**FTS-HRSA-OA**

**October 27, 2004**

**1:30 p.m. CDT**

Coordinator Good afternoon, folks. This is the conference coordinator. I
would like to inform all participants that this call is being recorded.
If you have any objections, you may disconnect at this time.

> At this time I'll turn the call over to Mr. Michael Beachler. Mr.
> Beachler, you may begin, Sir.

Michael Okay, good afternoon, everybody. Welcome to our quarterly Rural
Network Grantee conference call. I'm going to make hopefully very short
opening remarks and then we'll get the speakers going on.

> We developed this call largely because we were aware that a number of
> Rural Health Network grantees either had some sort of a voluntarinism
> built into their project or were contemplating it and we thought that
> we could develop a very interesting set of speakers and I think that's
> what we hope that we have done. I'm going to just very briefly
> introduce them.
>
> First we have to kind of give an overview, really the field, is a
> woman named Gail Golden, who is the Director of Community Partnerships
> for an organization that is Rhode Island-based, called Volunteers and
> Health Care. Actually Volunteers and Health Care has been serving as a
> national technical assistance center for these kinds of provider
> volunteers and projects for several years and they kind of morphed out
> of an earlier role where they were a national program office for a
> Robert Wood Johnson Foundation project called Reach Out that started
> in the early 90s. So really, they have they been at this whole issue
> from a national perspective for well over a decade now.
>
> Then we have the great state of Georgia, Frank Selgrath, CEO of the
> Coastal Medical Access program, which is a project that has used a
> decision volunteer model and it is a very exciting program that I
> think you will be interested in.
>
> Then we have a representative of a current Office of Rural Health
> Policy funded rural health network in Vermilion Parish, Louisiana, and
> we have Bob Hensgens, who is the Chair of the Board of the network and
> is the CEO of the Vermillion Parish Hospital and of the free clinic,
> if my memory is correct.
>
> I'm just going to step out of the way and, Gail, you're going to
> start. Give us kind of a broad overview of the field and of these
> provider-led volunteer efforts.

Gail Thank you very much. As Michael said, Volunteers in Health Care is
a national technical assistance and resource center, so we are very
happy to talk with you all today about clinician volunteerism. I'm
really just going to scratch the surface of clinician volunteerism in
about 20 minutes, so I look forward to talking with all of you and
hearing your questions that you might have and seeing if there are
others way that we can work with you. If I'm not able to address your
questions and concerns on the call, please do feel free to give us a
call and we'll be happy to talk with you after the call about this as
well.

