Outreach to Improve Patient Education at South Carolina Free Medical Clinics

Abstract

The University of South Carolina (USC) School of Medicine (SOM) librarians have partnered with eight free medical clinics in South Carolina to enhance patient education efforts. During these outreach projects, project librarians purchased and installed computers, projectors, screens, LCD monitors, and touch-screen information kiosks equipment in each clinic, conducted MedlinePlus training sessions with clinic staff, and added links to MedlinePlus on the patient education area of the clinics’ websites. As a result, the free medical clinics incorporated MedlinePlus into their patient education classes or use the self-playing tutorials in patient waiting rooms.

INTRODUCTION

Since 2006, the University of South Carolina (USC) School of Medicine (SOM) librarians have been partnering with free medical clinics throughout South Carolina to enhance their patient education efforts and promote the use of MedlinePlus. Produced by the National Library of Medicine, MedlinePlus provides up-to-date electronic health information about diseases, conditions, and wellness issues in layman’s terms for free.

The SOM project librarians have received project funding three times – one Express Outreach Award and two Outreach Awards from the National Network of Libraries of Medicine Southeastern/Atlantic Region – to work with a total of eight free medical clinics in South Carolina. The specific project objectives included: (1) purchasing and installing equipment in free medical clinics throughout South Carolina in order to enhance patient education efforts; and (2) increasing awareness and use of MedlinePlus at free medical clinics throughout South Carolina by conducting training sessions at each free medical clinic, as well as linking to MedlinePlus content on patient areas of the free medical clinics’ websites.

BACKGROUND

The South Carolina Free Clinic Association, which is affiliated with the South Carolina Hospital Association, is a network of 43 free medical clinics throughout South Carolina. The mission of the South Carolina Free Clinic Association is to support and assist free medical clinics in improving the quality and availability of health care to the medically underserved by managing the free medical clinics effectively and efficiently and by expanding those efforts in other South Carolina communities.¹ South Carolina’s free medical clinics, which may serve a particular county or region of the state, provide economically disadvantaged individuals who are predominately uninsured with basic primary medical care, prescription medications from a basic formulary, and wellness education. Some free medical clinics offer dental care, vision care, chiropractic care, and psychological counseling. Most free medical clinic patients do not have access to medical insurance and are ineligible for government programs.

Librarians from the SOM Library embarked on their work with free medical clinics after receiving an Express Outreach Project Award for the Partnering to Improve Patient Education (PIPE) project. The focus of the PIPE Project was to partner with the Free Medical Clinic in Columbia. Dennis Coker, the clinic director, shared positive feedback about the PIPE Project with the members of the South Carolina Free Clinic Association, which led to the idea of expanding the work to other member clinics in South Carolina.

To gauge interest for another free medical clinic project, Dennis Coker distributed an e-mail to the SC Free Clinic Association. In less than 24 hours after this initial e-mail, nine free medical clinics expressed interest in participating in a similar patient education project with the project librarians at the USC SOM Library.

To help in the selection process, project librarians created an online survey that obtained more information about each free medical clinic, including staffing information, facility space, the clinic’s patient education efforts, and technology needs. The survey included questions regarding the current patient education classes, availability of health information on their website, and computer needs.

Six of the nine free medical clinics completed the survey by the deadline. Based on the free medical clinics’ current and desired patient education services, the potential impact of this project on their patient population, the existence of medical libraries in their communities, and the region’s established and potential partnerships with the USC SOM, the USC SOM project librarians selected four free medical clinics to participate in the “Linking South Carolina Free Clinics to Quality Health Information” project: Greenville Free Medical Clinic (Greenville, SC), St. Luke’s Free Medical Clinic (Spartanburg, SC), La Clinica El Buen Samaritano (Columbia, SC), and the Mercy Medicine Clinic (Florence, SC).

After the “Linking South Carolina Free Clinics to Quality Health Information” project was completed in February 2010, the USC SOM librarians sent out a second online survey to the directors of free medical clinics in South Carolina to gauge interest in continuing the project. Ten free medical clinics were interested in being part of the current project, which runs from June 2010 through April 2011. The USC SOM project librarians were able to obtain funding to work with these three free medical clinics: Good Neighbor Medical Clinic (Beaufort), Good Samaritan Medical Clinic (Chester), and Orangeburg-Calhoun Free Medical Clinic (Orangeburg-Calhoun). Since this paper is summarizing the work of all three projects and to avoid confusion of official project titles and participating free medical clinics, these projects will be simply referred to as “free clinic projects.”

