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Delivering Patient-Centered Outcomes Research to the Nation’s Free Clinics

Webcast Transcript, Wednesday, March 30, 2011

Operator: Good afternoon, and my name is (Stephanie) and I will be your conference operator today. Please note that today’s conference call is being recorded. If you do not comply with this request, you may disconnect at this time.
I would now like to turn the call over to Mr. Howard Holland to start the Webinar. Please go ahead, sir.

Howard Holland: Good afternoon and thank you. We appreciate very much all of you joining us for today’s Webinar, which is titled “How Patient-Centered Outcomes Research Can Support The Nation’s Free Clinic”. This Webinar is hosted by The Agency for Healthcare Research and Quality also known as A-H-R-Q or AHRQ, as well as the National Association of Free Clinic. [Title Slide]

As the operator mentioned, my name is Howard Holland, and I’m the acting director of Office of Communications and Knowledge Transfer here at the agency. And it’s my pleasure to serve as the moderator today for our call.

AHRQ is committed to improving the quality, safety, efficiency and effectiveness of healthcare for all Americans. This tremendous task can only be achieved through the development of evidence based research, the kind of research that we here at the agency conduct through our effective healthcare program as well as the development of critical partnership that can help us convey this knowledge to consumers and clinicians. But, equally important are partners, partners who are vital in working with us to implement the tools and the results of this research so that we can achieve the long term improvements in healthcare that help us in turn reach our agency’s mission.

[Agenda slide] Speaking of partners, today we are thrilled to be partnering with the National Association of Free Clinic, NAFC, on what we hope will become a series of Web conferences, about the role of Patient-Centered Outcomes Research in free clinic environment. In the near future, AHRQ in conjunction with NAFC will be offering a series of Webinars discussing Patient-Centered Outcomes Research as it relates to specific topics. Topics such as type 2 diabetes, hypertension, high cholesterol, depression and other chronic health conditions once often identified in the very populations that free clinic serve. These Webinars speaking of free will be free. And, they will be offered to free clinic clinician exclusively and continuing education credit will be awarded for them.

I want you to know that response to today’s session has been tremendous, with nearly 300 registered attendees. We will soon be getting to the meet of the Webinar, but before we do that, let me please turn back to our staff, who are helping for providing a few technical notes before we dig in.

Male: Thank you, Howard. If you’re currently logged into the Webinar, you should see – go to Webinar control panel on the right side of the screen. The show panel is docked, you can only see a narrow bar with an orange arrow button. Clicking the orange arrow button will expand the doc and allow you to access some of the additional software functionality. Just below the orange button is the fullscreen button, which essentially maximizes the presentation window to fit your screen. When you expand the doc, you’ll see a window marked question, which is an area where you should submit text questions during the Webinar if you have them. During specific intervals in this Webinar, we will address questions by both text and phone submission. However, please feel free to submit questions using the questions panel throughout the Webinar.

At this point, I’ll turn it back over to you, Howard to get it started.

Howard Holland: Thanks again, I once again appreciate that. At this time, we will get started, but what we would like to begin with is to ask you to please respond to the first of three poll questions that we are going to have as part of our program today. If you’re using a computer, you can respond right online and you will see that coming up now. What we would like to get everyone in the audience to do is this. We would like to ask if you would please rate your understanding of Patient-Centered Outcomes Research and we would like you to do this on a scale of five options from, as you see, excellent to no understanding of Patient-Centered Outcomes Research at all. So, from excellent to no understanding there. And what we’re going to do here in real time is watch as people poll and look together at the results as they come in.

We are awaiting the jeopardy music to come up here, which should happen in a moment, no, that actually won’t happen. But, as we are waiting for the poll results, let us just say again, how pleased we are to be joining with our partners in NAFC for this Web conference and that again, how much we look forward to potential future Webinars that we may have to join with them on.

Again, as the poll questions begin to come in let me just go ahead and take a moment to actually introduce Nicole Lamoureux, who is the Executive Director of NAFC. Over the past year, Nicole and the National Association of Free Clinic have become one of the most – one of the agency’s very valuable and visible partners, helping us to reach diverse and often underserved communities. When we approached to her to discuss AHRQ, the Effective Healthcare Program and Patient-Centered Outcomes Research, she immediately recognized the importance of evidence based research and this information and together we started thinking of ways that we might convey this information to clinicians and disseminate this information to patients. Nicole, we’re very appreciative of the partnership and the chance to work with you today.

And before Nicole, we go into your slides, we’ll just look together at the results again of the poll question that we just post and obviously as all of you who are in front of your computer can see, it appears that moderate understanding of what Patient-Centered Outcomes Research with a leading response and something of a bell curve looking at a smaller percentage of people who rated at that point, then good. And then, on the other side of moderate, poor or no understanding. I think this would generally reflect what we would expect the results should be.

We know that as the field of Patient-Centered Outcomes Research has been talked about more recently, we’ve seen gains and people who understand they know about it. But that there are still people who aren’t aware and as a result, most people seem to indicate that they have a pretty moderate understanding of where we are in terms of what that means and what is included as part of that research. Thank you again for responding, we will have two other questions during the balance of the call.

And at this point, Nicole, we again want to welcome you and thank you for joining us. And, we will turn it over to you for your presentation.

Nicole Lamoureux: [Slide 1] Thank you so much. Thank you, Howard. I just want to take time here at the National Association of Free Clinic to thank AHRQ for everything that you have done, you’ve been an amazing partner with us and we look forward to working with you continuously in the future.

