Free clinics are private, nonprofit organizations that provide health services at little or no cost to uninsured and underinsured people through the use of volunteer health professionals, community volunteers, and partnerships with other health providers. There are currently 77 free clinics in Washington, today and that number continues to grow.
Washington Healthcare Access Alliance (formerly the Washington Free Clinic Association) estimates that Washington free clinics served over 74,000 unique patients in 2015 alone. For more than three decades, providers and community members across the state have volunteered to form free clinics in Washington in response to community healthcare needs that are not met within the Washington health safety net. At a networking conference in late 2007, individuals representing 25 of these free medical and dental clinics determined that they needed a statewide association that would support networking, quality improvement and stability in free clinics. The Washington Free Clinic Association was incorporated in March of 2008.
Free clinics range from tiny, once-a-week evening drop-in settings to large multi-day, appointment-based clinics (in Vancouver and Kennewick, for example). What they have in common is that they do not charge for their services and they depend on the dedication and commitment of volunteers from the community - doctors, nurses, youth, retirees, professionals, businesspeople -- every contribution is important. These clinics are born of necessity, and quickly face challenges of service quality, record-keeping, volunteer recruitment, retention, and training, board development and of course, funding. In the absence of a structured regulating body, clinics have been able to provide truly grassroots care to those most in need, but have struggled to access resources and information relevant to free clinic operations. In accordance with its mission, the Washington Healthcare Access Alliance now has the opportunity to facilitate direct networking and resource sharing.
Starting a free clinic is a rewarding and community-strengthening experience. Though each free clinic is different, the common thread is that free clinics are a response to the needs present within a community and they are supported by the generosity and resources available within that community. In order to start a free clinic in your community, you will need to better understand both the need and the resources available. This section outlines the necessary steps to assess the needs of your community, make important community connections, navigate the process of starting a nonprofit and ultimately launch a free clinic to serve those in need.
You can make a meaningful contribution to your community by spearheading an effort to start a free clinic. From the first discussion to the day the clinic’s doors open to treat patients can take anywhere from 6-18 months. The length of time required to plan and start a free clinic largely depends on the time-commitment of the steering committee members, as well as the community response and the availability of clinical volunteers.
The following are the major benchmarks and tasks of any start-up free clinic. They are mostly sequential, though some activities will occur concurrently within different committees, and others will be ongoing tasks, such as fundraising and volunteer recruitment.
The first step to take will be to share your idea for a free clinic with like-minded peers, local business people, your family doctor, your church and anyone else who you think could contribute to the vision of a free clinic. The steering committee will help to get some momentum behind planning your next moves. Down the road, you will need to divide planning into major areas of responsibility (e.g. medical/clinical, facility planning, marketing, fundraising, IT), so it will be very helpful to have someone knowledgeable in each of the planning areas. Individuals can get an overview of free clinics by visiting our website (wahealthcareaccessalliance.org), where they can learn about other free clinics in the state. The ideal steering committee would put the free clinic in touch with the community’s resources.
Free clinics are a response to the needs present within a community. A needs assessment provides the compelling justification for the organization and development a free clinic. A needs assessment serves to clearly define the need for a free clinic and analyze the potential impact of the proposed clinic. Most funding sources and partnering organizations will want evidence that demonstrates the need for such a clinic before contributing time and resources.
Before setting the criteria for whom to serve, the planning group should be able to clearly articulate the mission and goals for a clinic. For example, most free clinics decide on an eligibility level of serving those who fall at 200% or below the poverty index range. This covers those who are above the Medicaid eligibility level but still have no health insurance. You will need to gather statistics on the number of persons in the income and age range (if applicable) which your clinic will serve.
Needs assessment data can be partially gathered from existing data sources (see listing of sources on the next page). If sufficient funds and expertise can be acquired, it can be most helpful and powerful to do a community survey of the population, particularly of the workers in the workplace, to ascertain their health insurance status. A random sample telephone survey of small businesses within your community will give you a fairly accurate picture of the problem at the local level. It is also important to look at other factors in the community that may contribute to a high number of uninsured, for example: unemployment rate; employer closures; and downsizing. You may be fortunate to have the assistance of a local college or university graduate program to assist you in your efforts.