> One of the aspects that I enjoy most about my work at Volunteers in
> Health Care is how much every time I come to meet with different
> people, either in person or in the phone, I learn as much as I hope I
> am able to share with other people. So I do look forward to hearing
> all the stories that you have to share with me.
>
> I'm going to talk today about why clinicians volunteer, where they
> volunteer, and how rural communities are tapping into these resources
> to expand services to the uninsured. First the good news, rural
> communities have distinctly unique and important aspects that make
> volunteerism a viable option for addressing health care barriers.
> Rural communities, generally speaking, have familiarity with the
> provider community, and that community tends to already have a strong
> commitment to your target population.
>
> Indeed, charity care offered in physician offices is a day-to-day
> occurrence in rural communities. On average, physicians provide 11
> hours per week of charity care and nearly three-quarters of physicians
> do provide some type of charity care. Additionally, rural physicians
> are more likely than physicians in metropolitan areas to accept
> Medicaid and uninsured patients.
>
> Rural communities also have an advantage because they have an
> understanding of the need for resource sharing and usually some type
> of familiarity or existing relationship with the various other
> partners in your town. It may also be an advantage that smaller towns
> ... the stakeholders who are needed to reach agreements to move
> forward with a project. Rural communities understand the need for
> creating local solutions despite the lack of local funding. And
> finally, rural communities may have untapped resources that larger
> communities do not have, namely retired clinicians who seek out rural
> communities for the lifestyle and have the skills and willingness to
> help.
>
> Perhaps the largest hurdles rural communities face involves a lack of
> resources. I'm sure that's not a big surprise to any of you. Some of
> those lacks can be the lack of health care providers, particularly
> specialists, to a lack of health care infrastructure, such as
> easy-to-reach hospitals, to a lack of transportation, to a lack of
> trained interpreters for the growing limited English-speaking
> population, to a lack of funding. When deciding how to move forward
> with a volunteer initiative however, it is equally as important to
> identify in what ways your community is resource rich as it resource
> poor.
>
> Essentially, the various ways clinicians can volunteer falls into a
> few different categories and I'm going to describe a variety of them
> on this call. The most common is the free clinic. Free clinics, as I'm
> sure most of you know, are non-profit organizations that rely on
> volunteers to provide health care to the uninsured. They tend to
> either be volunteer-run or have a few staff members. They can range in
> size from once a month in a church basement to a large office building
> open every day of the week. Free clinics may provide episodic care or
> they can be true medical homes for patients.
>
> There are roughly 1,000 free clinics across the country providing care
> to 3.2 million uninsured patients. These clinics are often the only
> safety net provider in their community and the only way the uninsured
> are getting ongoing care, and that can be particularly true in rural
> communities. Of the roughly 5,000 small towns in the U.S. only about
> 10% have community health center clinics that receive U.S. Public
> Health Service grants to support free or low-cost care to low income
> people with inadequate insurance.
>
> There are various other strategies for using volunteers that can work
> in rural communities. The first, the referral network, or as some call
> it, a "virtual clinic" or a "clinic without walls", may be a
> particularly useful model for a community that lacks transportation
> services but does have an adequate number of clinicians. Two examples
> of this exist in Vermont; both are hosted by local hospitals. In these
> instances, the hospitals cover the cost of the program administrator.
> Patients call a phone number, speak with the program administrator and
> are screened for eligibility. The program administrator works with the
> clinicians' office and the patient to schedule an appointment and then
> follows up with the patient. Many referral networks involve case
> management components to ensure the patient shows up on time for the
> appointment, has an interpreter available if needed, receives
> follow-up care and generally stays connected to the medical and dental
> world.
>
> Many projects across the country combine the referral network and the
> free clinic. Sometimes this works as primary care provided in the free
> clinic with specialty care offered through the referral network. For
> those of you who had looked through our field reports ahead of time,
> that has a good description of some of those.
>
> There is also an offshoot of this that has been successful in the
> rural community in Florida, which happens to have a lot of retired
> pediatricians. The project runs a pediatric referral network, where
> children are seen in physicians' offices. Several retired
> pediatricians wanted to get involved, but given that they're retired
> they didn't have office space where they could see patients. So the
> project secured donated office space and developed a private practice
> staffed solely by volunteer retirees.
>
> Another popular method of providing health care in rural areas is a
> mobile unit, which can be outfitted for either medical care, dental
> care or both. This model works best for communities that lack adequate
> transportation or have a hard-to-reach subset of the population, like
> migrant farm workers, but do not necessarily have the number of
> clinical volunteers necessary to develop a referral network. Mobile
> units are essentially free clinics on wheels, that is, they can have
> full-time clinical staff that is augmented by volunteers that travel
> with the van, or, as the case of the mobile van that goes through
> Georgia and Florida, clinical volunteers are recruited ahead of time
> and meet the van when it arrives in their town. The clinicians can
> then volunteer for a short period of time, serving their own
> community. Some mobile units travel over large geographic regions,
> while others may only serve one county.
>
> Another strategy that is gaining in popularity is a big health care
> event where a large mass of volunteers provide health care over a
> short period of time to an even larger mass of patients. This strategy
> seems to be particularly popular among dental access programs. For
> instance, a new initiative called Kansas Mission of Mercy recruited
> 500 dental volunteers to provide care to over 2,600 patients over the
> course of just a couple of days. All of that care took place in 84
> temporary dental operatories located in the pit garages of the Kansas
> Speedway. The Kansas Mission of Mercy has replicated this program
> throughout rural southwestern Kansas and has plans to continue doing
> so.
>
> There are also two other health care initiatives that I want to
> mention at this point that can be useful in rural communities. One is
> integrating oral health screening into general medicine visits and the
> other is enrolling patients in the pharmaceutical companies' Patient
> Assistance Program. While these initiatives are not necessarily
> connected to clinical volunteers, they do require the interest,
> involvement, and commitment of the medical and dental community.
>
> Each of these models requires certain resources and has certain
> drawbacks. For instance, while volunteers might be more inclined to
> see patients in the free clinic setting, it may be more difficult for
> patients to reach a free clinic than their local dentist or
> physicians' office. A referral network may eliminate some of the
> hassles of transportation for your patients, but it may also require a
> greater number of clinician volunteers than are available.
>
> Mobile units certainly address the transportation barrier, but they
> are also very expensive to buy and certainly have high costs. As one
> program in rural Washington State that wrote one of our field reports
> experienced, they are also very expensive to replace when someone
> takes one out for a little joyride.
>
> A series of community volunteer events may get a large group of people
> needed health care, but it isn't a source of ongoing care. Although
> these events held over a couple of days can allow for volunteers from
> other parts of the state to lend a helping hand, that's increasing the
> capacity of your program to address immediate health care needs.
>
> Perhaps one of the most important components of developing a clinical
> volunteer program is to understand why clinicians volunteer and why
> they don't. If you think for a moment about your own volunteer
> experiences, you probably can come up with some of the incentives and
> barriers yourself. I recently asked a group of people about their
> volunteer activities and many of them mentioned coaching little
> league, volunteering at their children's' schools, teaching kids how
> to swim and working on advocacy efforts for the poor. Many of these
> people are inspired for similar reasons, it gave them extra time with
> their families, they felt a strong commitment to be involved in their
> community and it provided them with a way to relax while helping
> others.
>
> Clinicians volunteer for the same reasons and for several others. They
> volunteer because they have a strong spiritual belief or personal
> belief in access to health care. They volunteer because a colleague
> asked him or her to. They volunteer because they want to learn about
> the patient population because they want to use clinical skills that
> otherwise would not be put to use, because they are retired or in
> academic setting and because they want to practice medicine without
> the hassle of insurance paperwork.
>
> On the other hand, clinicians don't volunteer because they feel that
> they are already doing their part by providing free care in their own
> offices, and this can be particularly true for rural providers. They
> have misconceptions of the uninsured, they don't have the time to do
> it, they're worried about malpractice, they're concerned about safety
> conditions, particularly if you ask them to come into neighborhoods
> they are not familiar with. They are worried about the quality of
> health care that is provided through volunteer efforts. They are
> concerned that ancillary services will not be available and they may
> have no idea how to address language and cultural barriers.
>
> There are also policy barriers that can hinder volunteers and,
> specifically, licensing. While actively practicing physicians maintain
> licenses, retirees often do not keep their licenses for a variety of
> different reasons. If you are particularly interested in using retired
> clinical volunteers, this will emerge as a barrier.
>
> So now that you know why people volunteer and why they don't, what
> does that all mean? Well essentially, it's your job to figure out how
> to cultivate that desire to volunteer and then eliminate the barriers
> you can eliminate. Part of that is educating yourself about state laws
> in malpractice and licensing, which is information that Volunteers in
> Health Care can help you with, and part of it is identifying what the
> most significant barriers are in your community and then deciding if
> they are challenges your organization is willing to tackle.
>
> Some of these barriers may be easier to address than others. For
> instance, by creating a system of care for patients that streamlines
> services and assures that patients get the necessary ancillary
> services they need, many community programs have been able to convince
> physicians that participating in an organized volunteer effort will be
> much more efficient than offering charity care in their offices
> without any connection to others.
>
> Malpractice has been a huge barrier that we've heard of over many
> years, and it may continue to be. However, a new federal program is
> trying to address this issue. In the interest of time, I'll refer
> those of you who are interested in this program to our Web site for
> further information or I'm happy to answer more questions about that
> after the call.
>
> Other issues may be more complex and may or may not be within your
> control. Changing misconceptions of the uninsured, for instance, may
> be as easy as looking at Census Bureau statistics and having the local
> medical or dental society integrate that into newsletters and
> presentations, or addressing this barrier may require networking with
> other social service providers in town to figure out a strategy to
> raise awareness of who is uninsured. You may have to use recruitment
> events as awareness events too.
>
> Once you have decided to move forward with a volunteer initiative, it
> is important to keep in mind what makes a project successful. When I
> was in college I volunteered weekly to teach an older gentleman to
> read. I participated in the program as part of the Literacy Council,
> where I received about two hours of training, one time, on how to
> teach someone to read. I was then matched with my adult learner.
> Together we met weekly for three years.
>
> While the experience for me was deeply rewarding, it was also
> remarkably frustrating. I did not receive adequate training, I was
> never contacted by the volunteer coordinator to check in on my
> experience, I received no guidance on how to measure my student's
> progress, I was not given adequate tools, and while my willing student
> was remarkably committed and deeply grateful, I never received a thank
> you from the organization for the hundreds of hours of volunteer work.
> Similarly, I don't doubt that my student could have been better served
> and learned how to read quicker if the volunteer program had been
> better managed.
>
> Poorly managed volunteer efforts prevent people from getting the
> services they need and they turn volunteers off from being involved.
> Successful programs give volunteers training, tools, networking
> opportunities, ensure that the client is connected to all available
> resources, and most importantly, recognize the value of the
> volunteer's time and efforts.
>
> As you move forward with your work, I encourage you to think about a
> few questions. What are our most pressing community health needs? How
> would we expect clinical volunteers to address these needs? What kind
> of clinicians would be needed? Do we have those clinicians in close
> proximity? If not, what relationships do we need to build with the
> medical and dental community? What other resources or services should
> be in place to support the use of clinical volunteers? What is the
> perception of volunteerism in our community? What is the perception of
> the uninsured? Does this perception reflect reality or do we need to
> educate providers on who the uninsured are? Do we need institutional
> backing for this program? Do we have it? Does our community have the
> resources to dedicate to creating and maintaining a volunteer
> clinician program?
>
> And once you've started thinking about all those questions, know that
> you don't have to go the road along. Rural communities across the
> country have developed and are sustaining volunteer health
> initiatives. You'll hear about a couple of them today and you can read
> more about them on our Web site. Some of the links were provided in
> the e-mail that all of you got about this call.
>
> Should you like to be connected with more projects, we at Volunteers
> in Health Care invite you to give us a call so we can make that
> connection for you. While you're at it, I'd like to invite you to look
> through the many tools that we have available. We offer our own series
> of teleworkshops on a variety of subjects, ranging from the Medicare
> drug benefit to innovative dental programs to malpractice concerns for
> clinical volunteers. We do still have some space available for our
> Grant Writing Teleworkshop series that begins November 9^th^. This
> workshop is geared towards the grant-writing novice and more
> information about that is available on our Web site.
>
> We also have a wide variety of manuals and field reports available on
> our Web site and the Web site is volunteersinhealthcare.org and a
> Web-based database of pharmaceutical companies' patient assistance
> programs, and that Web site is rxassist.org. We also have patient
> tracking and pharmaceutical access software called RX Assist Plus and
> have recently launched a subscription-based newsletter geared towards
> programs that offer discounted or free medications to their patients.
>
> So that is a wrap up of the overview of clinical volunteerism. I look
> forward to hearing your questions and talking to you more about the
> work that all of you are doing. Thank you.