[Slide 2] I think that one of the first questions that so many people ask me is what is a free clinic? I think that’s normally the first question that gets and I think the definition of what a free clinic is, its pretty easy for us to be able to understand, it’s on the next slide first. And we are volunteer based organizations; provide a range of medical, dental, pharmacy, behavioral health services to the disadvantage individuals, who are predominantly uninsured. Free clinics are 501C3 organizations or a program component of a 501C3 organization. And you know, entity is that otherwise meet this definition, but may charge small nominal fees, can still be considered a free clinic especially and particularly, if the services that they are delivering, they’re given regardless of the patient’s ability to pay. That is a really big important part of this definition. Why that this definition is so important? When I started with this organization a couple of years ago, my first question was, what is a free clinic? And the board and our membership agreed and used this definition as to what a free clinic is.

[Slide 3] So, if we can move on to the next slide, I think it’s important to know about the history of free clinic. And some people, it depends, if you and so many of you have been a part of free clinic for a long time, you know that since the 60s and in some communities, even earlier than that, free clinics have been serving Americans working poor for such a long time. There was an old saying in the free clinic world that used to say, that when you have seen one free clinic, you’ve seen one free clinic. However, one of the things as we started to really understand the critical nature free clinics service in their communities, we change that.

What we want to say is free clinics are the communities response to the healthcare need in that particular area. We really worked very hard to have the community be a part of the services that we provide, not just through the volunteer efforts, but also through the partnerships we have with other hospitals and the specialists. As well as understanding the different disease states that are common across the country, diabetes being one of them, hypertension being one of them. But, also recognizing that when a hurricane or an oil spill or a fire happens across the country, the free clinics are there to be able to answer some of those needs that are very specific to that particular community.

And I’m looking for the next slide, please. [Slide 4] What is the National Association of Free Clinics? People ask me that all the time. The easiest way to say that is, we are an organization that was founded in Washington DC. And, we are an advocate for the issues of our clinics. So, we are the only non-profit organization and we are 501C3 organization whose mission is to solely focus on the issues and needs of the more than 1,200 free clinics and the people that they serve in the United States.

Our mission is to provide research in education and resources to promote and strengthen and advocate for a member organization. But, if you really want my honest opinion, it’s truly our vision that changed so many volunteers and has our patients really believing in what we do. Our vision is to be a central partner in building a healthy America. When we came up with that vision our board and our members understood that that was one big area (inaudible), and that’s exactly what they wanted to do. They wanted to be in a central partner in building a healthy America. [Slide 5]

Some basic information about free clinics, I think it’s very interesting and that many people don’t know is that we serve millions of patients each year and we mobilize tens of thousands of volunteers and for every dollar donated to a free clinic, a minimum of $5 in service is given to a patient. I think the two things that really standout for me as we’ve been traveling around the country and our clinics are talking to people is that 63 percent of our patients come from some sort of a working household, it’s really important to remember that being uninsured does not equal being unemployed by any mean.

The other point that we really want to stress to so many people and those of you who are volunteer at the free clinic know that better than anyone else. We’ve seen a 40 to 50 percent increase in patient demand in the last three years. And yes, I’m going to say that that again, 40 to 50 percent increase in patient demand in free clinics. And, we’ve also seen a 20 percent decrease in donation that have come into the free clinic. I’m constantly amazed at how free clinics continuously service their community and they do so much more with so little. [Slide 6]

Our patient, I think it’s important for everyone to recognize that free clinic serve our patient populations with little to no state or federal support. We rely very strongly just as we do on volunteers, we rely very strongly on donations and (sports fund) and products, and then we rely on grants in united way help, and our free clinics are amazing at their ability to find ways to service their patients that is at no cost to our patient. Again, I want to address the fact that there are some clinics, they may target administrative fee, sliding fees scale for their patient, but in order to be a member of the National Association of Free Clinic, no patient is denied services if they can’t pay.

[Slide 7] I think one of the biggest things that we have found that people ask me all the time is that people think that free clinics are urgent care centers or there are places that people, the patients drops in and out. And as you can see from this slide, there is an ongoing care that is given to the patient, when I asked so many patients as I travel around the country and I stated them, tell me who your doctor is, many of them say to me, my doctor is the Common Ground Clinic or the West Virginia Health Right, or the Christian Charitable Clinic. They don’t say to me, my doctor is so and so, they recognize that the care that they are getting is on an ongoing basis at a free clinic. In fact, one of the free clinic executive director was telling me a story that she actually has a patient that now is being put on a role in one of the state programs and that patient was having a hard time for 10 years. They had gone that same clinic for care. They were looking forward to being placed on Medicare as where they were going, but they were little sad to be leaving that pay clinic behind.

[Slide 8] One of the things that AHRQ has been an amazing supporter with us on has been our care clinics. Care clinics stand for communities that are responding every single day and these clinics started in conjunction with Dr. Ross, we held the clinic, our clinic in Houston stepped up to the plate being the first one NAFC has ever done and we saw 1,800 patient in that day. After that clinic, we’ve been to Little Rock, Arkansas, Kansas City, Missouri for two days. We’ve been to New Orleans twice. We’ve been to Hartford, Connecticut. And we’ve been to Atlanta, Georgia. And we’re going to De Como Washington now, at this point in time. We’ve helped over 12,000 patients, and you can show the next slide as well, and we have activated about 11,000 volunteers. [Slide 9]

One of the most important parts of these care clinics is that they are not just a one day solution, but rather what we do is each of those patients as we connect them to locations that can provide them care on an ongoing basis afterwards. And, we work very closely with the clinicians at these clinics to make sure that they get the information that they need, that we hear some of the questions that they maybe having about issues that they are finding either on this day or at their clinic that they work with directly.