Target Audience

The target audience for the free medical clinic projects is the staff and volunteers of the free medical clinics. Free medical clinic volunteers include physicians, nurses, nurse practitioners, interpreters, pharmacists, pharmacy technicians, clerical assistants, IT professionals, medical residents, pre-medical students, and nursing students. There are more than 2,000 staff and volunteers at these eight free medical clinics, and they have more than 12,800 patients. The patients of these free medical clinics will have benefited from the free clinic projects. The eight free medical clinic partners varied in levels of financial support and length of time they have been open. Some of the free medical clinics already had formal patient education programs, while other free medical clinics relied on this partnership with the USC SOM librarians to help get them started. The eight free medical clinics were geographically dispersed throughout the state (see Figure 1).

FIGURE 1.

Participating Free Medical Clinics

Clinic Profiles

The Free Medical Clinic <http://www.freemedclinic.org> is located in the Midlands region of South Carolina. The clinic primarily serves individuals in Richland and Lexington county, but also sees patients from 18 other counties. The clinic has seven full-time employees and three part-time employees, augmented by 780 volunteers. The walk-in clinic is open Monday through Thursday, and the clinic is open on Friday for patient education. In 2008, they had 12,025 patient encounters.²

La Clinica El Buen Samaritano, the Good Samaritan Clinic <http://www.goodsamaritanclinic-sc.org> is a free medical clinic that has been serving Richland and Lexington counties since 2001. Although La Clinica El Buen Samaritano is also located in Columbia like the Free Medical Clinic, their target population is the Hispanic community, and the clinic sees approximately 400 patients per year. In addition to providing medical care, the La Clinica El Buen Samaritano functions as a center of information, orientation, and reference to serve as a liaison between Hispanics and the different services, programs, and resources available in the community. Their phone line is open to the public, so they can call and ask questions and receive answers in their own language. La Clinica El Buen Samaritano has one staff member and 26 volunteers. In 2007, they conducted 24 patient education classes. Some of the class topics included HIV, sexually transmitted diseases, dental and oral health, prevention of chronic diseases, high blood pressure, and diabetes. They recently opened a satellite office in West Columbia; each office is open one day a week.

The Orangeburg-Calhoun Free Medical Clinic <http://ocfreeclinic.com> is a free clinic that serves Orangeburg and Calhoun counties. The Orangeburg-Calhoun Free Medical Clinic has seen more than 400 patients over the age of 60 since August 2009. The Orangeburg-Calhoun Free Medical Clinic is located in Orangeburg, SC, which is in the Midlands Region of the state. The Orangeburg-Calhoun Free Medical Clinic has two staff members and 80 volunteers. From August to December of 2009, they conducted approximately 80 patient education classes. Some of the class topics included diabetes management, hypertension, obesity, and diet.

The Greenville Free Medical Clinic has a 20-year history of partnering with two local hospital systems and related organizations to provide care for indigent patients, many of whom have low health-literacy rates. The clinic, which is located in the Upstate region of South Carolina, serves approximately 3,000 unduplicated, low-income uninsured residents of Greenville County. They have approximately 11,000 patient visits and 40,000 prescriptions per year. The Greenville Free Medical Clinic has eight full-time staff, six part-time staff, and 500 volunteers. They have approximately 400 patient education classes per year. They hold four diabetes classes per week, three women’s health groups per month, and a weekly HIV/AIDS class. They also conduct seasonal presentations which, during the appropriate season, occur about three times per week, such as Valentine’s Day Heart Health, October Breast Cancer Awareness, National Stop Smoking Day, and Summer Skin Cancer Safety. They have also held classes on the following topics: walking/moderate exercise programs, smoking cessation, and nutrition/weight loss. The Greenville Free Medical Clinic has one main office and three satellite clinic locations.

