January 2004

Grant Results

National Program

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

SUMMARY

From 1994 to 1995, St. Vincent de Paul Village in San Diego, Calif., expanded the services provided by its medical center, which is part of St. Vincent de Paul Village's extensive homeless shelter.

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

Key Results

  • During this project, St. Vincent de Paul Village recruited 255 new volunteer physicians and dentists, including 48 willing to see patients in their offices, and 66 noncredentialed health care volunteers.
  • Patient encounters increased 93 percent — from 13,407 in August 1994 to 25,950 in August 1998. This effect was not due just to caregiver recruitment under these grants, but to a combination of factors including expanded clinical facilities and situating area medical residency programs at St. Vincent de Paul Village.
  • In January 1998, the Peter F. Drucker Foundation of New York extended "special recognition" for nonprofit innovation to St. Vincent de Paul Village for its work.

Funding
RWJF supported this project through a grant of two grants totaling $299,265.

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THE PROBLEM

San Diego is the sixth largest city in the United States. Historically, it has been one of this country's most expensive places to live. During the 1980s, although it maintained a strong base of white-collar and defense-related jobs, its growth attracted service workers in occupations where pay is low and benefits minimal or lacking. In addition to large (and ethnically diverse) population of low wage earners, San Diego County has had a medically underserved population for many years, mostly because of its proximity to Mexico, which has helped create a large transient population (including legal and illegal alien families with high rates of illiteracy). A mitigating factor in this picture was San Diego's ample base of health care professionals, a potential source of volunteer caregivers.

Barriers to such volunteerism, however, included lack of an organized setting for this service — providing support staff and examination rooms — and much required paperwork. Area physicians also tended to experience impatience with indigent clients' inability to communicate in English, to follow medical instructions readily or even to keep an appointment (often for lack of taxi fare). For their part, "charity" clients often did lack transportation and feared medical visits or showed other effects of cultural isolation or misinformation.

St. Vincent de Paul Village
St. Vincent de Paul Village has provided shelter and food for homeless individuals and families in San Diego County since 1983. In the decade from 1983 to 1993, it provided more than 900,000 shelter-nights for 90,000 individuals. In 1994 it nightly sheltered up to 350 chronically homeless single men and women, and fed or otherwise helped 1,500 homeless still on the streets, while providing at the same location health care, social worker case management and other needed services, including child day care for 100 children, public schooling, a literacy program, job counseling, housing placement, life skills training and counseling services including mental illness and chemical dependency support groups.

Its medical center — a licensed community care clinic located in a medically underserved area (along with the village) — provided free primary health care to uninsured homeless individuals and free primary and dental care to its shelter residents, as well as periodic clinics in needed specialties. These included pediatrics and prenatal care, optometry, dermatology, pelvic examinations and Pap smears, mammography and podiatry. The clinic logged about 1,100 patient visits per month. Staff dispensed prescribed medications on site and gave clients transportation to and from appointments, as needed. Clinic personnel included a health educator and a caseworker to make community referrals and provide counseling. A volunteer base of approximately 100 physicians and 35 dentists (in 1994), and a small referral base of specialist volunteers (primarily obstetricians/gynecologists, pediatricians and psychiatrists), served patients. Paid staff included a part-time doctor, a nurse practitioner, medical assistants, a lab technician and a social worker. All services provided at the medical and dental clinics were on a first-come, first-served basis, free of charge. St. Vincent de Paul Village also coordinated with local hospitals and birthing clinics to provide free surgeries and deliveries of babies.

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THE PROJECT

This project expanded services at St. Vincent de Paul Village's existing medical clinic. St. Vincent de Paul Village proposed to accomplish this expansion primarily by recruiting 400 additional caregivers — physicians, dentists and others — to donate their services to patients in its clinics or in their private offices. Recruited physicians would be asked to provide monthly four-hour blocks of time at a St. Vincent de Paul Village clinic (with a minimum commitment of four hours per year) or to accept one referred patient to their office per month. The project relied heavily on the creation of a database of the available physician pool (the "provider database") and on the tracking of St. Vincent de Paul Village's recruitment efforts — noting volunteer availability, services offered and actual services provided.

The database was also intended to carry data regarding client intake, referrals and patient clinical records and notes. Other elements of the planned expansion included establishment of a governing board (made up of 14 individuals from the realms of private practice, medical education, public health and pharmacy), collaborations with area health training schools and service organizations (for a list of these, see Appendix 1) and project documentation in the form of a program replication manual, to be structured as a chronology of project development.

Project staff for this expansion consisted of a director (who was also the St. Vincent de Paul Village clinic's medical director), a project administrator and an administrative assistant. Existing clinic staff, although not funded under these grants, offered substantial in-kind assistance.

