January 2004

Grant Results

National Program

Reach Out: Physicians' Initiative to Expand Care to Underserved Americans

SUMMARY

Starting in August 1994, a managed network of volunteer medical providers called Commun-I-Care continued ongoing efforts to provide non-emergency health care to the uninsured poor in South Carolina.

Besides its volunteer health care workers, Communi-I-Care worked with four (and later five) free clinics and 22 hospitals statewide.

The state Department of Social Services provided patient referral and social services and four major pharmaceutical companies donated many medications.

Commun-I-Care's central office verified eligibility of clients and made physician referrals. Clients were offered one free health care visit per year, although providers often extended their free services as needed.

The project was part of the Robert Wood Johnson Foundation (RWJF) national program Reach Out: Physicians' Initiative to Expand Care to Underserved Americans.

Key Results

  • During the period of RWJF support, Commun-I-Care enrolled an estimated 17,500 patients.
  • By the end of the period, it had assembled a network of over 1,500 volunteer health workers, including some 1,100 physicians, 60 nurse practitioners and 100 dentists.
  • Thirty one hospitals offered free care to clients.

Funding
RWJF supported this project with a planning grant of $100,000 from August 1994 to July 1995 and an implementation grant of $200,000 from August 1995 to July 1998.

 See Grant Detail & Contact Information
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THE PROBLEM

In 1992 South Carolina ranked last in the nation in per capita spending for health care. Over 600,000 of its citizens had no health insurance; approximately 300,000 of these held jobs but did not qualify for Medicare or Medicaid.

In 1990 it was estimated that 15 percent of uninsured South Carolina families who needed health care did not get it at all, and 31 percent of uninsured chronically ill adults did not get needed care because they could not pay. In South Carolina, the most medically at-risk were children, African Americans and women, who tended to live in the poorer eastern part of the state.

Complicating matters, physicians sometimes chose not to practice in areas where poverty inhibited payment. Geographic barriers, transportation difficulties and lack of knowledge (some of it very basic: for example, how to make a doctor's appointment), also affected significant segments of the state's population.

On the brighter side, in 1990, roughly 13 percent of total physician costs in South Carolina were for care given as charity, at a reduced rate or written off. Still, in these instances physicians were not able to supply expensive pharmaceuticals, arrange for hospital services or refer patients for lab tests, imaging or specialized care.

Commun-I-Care began life in 1993 as an initiative of the Palmetto Project, a private nonprofit South Carolina organization founded in 1984, which sponsored volunteer programs in education, disaster relief, youth community service, race relations and other community based activities.

Modeled on a 1986 Kentucky effort and another in Arkansas, Commun-I-Care was a managed network of volunteer medical services and donated supplies, providing non-emergency care to uninsured South Carolinians with incomes below the federal poverty line. Roughly half of Commun-I-Care's $300,000 annual budget before the RWJF grants came from public sources. The Samuel Freeman Charitable Trust and BlueCross/BlueShield also provided the project with seed money. Other contributors were the Physicians' Health Plan of South Carolina, the Public Welfare Foundation and nearly 400 individual citizens.

Prior to the RWJF grants, Commun-I-Care had recruited approximately 530 volunteer general practitioners and specialist physicians, set up a toll-free number for client inquiries and secured agreement from four of the state's six free health clinics to accept Commun-I-Care referrals.

It had also secured the participation of three drug manufacturers, Pfizer, Johnson & Johnson and SmithKline Beecham, that all agreed to contribute free drugs through a participating pharmacy. An advisory council was in place (comprised of local and state agency personnel and representatives associated with Blue Cross/Blue Shield of South Carolina).

Imaging, lab work, overnight care and emergency care were integrated into the project via participation by about two dozen of the state's hospitals. In the period prior to the RWJF grants, Commun-I-Care had served almost 1,500 people, most in urban areas (Columbia and Charleston). Additionally, throughout 1994, Commun-I-Care was implementing pilot immunization outreach campaigns across the state in coordination with the Department of Social Services, as part of South Carolina Governor Carroll Campbell's campaign to raise levels of immunization among South Carolina's most at-risk 0–2 year olds.

