25 Steps How to Start & Strengthen a Free Clinic

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.

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".

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.