Project funding did not change the way patients were served. Patients entered the existing system in two ways: (1) directly requesting services from a clinic; or (2) via referrals from outside providers. An existing "client database" tracked their status within the system. Patient clinical data was kept as hard copy. Caregivers at the clinic — both staff and volunteer — examined and diagnosed patients, explained treatment plans, monitored treatments, followed up on specialist and emergency room referrals, arranged necessary testing and prescribed medications dispensed on site. For physicians volunteering their services outside the clinic, staff contacted them after patient encounters to obtain the patient's treatment options, and periodically to discuss their satisfaction as volunteers.

Planning Phase

During the planning phase (mid-1994 to mid-1995), the project established its governance board and purchased a San Diego Medical Society database of over 5,000 area physicians, all potential volunteers. This formed the basis of the provider database and was put to use tracking the project's physician recruitment efforts and creating an array of volunteer data — type of caregiver, licensure information, hours and schedule availability, clinic preference, type of specialty if any, languages spoken and so forth.

A local computer firm that donated its services was unable, during the grant period, to complete custom software to track, in addition, current volunteer status and services provided by these caregivers after they were recruited. St. Vincent de Paul Village relied on traditional "hard copy" filing for this tracking.

In this first year, primarily through person-to-person effort, St. Vincent de Paul Village recruited 46 new credentialed medical caregivers and 32 noncredentialed health care volunteers. Its patient encounters rose during the planning phase, from 13,407 (1994) to 15,727 (1995). During this period, perhaps influenced by St. Vincent de Paul Village's commitment to expansion under this project, four medical programs of the University of California, San Diego, and the University of San Diego chose the St. Vincent de Paul Village clinic as a training site — for a Nurse Practitioners Master Program (University of California, San Diego), a Family Practice Residency Program (the University of California, San Diego), Internal Medicine Resident Program (the University of California, San Diego) and a Nurse Practitioners Program (University of San Diego).

In mid-1995, with outside funding, St. Vincent de Paul Village established a "continuity clinic" staffed by seven residents of the University of California, San Diego, in the fields of Internal Medicine and Family Practice. Patients needing long-term care were also referred to this clinic, because of the patient-doctor continuity it offered. St. Vincent de Paul Village also initiated six half-day positions at its main clinic filled by rotations of the University of California, San Diego, Family Practice Resident Program. These residents programs — not funded under these grants, but in line with project goals — greatly boosted available medical personnel at the clinic.

Implementation Phase

The recruitment of physicians began in earnest in August 1995, with almost 11,000 mailings sent to physicians and dentists over the next three years. Current volunteers proved effective at soliciting other volunteers through hospitals, community groups, social service organizations and medical and dental organizations, and St. Vincent de Paul Village staff made formal recruitment presentations. Medical trainees from area programs in Nurse Midwifery, Psychiatry and from residency programs in Family Medicine/Psychiatry and Internal Medicine/Pediatrics came on board.

The clinic also benefited from externships served by area students in public health, medical assistant, and other fields (pharmacy and laboratory technician, dental assistant and dentistry), as well as from medical and nursing students using St. Vincent de Paul Village for the practicum parts of their training.

The project encountered a number of difficulties. It could not complete a needed integration of two computer databases: St. Vincent de Paul Village's existing client database (tracking its homeless clientele) and the project's provider database (tracking physician availability and recruitment), nor could it develop software needed to track volunteer services rendered. During the implementation phase the center hired an expert to begin this integration work, which was completed after the RWJF grant period ended.

St. Vincent de Paul Village also experienced difficulties, during the grant period, obtaining access on behalf of its volunteer physicians to free diagnostic testing including advanced radiology and endoscopic procedures, and difficulty obtaining surgery sites for volunteer surgeons. A shift toward managed care had left the medical system in San Diego with less pro bono capacity as medical facilities strained to increase their efficiency. The consolidation of hospital systems decreased the number of potential partners and left fewer total dollars available for free services from them. Project staff turnover was also a stumbling block during this period. Relatively low rates of unemployment made replacement of staff difficult in some cases.

In addition to RWJF funding and St. Vincent de Paul Village's pro bono health care and other providers, the project received additional general support from two state and federal grants, and from the general operating budget of the grantee organization, St. Vincent de Paul Village. For a complete list of other supporters, see Appendix 2.

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RESULTS

  • The number of providers (physicians and dentists) recruited during the project totaled 255. Approximately 50 percent of physicians recruited were primary care providers. The recruitment of noncredentialed health care volunteers (including registered dental hygienists and registered dental assistants, medical assistants and clerical volunteers) totaled 66 by mid-1997. Physician recruitment actually outstripped the client capacity of the clinic. Staff therefore slowed recruitment and shifted efforts toward managing volunteers, particularly in its new programs staffed by residents and attending physicians from area medical schools, which came to constitute a significant portion of St. Vincent de Paul Village services.
  • Newly recruited physicians and dentists willing to see patients in their offices (rather than volunteering at the clinic) totaled 48 by mid-1997.
  • The total number of patient encounters during the grant period increased by 93 percent — from 13,407 in August 1994 to 25,950 in August 1998. This effect was due not just to the project's efforts to recruit additional providers, but also to a combination of factors. By the end of the grant period in August 1998, the St. Vincent de Paul Village clinic had tripled in floor space and patient volume and was running at full capacity. Patient service did not consist only of primary care during these grants: for example, in year three of the project, donated surgery for three patients totaled $100,000.
  • In January 1998, the Peter F. Drucker Foundation of New York extended "special recognition" for nonprofit innovation to St. Vincent de Paul Village for its efforts.