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THE PROJECT

Commun-I-Care continued to build on the contributions of collaborators including the South Carolina's Medical Association, Pharmacy Association, Hospital Association, Nursing Association, Dental Association and the State Office of Rural Health. It operated from offices in Columbia. Its most active supporters were:

  1. The South Carolina Medical Association, which was instrumental in recruiting its member physicians as volunteers and securing needed partnerships with hospitals and pharmacists.
  2. The South Carolina Department of Social Services.
  3. Commun-I-Care's advisory council (headed by the immediate past president of the South Carolina Medical Association).
  4. A host of other supporters and collaborators, including insurers, pharmaceutical companies and others.

Commun-I-Care's central office managed a toll free phone for client inquiries, determined eligibility of clients, managed a database of system records (referrals, participating doctors and clients' clinical files), matched clients to volunteer doctors and conducted extensive program outreach. Local Department of Social Services caseworkers referred people to the program, and Commun-I-Care regularly compared its client database to the Department of Social Services' Medicaid lists to avoid duplicate coverage. RWJF grant funds were used for the ongoing administration of its network of volunteer physicians, client referral, extensive outreach activities and special activities such as HIV assessment, and a group studying potential client's difficulties accessing care called the Barriers Task Force.

The Commun-I-Care Model

When an individual needed care, he or she called an "800" toll-free number and was prescreened for eligibility by Commun-I-Care staff. Prospective clients were sent a one-page application or were referred to a local Department of Social Services office for one. The Department of Social Services caseworker or Commun-I-Care staff helped individuals fill out this form, then Commun-I-Care made a final determination of eligibility.

Medical care was available to individuals with income below the federal poverty level who did not qualify for Medicaid. Those eligible were then referred to a Commun-I-Care volunteer doctor or health care provider for free medical care — either at the doctor's office or in a clinic. Physicians who donated their time to Commun-I-Care specified how many patients per month they wished to see, and Commun-I-Care's computer monitored the volunteer workload.

Initially, Commun-I-Care offered the medically uninsured one free visit to a primary health care provider for non-emergency care. Although Commun-I-Care did not ask volunteers to see Commun-I-Care clients on an ongoing basis, most Commun-I-Care physicians absorbed clients into their regular practice, as needed. Commun-I-Care physicians prescribed from Commun-I-Care's formulary of donated drugs where possible; pharmacists in the client's zip code area, who waived their dispensing fees, filled these prescriptions. Although initially Commun-I-Care hoped to provide some transportation services for clients, legal concerns made this unfeasible.

Planning Phase

Commun-I-Care was already operational during the period of the planning grant (August 1994 to August 1995). In this period Commun-I-Care received 15,804 phone calls from prospective clients, mostly in urban areas. Outreach began in earnest in late 1994, with television, radio, billboard and print advertisements (and a number of print stories); mailings to potential clients with their food stamps and unemployment checks; and staff outreach to community leaders, schools, churches, rural electrical cooperatives and other community groups.

With grant funds, the project hired a full-time outreach coordinator. In May 1995, Commun-I-Care's parent, the Palmetto Project initiated "Heart & Soul," an initiative that trained volunteers in local rural African American churches to monitor blood pressure and teach healthy lifestyles to congregations.

Collaborators included the South Carolina Department of Health and Environmental Control and the South Carolina Coalition of Black Church Leaders. However, throughout 1995, rural client recruitment proceeded more slowly than expected. In June 1995, the Palmetto Project, in the course of three televised community forums addressing barriers to health care access for the uninsured in the state, confirmed that transportation was a significant problem for many potential patients in rural areas with few practicing physicians. Recruitment of volunteer dentists and nurse practitioners into the Commun-I-Care network began during the spring of 1995.

Implementation Phase

To recruit providers, Commun-I-Care reached out to health departments in rural areas and statewide health care associations, and used pharmaceutical representatives to distribute information about Commun-I-Care to rural doctors and nurse practitioners.