The mission of St. Luke’s Free Medical Clinic <http://www.stlukesfreemedical.org> is to provide comprehensive health services to Spartanburg County residents who lack access to medical care. St. Luke’s Free Medical Clinic, which is also located in the Upstate region of South Carolina, serves approximately 1,500 unduplicated patients per year. They have over 100 clinic visits weekly and dispense over 2,000 prescriptions monthly. The clinic also conducts over 3,000 lab tests and x-rays yearly. St. Luke’s Free Medical Clinic has seven full-time staff and more than 400 volunteers, and the clinic is open on Tuesday and Thursday.

The mission of the Good Samaritan Medical Clinic is to provide free medical care to residents of Chester County and surrounding counties who do not have medical insurance, do not qualify for Medicaid or Medicare, and whose income, if they work, meets certain guidelines. The Good Samaritan Medical Clinic, which is also located in the Upstate region of South Carolina, serves approximately 1,500 unduplicated patients per year. Good Samaritan Medical Clinic has 4.5 full-time staff. In addition to their volunteer physicians, there are 11 pharmacists and 15 nurses that work in the clinic. One hundred volunteer specialists see patients in their private offices on referral from the clinic. They do not currently have patient education classes.

Located in the Pee Dee Region of South Carolina, Mercy Medicine Clinic <http://www.mercymedicine.org> is a free clinic assisting Florence and Dillon County residents. The clinic further cares for patients through referrals to participating specialists who provide more complex procedures, as well as outpatient surgeries, free of charge. The clinic assumes the cost of medications through pharmaceutical programs, donated samples from sales representatives, and a local pharmacy. Mercy Medicine Clinic is the only free clinic in South Carolina that provides retinal care services, and they are just one of four free medical clinics in the state to feature dental care. In 2008, Mercy Medicine Clinic treated approximately 3,000 patients and accommodated more than 6,000 in terms of patient visits. They also opened a satellite office in Lake City in 2008. The Mercy Medicine Clinic has six staff members and about 125 volunteers. They held approximately 18 patient education classes in 2008 before the project. The primary waiting area was utilized for patient education after hours. Diabetes is one of the most popular class topics due to the prevalence of this condition in the Pee Dee region of South Carolina. Other class topics include diet and weight control, hypertension, women’s health, and smoking.

The Good Neighbor Medical Clinic was established in December 2007 with the support of area churches, leaders of the local medical community, and other concerned citizens. The Good Neighbor Medical Clinic, which is located in the Low Country region of South Carolina, opened with physician visits in June 2009, having seen over 800 patients thus far. The Good Neighbor Medical Clinic’s RxACCESS program, which assists clients in accessing the most economical source for their medications, has assisted more than 300 patients in obtaining approximately $69,000 worth of prescriptions. The Good Neighbor Medical Clinic has one and a half full-time staff and more than 100 volunteers. They hold one-on-one patient education sessions following the visit with the physician. They partner with Beaufort Memorial Hospital, Beaufort-Jasper-Hampton Comprehensive Health Services, and South Carolina Department of Health and Environmental Control Region Eight to provide diagnostics and treatments for their patients. They are currently expanding their diabetic education program and planning a women’s support series with topics such as nutrition, exercise, stress management, and depression.

METHODOLOGY

Generally, the project librarians visited each free medical clinic at least three times. During the initial site visit at each free medical clinic, the project librarians toured the clinic, discussed the project, and assessed the clinic’s equipment, training, and website needs. On the second visit, project librarians taught the MedlinePlus class and delivered the equipment, although, these events were occasionally completed as separate visits. The final site visit was used for project feedback and to take pictures of the equipment.

Equipment

All of the free medical clinics selected have Internet access and at least one volunteer who can help install and maintain computer equipment (see Table 1). A computer, projector, and screen were purchased for the Free Medical Clinic (Columbia, SC) and the Orangeburg- Calhoun Free Medical Clinic. Both free medical clinics have a designated room for patient education. Four free medical clinics are using MedlinePlus interactive health tutorials in the waiting room where they have a captive audience. These four free medical clinics received computers and 40-inch, flat panel, LCD monitors. Due to limited space, La Clinica El Buen Samaritano (Columbia, SC) uses the waiting room for formal patient education classes after clinic hours. Since La Clinica El Buen Samaritano has a satellite office, the project librarians purchased two LCD monitors, one for each clinic, and a laptop to use to hook up to the monitor, depending on which clinic was open that evening.

