Networks of care

Carol cradles her right foot in her hand, taking off her black Croc sandal and white sock. The callus on her heel is so hard it has worn a hole in the shoe. She could live with that, but up higher, on the fleshy part of her foot, sits a large, soft tissue growth. Every time she walks on it, pain shoots through her leg. Just walking to the bathroom is painful.

Michelle Carr, a nurse at Shelter Health Services in Charlotte, tells Carol she has an appointment with a well-known dermatologist: "They agree to see you Thursday morning, but I need to know if you can make it. … If you take the appointment, but then don't show up, they will never allow us to do this again."

Carol has lived with the growth for two years but found it difficult to work. Doctors were mystified and a podiatrist refused to work on it because he was afraid of making it worse. The homeless shelter clinic has worked to get her an appointment with the specialist, who agreed to charge only $20, which the clinic will pay. The appointment could change Carol's life - if she shows up.

She does. The morning of her appointment she calls to verify that she will see Dr. Libby Edwards at Mid-Charlotte Dermatology & Research. Edwards biopsies the growth and diagnoses a cyst. She refers Carol to Dr. Hazem El-Gamal from Charlotte Dermatology, who operates and removes the cyst, charging a $20 co-pay, which the clinic pays. Carol can soon walk without pain.

Carr summarizes the problem: "There has always been a safety net for the poor. They just don't know how to access it. But we do, and we connect them." Many charity clinics do the same: They provide primary and preventive care, and when a patient needs surgery, cancer treatment, or dialysis, they rely on formal and informal networks to provide those services.

For example, Shepherd's Clinic in Baltimore partners with Union Memorial Hospital (UMH) to provide care for people like Levan, 61, a mechanic with a heart condition that has put him in the hospital three times. When Levan recently had gall stones and lower back pain, he went to Shepherd's rather than the Union Memorial emergency room for treatment.

The partnership began when Dr. William Finney, retired UMH chief of staff, became the clinic's first volunteer medical director and forged the reciprocal relationship. For more than 20 years, the hospital emergency department has sent its non-emergency, uninsured patients to Shepherd's for primary care. The clinic, in turn, refers patients to the hospital for diagnostic procedures, specialty consultations, and surgical procedures, which it performs as part of its charity care. Last year the clinic made more than 2,200 referrals back to the hospital.

The Project Access referral model began in Buncombe County, N.C., in 1996 (Asheville is the county seat). Project Access successfully recruited specialists and general doctors into a network to provide medical care to the uninsured. Specialists who volunteer through Project Access provide healthcare within their specialties, and the organization makes sure that patients get necessary lab work, X-rays, and follow-up care, including surgery and hospitalization.

The Buncombe County Project Access today involves more than 600 doctors, home healthcare groups, and local hospitals, providing care to 3,000 uninsured patients each year. The model is simple: Patients go to primary doctors or a charity or sliding scale clinic for a referral. Project Access screens patients to make sure they are county residents, have no insurance, and fit within income guidelines (currently 200 percent of the federal poverty line). Project Access then refers patients to a specialist, who sees them in his own office.

Since Buncombe County's Project Access saw its first patients in 1996, the model has spread to more than 50 cities, including Portland, Seattle, and Wichita, giving doctors across the country another avenue for volunteering. In some places, funding for administration comes from county government, foundations, or local medical societies. Other clinics also rely on informal doctor-to-doctor networks to secure treatment for patients.

Uninsured people also need help getting affordable prescriptions. Pharmaceutical companies have programs to provide free and low-cost medications to uninsured people who earn less than 200 percent of the federal poverty level, and receive tax benefits in return. The process varies from state to state. In North Carolina, MedAssistNC acts as a mail order pharmacy for the working poor: It receives free medications from drug companies and dispenses them to qualified individuals and clinics. The average client has three prescriptions, with help for diabetes, hypertension, and heart disease most common. Last year, MedAssist dispensed 160,000 medications worth $19 million wholesale, with drug companies donating 90 percent of that.