[Slide 10] And working with AHRQ has been great. We started partnership in 2010, and I think to say that we felt there was a real kindred spirit and things that we could both work on would be an understatement. We started talking about our care clinics and said this is an amazing opportunity to get some of the material that you have in the hands of clinicians, who really want to help and be a part of it. And, they have come to our care clinics and provided information and have been the way to work it, and they even came to the national summit, which is where we bring together all free clinic executive, directors, volunteers, clinicians to talk about issues that are important to free clinics in our patients population. And their presentation was very well attended and very well received and we would invite, we’re going to invite them back if that tells you how that goes for us. And currently, AHRQ is working with our NAFC, North Carolina Clinics on health outcomes project that they have going on there.

And that’s it, next slide. [Slide 11] At any point in time, any one on this call has any questions, I know you can outreach to AHRQ directly, and they will be happy to put you in contact with us. But, we did want to put our contact information, and my name is Nicole Lamoureux, Kerry Thompson is here with me on staff. And, you have our phone numbers and emails. Please feel free to drop us off a phone – leave us a message or drop us an email, we’ll be happy to answer any questions that you may have. And, thank you for joining us today on this call. We’re very excited that you are here with us.

Howard Holland: Nicole, thank you so much for your presentation. I appreciate it. And just once more, please know, how pleased we are to be able to be working with you. There were a number of things from your presentation that I’m sure stuck many of us, one of the phrases that you used building a healthy America. I think, it helps to underscore the important role, the work that you do has and getting care to people who wouldn’t otherwise need it. And so, we thank you very much that you are doing the work that you are doing. [Slide 12]

I’d now like to welcome AHRQ’s Director, Carolyn Clancy, who will be our next speaker. Yes, this is the very same Carolyn Clancy, who was on the faculty of the Medical School of Virginia, Commonwealth University and who has been unceasingly singing the praises of the Men’s Basketball team and their appearance in the final four. She is excited about that and all thing Richmond at the moment, but we’re very excited about her, as our Director here and the work that she does in leading our agency.

And Carolyn, I’ll turn it over to you now for your presentation. Carolyn herself too had some free clinic experience in her day about which she may speak either during her presentation or at some point later during the Q&A.

Carolyn Clancy: Well, thank you very much Howard, and I’m really thrilled that you all could join us today. Let me just say, working with the Free Clinic and actually serving on the board of that clinic was one of the reasons I remain such as, about Richmond. And I did go to quite a few basketball games back in the day, but they never played at this level. So I’ll just leave it there. [Slide 13]

As you just heard from Nicole, our partnership with the National Association of Free Clinics actually began in 2010. And, we were actually privileged to support three of the care clinics in Washington DC, in New Orleans, one of my favorite cities besides Richmond and Charlotte, North Carolina. In addition, we participated in the annual summit in Cleveland, Ohio and responsive session about the effective healthcare program here at AHRQ and the application of patient centered outcomes research in the free clinic.

[Slide 14] So, as you heard, Howard say earlier, but you can’t say it often and often in my view, our mission is to improve the quality, safety, efficiency and effectiveness of healthcare for all Americans, very, very consistent what you’ve heard from Nicole, building a healthier America. So, we’re a science agency, we don’t pay for care, we don’t provide it, we don’t regulate it. We support research that helps people make more informed decisions and improves the quality of healthcare that they get. About 80 percent of our budgets is invested in grants and contracts focused on improving healthcare. Because, we’re a science agency, but our aspiration and mission is to improve care. We recognize very clearly, that that means that we have to make sure that the work that we are supporting is translated as practical information and tools that can be put to use every single day in free clinics and elsewhere.

[Slide 15] So, at a glance big priority areas for ARHQ, in addition to the effective healthcare program, which is shown here on the slide, and I should just note that our authority requires that we make sure the information is available in understandable way to multiple audiences. The shortest versions by the way for policymakers, no comments on that. Clinicians in general want more of the needy gritty clinical details and actually working with individuals of varying levels of health literacy to help them think through with you as a clinician, which of multiple options is likely to be good fit for their needs and preferences.

It’s pretty complicated cognitive stuff, it’s kind of like looking through consumer reports to buy a product on steroids. Same issue of making effective comparisons, but the reality as you’re talking about decisions that effect how you feel everyday, whether you can get to work, how you’re going to do with your family and so forth.

In addition, two other big prime areas for us are research that helps to make care safer, helps all of us avoid potential harms that result from errors, from near misses, from poor communication and so forth. And, we support quite a bit of work in looking at how health IT can be part of that solution. Health IT doesn’t solve anything all by itself, but we recognize that it can be a very important part of the toolbox and we make a whole lot of data available, could be topic just for a Webinar on its own.

[Slide 16] So, the Effective Healthcare Program, just drilling down to today’s topic, the goal is to provide current and unbiased evidence on which treatments work for which patients under which circumstances. The great thing about being alive in 2011 is for many decisions whether that diagnosis treatment even prevention. There’s often two or more good options, that’s a real tribute to the biomedical research enterprise in this country, we have a global leadership position and so forth. What there’s not, however, it’s good information that clinicians and patients can access in real time when they’re struggling when trying to figure out, what’s the right choice for me.