An important aspect of gathering information for a needs assessment will be determining which populations are currently being served by local resources. For example, the pediatric population might be able to receive dental care or primary care through a state program. Sometimes pregnant women can receive prenatal care through state programs, Planned Parenthood or other sources. Certain ethnic groups may be less likely to be insured based on where they live. A list of current programs and resources may be useful for referrals from your clinic as well as to determine if your free clinic will be viewed as a competitor or friend. The lack of these resources may also further emphasize the need for a free clinic in your community. In rare instances, the research may show that all needs are being filled. It is also important to look at the amount of dollars being spent in areas such as charity care provided by local hospital emergency departments and in physicians’ offices. This can provide great insight into the depth of the problem of the uninsured.
A critical part of the feasibility study is outlining the impact on the community. At a minimum, a free clinic will stabilize the community’s workforce and improve the community’s overall health. It is also important to emphasize that a free clinic will not compete with local physicians, the hospital, or other community health care organizations. In fact, just the opposite will happen. A free clinic will decrease the number of primary care cases seen in the hospital emergency room and may reduce the number of pro-bono cases in the physicians’ offices.
The following sources publish existing data that you may find helpful:
The mission statement of an organization is an action-oriented expression of the organization’s reason for existence and should summarize its vision.
Consider the following when drafting your mission statement:
Christ Community free clinic is a medical mission providing free quality urgent medical care and referral services with compassion and dignity to the uninsured of our community.
The ECHO mission is to provide basic medical care for low income people without insurance or readily accessible health care through the professional operation of a volunteer free community health clinic.
The free clinic of SW Washington mission is to provide and facilitate access to free, compassionate, quality health care for children and adults who are otherwise unable to access such services.
The mission of the Mason Community Dental Clinic is to increase access to primary and preventive dental care for low-income uninsured and underserved populations.
The mission of VIMO clinic is to improve the quality of life for people on the Olympic Peninsula by providing for the health and wellness needs of the medically underserved.
Starting a Nonprofit in Washington
Once you have established that starting a new nonprofit, rather than partnering with an existing nonprofit, is the right choice for your community, you will need to complete a series of steps. The King County Bar Association publishes a FREE comprehensive guide on forming a nonprofit called How to Form and Maintain a Nonprofit Organization:
The following is a summary of the specific steps to be taken in order to establish a nonprofit organization that meets legal requirements in the state of Washington.
Opening a free clinic is not as costly as it may at first appear. The first big expense is the $750 501(c)3 filing fee. There are other miscellaneous fees associated with incorporation and registration with Secretary of State as noted above, and it is important to secure a general liability policy for your clinic facility. From there, the cost of start-up varies depending upon your level of infrastructure, but you should be able to open a clinic with $2,000 or less. There are several steps to take when starting a free clinic, but the benefit to the community is well worth the time and effort.
Sample policies and procedures have been graciously shared by clinics around the state and are included in the Appendix. You are welcome to reference them or revise them to meet the specific needs of your community and your free clinic. The attached do not represent all of the policies and procedures that your clinic will need to establish, but they are intended to serve as a starting point.
Appendix A Sample Clinic By-Laws Guideline
Appendix B Sample Philosophy of Care Policy and Procedures
Appendix C Sample Board of Directors Job Description and Agreement
Appendix D Sample Medical Director Job Description
Appendix E Sample Site Medication Dispensing Policies and Procedures
Appendix F Sample Universal Precautions Policy and Procedures
When organizing a free health clinic, it is important to develop relationships with organizations in the community that represent significant healthcare interests. Such entities include hospitals, health systems, public health, medical society, academic medical centers, health professions training programs, and other health safety net providers.