Pat Michael, before you introduce the next speaker -- this is Pat -- I'd
just like to take care of some housekeeping.

Michael Sure.

Pat If everyone could please put your phones on mute. Sometimes there is
some environmental noise that comes in, so if you could do that it sure
would help.

Michael You can also hit \*6 and that also puts it on mute, is what the
operator just told me. He cut in on me.

Pat Take her away, Michael.

Michael I think I'd like to take a couple minutes of questions before we
transition to Frank. You know, we won't go on too long, but if we have a
couple of questions for Gail; I know I do. But I'd like to kind of just
open it up for folks in the field, for any questions that you might
have.

Pat Gail, this is Pat Coda again -- I was just curious to know if you
know of any Volunteer in Medicine programs that are linked to schools.

Gail We're Volunteers in Health Care; Volunteers in Medicine is another
project out of South Carolina; I just want to clarify that for people,
and they use a specific model for retirees. There are certainly
volunteer-based programs that incorporate a school-based model, that
retired pediatrician model that I was actually talking about in the
talk, is a school-based, the office is at a school, so there are
definitely some innovative models that do involve schools.

Michael Gail, I'd like to take you up on your offer to say a little bit
more about the new malpractice provision. I'm actually looking at the
HRSA Web site, but I guess the questions that I have on this are -- I
mean, could you give us a little detail on it, number one? Number two,
will it apply to both, it looks like it's easily applied to free clinic
models, but could it also be used for organized and structured free
clinics without walls or referral models? Then I guess the third
question is is the thing being used? I mean, is it ready for prime time
to be able to be used?

> So I guess those are three interrelated questions on this. But go into
> a little bit of detail on it because I think it's a pretty important
> policy development for free clinic-type models.

Gail Sure, for everyone who doesn't know about this, it's called the
Free Clinic Federal Torte Claims Act Medical Malpractice Program, even
though we suggested to HRSA that they shorten that up just a little bit.
But what it did is it stemmed from Section 195 of HIPAA, which passed
law in 1996 and created a program where volunteer clinicians would be
indemnified much in the same way that federally qualified health center
employees are covered. Essentially what that means is volunteer
clinicians that register under this program would have their malpractice
covered by the federal government.

> Now it was passed into law in 1996, but it required an appropriation,
> Congress to appropriate funds in order to get regulations written by
> Health and Human Services and then to get the program going. The
> appropriations were made in March 2004 and the program has started as
> of September 24, 2004. So in terms of enrollment, we certainly have
> had a lot of people to call us to ask questions in the process of
> applying; I don't know that they have received an application yet.
>
> But in terms of its application outside of the free clinic world, we
> have asked for HRSA for some clarification on that. Essentially what
> it does is it allows for any program that will meet the criteria set
> forth by HRSA, it will cover the malpractice for volunteers. Now,
> there are certain requirements and some of those involve that it be a
> free clinic.
>
> The requirements are all essentially of the organization, even if the
> coverage is for the volunteers and not the organization. But the
> organization has to meet certain risk management standards and
> credentialing and privileging standards and it also has to be a
> non-profit organization that doesn't charge for services. But it's a
> little bit unclear about whether or not it could be an organization
> that charges for some services, but no the ones that the volunteers
> would be covered for under this. So there are several points of
> clarification that we have been asking for and hopefully we'll get in
> the next couple weeks.
>
> HRSA is going to work with us to do a teleworkshop, probably this
> first week of December; that will be all greater detail about this
> program, so people are welcome to check back on the VIH Web site to
> see about that.

Michael What is your guess? I mean, I'm looking at what the basis
criteria is, but you talked about a hospital-based model, which you may
have under a rural health network kind of thing, where the organization
entity, but they use a kind of renewal network or clinicians without
walls, but it has a structure to it, it has a not-for profit base. Have
you gotten HRSA to weigh in on that yet?

Gail No, we're hoping that they will. I mean up until this point it
actually hasn't been as big a problem in the referral network that is
solely referral network because clinicians usually have their
malpractice -- you know, their patients going into their office and
their malpractice covers whatever patients they are seeing that day,
whether or no the patient paid. So for the most part it has not been a
big problem.

> There has been some - sometimes it becomes a recruitment barrier that
> people don't want to use their malpractice to cover that. But in terms
> of whether or not their malpractice can at this point, you know, we
> haven't had too many people tell us that their malpractice is refusing
> to cover that.

Michael But it could, at least hypothetically down the line, if I'm a
clinician on the fence of whether I want to join one of these referral
networks or not. You know, if you're looking eight, five, six, seven
years down the line my understanding is if you got covered under this,
at least hypothetically, this could have - in the absolute rare case
that you might get sued, this protects you. While it wouldn't totally
insulate you from it, it might basically give you a greater level of
protection than your private malpractice insurance, or at least a
feeling of greater protection on that act.

Gail Yes, if you're covered by it, I mean basically what ends up
happening is the patient has to sue -- this is kind of a simplification
of it, but the patient sues the federal government and doesn't sue the
provider. So ultimately for being a clinical volunteer, that's a pretty
good win/win for everyone because it still allows the patient to be able
to get some recourse, should there actually be malpractice, but it also
protects the person who's interested in volunteering.

> It actually goes hand-in-hand with a few other laws. There are
> certainly state laws, 43 states have charitable that affect clinical
> volunteers, and then there's also the Volunteer Protection Act of
> 1997, which is federal law which essentially makes it more difficult
> to sue a volunteer of any type, not just clinical volunteers. So all
> of that kind of tied together, the liability risk of being a volunteer
> is very low. And certainly the research we have shown in the field
> shows that as well.

Michael Okay, are there other questions from folks?

> Frank, do you want to talk to us about the program down at Coastal
> Medical Access program? Frank? I bet you he's on mute. Hello?

Catherine Michael, some people may not know what star number to press to
unmute.

Michael Okay. Is that Catherine?

Catherine It is.

Michael Okay, do you know what it is? The operator didn't tell me that?

Catherine Unfortunately, I don't. I just use the mute on my phone.

Michael So did I.

Catherine The operator should be listening in to be able to tell us,
though.

Michael Yes.

Catherine Maybe.

Michael Maybe.

Tia I'll call and try to find out.