As already noted, Commun-I-Care found unexpected difficulty in reaching Commun-I-Care's potential rural client population, many of whom live in a world isolated from traditional channels of mass communication. In 1996, Commun-I-Care hired a national advertising firm, Newman, Saylor & Gregory, to coordinate a renewed advertising campaign, particularly targeting rural areas.

This client outreach included public service announcements run regularly in all television media markets, posters, brochures in Department of Social Services offices and a statewide billboard campaign. During 1996, Commun-I-Care also began two pilot projects of community-based screening, treatment and education in 58 African American churches in South Carolina.

The most successful outreach, however, remained the most direct: flyers of solicitation in the envelopes containing food stamps and unemployment checks and referrals from Department of Social Services caseworkers.

New state laws allowing nurse practitioners greater flexibility in the treatment of patients, in areas where physicians are scarce, increased recruitment of patients. In 1997, Commun-I-Care began encouraging its providers to absorb into their practice patients with chronic conditions needing ongoing care. It also targeted recruitment at state medical schools' Family Practice Residency programs — many of which were already seeing Commun-I-Care patients — by using the resultant access to free pharmaceuticals as an incentive to establish medical homes for these patients.

In addition, Commun-I-Care recruited an Academy of Family Practice board member to join Commun-I-Care's board. In 1997, Commun-I-Care was spun off from the Palmetto Project, becoming a freestanding nonprofit organization. It is governed by the six health care provider associations in the state: the South Carolina Medical Association, South Carolina Pharmacy Association, South Carolina Hospital Association, South Carolina Nurses Association, South Carolina Dental Association, and the State Office of Rural Health.

Since its inception in 1993, Commun-I-Care received support from a number of sources besides RWJF. See the Appendix for a list of other supporters.

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RESULTS

  • During the grants period (August 1994 to August 1998), Commun-I-Care enrolled an estimated 17,500 patients. By the end of the grants period, the network had over 6,000 active patients in the system.
  • By August 1998, Commun-I-Care had developed a network of more than 1,500 volunteer physicians and other health care professionals. This figure includes approximately 1,100 physicians, 60 nurse practitioners and 100 dentists. Collaborators also included approximately 240 pharmacists. Thirty-one hospitals had signed on to provide free services.
  • Four pharmaceutical companies (Eli Lilly, Johnson & Johnson, Searle and Pfizer) provided a comprehensive formulary of free medications for all Commun-I-Care patients. This was particularly valuable because of the relatively widespread incidences of diabetes and hypertension among Commun-I-Care's target client population, illnesses that respond readily to drugs available through the Commun-I-Care formulary.

Evaluation

In the spring of 1997 Commun-I-Care commissioned a project evaluation conducted by a faculty member of the Medical University of South Carolina in Charleston. Findings, based on Commun-I-Care statistics and surveys of 138 volunteer Commun-I-Care providers and 277 Commun-I-Care patients included the following:

  • Six chronic conditions comprised over 60 percent of the chief complaints of Commun-I-Care patients. These were hypertension (23.7 percent), diabetes (12.5 percent), arthritis (10.1 percent), anxiety/mood difficulties (7.1 percent), asthma (3.9 percent) and allergies (2.9 percent).
  • The uninsured working poor will delay medical care because they cannot afford treatment. For some, seeking care through Commun-I-Care will also be delayed because of the one-visit limit initially imposed by Commun-I-Care.
  • While patients were guaranteed only one free visit a year, many Commun-I-Care general practitioners, and 72 percent of its specialist volunteers, had continued to see a Commun-I-Care patient at no cost after the first visit.
  • Providers and clients alike reported high satisfaction with Commun-I-Care, and experienced little difficulty in participating.

Communications

Commun-I-Care staff spoke about the project at a number of South Carolina health care professional conferences during 1996 and 1997. Articles about Commun-I-Care appeared regularly in South Carolina newspapers.