So, our goal is to help consumers, providers and policymakers, make informed choices. Now, who defines informed choices are those people, this not a prescriptive program, we don’t make recommendations, what we try to do is present the information and touch away that it’s easier for individuals to make their own decision. The long term goal here is to improve healthcare quality and patients have outcomes, their end results to informed decision making by patients providers and policymakers.

[Slide 17] So that taking a queue from the calls very, very clear presentation, then what Patient Centered Outcomes Research? I’ve started to think about it as precision science, because it helps compare different intervention for common conditions by rigorously evaluating existing literature that is to say, what we know and generate new findings to scientific studies of different treatment and diagnostic interventions. So, we’ve got a lot to do because if you think about, there is usually a real gap between all kinds of knowledge and information out there and what you need right this minute to make a good decision.

[Slide 18] Now, the importance of this kind of work was explicitly recognized in the Patient Protection And Affordable Care Act by the creation of something called “The Patient Centered Outcomes Research Institute,” since we can shorten anything to an acronym here in Washington that is fondly known as (PCORI). Many people think this research is just fantastic, they’re a little worried about how it will be used, will the entity that’s sponsoring the research kind of make recommendations or present information in such a way that people are steered in one direction or not. So, the legislation actually says that this institute does not mandate anything, it doesn’t make practice guidelines, Medicare and other programs cannot deny coverage based on this information.

What we are excited about here at AHRQ is that 16 percent of the total budget, which will be up to a $150 million next year. So, 16 percent of that funding comes directly to AHRQ to disseminate research findings of the institute and similar research sponsored by other entities including those sponsored by the government. We also can use those resources to build capacity for this work. So, imagine that we have a perfect electronic health record and all of your clinics get it tomorrow, and it’s not only easy to work with it’s actually fun. And, there are no (pains) of bugs that’s just a fantasy, sorry. But, if you can imagine getting to that day, which I don’t see is all that far away, there’s a number of free clinics in a lot of community health centers for example that have these records now. We could actually be working with you to take advantage of the information that you collect taking care of patients, protecting their privacy, of course, to try to figure out more about this precision question, which treatments work the best for which patients and so forth.

[Slide 19] Now, there’s a lot of different ways you could think about doing this. If you think about interventions, well that is like one big bucket. We could be just looking at comparing drugs, or comparing surgical procedures, you know, instead, we’re working very collaboratively and getting a lot of input from public and private sector entities and as well as many individuals. Our work is framed by priorities that is to say conditions. Most of the time people don’t walk and say, jeez, what kind of pacemaker do I need, they say I’ve got a problem or you as a clinician working with the patient based on the lab test or something like that say, you know, high cholesterol is a problem that you and I are going to need to deal with. Here’s some of the options that are available for you and so forth. And I won’t read the list out loud except to just note that if you were trying to think about big ticket items that’s what really these conditions shown here as priority conditions represent.

[Slide 20] Now, OK. So, fast forward, you’ve got good information, we’re really excited about partnership thrice and flawless. How do you began to take that information and make it the basis of an informed conversation with the patient? Now, our research shows that most patients want to receive information about their treatment options directly from their doctor. We also know that many patients, some patients actually want to be in the driver’s seat and think of a clinician as kind of a consultant. This tends to be highly correlated with age, you won’t be surprised. So, people my parents’ age, quite a bit older than most of you, as I’m going to say about it. But, I mean getting up into the older ranks of Medicare folks in general want to know what the doctor recommends, period.

Middle aged baby boomers, you know, want to be a part of the decision making process, but even many of them will say, OK, this is really helpful, I’m glad you told me about all my choices. What would you recommend for your brother, sister or whatever? And younger people often act like a second opinion means, Google. So, you know, it’s kind of a broad specter or possibilities here. The reason we think this research is valuable and why we’re really excited about the opportunity is because it reviews alternative treatment options and presents them in an unbiased manner. We’re not saying buy this one or go this way, what we are saying is, here’s what the best research available tells you about the choices that you have to make. And what we firmly believe and there’s a growing amount evidence to support is that when both clinicians and consumer know and discuss the options the result is better care. And by the way even the folks who really want you as a clinician to make that recommendation, they really want to know what the choices are, many considered it a matter of respect, even if they’re waiting for you them to say, you could choose, A, B, C, D or E. And, I would recommend C, that’s OK. They still want to hear about all the options. So with that I’m really, really excited to introduce, turn this back to Howard, I’m sorry, I thought I was introducing, I was trying to take his job away.

Howard Holland: No problem Carolyn, that’s your purgative as executive director. Thank you very much for that overview. I think even for those of us who may have responded, we know in great deal about what Patient Centered Outcomes Research is or who may have something familiarity with AHRQ in the effective healthcare program that provides a terrific background and helps us to really focus on the fact that what we’re driving at is informed choices that patient get to make and helping them to have information together with their clinicians, they can use to make decisions about what the best care is for them based on their unique needs and situation.

[Slide 21] Thank you, again. I’d now like to introduce Dr. Karen Friday, from the Common Ground Free Clinic in New Orleans. Last year we had the pleasure as you heard, meeting Dr. Friday and some of her staff members when AHRQ participated in a National Association of Free Clinic two day citywide CARE clinic. It was the five year anniversary of Hurricane Katrina and we were not sure who we would meet and how valuable the information that we were planning to distribute the patient following their exams would be. The fact that the Dr. Friday is here today speaks to the question that we had about value and use of the materials in the affirmative and asserts we think about how useful the information from the effective healthcare program can be.