Michael Thanks, Tia. Well, we've got a minute. Gail, could you say a few
words about what you guys are planning to do in relationship to, I know
you have very substantial pharmaceutical assistance products, but what,
if anything, are you planning to do with the new Medicare benefit that's
coming online, you know, from a software, from an assistance standpoint?
And if you're doing something -- I've gotten a lot of feedback about
this Access to Benefits Coalition that's emerging down out of DC, out of
the National Office of Aging; are you coordinating your efforts with
those folks as well?

Gail I'm going to let Janet Walton, who is the director of VIH, who is
in the room with me, answer that.

Michael Okay.

Janet Hi, Michael.

Michael Hi, Janet.

Janet Well, what we've been doing, we've been following what has been
happening around the Medicare drug discount cards very closely and how
they specifically affect low-income seniors. We've also been looking at
the intersection between the drug discount cards and the pharmaceutical
manufacturers' patient assistance programs. It has become a very
complicated universe now with various cards, the PAP program still
exists, some manufacturers are extending benefits to low-income Medicare
beneficiaries now.

> So we have not incorporated anything into our software, we are
> covering some of these issues in the newsletter that Gail described,
> which is RX for Access. But Stephanie Geller, here on staff, has also
> put together a chart, which compares some of the various eligibility
> requirements and benefits of the different cards, which we would
> certainly be happy to send on to people if it's not posted on our Web
> site- I can't remember if it actually is posted.
>
> In terms of our relationship with the Access to Benefits Coalition, we
> don't have a formal relationship with them. We obviously know what
> they're doing; we go to their Web site quite frequently to see what
> kinds of information they are posting on their Web site and there is a
> great deal. I have to say, this is an unknown universe for many people
> in terms of what the drugs manufacturers will do once the drug benefit
> comes into being, what the effect will be on dual eligibles, what the
> senior population is feeling in terms of how to manage all this
> information. And of course, it has been a big interest and area of
> confusion for advocates who are trying to keep all of this straight.
>
> So although we've not done anything formally now, we are certainly
> keeping abreast of all of the developments and we are trying to codify
> things into charts wherever we can and put out brief articles through
> this newsletter, which covers other kinds of issues as well, but also
> keeps an eye on what's happening in the Medicare world.

Michael Thank you, Janet. Just two related requests and I guess I'd like
to take both you and Gail up on some of those offers. I think perhaps
maybe the best person to do it would be the folks in Georgia itself or
myself. We'll get back to you on this. But we'd like to at least let our
network crowd know about both the teleconference on the malpractice
issue. Then also this chart regarding the various eligibility, if that
could be -- and maybe Catherine and I can talk about whether it goes to,
it will probably go to Georgia, but whose e-mail address it goes to or
perhaps it will go here. But we'd kind of like to take advantage of the
resource that you guys are and try to get it out to our networks as
well.

Janet That would be fine. We can also send you PDF copies of the RF for
Access newsletter and people can see how we've spoken about the Medicare
low-income beneficiary entanglement through that as well.

Michael Great, thank you both. Do we have Frank back on yet?

Frank Can you hear me?

Michael Okay, yes.

Frank Good. I hit \*6 and didn't know how to get out of it, so I had my
secretary call and they said they would fix it from their end and
apparently they did.

W Hello?

Frank Hello?

W Is this Frank?

Frank Yes.

W Okay, I'm sorry.

Michael Okay, Frank, do you want to start us off?

Frank Okay. I wanted to compliment Gail, first of all, on her
presentation; I thought it was superb and lent itself very readily into
some of the things I wanted to address about our clinic.

