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Case Study: Neighborhood Health Clinic, Naples, FL

2012 Budget: $1,667,000
Patient Visits in 2011: 9,222 patient visits and 2,019 unduplicated patients
Website: http://www.neighborhoodhealthclinic.org/

Abstract

While many free clinics integrate varying degrees of pharmaceutical services into their care model, the Neighborhood Health Clinic has made its pharmaceutical services central to its day-to-day clinic operations.  Due to their high utilization of volunteer providers, not unlike many free clinics, the Neighborhood Health Clinic  alsopays close attention to improving continuity of care for patients.   Although providing pharmaceutical services in the clinic is generally regarded as contributing towards higher compliance rates, the reality is that providing such services can be prohibitively expensive. Providing these services in a free clinic setting is generally dependant on local resources and volunteer manpower. The Neighborhood Health Clinic has invested in its pharmaceutical services, and fills all prescriptions for all patients utilizing a modest pharmaceutical budget, bulk rate purchases from McKesson, donated medicines, and PAP programs. They have structured their pharmaceutical program so they have an additional measure to address continuity of care and built a practical system to monitor and control expenses. Feedback from nurses and volunteer doctors indicate that this process makes their jobs easier.

The Medication Room

The medication room at Neighborhood Health Clinic is led by a full time certified pharmacy technician, who coordinates a part-time retired pharmacist, two part-time pharmacy techs, and a small team of rotating volunteers that primarily coordinate the PAP applications. Additionally, the medical director is intimately involved in high-level decisions about the integration of the medication room in day-to-day operations and has recruited a pharmacist to sit on the medical committee of the clinic Board of Directors.

Together, this team dispenses approximately $347,000 worth of pharmaceuticals every month, which translates to an average of 280 prescriptions filled in each of their 6-hour clinics (although the outlier of 451 filled prescriptions in one clinic is an all-time record they strive to exceed). The first line of pharmaceutical supply to the clinics/patients is patient assistance programs and pharmaceutical donation programs. A secondary source of pharmaceuticals is procuring from McKesson’s bulk purchase rate and a local pharmacy that charges the Neighborhood Health Clinic their purchasing rate. The Neighborhood Health Clinic does not dispense narcotic prescriptions or controlled substances from its medication room.

The room itself is set up with removable shelves, in case the clinic needs to adjust them to accommodate unplanned inventory, which happens when the clinic stocks up on a high-need item through a donation program. Neighborhood Health Clinic has identified its top 50 prescriptions dispensed (nicknamed “fast movers”) and has set up the most immediate section of its medication room with these pharmaceuticals pre-counted into 30-day supplies. This maximizes the efficiency of filling most patient prescriptions. The clinic has found that by making multiple 30-day supply prescriptions of the same drug at once, they have cut down on error and increased efficiency.  You can see the layout of the medication room in Appendix B, entitled, “Medication Room Layout”.

Pre-clinic Prep

Every month, the medication manager releases a list of the in-clinic pharmaceutical inventory that is coming up on expiration and posts it throughout the clinic – in the exam rooms, at the nurse stations, in the medication room, and at the front desk. This encourages staff to think about utilizing this inventory if possible before it expires.

Before clinic, the medication manager reviews the patient file for all patients that will be seen that day. She looks closely at the treatment plan outlined and makes notes for the volunteer MD that will be seeing that patient. She highlights pharmaceuticals used to treat any acute conditions so that the doctor can follow up on those conditions, and also outlines questions about any chronic prescriptions that may have been changed recently. If the clinic has easier or cheaper access to an alternate pharmaceutical in the same drug category available that month, she makes note of it for the doctor to review while with the patient.

The medication manager pre-fills chronic prescriptions in anticipation of no change in their dosage so that during clinic hours her staff are only filling prescriptions for acute conditions or for new conditions diagnosed, which cuts back on the wait time for the patient and allows the doctors to see more patients while also being able to go over the prescriptions with the patients. All of this work is extremely organized and color-coded to indicate incoming or outgoing information from the medication room, so that once the clinic is open, everything runs smoothly.  See their color code chart in Appendix A, entitled “Color Coding System”.
 

During Clinic

Neighborhood Health Clinic has all patients fill out relevant paperwork as a requirement to being seen by an MD for the first time. Specifically, they must self-declare their income, provide proof of income (pay stub, tax return or a notarized cash form), and sign a form that provides the clinic all authorizations they need to complete PAP applications on behalf of the patient. This way, the clinic has effectively streamlined much of the process to submit PAP applications on behalf of patients and can quickly offset the pharmaceutical demand on its medication room.

Once in the flow of operations in the clinic, the patient only receives one month’s worth of prescriptions at a time, incentivizing them to be seen every month at the clinic. If a patient proves compliant and is stable, he/she may qualify for a “fast track” visit – during which a patient receives a quick wellness visit from an RN and, if everything looks good, their prescription for the next month. Because all patients must schedule appointments and all chronic condition prescriptions are filled in advance of clinic hours, the patient may only be in the clinic for 20-30 minutes, but also has the opportunity to check in with the medical staff monthly.

All patients have medications delivered to them in their exam room by a registered nurse.  When pharmaceuticals are dispensed to a patient, they are reviewed by the medication manager (in pre-clinic prep), a pharmacy tech (if there are any changes in the Rx), senior staff (on the way out of the medication room, must be double checked), and finally again by the nurse that delivers the medication to the patient.

About the Clinic

  • Clinic has a core group of one full time paid nurse, one part time RN, and a “halo” of rotating volunteer MDs, nurses and non-medical administrative supporters
  • Two six-hour clinic sessions every week, and  clinic sessions every other Saturday
  • All patients are seen with appointments; no walk-ins; although there is time allocated during each clinic session for patients who do walk-in with conditions needing immediate attention
  • Specific programs for breast cancer, smoking cessation, healthy lifestyles, and diabetes
  • Located within medical community in Naples to provide an easy volunteer opportunity for its medical providers

Appendix

  1. Table outlining color coding system (PDF)
  2. Layout of medication room (PDF)