The program benefited from media coverage following a February 1997 press conference in Columbia, S.C., featuring then South Carolina Governor David M. Beasley. The event marked Eli Lilly's agreement to join Commun-I-Care's network of drug providers. Public service announcements aired on four radio stations in Charleston (during 1995 to 1997) and regularly in all television media markets. A yearlong intensive billboard campaign aimed at rural areas was initiated during 1996. Commun-I-Care published a quarterly newsletter mailed to between 2,000 and 3,500 providers in the state. For more details, see the Bibliography.

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AFTER THE GRANT

Since the end of RWJF support in August 1998, Commun-I-Care has more than tripled its patient volume. In 2000, Commun-I-Care terminated its adult dental component (because of difficulty retaining providers willing to treat its adult patients, who typically needed complex treatments over many visits), but between 1998 and 2001 Commun-I-Care opened three dental clinics for uninsured children across the state (Greenville, North Charleston and Allendale county).

In 2000 it also began its own mail order pharmacy, accepting bulk donations from seven major drug companies, and shipping prescriptions daily to Commun-I-Care physicians. A database, contributed by ComCoTec, a national insurance benefits administrator, monitors potential drug interactions in Commun-I-Care patients.

In June 2000, Commun-I-Care won a Health Resources and Services Administration "Models That Work" award — one of only six awards given to programs offering innovative solutions for improving the health status of the nation's underserved and vulnerable populations. The award has allowed current Commun-I-Care Executive Director Ken Trogdon to speak extensively to groups interested in replicating the Commun-I-Care model in locations across the country.

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GRANT DETAILS & CONTACT INFORMATION

Project

South Carolina Commun-I-Care

Grantee

Palmetto Project (Charleston,  SC)

  • Planning Grant
    Amount: $ 100,000
    Dates: August 1994 to July 1995
    ID#:  024560

  • Implementation Grant
    Amount: $ 200,000
    Dates: August 1995 to July 1998
    ID#:  027450

Contact

Bartolo M. Barone, M.D.
(803) 933-9183

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Other Sources of Project Support, Including In-Kind Support, August 1994 to August 1998

OrganizationAmountDate
Greenville Hospital System Foundation$150,000May 1998
South Carolina Health and Human Services154,0001994–1995
South Carolina State Agency Funding225,0001994, 1997–99
Sister of Charity Foundation25,000January 1998
Roper Hospital Foundation21,000June 1998
Individual giving7,500during 1998
Pharmaceutical Corporations5,0001997
In-kind SupportAmountDate
Pfizer Pharmaceutical$800,0001996–1998
Eli Lilly and Company510,0001997–1998
Johnson & Johnson Pharmaceutical350,0001997–1998
Searle20,0001996–1998
SmithKline Beecham Clinical Labs10,0001996–1998
Patterson Dental Supply8,0001998
Crest/Procter & Gamble1,8501998
IndividualsAmountDate
Direct Mail Solicitation$10,9881995

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Book Chapters

Bowsher P. "Commun-I-Care." In Case Studies on Economic Revitalization and Health Care, Desmond K (ed). Washington: The Robert Wood Johnson Foundation and the Baxter Foundation, 1995.

Articles

Barone BM, Egan BM, Brown TE, Resch ML, Woodard L, Trogdon KP and Lackland DT. "Commun-I-Care: Experience in the First Four Years." Journal of the South Carolina Medical Association, 94(4): 318–322, 1998.

Skardon S. "Commun-I-Care." Business and Economics Review, 40(4): 3–5, 1994.

Reports

Bowsher P. Strategy Alert: A Quarterly Report of the Community Information Exchange. Washington: Community Information Exchange, Issue #44, Spring/Summer 1995.

Survey Instruments

"Commun-I-Care Beneficiaries Survey — Greenville." Survey Research Facility, Department of Biometry and Epidemiology, Medical University of South Carolina, fielded March–July 1998.

World Wide Web Sites

www.communicare.org provides information on Commun-I-Care. Columbia, S.C.: Dr. Ben Wright, April 1998.

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Report prepared by: James Wood
Reviewed by: Janet Heroux
Reviewed by: Marian Bass
Reviewed by: Molly McKaughan
Program Officer: Susan Hassmiller

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