TABLE 1.

Summary of Free Clinic Projects

Project Period	Clinic	Equipment
11/06 – 11/07	The Free Medical Clinic	Computer and projector
09/08 – 02/10	Greenville Free Medical Clinic La Clinica El Buen Samaritano Mercy Medicine Clinic St. Luke’s Free Medical Clinic	Health information kiosk Computer and LCD monitor Computer and LCD monitor Computer and LCD monitor
06/10 – 04/11	Good Neighbor Medical Clinic Good Samaritan Medical Clinic Orangeburg-Calhoun Free Medical Clinic	Computer and LCD monitor Health information kiosk Computer and projector

Prior to the free clinic project, the Greenville Free Medical Clinic had been holding patient education classes in their conference room, which was already equipped with a projector and workstation. They wanted to supplement the current classes with a more on-demand, interactive approach by installing a health information kiosk in the waiting room. The project librarians decided to purchase a touch-screen information kiosk for the waiting room. After answering a few health survey questions (in English or Spanish), MedlinePlus opens (see Figure 2). The patient educator helps patients access health information in MedlinePlus, which is the only website that is accessible on the kiosk. The kiosk, which includes a printer, has a 15-minute time limit. The clinic director was trained to access the survey results.

FIGURE 2.

Kiosk Survey Questions

The Good Samaritan Clinic was the second clinic to use the kiosk approach for patient education. Their information kiosk, which takes users to MedlinePlus after completing the kiosk survey questions, was installed in January 2011.

Training

The project librarians used a “train the trainer” approach for the free clinic projects. After training the greatest number of staff and volunteers possible at each free medical clinic in the use of MedlinePlus, the class attendees then trained other clinic staff and volunteers to use MedlinePlus. The clinic staff can choose to incorporate the MedlinePlus content or use the online tutorials in their patient education classes.

The project librarians have taught six MedlinePlus training sessions to date for the free medical clinics with plans of teaching one more. Training sessions for staff were tailored to their needs and varied from hands-on sessions in a computer classroom to a demonstration in the director’s office with staff seated around the table. Class sizes ranged from two to seven participants. The sessions lasted approximately one hour and covered content from the following areas of MedlinePlus: health topics, drug information, medical encyclopedia, news, and directories. MedlinePlus’s interactive tutorials were a focus of the sessions since the free medical clinics are using some of these tutorials for patient education in their waiting rooms. Participants watched how to set up the self-playing mode for the tutorials and received an accompanying handout.

Towards the end of the training session, the project librarians briefly covered ClinicalTrials.gov and NIHSeniorHealth.gov. Resources available for trainers from the National Library of Medicine <http://www.nlm.nih.gov/medlineplus/training/trainers.html> were also mentioned for the clinic staff to use when showing other clinic staff and volunteers how to use MedlinePlus. Although the project librarians offered to provide additional MedlinePlus training sessions to each of the free medical clinics, none have been requested.

Patient Education Web Pages

Since the clinic staff and volunteers use the equipment and MedlinePlus content during their patient education classes, the project librarians worked with the free medical clinics to create “Patient Education” pages for the clinic websites. There were three purposes to the “Patient Education” pages: the clinic staff can easily access MedlinePlus content to supplement patient education classes, the clinic staff can quickly retrieve a menu of tutorials to show in the waiting rooms, and visitors to the clinic websites have access to authoritative consumer health information. Each page includes a description of MedlinePlus, a MedlinePlus search box, and customized links to MedlinePlus health topic pages and interactive tutorials based on the most commonly seen conditions and health topics at each clinic. Some of the free medical clinics embedded the html code in their own website template, such as <http://www.ocfreeclinic.com/fmc/PatientEducation/tabid/82/Default.aspx> and <http://www.goodsamaritanclinic-sc.org/patient_education.htm>. Alternatively, other free medical clinics selected to link to a page the SOM Library hosts, such as <http://uscm.med.sc.edu/mmlinks.asp> and <http://uscm.med.sc.edu/sllinks.asp> (see Figure 3).