Meetings with key leaders from these healthcare interests can serve multiple purposes:
The meeting is ideally with the chief executive of or at least a decision-maker within the organization. Wherever possible, include in the meeting an individual from the planning group who may already be known to the leader(s) with whom you are meeting. When setting up the meeting, ask for at least 30 minutes and request up to 60 minutes if it's available.
An agenda for the meeting might include the following:
Take good notes during the meeting. Be sure to thank the person or people with whom you met, within 24 hours preferably. In the thank-you note, summarize any key discussions, decisions, or next steps that were agreed to. Indicate you will follow up accordingly, and be sure to follow up. Failure to do what you say you are going to do will cause you to lose credibility and do harm to this young partnership.
It is also recommended that you compile a list of other service-based organizations and set up a series of introductory meetings. These organizations often offer a great deal of community support, in terms of financial resources, volunteers, and leadership.
Washington is one of many states without direct legislation to govern free clinics. Instead, free clinics must piece together the legal mandates by referring to legislation that governs healthcare entities, healthcare providers, and nonprofit corporations. The applicable Revised Code of Washington, or RCW, is listed in the appendix for your reference.
Mailing: P.O. Box 2508 Cincinnati, OH 45201
Phone: (877) 829-5500
Physical: 801 Capitol Way South Olympia, WA Mailing: PO Box 40234 Olympia, WA 98504- 0234
Phone: (360) 725-0377
Physical: 801 Capitol Way South Olympia, WA Mailing: PO Box 40234 Olympia, WA 98504- 0234
Phone: (360) 725-0384
Mailing: PO Box 47850 Olympia, WA 98504 Phone: (360) 236-2812 Website: doh.wa.gov
Mailing: P.O. Box 42682 Olympia, WA 98504- 2682
Phone: (360) 923-2777
Many of the resources required to operate a free clinic come in the form of donated or in-kind goods and services, but some funds are necessary to cover expenses. Securing sustainable funding is a common challenge among free clinics. Your board of directors is encouraged to consider developing a long-range funding plan in order to ensure the stability and success of your clinic. Sustainable funding is reliant upon diverse revenue streams. The following organizations provide funding and may be a useful lead to support your planning process.
The practice of pharmacy is regulated (along with other health-care professions) by the Washington State Department of Health WAC (Washington Administrative Code) Title 246 and by the RCW (Revised Code of Washington), 18.64 (Pharmacists), 18.71 (Physicians), and 18.57 (Osteopathic Medicine). The websites apps.leg.wa.gov/wac/ and apps.leg.wa.gov/rcw/ provide the complete WAC and RCW.
A free clinic has a choice of two options; it can operate with licensed pharmacy or it can dispense medication under a physician’s license.
The state board of pharmacy regulates the practice of pharmacy and enforces all the laws placed under its jurisdiction. Thus, if the free clinic chooses to operate with a fully licensed pharmacy, it must comply with all requirements for record keeping, physical standards, license and fee responsibilities, drug storage and procurement, and all other requirements defined in WAC 246 and RCW 18.64. A significant necessity is the presence of a licensed pharmacist at all times the pharmacy is in operation.
The operation of a licensed pharmacy is an expensive and resource intensive undertaking. If the free clinic has the funding, can meet the physical requirements, and has reliable access to licensed personnel, can be given to this option. Otherwise dispensing under the authority of the medical director’s license is an option.
If the free clinic chooses to physician dispense medication a set of written policies and procedures should be maintained in order to define conduct designed to promote the public health and welfare. Appendix I can be used as a guide for developing a set of policies and procedures specific to your clinic.
The Medical Director should consult with all interested parties and develop a formulary of inexpensive generic drugs covering both acute and chronic disease states defining those medications that will be used for dispensing. Controlled substances should be excluded. If Free Clinic Handbook – Washington Healthcare Access Alliance you intend to provide only short term care with the goal of moving a patient into the mainstream for his chronic care, you might choose different medications than a clinic who intends to provide long-term follow-up therapy for chronic diseases.