> We are located in Brunswick, Georgia and we cover three counties in
> Southeast Georgia. Many folks do not know that Georgia has a
> coastline. We do, folks, it's a very attractive coastline, it's about
> 120-miles long and it has some of the most affluent areas in the
> United States, but it also has some of the poorest communities in the
> country.
>
> We cover three counties; to the north of us is McIntosh County, we're
> located in Glynn County, and south of us, along the Florida border, is
> Camden County. Now we have the good fortune here in Glynn County of
> also having part of our county Sea Island, which is the sixth most
> affluent place in the United States, and St. Simon's Island, as well
> as St. Mary's, which are retirement communities, which attract, as
> Gail said, a lot of retired physicians and a lot of retired medical
> professionals.
>
> However, on the other hand, in our rural areas all three of our
> counties have some very unique rural communities that are very poor.
> They only have two primary care physicians in McIntosh County.
> Brunswick County has quite a few physicians, 207, and Camden County
> only has nine. Camden County and part of Glynn are the second fastest
> growing area in the state of Georgia, which is the fifth fastest
> growing state in the United States. With that comes a lot of the
> bonuses of having rapid growth, we have increased economic
> development; we have the attraction of retired folks to a developing
> area.
>
> But also with that goes the problem of the working poor who have no
> insurance coverage and it also attracts a lot of retirees, who quite
> often, develop chronic illness and although they have a physician and
> in many cases Medicare, they don't have a pharmaceutical assistance
> programs. So increasingly, the hospital becomes the family doctor for
> more and more people and these are folks that are attracted here
> because of the service industry, because of the opportunity to start
> businesses, and in many cases they can't afford their own insurance.
>
> So a few years back the community really started to get concerned
> about health care in general because the local hospital system was
> going through some financial turnaround at the time and it really
> raised the awareness of the local folks as to what would we do if
> something happened to the hospital? What would we do if it wasn't for
> the safety net provider of public health?
>
> So from a group of folks from public health, from the hospital, from
> industry, from the faith-based organizations, they began to meet and
> discuss some of the ways in which health care access could be
> improved, and this was in 2001. And they looked at several things they
> could do, they got together under the leadership of a local county
> commissioner, her name was Henri Woodman; the lady has since passed
> away from cancer herself.
>
> But I can't emphasize enough the necessity for leadership within the
> community. That's essential to any organization that looks to
> providing community solutions to the health care problem. And if the
> leadership is present, and I believe most communities have that
> leadership, it just remains to be identified, then they can accomplish
> many things that will help the health care access delivery.
>
> Henri's contribution was to get everybody together and all on the same
> page. As I said, they drew from various areas of the community and
> they decided to look at areas in which we could help. There were all
> sorts of ideas, but the three that they decided on was that case
> management of people with chronic illness was extremely important
> because case management were among those who were laid off from the
> hospital during the transition. There were about 100 layoffs at the
> local hospital; a good portion of them were social workers and other
> folks that were doing case management.
>
> The second thing that they thought they could do from a community
> point of view was to provide pharmaceutical assistance. PAPs, we call
> them "Med Banks," which are organizations that basically go through
> the complex maze of paperwork necessary for people to receive free
> pharmaceuticals under the pharmaceutical companies' programs. There
> are 102 pharmaceutical companies with 102 different applications, all
> of them which change on a regular basis and they are pretty complex
> and most of our people in the Med Bank program do not have the skills
> or the ability to navigate that process.
>
> The third thing they decided to do was operate a free clinic and
> that's what we'll be talking about most today. They decided to model
> that clinic on the Hilton Head Clinic, the free clinic in Hilton Head.
> We were similar, and I think the uniqueness of our area, the
> uniqueness of any area, will determine basically what type of program,
> what type of approach they will take to providing free care. In some
> areas they don't have the physician population, the professional
> population to open a freestanding clinic. That, of necessity, must be
> done in doctor's offices or through referral networks.
>
> We are fortunate in our region, as I spoke of earlier, to have quite a
> few retired physicians that retire on the coast. We also have
> centrally located in order to service those affluent areas. In
> Brunswick, we have a fairly large physician component of active
> physicians. What we needed to do then was to establish a type of
> structure that would allow us to take advantage of the presence of
> retired and active physicians and yet disseminate that service in a
> way that we could assist the folks in the most rural areas of McIntosh
> and Camden County.
>
> So we started April 1, 2002 and we had some local folks that held
> orientation events and cultivation events at their home with
> physicians to acquaint them with what we were doing, and we were able
> to recruit a cadre of physicians that were willing to work within the
> free clinic. The first question the physicians always asked was the
> one that was asked just previous to my talking, and that was about
> malpractice.
>
> One of the areas that is very helpful to us here in Georgia, we have
> one of the strongest Volunteer Medicine acts in the United States and
> it has been challenged in court and upheld. Basically, what it says in
> some substance is that a medical professional, be that a nurse or a
> doctor or a dentist or a nurse practitioner or a PA, that is
> performing in an uncompensated capacity is immune from litigation
> provided a couple of conditions exist. Number one is that there was no
> gross negligence. Number two is that the patient is informed of the
> restrictions of their ability to sue at the time they seek services.
> So our forms, we have a place where they are informed, both verbally
> and in writing, of the limited litigious rights they have and they
> sign that before treatment.
>
> That eased the mind quite a bit of the physicians, both active and
> retired, who were concerned, rightfully, about litigation; they didn't
> want an increase in many cases in their own malpractice and they
> didn't feel comfortable volunteering unless there was some sort of a
> safeguard against litigation. One of the first things we did as an
> organization was we paid money to get a prestigious law firm in
> Atlanta to do research and verify and give us an opine as to whether
> or not the Georgia legislation was significant enough to safeguard the
> positions concerned.
>
> So at any rate, there was also a federal law, which, as Gail alluded
> to, was just recently funded. In fact, the federal register Number
> 135, dated July 15^th^ of this year, finally funds that and defines
> free clinics and free clinic professionals, and I can provide that to
> anybody if they don't have that. But it defines what is a free clinic
> and what that provides for, the federal legislation, is that if there
> was a suit, then for purposes of litigation, the volunteer position is
> considered an employee of public health and would therefore be a
> public health service employee and defended by the federal government.
> So that adds further impact to the concerns of the physicians about
> being not able to be safeguarded from litigation.
>
> Most of the doctors -- I enjoyed what Gail had to say -- most of the
> doctors I think we have, have been providing in some capacity free
> care for a number of years. They have patients that they've dealt with
> for years, they have patients that come to them, either through the ER
> or either come to them by paying cash and then not being able to, and
> they still have been seeing them. They didn't have an organized
> fashion of doing that before. They welcomed that.
>
> The volunteer physicians that we have, we have two clinics, one Camden
> County and one in Brunswick; the one in Camden County was not an
> initial plan of ours, it opened in response to the closing of a large
> paper mill, which was the second largest employer in the county after
> the Navy base. We opened in response to that plant closing, which
> forced all of those employees not only out of work, but they were also
> self-insured and therefore had no, they were in dire straits as to
> medical coverage because they couldn't even COBRA in their benefits,
> even if they had the money.
>
> So we opened our second clinic in response to that. As to recruiting
> the physicians, we've done that through a variety of fashion. We've
> worked closely with the hospital. We worked with the health
> department. We worked with the medical community itself. We addressed
> the hospital medical staff. We had cultivation events, as I mentioned,
> in homes, and we now have 27 primary care physicians, of whom about
> 20% of them are retired, the rest are in active practice, that
> volunteer in our two clinics.
>
> One of the issues, that Gail also raised, was they were concerned
> about the quality of care. We work very closely with the hospitals and
> with the public health service. We have all the ancillary services
> provided through the Indigent Care Trust Fund moneys. We do the
> pre-screening for the folks in the clinics and then the hospital does
> accept them.
>
> We have other physicians who read all the x-rays on a volunteer basis,
> that read the CAT scans. We have an additional 38 sub-specialists and
> specialists who also will see a number of our patients in their
> offices. They don't see them in the clinic because of obviously the
> necessity for special equipment and the ability to see them, but we
> are able to get slots within their offices. So it does allow us to do
> a really holistic approach to health care for the chronic patients.
>
> We have a very, as time has shown, we've had a very complex patient in
> most instances. We've delivered so far in a year and a half 2,000
> patient visits. Over the two clinics we have a little over 900
> patients at the present time. We also augment our ability to attract
> physician help, specialist help, by providing our second service,
> which is not directly a component of the free clinic, and that is what
> we call "Med Bank," which is a pharmaceutical assistance program.
>
> What we do there is we have volunteers that provide the service of
> filling out the applications for the medical community, whether they
> volunteer in our clinic or not. In other words, a physician within the
> community, be that a specialist or a primary care physician, who has a
> group of Medicare patients, for instance, who have Medicare and
> insurance and can be seen in his office, but they have no drug
> coverage.
>
> In many instances, many of these folks are on social security -- 58%
> of our people in the Med Bank portion of what we do are on social
> security. They may own their own home, they may have a little money in
> the bank, but suddenly they are faced with a \$950-\$1,000 month drug
> bill because they've developed a chronic illness, and which of could
> withstand that for very long? Pretty soon the money would be going
> from the bank and the house would be going. And these folks don't
> generally appear in the indigent census data, from which you can
> fairly well predict how much utilization you'll have. These folks are
> folks that don't normally seek help in other areas.
>
> So we were quite surprised by the number of people that quite
> literally came from out of nowhere when we opened our Med Bank. We,
> today, have 2,300 people in Med Bank. We have provided close to \$2.7
> million in free pharmaceuticals. How that allows us to recruit
> physicians is many times the physicians have been attempting on their
> own, in their own offices, to provide these drugs for their patients,
> and haven't been able to do it or haven't been able to afford to do
> it. By us doing that, it provides sort of a quid pro quo to a certain
> degree, where the physician says, "You help me with my patients and
> I'll see your patients." So that's one way that we've kind of tracked
> physicians.
>
> The ancillary services I addressed, we have a population in Brunswick
> that is, as is so often the case around the country, there is a large
> Latino population here now. We received a small grant from Emory
> University to hire a Latino outreach. We now have 22 folks that
> provide interpretation services for us. They are always available when
> there is a clinic or a Med Bank patient.
>
> We've recently received from the Office of Disparities here in
> Georgia, some training that was provided to three of our volunteer
> interpreters to do medical interpretation, because even though they
> speak excellent Spanish and English, it's not necessarily the case
> that they were able to accurately convey in medical terms the way it
> would have been better for them to do. So now we have three people
> that are trained in medical translation.
>
> The licensure issue, for some of our retired physicians is also
> addressed in Georgia statute and it provides that a physician who has
> retired in good standing from another jurisdiction can receive, if
> they are not licensed in Georgia, a Volunteer in Medicine license,
> which allows them to practice in a free clinic, although they can't
> open up a practice through that licensure. But that process is fairly
> lengthy; it takes about two to three months to have a physician go
> through that process. But provided they are credentialed and provided
> they meet the requirements for that, they can get licensed for free
> and can practice in the state of Georgia.
>
> Safety is always an issue. We try to locate all of our offices close
> to medical facilities. We have one building that is right across from
> the hospital emergency room and we have another building that is
> located a block away from the hospital. Those sites are provided free
> of charge to us by the hospital. We have our Med Bank offices located
> in areas where, since so many of our people are elderly, where the
> folks feel secure. We are co-located in what is known as a
> multi-purpose center, which is run by the City of Brunswick, which is
> sort of a senior daycare center, and we co-locate there.
>
> In sum and substance, in 30 months we have, as I said, we've provided
> close to \$2.5 million in drugs in 2003. We had 10,600 volunteer hours
> in 2004, to this date we have 9,774 hours and we're still about 2.5
> months away from the end of the year. Our Med Bank patients themselves
> number 1,769 that are in the other physicians' offices and a little
> over 500 that are in our clinics.
>
> On the intensive case management part, which is an important part
> about keeping our physicians involved in the quality of care, is that
> we employ three nurses who will continually track and monitor the
> compliance of the chronic patients that we'll coordinate between
> physicians' offices and specialists and coordinate between any surgery
> centers or hospitals in which our patients are at that moment. And our
> patient visits, as I said, in Brunswick, are now over 1,000 and in
> Camden are over 1,000 in almost 2,000 patient visits. We're just
> moving forward.
>
> Now that we're in permanent sites, we weren't initially in permanent
> sites; we had to operate our clinic out of the hospital outpatient
> department for about seven months. We had to take everything in there
> in suitcases, phones and fax and patient records and everything else.
> We have our permanent sites in both counties now, due to the
> generosity of the community. We are now able to open a pharmaceutical
> dispensary and are in the process of securing dental equipment and
> have several physicians who are lined up to provide dental service
> because, as someone had said a little earlier, dental service is a
> very integral part of the care for peoples' chronic illness that
> haven't had appropriate care over the last number of years.
>
> So that's what we do here in southeast Georgia. Our first grant came
> through the Georgia Health Policy Center, which gave us quite a bit of
> technical advice, and without them we probably would not have been as
> successful as we are.
>
> Any questions?