Another example: Dispensary of Hope, founded in 2007 in Tennessee, now has 80 network dispensaries in 15 states and is licensed in 11 more. This Nashville-based nonprofit has a Christian mission to provide medications to the indigent and uninsured. It receives donations from manufacturers and unexpired samples from 1,300 doctor's offices. Dispensary of Hope then distributes the medications to its network of nonprofit clinic dispensaries and community pharmacies, which then give needy patients immediate short-term help. Dispensary of Hope also helps those patients enroll in long-term prescription plans run by pharmaceutical companies.

Other networks also are growing - and medical services are only part of a holistic outreach to the poor. Many clinics have food pantries. In Charlotte, N.C., a bright blue sign identifies the Betesda Centro De Salud (Bethesda Health Center). Located in a strip mall near an Auto Tune Total Car Care shop, the small clinic sees patients 27 hours a week. It stocks its food pantry with donations, including some from local grocery stores such as Compare Foods. Executive director Wendy Mateo-Pascual says being "patient-centric" means asking if patients have enough food: If not, the clinic connects them with the food pantry, which partners with Loaves and Fishes.

Compassionate medical professionals need their own network of care: Work in some clinics serving the impoverished can be isolating. Sarah Defelice, a staffer at Jericho Road Family Practice in Buffalo, N.Y., says she sometimes feels unable to discuss her work with friends from suburban specialty clinics: "They have no idea what I am talking about."

Two years ago Scarlett Stewart, involved in starting Grace Medical Home in Orlando, Fla., struggled with the basics of opening a clinic: "I wish someone would have given me a manual … and a tutorial on effectively recruiting, retaining, and recognizing volunteers." She couldn't find a manual, but shortly after Grace opened, the clinic joined the Christian Community Health Fellowship (CCHF), which provides just that sort of help.

CCHF, based in Memphis, Tenn., is a network of more than 3,500 medical professionals committed to serving Christ through medicine. Executive director Steve Noblett fields questions from churches like one in San Francisco that contacted him about providing charitable services in its neighborhood. Noblett connected the church with clinics in San Jose, Calif., and Gresham, Ore., and saw once again that doctors in the network "want to be used to help the next guy get started."

Noblett says CCHF is "more of a community than a trade association." It helps clinics find and keep mission-minded doctors, by providing training, fellowship, and technical assistance. To doctors, he says, "When you go on vacation, ask if there is a Christian clinic in that area that works for the poor so that you can fellowship with them and see what happens there."

Many charity clinics are members of the National Association of Free and Charitable Clinics, which claims more than 1,000 members. Twenty state level and two regional associations also serve clinics. For example, 104 charity clinics, many of them faith-based, belong to the Georgia Free Clinic Network (GFCN), and collectively provide $200 million to $400 million in free care to Georgia's 1.7 million uninsured citizens.

GFCN helped pass the 2005 "Health Share Volunteers in Medicine Act" that provides immunity from medical malpractice suits for volunteer doctors and paid nurses in free clinics. GFCN also worked for a policy that allows doctors to earn continuing education credits by volunteering at charitable clinics: That allows volunteers to save money and fulfill educational requirements, and gives free clinics a source of quality labor.

Two other groups provide start-up guidance for clinics: Volunteers in Medicine (VIM) is a network of 90 free clinics in 28 states, modeled on the first VIM clinic on Hilton Head Island, S.C. ECHO, a Fort Worth, Texas, nonprofit, provides free consultants to churches and other organizations wanting to set up clinics for the uninsured.

Sometimes the networks are not sufficient-and frustration grows. Pam Snape, volunteer medical director of Greenville Free Medical Clinic in Greenville, S.C., sometimes can't get patients the specialized treatment they need "because we don't have access. … We can't send them somewhere free of charge."

We can tear down the networks of care and start from scratch. Or, we can bulwark and expand them.

With reporting by Tiffany Owens and Christina Darnell