Needless to say, Dr. Friday has a story to tell and we are very pleased, Dr. Friday to have with us today to have tell that.

Karen Friday: Thank you, Howard. Welcome to everyone today and welcome to you Common Ground Health Clinic, in New Orleans. The picture you see in the upper right corner is the way the clinical looked for about five years and very recently we had it painted, its now currently yellow color with green trim, but it’s a very colorful place filled with very colorful volunteers and employees and patients and we would like to give you a little highlight on that.

I was asked to keep my slides rolled to the brief, so if you have other questions, afterwards I’d happy to answer them. [Slide 22] It has an incredibly unique history and is a strongly Type 2 Hurricane Katrina. The clinic was initially started on September 9th, just less about a week after Katrina in an unflooded section of New Orleans called, Algiers early location were varied.
The first location was in the Mosque across the street marked present location. Donated goods were stored in tents and peoples in the yards. A clinic now operates in a converted corner food store. A clinic also was initially created entirely with volunteer help, but now through some funding that’s been purely unique in all rooms, we now have some paid staff and some volunteer staff.

We have a population that’s predominately middle age adults. We see occasional children, occasional seniors, the race is served are largely African American, its probably about two-thirds African American, about another 20 percent Hispanic in our case and we tried to serve Hispanic population, particularly the Spanish speaking population that can’t get services elsewhere and then we also see Caucasians and occasional Asians.

Insurance is covered or insurances that patient have, majority are uninsured, but we have now started, since Medicaid patients we have always seen a few Medicare patients that kind of consider the clinic their local clinic and we also do see some private pay patients that either – that comes to you – come to as we’ve unique services. The services that we provide are both traditional and unique, we have the largest proportion of our care is primary care, which is served by family practitioners, internal medicine and nurse practitioners. I myself, I’m an Endocrinologist, so I provided some specially endocrine care as well.

We have a Dermatologist that come half day a month and sees patients. We also have acupuncture services, one afternoon every week. We have herbal medicine specialist that are there everyday and they are actually widely sought after. And, we also have a social worker using the clinic everyday.

The diseases that are covered, predominately I think probably the major disease that we cover is hypertension. We also see an incredible amount of hyperlipidemia, diabetes, musculoskeletal diseases.

We have now started women’s health QIM services, we also see a pair number of pre-employment or pre-education physicals and we also do see some mental health, but we also refer a lot of mental health out to our local free facilities as well.

Languages that are provided in addition to English include Spanish, we have multiple Spanish interpreters in clinic and we also one interpreter that speaks Portuguese.

[Slide 23] Our affiliations with NAFC have been very strong, we are currently a member and have been a member of NAFC. I understand they were very, very, very supportive in helping the clinic grow and survey and we have also been very active participants in the New Orleans free care clinics that have been held at the conventional center in 2009 and 2010.

[Slide 24] We have also being utilizing the many forms of patient education, but including the effect of healthcare patient guides, I know, you certainly have been using a lot of the diabetes educational materials as part of our – as one of our many educational resources, patient education is almost always provided, at the time of intake by our nurses, educational materials are also provided by the clinicians at the location after the intake session. We have a wide variety of educational materials available in the waiting areas that patients can pick up and read.

And then, one other resources that we have that is a very unique type at clinic is that the clinic has developed a community resource guide, which has been distributed at the pre care clinics and is available online through our Website, and I believe that’s my last slide.

I will turn it back to you.

Howard Holland: Yes, I think that was, we were looking here as well, I do believe that was the final slide.

Karen Friday: Yes.

Howard Holland: And thank you for sharing that I think we have both Nicole’s presentation and then Carol and yours help to drive home the point for us of how real the service are for the people and important there are for actual individuals who receive them and again just critical it is in terms of making healthcare available to people who wouldn’t otherwise receive it. And once more as with Nicole, we are very happy to be partnering with you and I know staff here and others who were involved in the events in the New Orleans that we participated in, have spoken so highly of those and of the chance to work with you on them, so thank you for that too.

[Slide 25] We are now at the point in our Webinar where we would begin, we would like to begin engaging with all of you who are joining us today by submitting questions for our panelist. So, I encourage you to please begin doing that and while you are doing that while you are submitting questions, we might try something just a little bit different to get a start and that we would like to offer our panelists an opportunity to ask one another question. To engage one another if you will and a brief dialogue before we begin to queue up the questions that you who are participating on the Webinar might have. In doing so, we hope our panelists might be able to offer just a little bit more background or detail or context to this discussion and the relationship between Patient Centered Outcomes Research, the nations free clinics and the role that AHRQ we hope can play in facilitating this relationship. Caroline, Nicole and Dr. Friday, who between who might like to pose the first question.

Nicole Lamoureux: I have a question and this in a call if I could?

Howard Holland: Yes certainly, Nicole.

Nicole Lamoureux: Dr. Clancy, I am always interested to understand what made you to volunteer your free clinic and would you recommend volunteering other free clinic to other clinicians?

Carolyn Clancy: Yes, really good question Nicole, thank you. I will tell you, I think, I first went there because I had heard such wonderful things about these clinics when they got started in late 1960s. I was kind of just behind that (co-ward) of people who were in colleges then. So, it was like one really important thing I thought I missed in 1960 so when I was heard there was one in Richmond, I went running right down. Overtime it become very important to me, because I become the medical director of the primary care clinic, at the medical college of Virginia which itself is a safety med institution that means that not only did I understand in quite a bit of detail as part of my day job how much unmet needs there was. I also knew that how limited our capacity was to get patients in. So, I thought it a very important adjunct to, well we were providing to patients in the community and I also thought it was a very important opportunity for residents to learn more about different patient population and the ones who necessarily had got in plugged into our clinic long time ago because they ended up being our first priority.