Michael Frank, I'll start off with, could you talk about the issue of
visibility? How visible have you been in the community? When did you
become more visible, if that's the case? How did you think through the
issue of marketing the service and marketing what you guys are all
about? My guess is it could be a little tricky.

Frank It is, and our approach changes, Michael, as we move on. In the
beginning I, as well as Commissioner Woodman and some of the original
founding board members, we did quite a bit of community outreach to
folks within the community that needed to know of our presence, and I'm
talking about agencies that help the poor and the indigent and I'm
talking about having stories in the newspaper, requesting volunteers.
That was where we addressed two organizations as the medical staff. We
finally attracted some people that would offer their homes. We had
awareness sessions in city council and we had awareness sessions that we
did in conjunction with the Health Department, just to make people aware
of who we were and saying where we wanted to go.

> Once we had a small cadre, and it didn't take very long, of about six
> or eight weeks, and we had a location in which we could at least have
> administration offices and start our Med Bank program, we started to
> just request press information. I would give interviews to the press
> continually to get volunteers. Once we got the volunteers, these same
> articles attracted patients.
>
> After we were open about six months, I'll give you an example, we had
> only predicted to have 250 patients in our initial six months in Med
> Bank and that would have been with most of our physician population
> participating. We were way off on the number of people that would come
> through on that. We had only 19 physicians participating after six
> months and we had almost 1,000 patients. So it alarmed us to the
> degree that we didn't want to be creating expectations that we
> couldn't meet.
>
> So we stopped doing a lot of the sort of, if you will, billboard type
> of activities to make people aware of us. We started to address our
> marketing approach more to professional groups that could provide us
> either with volunteers or financial wherewithal. We started to do
> patient awareness not in such an overt fashion; we worked with the
> hospitals, who have our phone number and our services listed on their
> discharge criteria. We worked with the Health Department, we worked
> with the college, but we ceased doing things that would attract the
> patients in such a volume that we couldn't handle it.
>
> Quite frankly, that has been sufficient; we have a waiting list for
> our clinic of about four weeks now in each clinic. Every time there is
> a story done on us, and we received a large contribution from the
> hospital last week, and that was in the newspaper, and every time we
> do that the patient phones leap off the hook. It's estimated that we
> have 22,000 eligible people and you can imagine when people become
> aware of that, the demand for services is huge.
>
> Volunteer clinics are merely scratching the surface of what needs to
> be done in health care. As far as some of the things we're doing here
> in addition to the free clinics and CMAP, we have, in order to address
> the need among the Medicaid and people with underinsurance, we have
> applied for a community health center grant from HRSA and formed a
> separate non-profit in order to do that. That's critical; we will be
> working with the state of Georgia on some of these upcoming novel
> approaches to insuring some of the small employers. So we're trying to
> take a holistic approach.
>
> But as far as marketing goes, you have to time that to where you are
> in your development and you have to target it as to just what it is
> you're trying to attract. If you're trying to attract volunteer
> physicians and nurses and skilled laypeople, then you have to go where
> they are. If you're trying to attract the patients, if you have
> difficulty doing that, then you go where the patients are made aware,
> at health clinics and health fairs -- and we did those health fairs in
> the beginning and we provided free blood pressure screenings and those
> types of things in order to attract patients.
>
> Now our patient load is steady and continuous and as that grows we
> have had to emphasize volunteer recruitment and resource development.

Eric I have a question.

Frank Go ahead.

Eric This is Eric Baumgartner. I really appreciate the incredible work
that you all have been doing in sharing that with us. I wanted to ask
you, I've heard some confusion in the past and perhaps you can clarify,
there is a distinction between the indemnity on whatever the vehicle is,
the protection of volunteer physicians based on their not being paid so
that's clear, versus the patient paying something to the clinic and they
cover some of its administrative costs and so forth. Do you understand
the question?

Frank There is an interesting footnote on the federal register and it
sort of contradicts itself, but it does provide some clarity. On the
section where it talks about a free clinic's ability to charge, under
the act, and I'll read directly from this, it says, "Subsection A" under
paragraph two under "Definition of Free Clinics," it says that a "free
clinic is a health care facility operated by a non-profit private entity
that" and then it lists a number of things here. "One, in providing
health care does not accept reimbursement from any third-party payer,
including reimbursement from any insurance policy, health plan or
federal and state benefits program. And two, in providing health care,
does not impose charges on patients to whom services provided or imposes
charges on patients according to their ability to pay" and it has an
asterisk there.

> If you go to the asterisk, it says at the bottom, "Free clinic
> entities may impose charges based on a patient's ability to pay, but
> in so doing, negate the FTCA coverage of the volunteers for the
> specific services for which the clinic received payment." I'm not an
> attorney, but the way I read that is if you do ask for payment from a
> patient on their ability to pay, then you may, as it says there,
> negate your coverage under the federal act.

Gail I just wanted to put in also that the other couple of things that
make it a little unclear from, as you heard, that's the actual wording
of it. So it's a little bit unclear whether or not does that mean if
some of your physicians receive, you know, you don't collect any payment
from them to provide primary care, but you collect payment for dental
services, does that mean your dentist can't be covered but your
physicians are? So that is something that we've asked HRSA for
clarification on.

