The number of uninsured residents in Chicago is higher than the national average; more than a quarter of Chicagoans younger than 65 years of age had no form of health insurance in 2004.1 (In contrast, 15.7% of nonelderly U.S. residents were uninsured in 2004, according to CoverTheUninsured [http://covertheuninsured.org], a project of the Robert Wood Johnson Foundation.2) Because universal coverage can't be implemented at a local level, members of many communities nationwide are struggling to find solutions that will allow their uninsured neighbors and colleagues to access adequate health care. One alternative is the free clinic staffed by volunteers or providers funded by foundations.
One such clinic, the nonprofit Helping Hands Health Center, opened on Chicago's north side in November 2002. Volunteer NPs, RNs, physicians, and other health care workers provided care to uninsured patients. Initially, the energy and enthusiasm of a core group of volunteers and paid staff drove the clinic's development, but over time, the facility's success necessitated making difficult decisions about how to sustain growth.
The founders of Helping Hands Health Center were motivated by one hospital's decision to close one of its community clinics, located in a building where the hospital still had a long-term lease. The hospital corporation offered the facility for two years at a nominal fee to John O'Brien, a physician at the hospital, to establish a free clinic. Dr. O'Brien had previously volunteered at a free clinic for the uninsured, and he immediately contacted Joy Glazer, who had served as a coordinator at similar clinics for the uninsured. Ms. Glazer established an enthusiastic volunteer network of nurses, physicians, and community leaders, and a board of directors and advisory board were formed and became actively involved in the clinic's development. Members were responsible for developing policies and procedures, credentialing and obtaining privileges for physicians and NPs, establishing appropriate documentation for other volunteers, producing brochures and press releases, and writing and implementing a business plan that included procedures for tracking expenditures and charitable donations. The clinic applied and qualified for federal tax-exempt status as a 501(c)(3) organization.
Helping Hands volunteers provided services to anyone who had no private health insurance, did not qualify for Medicaid or Medicare, and could not afford to pay the customary charges at a traditional clinic. No fees were charged for services, though donations were accepted. Because the volunteers did not receive payment for their services, they were protected from lawsuits under the Good Samaritan Act.
WHO ACCESSED THE CLINIC?
During the first few months after opening, the number of visits doubled each month. Within six months of opening, Helping Hands had 200 monthly visits, the cap imposed by its board of directors. Although volunteers were willing to work more hours, the board believed that a bilingual receptionist-data manager and a staff nurse should be hired, for pay, before the clinic could expand further. After receiving a small grant, a part-time receptionist was hired. The number of providers again expanded, and the clinic was able to increase patient visits by 33% in one month.
Helping Hands provided services to a diverse population over a wide area, including 32 city zip codes and eight surrounding suburbs. The clinic served large Latino and Polish communities, in addition to other non-Hispanic whites and African Americans. Some volunteers spoke Spanish or Polish, and interpreters were also available. The services provided included health promotion and preventive care; treatment of routine, complex, and chronic illnesses; laboratory testing; medication (as available); disease management education; and counseling and referral to specialized services.
Patients' primary conditions included uncontrolled hypertension, diabetes, and hypercholesterolemia. Many of the patients had had these conditions for years but had been unable to afford treatment. Women received preventive care, including Papanicolaou tests, birth control, and referral for mammography. Reasons for episodic visits included strep throat, upper respiratory tract infections, and flu symptoms. Depression was also prevalent.
WHAT WERE THE CHALLENGES?
Initially, the community in which Helping Hands was located was skeptical about having a free clinic in the neighborhood, but before it opened, Ms. Glazer and other board members visited the neighborhood police precinct, politicians, and organizations to explain the clinic's mission. The community quickly rallied and showed its support by organizing a fundraising event, providing volunteers, and inviting clinic staff and board members to speak at many community events.
Fundraising was a major challenge for Helping Hands. Although volunteers provided their services for free, many other things had to be paid for, such as laboratory and office supplies, cleaning services, and basic repairs. Many corporations made important donations, including laboratory services and pharmaceutical supplies. Several foundations provided funding. For example, a grant from the Visiting Nurses Association Foundation of Chicago went toward hiring one full-time NP, and the Ravenswood Health Care Foundation funded the salary of a clinic coordinator. Direct mail solicitation and board members' speaking engagements before community organizations also raised awareness about the clinic and its needs.