Communications

Current volunteers in the project constituted the most effective recruiting means — reaching out to their peers and their professional organizations within the medical community of San Diego County, with Spanish speaking volunteers placed in key positions where possible (currently 60 percent of "front line" staff are bilingual). Their efforts during the life of this project were backed by recruitment mailings of about 11,000 pieces, plus quarterly newsletters to area health care providers and others.

St. Vincent de Paul Village conducted its own extensive promotion and area fundraising during the grant period, which benefited the project. This consisted of a weekly TV program, an annual holiday telethon on cable TV and TV "infomercials," among other things. In 1995, the project director wrote an article, "Health Care and San Diego County's Homeless Population" for the San Diego Medical Society Journal. Project staff also wrote one chapter for an unfinished project replication manual, structured as a chronology of project development. The chapter focused on the recruitment, servicing, retention and replacement of volunteers in a clinic setting. St. Vincent de Paul Village's efforts were the subject of three articles in the San Diego Union Tribune, in 1994, 1995 and 1996. For further details, see the Bibliography.

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AFTER THE GRANT

St. Vincent de Paul Village planned to maintain the 1998 level of volunteerism at its clinic and to expand its medical services gradually, with particular attention to the provision of donated specialty care, diagnostic procedures, one-day surgery and hospital-stay surgery. In 1999, it added medical information to its client database. Its provider database now tracks volunteer status and services rendered. The two databases remain separate systems.

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GRANT DETAILS & CONTACT INFORMATION

Project

St. Vincent de Paul Village

Grantee

St. Vincent de Paul Village (San Diego,  CA)

  • Planning Grant
    Amount: $ 99,265
    Dates: August 1994 to July 1995
    ID#:  024562

  • Implementation Grant
    Amount: $ 200,000
    Dates: August 1995 to July 1998
    ID#:  027452

Contact

Christopher Abbott, M.D.
(858) 233-8500, ext. 1133
jserafy@neighbor.org

Web Site

http://www.svdpv.org

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APPENDICES


Appendix 1

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

St. Vincent de Paul Village Project Collaborators, August 1994 to August 1998

  • University of California, San Diego, School of Medicine
  • University of California, San Diego, Nurse Midwifery Program
  • University of San Diego Nurse Practitioner Program
  • San Diego State University Nurse Practitioner Program
  • Scripps Green Hospital Internal Medicine Residence
  • Multicultural Primary Care Medical Group
  • Grossmont Hospital
  • Mercy Hospital
  • Lion's Club
  • The San Diego Medical Society
  • The San Diego Dental Society


Appendix 2

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

Others Providing General Project Support, August 1994 to August 1998

  • Volunteer medical and dental service providers
  • Volunteer support staff
  • A federal Health Care for the Homeless grant (since 1987)
  • A California's Expanded Access to Primary Care grant (since 1989)
  • Mercy Hospital, San Diego (for pro bono surgery and hospitalization)
  • Scripps Clinic, San Diego (for pro bono surgery)
  • University of California, San Diego, Medical Center (for pro bono surgery)
  • University of California, San Diego, Residency Training grants (a federal Housing and Urban Development funded grant, since 1997)
  • ADEC Corporation, San Diego, Calif. (donation of two dental operatories)
  • Sullivan Shien (installation of dental operatories)
  • Private donors (of both funds and medical equipment and supplies)
  • LabCorp, San Diego, Calif. (donated laboratory services)
  • Numerous pharmaceuticals representatives (donated samples)
  • St. Vincent de Paul Village general operating funds

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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

Abbott C and Serafy M. "Building and Maintaining a Team of Healthcare Volunteers." San Diego: St. Vincent de Paul Village, 1998. Unpublished chapter of a services replication manual.

Articles

Abbott C. "Health Care and San Diego County's Homeless Population." San Diego Physician, 82(10): 9–11, 1995.

Newsletters

Clinic News. San Diego: St Vincent de Paul Village. 12 issues published January 1995 through October 1998. 4,500 copies mailed per issue to doctors, dentists, nurses and others in the San Diego region.

Survey Instruments

"Medical Clinic Provider Volunteer Comments." St. Vincent de Paul Village, fielded 1996–1998.

"Dental Clinic Provider Volunteer Comments." St. Vincent de Paul Village, fielded 1996–1998.

World Wide Web Sites

www.svdpv.org provides information about services available at St. Vincent de Paul Village, including medical services, and volunteer contact information. San Diego: St. Vincent de Paul Village.

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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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