> The other thing is it includes saying that you can accept donations
> from your patients, but we just want to clarify, nowhere does it
> stipulate if there is a maximum donation, nor does it discuss what if
> all of your patients happen to donate \$5, which might be in lieu of
> what used to be a charge of \$5. You know is that something that's
> going to put up a red flag?
>
> But that's the federal law, and the state laws all vary and some of
> the state laws don't talk about payment at all and some of them do. So
> that's really dependent, and eight of the states have a very similar
> program as a federal program, so it's only in the other states that
> don't have that that the federal program might be more applicable than
> what the eight states that do have the program already have.

Frank Further on that, in the legal opinion that we received, as I
alluded to when I was talking, that they closed legal opinion with this
phrase, and that may help you -- this is under Georgia law, but they
incorporated what they felt was an accurate interpretation of the
federal statute as well. They closed it with, "To ensure the maximum
degree of community protection for the health center and its volunteer
providers, we would also strongly suggest the following steps be
considered: Post notices in the clinic saying doctors and others don't
expect compensation. Two, obtain written acknowledgement from
participating providers agreeing not to accept compensation, even if
offered. And three, draft a release form to be signed by patients,
informing them of the immunity statutes and how this impacts their legal
rights."

> Now is that going to, in every case, as Gail said, in every state, is
> that going to necessarily apply? You have to look up your own state
> laws. But in general, even if there is a strong Volunteer in Medicine
> protection, it was our law firm's opinion that we should look at doing
> those additional things in addition to not charging.
>
> Any other questions?

Michael Just one follow-up, because the example that Eric used was
really the suggested payment or the suggested donation was not for the
clinical care delivered but maybe the core costs of turning on the
lights or that. I mean, does that create some potential comfort from the
immunity or is your guidance you better talk to your lawyer?

Frank Right, no, I wouldn't say talk to your lawyer. The main reason
that these legislations and these protections are there is so that
physicians and your professional volunteers feel comfortable in
volunteering within your clinic. I wouldn't feel comfortable going to
some of our doctors saying, "Well our lawyers say this is fine." But
some of our physicians have said, "Why don't you just put a tip jar" so
to speak, "on the counter, that somebody, if they want to throw \$1 or
\$2 in there can do that to help keep the lights on?" I haven't heard
anyone, lawyer, doctor or anyone, come up with any kind of proof that
you couldn't do that.

> The reason we don't do that is, as I said, to keep the comfort level,
> to keep that barrier of comfort there for the physicians. If any of
> our doctors would feel uncomfortable with us doing that and therefore
> wouldn't volunteer, then I'm not sure it's worth it. So that's a
> management decision and something you would discuss with your
> physicians; but we have no reason to believe that just doing it in
> sort of a tip jar, accepting contributions of some sort somehow would
> break that veil of immunity. I don't know how to answer that
> otherwise.

Gail That's an interesting distinction about the money going to the
clinic. The laws are very clear, both the federal and the state laws,
that the clinician has to be volunteering and receive no payment and
there is some allowable for reimbursed expenses, but it is very clear
that there can be no payment to the clinician, so any donation has to be
directed towards keeping the lights on. That's really where the question
lies.

> It's, particularly in ... federal law, because we're talking about
> money flow to the clinics but the clinic itself would not be covered
> by the federal law.

Frank Okay, any other questions?

> Thank you. I've enjoyed it.

Michael Thank you, Frank. Bob?

Bob Am I there?

Michael Can you tell us what's going on in Vermilion Parish?

Bob First of all, I'd like to thank you all for inviting us to do this.
I want to thank Frank and Gail; so much of their story, especially
Frank's story, could be our story with our physicians practice free
clinic out here that it was crazy, so I won't be mad at him for stealing
some of my story. But I just want to -- and I agree with Gail's point
that she made earlier, about the local communities making local
solutions. That's what Vermilion Health Network is; it took leadership
of the three hospital districts to get it together and go out there and
start the program.

> I'd like to start off with our virtual dental clinic. It has been a
> real stealth performer for the Vermilion Health Network and Vermilion
> Parish. The ableness to perform the task came indirectly when our
> executive director created a health benefits counselor position. As
> our counselor started going around the Parish, counter to the rest of
> you guys, one of the local dentists heard about her service and called
> her and said he wanted to sign up, what was he to do. Our executive
> director then grabbed the ball and took off running with it. She
> called Baton Rouge, where they had already had a virtual dental
> clinic. We took that template and started using it for our system.
>
> The VNet staff handles all appointment scheduling; there is no direct
> pressure on any of the dentists to take a patient. All possible
> patients who may want the appointment must first call VNet staff and
> they must see a physician over at our charitable clinic. The clinics
> are verifiers of income eligibility and physicians verify that the
> patient actually needs a dental service. Then VNet sees if they have
> an open slot in one of our prearranged appointments.
>
> When I say "prearranged appointments," early on we made a pact with
> our dentists not to bombard them with as-needed visits; instead, VNet
> staff calls once a month and asks how many slots are available with
> each one of our dentists around the Parish. We have found this keeps
> our working relationship with our dentists at an optimal level. VNet
> works by tracking the dental hours, they calculate the value of the
> services by dental code and reports to the dentists on a regular basis
> on the services that he has performed over the month.
>
> I believe a great deal of our success of this program has been the
> covert participation of our dentists. These guys wanted to help, but
> no way they wanted phone calls from patients or VNet staff begging for
> extra appointments. You know, they didn't want that, "We found this
> little girl and she just needs help today" thing, because they didn't
> want that pressure because they knew they would have to take them. We
> know what slots we are allowed and patients go to them and we use no
> more than what they give us. We have found that over the last few
> months they have actually given us more slots when they see how
> efficient it works and it doesn't upset their staff at all.
>
> The hospital backup for our charitable clinic has been a natural
> outflow of the fact that our hospital districts are the Vermilion
> Parish Health Network. They made a huge push to get the charitable
> clinic off the ground, but both the hospitals in the Parish provide
> x-rays, labs, and the facilities to provide the clinics, both in
> Kaplan and in Abbeville, two towns in our Parish.
>
> We work with the Gardner Center in the third town through a voucher
> card system, kind of like our virtual dental clinics. It's just in the
> infancy stages, started about two months ago, where Gardner has agreed
> to see up to say six pap smears and track six diabetic patients a
> month for the free clinic programs. So they come in with a card system
> and we know it was a prearranged appointment, this is a free patient
> from the free clinic and Gardner is giving us some administrative
> adjustments down to free, to see these patients and keep them tracked.
>
> In December we are going to evaluate the program after we collect the
> data over the first quarter to see if we can expand it, possibly to
> other providers and other services in the Parish, to show the other
> private providers out there that we're not that big of a hassle to
> them to work on. We also, of course, have our PAP in charitable
> pharmacy program. This program is on the verge of reaching the \$1
> million mark for this year alone. It came close to the \$1 million
> last year of prescription drug assistance and this year we think we're
> going to cross over \$1 million pretty soon.
>
> Our outreach worker is currently working with 55 physicians in the
> Parish, although 40 of them in the Parish and 15 are specialty ...
> outside the Parish. It's incredible respect from their staff for our
> outreach worker that has really grown; when we started we probably had
> four people in the Parish, providers doing any PAPs in their office
> and now we're over 40. We also have a charitable pharmacy, open every
> night the free clinics are open and to add ... hospital. We have ten
> volunteers that work with our volunteer pharmacists to assist in
> verifying qualification and going through days of the paperwork before
> and after the clinic on clinic nights.
>
> The good thing about where we are down in Cajun country, Louisiana, is
> our culture of extending a hand to the others. We know our neighbors;
> we don't just recognize them when we see them. When it comes to
> attracting volunteers we have no problem. Our clinic or staff, the
> laypeople in our clinic are city councilmen, bus drivers, registered
> nurses. We have people who qualify for services that actually come
> back and do some volunteer work.
>
> On our physicians and dental side we are having very good success with
> the virtual aspects of it. The physicians are a little bit harder to
> find, but we're having a very good relationship with our mid-levels,
> nurse practitioners and physician assistants helping us out on our
> free clinics. But we've found that our virtual model our providers
> seem to like the most, they seem less overwhelmed and therefore
> they're willing to come back and do more for us.
>
> Like I said, much of our story goes along with Frank's; I don't want
> to repeat everything he said about building up -- how we started out
> and everything, because it goes along the same line. But if anyone has
> any questions, I can try to help and answer or extend my explanation.