Contact the major pharmacies and hospitals in the area to locate one who is willing to supply bulk quantities of those drugs on the formulary on prescription from the Medical Director. These are typically bottles of 500 or 1000 tablets (or capsules). These bulk bottles would then be broken down into standardized pre-packaged units (for example: amoxicillin 500mg #30 – for 1 capsule three times daily for 10 days). These units would be labeled with the name and strength of the drug, the lot number, and the expiration date. When the pre-packaged unit is dispensed any further required information would be hand written on the label. The bulk container (with the lot number and expiration date) should remain in the bin until all the pre-packaged units have been exhausted. Further, a small sticker with the expiration date for the medication can be affixed to the bin for easy recognition of out-of-date product. These medications would be administered free of charge to the patient.
Some patients may be able to afford purchasing their prescriptions or, if used for a chronic condition, they may receive a one-month supply from the clinic with a prescription for a one year supply. Several pharmacies (e.g. Fred Meyer, Target, and Wal- Mart) provide for $4 prescriptions and others (Costco, Walgreens, RiteAid, Safeway, etc.) may match the $4 commitment or have prices that are only slightly higher. It would be preferable to develop a relationship with one pharmacy, but any contractual long-term relationship should be avoided.
Many of these pharmacies are community oriented and it may be possible to strike a deal with one that would provide the patient with a less expensive option. For example, one might ask the pharmacy to donate a dollar or two of the $4 to the clinic via a coupon the patient would present at the time of filling in order to receive their medication for 2-3 dollars.
These are labeled vials, bottles, or unit of use medications, often being donated by a surviving partner. They cannot be accepted for re-use by the clinic. If you choose to accept these medications for destruction at the clinic, do not accept controlled substances and be sure to black out all patient identifiers to remain HIPPA compliant.
If you choose not to accept any patient specific medications, provide a handout or information on the most environmentally friendly method of disposal.
These are unopened, sealed packages that provide lot numbers, expiration dates, and are marked and supplied as “samples.” These medications are primarily the latest and most expensive alternatives for a given disease state.
Samples that are used for acute disease states (e.g. infection, etc.) may be appropriate for clinic use. Samples used as maintenance medications are generally not appropriate to initiate therapy for most patients visiting the free clinic. Their expense would generally prevent the patient from obtaining his refills from an outside pharmacy. If your clinic intends to follow such patients, then acceptance of these types of medications may be warranted.
These can be of great value to the free clinic patient, but often they get forgotten and end up going out of date, especially when stored in the pharmacy. Try providing a supply of common over-the-counter drugs (e.g. vitamins, antihistamines, cough preparations, analgesics, etc.) in the exam room so that they may be dispensed to the patient as they are being evaluated.
Pharmaceutical companies can be a potential source of resources. All companies have programs oriented toward the community and depending on their structure, some may provide resources directly or others through their sales representatives. You can call the company or search their web sites to determine the best way to approach each individual company for contributions and how to contact local sales representatives. Roche, Bayer, Abbott, and J & J are major players in the field of diabetes, providing monitors, strips and lancets and may be a source of diabetic supplies.
Johnson & Johnson jnj.com P.O. Box 726 Langhorne, PA 19047-0726
GlaxoSmithKline gsk.com 1-888-825-5249
Abbott Laboratories abbott.com Abbott Park, Illinois 60064-3500 847-937-6100
Bristol-Myers Squibb bms.com 800-332-2056
Pfizer, Inc. pfizer.com 235 East 42nd St. New York, NY 10017 212-733-2323
Roche (F. Hoffmann-La Roche Ltd) roche.com 2075 North 55th Street Boulder, CO 80301 1-303-442-1926
Merck & Co. merck.com 1 Merck Drive Whitehouse Station, NJ 08889 908-423-1000
Eli Lilly & Company lilly.com Lilly Corporate Center Indianapolis, Indiana 46285 USA 317-276-2000
Volunteers can fill many positions in a clinic from the physicians to nursing staff and records clerks.