So, literally one of the last things I did before I moved from Richmond to Washington was to actually work with the lawyer at the University Hospital to make sure that the residents could work there and get covered under malpractice, you know, these lawyers are little fussy about that. So, that actually happened and that meant that more and more residents could and indeed did volunteer.

Nicole Lamoureux: That’s excellent, thank you.

Howard Holland: All those of our panelist who may have questions for each other.

Carolyn Clancy: Well, I will try one.

Howard Holland: Go ahead.

Carolyn Clancy: Nicole you had an opportunity to see and review some of the tools and publications from our program and maybe talked with some clinicians about them and as we said AHRQ has participated with some of your care clinics in DC, New Orleans in Charlotte, do you see the value that they might serve in free clinics across the nation and Dr. Friday would also be interested in hearing about what you think?

Nicole Lamoureux: [Slides 32-33] This is Nicole and I have to say that every single clinician that has read the material that you all have provided to has said how can I get more. So, always we know that’s very important. I think that the material you have especially it’s on that disease states that we see so much, the diabetics, the hypertension, those are things that are helping our clinicians understand how to be more responsive to their patient and they can be helpful to you and others. I know that, I think that we would love to continue this conversation because as we know outcome of this so important and these documents that you have, you have done a really nice job of making it easy to understand for the patient as well as for the physician to move on. Dr. Friday would you agree with that?

Karen Friday: Oh, absolutely, I think that’s probably the most beautiful part about this publications they are incredibly easy to read and understand yet provide a great, provide some very specific information in a easy format and if you know it excellent that they are available in both English and Spanish and that they are available online, so you wouldn’t necessarily have to have them send it you, if there is a disease state that you wanted to, you know, you could go to the internet, print it out and hand it to the patient right there, which we so often do.

Howard Holland: Oh, that’s really, really great think here. Let me ask our presenters are asking one another question, just jump in to say that for all of you participating, if you yourself have questions please submit those and we will be glad to incorporate them as we are discussing on the topic here from the Webinar today. I might ask a question and that might be to Nicole to you and to Dr. Friday, I mean obviously we as an agency put a high priority on partnering with groups unlike the ones that you representing and I think you have touched in some ways on ways in which effective healthcare products themselves can be useful but, you know, are there other ways that you see partnership emerging between either other organization that are like your that we hear the agency might work with or a ways in which we can bridge across other providers who are attempting to reach these same audiences so that we could hopefully build on the work that you are conducting?

Karen Friday: This is Karen Friday. You know, I am certain there, that there are opportunities and there may also be small opportunities with some of the disease oriented organization such as I know that’s the American Diabetes Association and American Heart Association have combined forces to work on heart prevention and complication prevention in diabetes. So, I am sure there is many creative you know, ways that new bridges could be formed and more information could be disseminated.

Nicole Lamoureux: And, I agree with all that, this is Nicole, and I also think one of the things that is beautiful about free clinic is that since we utilize so many volunteers and so many volunteers have practices of their own and they work in hospitals, this is another opportunity for us because its so easy to use in army internet that many of our volunteers will be happy to take this into the other aspects of their life as well.

Howard Holland: Thanks very much. We do have a question in from the audience and that is the would we talk just a little bit more about the EHC, the Effective Healthcare patient guide and where they can be found and all of the information about our agency as effective healthcare program can be found on the effective healthcare program Website which is [Slide 34]

Carolyn Clancy: And I will just try and amend that, this is Carolyn Clancy, I have shared them with a number of friends in college and they, frankly their comments would echo what Dr. Friday had to say earlier that it is very easy to understand and sometimes I can here sigh of relief or huge relief on the other end of an email as people realize oh, so, that’s what that termed that someone was talking about and I didn’t have a chance to say, so, what do you mean by that means. So, that’s always very gratifying for us.

Howard Holland: As other questions are coming in let me, Carolyn pose one to you if I may and that is that I know in so many of your presentations, you talk about the importance of shared decision making and this relationship between more evidence based information and how that can be used by patients, can you perhaps say just a little bit more about why that is so important as we try to work toward improving the quality and safety of care that patients receive?

Carolyn Clancy: Sure and thank you Howard. [Slide 31] You know, ultimately in my view the definition of quality care is the right care for the right patient at the right time and I was quite struck by Nicole’s comments earlier about both how many patients come back to these clinics but their main identity or affiliation is with the clinic rather than an individual because there were so many volunteers and so forth and yet at the same time there is a fair number of folks who don’t actually get the opportunity to come back or their schedules don’t allow it or that pre-employment physical was very positive and they get the job and move away. See, it’s a little bit like working in emergency room on urgent care centre, you don’t know all the time who is going to come back. So, the better choice you can make the first time this decision comes up the better off you will be. The other point I would just say is, you know, there is a growing body of evidence that effectively says that patients who act as partners in their own care particularly for chronic illness have better outcomes. So, it’s not just a nice thing to do, it’s actually really important.

Howard Holland: Thank you very much. Dr. Friday, perhaps a question for you and obviously as everyone is aware on the call the economic downturn, the recession that we have gone through, unemployment often means no health insurance or lose of health insurance, what impact has that had on the Common Ground Clinic and perhaps what are some of the issues the economic health otherwise that you see sort of converging in and among the patients that the clinic serve?

