been well received by residents and faculty. We are currently evaluating the effects of the program on residents' confidence and use of learned skills. And we are working to expand this program to every department and to create innovative means of measuring resident competency in teaching and its ultimate effect on student learning.