Finding the right volunteer can be an involved process but only because you need to know exactly what your needs are. Targeting volunteers is one approach. Getting the word out is the first step. Initially, you may only need a few people and as you expand, so may your needs. First, decide what you want to accomplish. Second, seek out volunteers through word of mouth or visiting local organizations that are known to have people with the skills needed.
When targeting a group, you must ask yourself several questions:
Having clear goals and deciding on a package of job descriptions is critical to the success of your volunteer recruitment campaign. When searching for volunteers, being able to explain the nature of the job required is a must. Unclear tasks and goals will leave you looking unprepared as well as unprofessional. Explain to potential volunteers why you need them and why your organization is worth their time. Be direct. But also leave them with a feeling that they will serve a purpose in a worthwhile organization. Also, let them know they have opportunity to use their skills as well as improve them and/or teach others these skills.
What type of clinic are you running? Is it a formal process or casual? Do the volunteers have the freedom to move about different workstations or are they assigned a specific task and location? How you design the process and what those results are should be part of your recruiting speech. Potential volunteers want to know what is expected in your working environment. Two excellent questions you have to ask yourself are: 1) would I want to volunteer here? 2) would I recommend this clinic to friends and family as a good place to volunteer their time? Make the match between your clinic’s culture and the volunteer’s needs and skills.
Are you ready to employ volunteers? Are job descriptions clearly defined and does the organization understand exactly what the volunteers will be doing? Do you have a training program to effectively integrate a volunteer into his or her new job? Are safety concerns addressed in regard to working with the sick and injured, occupational hazards, potential combative clients, or Privacy Act and Personally Identifiable Information security? Evaluate and analyze your Clinic and the work you will do before you recruit volunteers so you will be better able to the volunteers to specific jobs within the organization. Above all, be ready to provide orientation and training, and fully understand your role in supervising volunteers.
Have you resolved any legal and liability issues pertaining to volunteer involvement? Do you have a training program in place? This does not necessarily need to be a professional employee handbook but at least have written guidelines and practices ready for your volunteers. Do you
have or need liability insurance for the building, providers, or some safety net in place for those unforeseen circumstances such as accidents, slips/falls, needle sticks, blood-borne pathogens, etc.? You may also choose to conduct background checks on volunteers at the free clinic. The patients of free clinics represent a vulnerable segment of the population and it is important to preserve a safe environment for them. Local law enforcement can assist with background checks if you choose to perform them.
It is also important to develop and implement a clear protocol for verifying providers’ licenses on an annual basis. A “Medical Director” can determine the process and take on this task to ensure that each provider stays within the scope of practice designated by your Clinic. The Washington State Department of Health Licenses provides and maintains the data and status of current licenses and offers assistance in regard to Malpractice Insurance for volunteer and retired providers. Your local Medical Society may have pertinent information and offer assistance with providers in your area. The state Department of Health provides a free on-line health license verification service.
In the beginning, the “staff” may just be you and one provider. As you grow, make sure your policies, procedures and training grow with you. Prepare each volunteer to become a trainer for the next volunteer. Also, be prepared for volunteers who may not have the skills needed for a particular situation such as when other volunteers are unable to be there due to illness or family issues, or when urgent clinical situations arise, or more clients check in than you are prepared to handle that day. Patience and understanding will go a long way to make your volunteers feel
appreciated and more fully able to contribute. Be supportive and use every opportunity to train and improve the process. Listen to your volunteers’ feedback when they have suggestions for improving their experience.
Remember that your volunteers want to be there! Respect for them is as important as it would be for any other employee. They deserve the same time and commitment from management and should never be taken for granted.
A few keys things to consider:
And finally, encourage your volunteers to recruit volunteers and give them the tools necessary to do so. There is no better recruitment technique than a volunteer who shares with others the stories of joy and reward that come from volunteering at the free clinic.