Karen Friday: Well, as you know, we don’t have to, we not only worry about an economic downturn, you know, Katrina changed just you know, the whole infrastructure of healthcare and economics and academic medicine and you know, how patients get cure, how they pay for their medicine. How, you know, it’s so, it’s, so, I think we are perhaps better prepared for the economic downturn. But, you know, it’s, if, but it makes a huge difference, you know and especially free clinics that were provided downtown at convention centre throughout, drew a huge crowd of patients who haven’t seen a doctor since before Katrina and then lost their job after Katrina and haven’t seen, they haven’t been to clinic in years despite the presence of blood pressure problems or diabetes or you know what, just needing glasses or dental care and I can’t see other very sad reality is that when patients loose their e insurance they also loose their ability to buy those very, very expensive medicines and instead of trying to find, you know and so one of the things we do when they come on the very first visit to Common Ground Health Clinic is that we try to find inexpensive generics that will safely and effectively treat their chronic disorder and we are very creative in telling that and when we can’t find cheep, the inexpensive generics, we will use the patient assistance program to help get them the medicines that they need.

Howard Holland: Thank you very much. Let me queue our operator if I could, I believe that we have one caller on the phone who has the question. We would like to open the phone line for that person as we or when we do that, you would just please identify yourself, and if you were wanting to direct your question to one of our three panelist or all three?

Operator: Thank you. If you do have a question via the phone line, please press star one on your telephone keypad at this time.

Howard Holland: And again, I thought we perhaps had one caller already in the queue with a question, is that correct?

Operator: Not at this time sir, we don’t have any questions in the queue.

Howard Holland: All right. Thank you so much. Well, then Dr. Friday, let me just ask a brief follow up question to you, there is also one from among audience questions, sent by email and that’s, are you able to refer patients to community health centers or to perhaps other cons of provider networks that you maybe connected with too?

Karen Friday: Yes, absolutely. That we rely very heavily on, not you know, it’s certainly there are things that we are not equipped to do in our small clinic. And, we would, such as we don’t have radiology resources. And so and we don’t have many of subspecialty care and we are a little bit different norms that there is a safety that state mandate or the state funded hospital system called, Medical Center of Louisiana. And initially after Katrina that wasn’t functioning for a long period of time. But, it’s now back in a fairly good form now. So, we are able to refer patients in for especially cardiology care, specialty GI care or some of the other more complicated cases. We’re able to refer those patients since and also we struck creative – the clinic struck creative deals with many of the local care providers, so that before the state hospital system had their clinic something going again, they were able to coordinate, do scan at laboratory rates with one of the local laboratory providers. They were able to provide discounted optometry rates with the local providers. We have some radiology providers that will provide discounted rates as well. So, it’s been a combination of creativity as well as utilizing and knowing the resources in your area.

Howard Holland: Just as a process note, we obviously are coming up on the top of the hour, we are going stay together just for a few more moments, we have a couple of additional questions here in the queue that we would like to get to and a final poll question that we want to ask everyone, who is on? Nicole, this next question or actually two related questions are for you from the audience and that is first, does NAFC work with NACHC, the national health center and if so what might be the overlap between your two groups or the distinction if you will and what you each do?

Nicole Lamoureux: Sure, thank you so much. We do work very closely with NACHC and in fact, the head of NACHC and myself, there are numerous committees and boards together in Washington DC as you know, (Dan Hawkins) is a great man. I think one of the things that we do just as if our free clinics do, is we understand, it really takes a safety net to service the uninsured populations here in the country. There are definitely some very, very differences between community health centers and free clinics, so I think the biggest difference without getting two technical is that they receive 330 funds and grant funds from the federal government and free clinics do not.

And because of that there are definitely some differences under their national organization and our national organization since we don’t get those funds. But, we do work very closely together on issues that align for ourselves and we continue to work on that partnership.

Howard Holland: Somewhat related Nicole, how is that on – if there are people who are out in the audience and they are with groups who want to get involved in your organization NAFC and in partnership with you to provide care and do the kinds of things that you all have been describing. How would they best go about doing that?

Nicole Lamoureux: The best way to get in touch with the National Association of Free Clinics is to visit our Website, Exit Disclaimer and right on that Website is phone numbers and emails directly to us and staff and when you call, you can ask for Kerry or Nicole and we’ll be happy to talk with you as well. And it’s a great resource for you on our Website to see more information about who we are and what we do.

Howard Holland: Thank you very much. We’re now going to go to our final poll question and we would like to ask (Austin) yes, if he would please help bring that up as we do that, Carolyn a question for you and that’s perhaps could you speak again a little bit more to the value of evidence based information itself and perhaps how that evidence based information maybe different in some other kinds of research that our agency or other agencies produce?

Carolyn Clancy: [Slide 35] It’s actually a great question, I mean, to be a clinician whether you’re a physician, nurse parishioners or physician assistant or what. You had tons of training and you’ve learned all about diseases and all that and yes, often the gap in training particularly for younger healthcare professionals is still in the very specific practical stuff. OK, I know, all about metabolism and diabetes, but now specifically what do I do and what are the practical implications of starting with Metformin versus starting on different types of insulin and so forth and what’s going to be required of the patient. So, a big part of this work isn’t just like kind of generating information about answers, but it’s also very much about how do you apply this in real life. When you are in med school and I’m sure the same as too for other training you’ve learned all the science. And you are always told, well the best part about being a doctor is you get to tailor that and customize it for the needs of the individual patient and frankly I think that remains what excites, most practitioners today, that get very passionate about and very creative about that. But, when they find themselves lacking information in real time at the point of care, that can be extremely frustrating, so we are hoping to fill that gap.

