1. Garner, Catherine DrPH, MSN, RN, FAAN

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One of the most significant reasons for repeat visits to the ED and readmission to acute care settings is patients not having an established primary care provider. Those without health insurance are less likely to have a primary care provider, seeking care in EDs for nonmedical emergencies or delaying care, resulting in worsening conditions. Despite the advances of the Affordable Care Act (ACA), many citizens still can't afford medical care or health insurance. Even in communities where health insurance is affordable, the nation's shortage of primary care providers is a frequent barrier to establishing a medical home and being able to access it in a timely fashion.

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Filling the need

Starting in the early 1960s, many communities around the nation recognized that indigent people needed access to healthcare. Since then, some 1,200 free clinics in the United States provide care for people with no access to established medical care. The free clinics rely on volunteer physicians (often retired) and NPs, along with countless other volunteers to provide care in a less structured setting. Some of these settings have paid staff, supported mostly by community grants and donations. These clinics serve as safety-net organizations, providing a range of medical, dental, pharmacy, vision, and behavioral services to those who meet the financial guidelines of the individual clinic, usually up to 175% of federal poverty level and not eligible for Medicare and Medicaid. The federal government establishes the poverty level each year. In 2016, the threshold for an individual is $1,733/month and a family of four is $3,544/month.1


The National Association of Free and Charitable Clinics (NAFC) was established in 2001 for clinics to work together to educate policy makers, the press, and the public about the plight of those who have no access to healthcare. Members share ideas and resources across the nation. The organization has helped establish partnerships with major pharmaceutical vendors to provide discounted or free medications to free clinics. The NAFC reported 5.9 million patient visits to free clinics across the nation and more than 160,000 volunteer providers.2


South Carolina case study

The South Carolina legislature has consistently decided not to expand the state's Medicaid program after the advent of the ACA, leaving approximately 587,877 adults without health insurance. The public health infrastructure is weak to nonexistent in most counties. South Carolina ranks 13th in the nation for the highest percentage of the population living in rural areas. The estimated poverty rate for rural areas of South Carolina is 23.9%. South Carolina has the 33rd lowest number of primary care physicians, with just 77.5 per 100,000, compared with 90.1 nationally. Almost every county (or part of it) has been designated a primary care shortage area.3


In response to concern over the high rate of uninsured citizens, the state legislature appropriated funds in the 2014 fiscal budget for hospitals in select communities to address the needs of the uninsured through appropriate utilization of health resources and improvement in health indicators. The initial intent was to identify low-income, uninsured, chronically ill "high-utilizers" of hospital services. Greenville County is located in the northwest corner of the state, with approximately 73,359 uninsured residents. The area has two major health systems: a multihospital academic health center and a nonprofit Catholic system. Multiple stakeholders met to determine how to proceed. What resulted was a proposed system of care-the Healthy Outcomes Plan (HOP)-that included the hiring of hospital case managers to identify indigent patients without a medical home and establish them with either the Federally Qualified Health Center or the Greenville Free Medical Clinic (Free Clinic).


The Free Clinic was established in 1987 to serve the uninsured of Greenville County. By 2015, the clinic had four sites, with over 400 volunteer healthcare providers and 200 nonmedical volunteers, and 14 full-time and 7 part-time staff members. In 2015, the clinic served over 4,000 patients as their primary medical home, with 9,429 primary or specialty medical visits. The dental clinic, partnered with the Medical University of South Carolina College of Dental Medicine, provided 2,296 free dental visits. The pharmacy dispensed nearly 41,000 prescriptions/refills, valued at $7 million. Volunteer health educators provided health education classes and over 300 bilingual diabetes class visits. Both area hospital systems have long-standing relationships and provided substantial free diagnostic and radiology support to the Free Clinic.


The Catholic Health System, located within the same neighborhood as the Free Clinic, provided the salary for an additional full-time NP to handle the referrals to this program from the hospital case manager. Social workers and case managers in the ED and during hospital discharge planning identified patients with no medical home and made follow-up appointments for them at the Free Clinic. One case manager frequently met patients at the Free Clinic to introduce them to providers and staff, establishing a relationship that improves the likelihood of patient engagement. Care management plans were developed for these individuals to address a wide variety of medical and social/behavioral issues. The majority of the patients have multiple comorbidities and take multiple medications, with the top diagnoses of hypertension, heart disease, and diabetes. Documentation of patient need has resulted in the Free Clinic receiving a grant to fund a part-time licensed professional counselor to work with patients with social and behavioral health issues.


One year later, the patients who were consistent with their care plan for at least 6 months improved on 16 health outcome measures, with a 11.01% relative decrease in overall preventable inpatient stays and a decrease in 7- and 14-day inpatient readmission rates. There was also a significant decrease in emergency visits for primary care treatable conditions in this population.4


Similar outcomes with patients referred from the academic health center have resulted in new organizational funding for another full-time NP and part-time pharmacist to serve this population. Both hospital organizations have now implemented the same health information management systems. Combined with this support and a grant from the South Carolina Department of Health and Human Services, the Free Clinic will be fully networked into both systems by the end of next year, adding to the timely flow of information from one service site to another.


Planning for positive outcomes

The HOP is generating statistics to show to policy makers that consistent transitional care planning and management in this high-risk population can yield positive health outcomes and financial savings. The successes have come from a collaborative community-wide endeavor to coordinate resources to create a broader safety net. Similar relationships are happening in other communities. In addition to connecting with free clinics for patient care, consider volunteering your time and expertise to this underserved population. Information on free clinic locations can be accessed at




1. Federal poverty level. [Context Link]


2. National Association of Free and Charitable Clinics. Infographic and report. [Context Link]


3. Sciway. South Carolina-income and poverty statistics. [Context Link]


4. SCDHHS. Healthy outcomes plan. [Context Link]