Michael Bob, could you talk about how your Federal Office of Rural
Health Policy Network grant touches the series of services? I mean, is
the outreach worker connected with the grant? Is the other position you
talked about, the benefits counselor, how does the federal support kind
of touch these clusters of services?

Bob It's exactly what it is. We couldn't have done it without it,
Michael. The Vermilion Health Network is a federal development grant
form HRSA. This grant has allowed us to hire the outreach worker who did
all of the services on Medicaid applications, helping setting up with
the dental program, helping setting up with the PAP program. Every
service that we have has come from the HRSA grant.

> It originally was the three hospital districts and our Parish
> government got together and decided what can we do to take care of
> those people out there that aren't getting the services they need. We
> sat down probably for about a year and a half before we got the HRSA
> grant and just got over our, as I call it, the whole football
> mentality of Vermilion Parish, you know, one end doesn't want to help
> the other because of some football game 20 years ago or something, or
> a competition between the hospitals. We just all sat down and said,
> "Abbeville has this, hospital district two has this, let's put it
> together and use it in the best ways that we can." We went out with
> that idea and got the HRSA development grant. It gave us the money to
> go out and hire employees that can help us do this.
>
> I mean, the people on the board, like all the boards, of course have
> their own jobs, taking care of their own hospital district stuff in
> their own area, and this has given us the ability with Margaret
> Jackson, our Executive Director and our outreach worker to go out and
> perform the tasks that we can identify and find the new stuff to do.

Michael Now, Bob, are you a little bit like BiNet, have you built in
some sort of fee structure into either your Medicaid eligibility work or
to your PAP program? I know that BiNet has received some compensation on
that end; are you guys following that model?

Bob We are. BiNet is kind of our big sister, so we kind of follow
everything that they do along the line somewhere. We are receiving fees
for our Medicaid application program. We receive some fees on the PAP
program.

> We also do benefits to local businesses and we're hoping to start
> collecting fees on that area. Our benefits counselor goes out to the
> local businesses and speaks to their employees and finds what health
> care benefits they do have that they don't know about. Like we had one
> of our municipalities in the Parish cut out employee health insurance
> about three months ago and we went out there and our health benefits
> counselor went out there and spoke to them and really eased off on
> some of the nervousness of the employees and told them, "You all have
> benefits you all don't know about. Here are some benefits you can draw
> from" and we were hoping to be able to start charging something for
> those fees also.

Michael Who would you charge in that instance, the business or?

Bob The businesses; they have been calling us out. We've probably had --
there's been an automobile dealer that called us out last month and
other businesses like that that have been asking us to come do it after
some of their employees, whose spouses were employed by the
municipality.

Michael So in this instance, they payment would be for if some of the
employees were also eligible for other benefits that they didn't know
about, is that kind of the deal?

Bob That is correct.

Michael Okay, that's an interesting approach. Other questions for Bob?

Margaret Mike?

Michael Yes?

Margaret Let me say that in Vermilion Parish, I'm a part of that staff,
and the board really has been such a buttressment, such a support for
evolving the concept and then putting together the structure that
supports everything else. First it was conceptual, as Bob said, to
recognize that there were a lot of things that would benefit everyone,
and secondly, the infrastructure that the board helped put in place
allowed for the volunteers to be trained to have that sense of
satisfaction that we talked about earlier, to say, "Do you know what the
opportunity is?" They are very well supplied with recourses and backups
for questions.

> So the volunteers, thanks to the board members' effort in putting all
> this together, the volunteers have a very ... volunteer situation,
> where they feel the appreciation every time they come to work because
> they see that the progress is being made. The infrastructure feeds
> back to them on a monthly basis how many people were cared for, how
> much dollar value was given out and so on. So the board deserves a
> tremendous amount of credit.

Michael This is Margaret, right?

Bob Yes, that's Margaret Jackson, our Executive Director.

Michael Margaret, I really appreciate that comment, because my sense is
that many of these provider volunteer projects have a charismatic
physician leader who starts the whole ball rolling and my sense is that
maybe there's a bit of that in Vermilion Parish. But your comment also
says that it was a wide variety of folks, including folks from the
hospital community, that got over some of the traditional issues that
had kept people apart and that there is a ton of people in Vermilion to
pass the credit around. Is that a fair statement?

Margaret Very fair.

Bob I agree with Margaret on that, there really is. It took a
community-wide effort and it took, the whole Parish came together for
the effort.

Michael Thank you both. I think -- Pat, help me if I'm not tailing this
out the right way -- but my sense is that we may be reaching the end. We
can now open it up for any sweep of questions for any of the speakers
and if we don't get those then we want to thank everybody for
participating and we do know that this thing has been taped and you will
have the opportunity to visit it at a later point in time.

> Thea, do you have the date for the next call?

Thea I have it, Michael, January 26^th^.

Michael January 26^th^.

Thea Right, and we'll be getting information out regarding the actual
topic. We've got some ideas and we're certainly open to suggestions as
well.

> I'd just like to take the opportunity right now to thank you, Michael,
> for pulling this together; you really did a fantastic job. And Gail,
> Frank and Bob, thanks so much for your wisdom; expect a few phone
> calls.
>
> What we have found is these conference calls, while they are not ideal
> by any stretch of the imagination, it seems that there is a lot of
> activity after the call, when people want some additional information.
>
> As I said, the next call is January 26^th^ and Michael, Tia and I will
> be back in touch with you, and perhaps Gail, to get additional
> information on the teleconference that HRSA will have on malpractice
> and that chart eligibility and then we'll post it on the LISTSERV.
>
> I would also like to remind every one to check Gail's Web site at
> rxassist.org or volunteersinhealthcare.org; there's a tremendous
> amount of information on there.
>
> Any final questions? Okay, Michael, thank you so much.

Michael You're welcome. Good call. Thanks, everybody.

Thea Bye-bye.

Michael Bye-bye.

Frank Bye-bye.

Gail Thanks. Bye.