Howard Holland: Thank you very much, Carolyn. We would like to ask if there are any people who are in the phone queue if, for the instructions of our operator, you’re wanting to way in via a phone to ask a question. Is there anyone on the phone who may want to pose a question and we don’t want miss you if there is.

Operator: Yes, we do have question that was in the queue and your first question comes from Pamela Karen.

Howard Holland: Hi Pamela, please go ahead.

Pamela Karen: Hi, I’m wondering if any of the presenters are aware of new sources of financial support that might be coming to free clinics who want to continue, continue to utilize the tools and all continue fashion to significantly improve and demonstrate the quality of clinical care in the clinic. The question really about financial resources, I think the experience of any organization whether it’s a well funded hospital or considerably funded community health center or a free clinic. We know that it does take resources in order to deeply engage clinical quality improvement and I’m just wondering if any of the presenters are aware of channels for financial support for free clinics, who wish to do that?

Carolyn Clancy: Right now, at this instance I’d have say no, that said, I think we would be interested in exploring other options with you, I know that for many of my colleagues at the Department of Health And Human Services, as we are thinking about implementing the affordable care act and so forth. We are very, very attentive to the vital role that safety net providers by including free health clinics. So, this topic is high on our brains, my hope and aspiration is that we can translate that into a practical answer to your question. So, please stay tuned, I don’t mean in the next five minutes but I mean obviously in the very near future. Because the point made are exactly right.

Pamela Karen: Thank you.

Karen Friday: This is Karen Friday from Common Ground. We have within the last year started applying for community health clinic funding to help, sustain and continue our important work and as well as we have people writing grants all the time.

Nicole Lamoureux: And this is Nicole Lamoureux, and I think that your question is one that (Kerry) I work on pretty much on a daily basis trying to find where we can have some more of those grants, so outside of the grants that so many free clinics rate all of the time and you work with your united ways and the Crusty Foundations and other foundations that exist. It is our hope and our continued work with the department of health and human recourses as they are implementing the Affordable Care Act to make sure that free clinics are entities that are specifically named as the ability to take advantage of some of those grants. We understand that how hard it is for so many of you and we also understand that they are not as many opportunities available to free clinics as there are to some of the other safety net providers and that is something that we are continuing to work on. At this time we do know of some grants that are available for different opportunities and if you are a member of the NAFC, we send those out to you all, but nothing specifically for this at this point in time.

Howard Holland: Pamela, thanks for your question. We have time for one other questions from the phone queue, and we’ll just review the quick poll and then we’ll be wrapping up.

Operator: Thank you.

Howard Holland: We have another question on the phone.

Operator: Yes, your next phone question comes from Dr. Nancy Hart.

Howard Holland: Hi Dr. Hart.

Nancy Hart: Hi, I’m calling from the University of Florida where we have our free clinic in a bus. And we were just – I’m here with two medical students, and we were just scrolling around on your Website looking at the patient care guides and wondering if there was anything that we would just be a one page so that we could print off on our little printer on the bus, because we can’t carry around a lot of stock.

Howard Holland: Dr. Hart, we will look forward to following back up with you with some information, yes, that can help to address that need.

Carolyn Clancy: One second, Hart.

Nancy Hart: How are you doing Dr. Clancy?

Carolyn Clancy: I’m doing great, thank you. I knew you would be doing great stuff back in Florida.

Nancy Hart: I don’t know if you all know about our medical students have actually a network of medical student around the free clinics in Gainesville, Florida, it’s very impressive.

Carolyn Clancy: That’s cool.

Howard Holland: Well, let us turn to, I thank you again Dr. Hart. We want to turn to our quick poll results and we’re flattered to see that as many of you as all would be interested in using our publication and other tools with your patient. Obviously, the attempt, the goal behind these Webinars is both to inform and share information that we held will be useful and get feedback on ways on which could be more easily and readily acquired and we’re flattered to see that these would be the cons of resources that you would think would be valuable. I’m sorry, if there are others who are on the phone that we’re not able to get to your questions, but for you and for any other who may yet want to ask questions of the panelists or of us here at AHRQ, I hope you’ll please email us at the following email address,, again, if we were not able to get to your question today or if you have questions that occur to you later, please email us that, and that address maybe coming up soon,

In addition, as we described earlier, the effected healthcare Website, but to access more information about the effected healthcare program and to order resources for your own clinic or your patient, please visit the Website at the address you see there, Let me again, thank all of our speakers today, Nicole Lamoureux, Carolyn Clancy, Dr. Karen Friday. I would also like to thank all of our participants for joining us today. We do hope that the information presented here was informative and has perhaps inspired you to learn more about AHRQ, Patient-Centered Outcomes Research, the Nations Free Clinics and the important work that’s being done through them.

As we conclude this Web conference, let us remind you that we have more in mind for the future and that this event will be archived and available shortly on the Effective Healthcare Website, should you like to go back to it. Once again, thank you very much for being with us today.

Nicole Lamoureux: Thank you, Howard.

Karen Friday: Thank you, Howard.

Operator: Thank you. Thank you for participating in today’s teleconference. And at this time, you may now disconnect.