FIGURE 3.

St. Luke’s Free Medical Clinic Patient Education Web Page

RESULTS

Each free medical clinic had unique equipment needs based on their physical space and services. Of the five free medical clinics from the first two free clinic projects, the project librarians conducted four MedlinePlus training sessions. Since the Greenville Free Medical Clinic was using the kiosk approach, they did not see a need for a MedlinePlus training session or a patient education web page. Their nurse educator, who was already familiar with MedlinePlus, assisted individuals using the kiosk if they needed help. The Greenville Free Medical Clinic director is able to download usage statistics from the kiosk. From January 4, 2010 – February 22, 2010, 135 people used the health information kiosk at the clinic (see Table 2). Eighteen of the 135 used the Spanish interface. The following tutorials have been viewed: asthma, heart attack, knee arthroscopy, and diabetes meal planning. Projects librarians are currently in the final quarter of the most recent free clinic project.

TABLE 2.

MedlinePlus Health Topic Pages Viewed on Kiosk

Abscesses

AIDS Medicines

Alzheimer’s disease

Angina

Back Pain

Breast Cancer

Cholesterol

Chronic Obstructive Pulmonary Disease

Diabetes

Diabetes Complications

Earthquakes

Emphysema

Fractures

Gastrointestinal Bleeding

Joint Disorders

Kidney Transplantations

Knee Injuries and Disorders

Marijuana

Muscular Dystrophy

Rashes

Smoking and Youth

Tendinitis

Tinea Infections

Weight control

Winter Weather Emergencies

Project Promotion

The free clinic projects have been promoted by the SOM project librarians in a variety of ways. The projects have been announced on the “Library News” portion of the home page, articles have appeared in Communications, the SOM Library newsletter; and the free clinic projects are featured on the SOM Library’s Community Outreach web page <http://uscm.med.sc.edu/outreach.asp>. In 2010, the project librarians presented posters about the free clinic projects at the Medical Library Association (MLA) Annual Meeting and the annual meeting of the Southern Chapter of the Medical Library Association (SC/MLA). Project librarians also encouraged the free medical clinic partners to publish articles about the project in their own newsletters and web publications.

The project librarians met with three hospital librarians near the free medical clinics to discuss the project and possible information services they could provide to the free medical clinics near them. Since there are no hospital libraries near the current free clinic project’s clinics in Chester, Orangeburg, and Beaufort, project librarians will meet with public library directors and possibly academic library directors in these communities to discuss the project and possible information services they could provide to the free medical clinics and their patients.

Additionally, the project librarians supplied the free medical clinics with promotional materials for MedlinePlus, such as bookmarks, pens, and copies of the NIH MedlinePlus magazine. While the primary target audience for promoting MedlinePlus was the staff and volunteers at the free medical clinics, the patients of the free medical clinics were also exposed to the consumer health content in person and potentially via the clinics’ website as a result of the project.

Project Evaluation

After each MedlinePlus training session, the participants were asked to fill out an evaluation form. There have been 23 participants. On a scale of 1–5, with 5 being the highest (1-Poor and 5-Excellent), 22 participants rated the overall effectiveness of the teacher as 5, and one participant rated it as a 4 from the free medical clinics that have received training thus far. Twenty-one participants selected “yes,” the class met their training needs, one participant selected “somewhat,” and one participant selected “no” (with yes, no, and somewhat being the only responses).

The National Network of Libraries of Medicine Outreach Activity Data Collection Form <http://nnlm.gov/evaluation/tools/ActivityInfo.pdf>, which is used to assist Outreach Librarians and Principal Investigators in reporting and sharing training or exhibiting activities, was distributed to each free medical clinic, and project librarians requested that the form be filled out during patient education sessions and sent to the project librarians. To date, project librarians have not received any Outreach Activity Data Collection Forms from the free medical clinics.