Recruiting and retaining volunteers were constant challenges. Despite the dedication of a central group of volunteers, more were needed as the number of patients grew and the clinic's hours of operation expanded.
In addition, Helping Hands staff were frustrated by the fact that patients who were eventually covered by insurance because of employment or public aid could no longer use the clinic, negatively affecting the continuity of their care.
WHO WERE THE VOLUNTEERS?
Nurses and others volunteered at the clinic for many reasons. Nurses who were not working-because of retirement or family responsibilities-cited the opportunity the clinic gave them to maintain their skills and a connection to nursing. Academic nurses also saw it as an opportunity to provide direct care. Still others wanted to support the uninsured simply because they'd at times lived without insurance themselves. Some worked one clinic session each week, others worked once a month.
The feelings of Susan Gatziolis, MS, RN, one of the clinic's founders, illustrate why volunteers work in clinics like Helping Hands. She initially volunteered several days each week, providing assessment, laboratory and diagnostic testing, documentation, referrals, and education. While physicians tended to volunteer one or two days a month, many nurses volunteered more often, so patients got to know them. "The nurse was the most consistent person on the health care team," Ms. Gatziolis said. "It's the nurse who followed up with patients and solved problems."
In addition to patient care, Ms. Gatziolis oversaw daily clinic operations, developed policy, assessed resources for patients and the community, provided education to staff and patients, implemented technologies within the clinic's budget, and developed resources. She described why she committed so much of her time: "I wanted to help the clinic get on its feet. People had gone to other clinic systems and came to Helping Hands because we treated people with dignity. We put them on the road to taking better care of themselves," she said. "The clinic needed nurses."
WHO WERE THE PATIENTS?
Although patients were not charged for services, many donated generously. The stories of two patients (their names have been changed to protect their privacy) are indicative of the circumstances that brought people to the clinic, as well as their appreciation for the care they received.
Henry Jones, 54, made a donation even though he was unemployed and had only $5 in his pocket. A taxicab pulled up as Mr. Jones left the clinic after his appointment on a cold, rainy night, and the driver asked him if he had just been seen at the clinic. When Mr. Jones said yes, the cab driver said that he too had been a patient there, and he offered Mr. Jones a free ride home as a way to repay the kindness of the clinic staff.
Leslie Clark, a 34-year-old single mother with diabetes, asthma, and hypertension, lost not only her job but also her family's health insurance. Her network of emotional support was fraying because of a recent death in the family and other family members moving out of state. When her daughter became ill, Ms. Clark hoped that the health center at her daughter's high school would dispense enough medication for both of them. When the school nurse learned about the family's need, she referred them to Helping Hands for treatment. Ms. Clark called the clinic and was seen that week.
"The staff is beyond superb, always helpful, answering any question," she said. "It is better than care I received when I had insurance." After coming to the clinic she followed a recommended diet, lost 30 lbs., and took the medications that were prescribed for her chronic conditions. She received free medications through a program sponsored by several pharmaceutical companies. Laboratory work was performed at no cost at the clinic when she came in for appointments.
HOW DID THE CLINIC EVOLVE?
The growth of Helping Hands forced unexpected decisions. For example, the central group of volunteers could not accommodate all of the patients. Also, as the initial two-year lease neared expiration, the board had to decide whether to move to a new location or try to raise the money to stay in the existing space. The challenges of fundraising exceeded the talents and time constraints of the largely volunteer staff.
As these issues were being explored, a new option came to light: becoming part of the significantly larger and well-established Erie Family Health Center. The 45-year-old organization had a strong reputation for providing bilingual, culturally competent service to the rapidly growing Latino population and, as a federally qualified health center, could receive federal grants and other forms of reimbursement for services to the uninsured and medically underserved. Finally, because Erie served not only the uninsured but also patients with Medicaid, Medicare, and private insurance, continuity of care could be sustained when patients obtained insurance. Erie saw acquiring Helping Hands as a relatively safe way to expand, because the clinic already enjoyed the support of local community leaders, legislators, and private foundations.
Helping Hands lives on as Erie Helping Hands Health Center, one of seven Erie Family Health Center sites. One of us (JJZ), an original Helping Hands board member, is a voting member of Erie Family Health Center's board. Some of the original volunteers and paid employees remain, while others have taken on different roles or are no longer involved. Erie Helping Hands continues to fulfill its mission to provide care to the uninsured.
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