An online survey was not used for evaluating the first free medical clinic project, PIPE Project, but the director of the Free Medical Clinic was impressed with the large amount of quality information available through MedlinePlus and encouraged the project personnel to replicate this project in other free medical clinics in South Carolina. For the second free clinic project, the project librarians created a brief online survey to collect feedback about the equipment, as well as the overall project, from each of the four free medical clinics. Survey questions were tied directly to the project objectives, such as the clinic’s satisfaction with the equipment and whether the project had enhanced patient education services by increasing awareness and use of MedlinePlus. The survey link was e-mailed to the four clinic directors.

All four directors agreed that the equipment purchased for this project enhanced the patient education efforts at their free medical clinic and that this project increased the awareness and use of MedlinePlus at their clinic.

Other comments included in the survey responses were:

“We would use the program much more if there was a loop of the tutorials to play in our lobby while our patients are waiting to see the physician.”

“The possibility to add MedlinePlus content to our website has been great because people can go directly to get information in any health topic they need or want to know.”

“Although the health information kiosk has not been in place long, we are already getting positive patient feedback on the interactive and confidential aspects of seeking accurate health information. This effort is part of a larger community initiative to install additional information kiosks in places that would be most advantageous for medically-underserved individuals.”

“We are so excited to have this valuable resource for our patients and staff!”

The online survey will be used to evaluate the current free clinic project.

DISCUSSION

The USC SOM librarians have agreed to provide additional technical support for the free medical clinic equipment after the project period is complete, and will continue to maintain, update, and host the patient education web pages. The free medical clinics have agreed to cover ongoing costs of the equipment after the project ends. Kiosks may be more effective than the flat screen setup for providing customized patient information at the point of need because patients can search the kiosk for their specific health concerns. In the flat screen setup, tutorials may be shown that are not relevant to patients in the waiting room.

This project also increased awareness of MedlinePlus as a resource for patient education content. The Mercy Medicine Clinic (Florence, SC) is selecting tutorials from MedlinePlus to show in the waiting room based on the ten most common health topics from the week before. After the self-playing mode of the tutorial ends, a clinic staff member restarts the tutorial or selects a new tutorial. St. Luke’s Free Medical Clinic (Spartanburg, SC) requested a tutorial looping option in the open-ended feedback portion of the online project survey, and the Mercy Medicine Clinic asked about a looping option during a site visit. Although the USC SOM project librarians have not received a response, in February 2010, they e-mailed the Patient Education Institute about the possibility of adding a looping option for their interactive health tutorials. The NN/LM SE/A project contact also contacted the Patient Education Institute about this option.

Visiting the clinic before selecting equipment is essential. Each free clinic is unique in the services that they offer, hours of operation, level of funding, and staffing. Ideally, project librarians would be able to visit the clinic before writing the proposal to get a clearer picture of what is needed rather than simply using the data from an online survey. In the survey feedback, the Greenville Free Medical Clinic preferred to install a projector and screen in the waiting room for larger group presentations. After the first site visit, they had become involved in a community-wide project that was looking at installing information kiosks in Greenville, so they wanted to try using a health information kiosk instead. Luckily, the clinic had money they could contribute to the cost of the kiosk.

The main barrier encountered during these projects was the inability to order equipment for over five months of the one-year project due to the delay of the University of South Carolina’s Office of Sponsored Awards Management in setting up the grant account. Another difficulty that occurred during the second free clinic project was that one USC SOM Library staff member, who was assigned the role of selecting, purchasing, and assisting with the installation of the equipment, resigned during the early stages of the second free clinic project.

Project librarians learned to be persistent; clinic staff and volunteers, especially at free medical clinics only open one or two days a week, were juggling a variety of tasks, and often needed to be contacted multiple times to get input about equipment or scheduling a training session.

As far as collecting project feedback, the project librarians would like to create quicker methods of providing MedlinePlus usage feedback. The free medical clinics have to fill out a great deal of paperwork for each patient, so it is not surprising that the free medical clinics have not submitted any Outreach Activity Data Forms.

CONCLUSION

The free clinic projects present a model for libraries to use with free medical clinics or other non-profit health programs to enhance their patient education efforts by providing MedlinePlus training and equipment. After the third project is complete, the USC SOM librarians will have provided eight free medical clinics with equipment to help them educate their patients about their health. The SOM project librarians hope to continue this work with other free medical clinics in the state.