N587 Redmond


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  • part of Volunteers In Medicine clinics for the uninsured The additional requirement was new to VIM organ which uses a culture of caring at the center of their model. The decision was Diagnostic treatments in the form of charity care was previously paid by Martin Memorial HS for clinic patients, including many suspected illegal immigrants. The Stuart Clinic’s $550,000 operating budget was unable to handle this expense, as the hospitals ‘ care totaled over $2.3 million in 2007 alone. To continue the care relationship, the mutual decision was made to restrict care to legal US residents only.
  • Although this decision seems simple, it stands to have far-reaching implications for not only the non-profit healthcare landscape but for Volunteers In Medicine as well, an organization with a mission to help the uninsured in need. This politically charged issue forces VIM to consider instituting a national policy change restricting care to illegal immigrants based on residency status-something not done before.
  • Started In 1992, Volunteers in Medicine is the only national non-profit organization dedicated to opening clinics with free, quality health care services for the working uninsured. The VIM model has been used to establish over 200 clinics nationwide. VIM clinics rely on donated time from volunteer retired medical professionals and provide primary and preventative health care . Many patients are employed but cannot afford health insurance and make too much money to qualify for state and national aid. This population often falls through the cracks of the health care system and the clinics seek to close the gap.
  • The clinics accept no federal or state funds, but rather thrive through private philanthropy and as a result are not subject to many federal regulations. VIM partners with secondary care centers to perform additional needed procedures and tests. VIM is not a safety-net program like government-sponsored clinics or local emergency rooms, but seeks to reduce the medical and societal burden as patients are treated before they ever need urgent and more expensive tertiary care. Prevention is the key conceptual component and together with a network of community providers, patients can be referred to get appropriate help.
  • According to the 2007 U.S. census, 45.7 million Americans are without insurance, and this includes over 12 million illegal immigrants .The actual number of illegal immigrants treated in VIM clinics cannot be accurately estimated since status is not currently an eligibility requirement, but many clinics believe undocumented residents overwhelm facilities and absorb resources at the expense of the legal uninsured. Current use of VIM services has strict eligibility requirements that does not include status. By adding this nationwide eligibility requirement, clinics would be making a strong statement. The decision could have legal, financial, and ethical ramifications for stakeholders involved, and also threaten the public health
  • Justification for the organizational policy change would be based on the items listed. The risks of not being able to serve the intended population- that group that falls between Medicaid and private health insurance- due to both financial and material resource depletion, threatens the very heart of the organization. The fragility of the current U.S. health care system makes it inadvisable to delay instituting a revised eligibility policy. Until comprehensive national immigration reform occurs, eligibility requirements may be the best course of action for private, non-profit VIM clinics that want to remain viable.
  • The decision would face few barriers with the exception of ethical and personal beliefs. Volunteers in the clinics may feel uncomfortable allocating care based on residency status and may opt to not participate, thereby decreasing available staffs. It is also possible that restricting access based on status may turn volunteers and facilities into unwitting immigration watchdogs. However, this decision does uphold national law and aims to protect not only the financial structure of the clinics, but the mode of care for the legal uninsured.
  • Facilitators to implementing the change include the projected cost-savings to VIM clinics and secondary care centers, provider motivation, and decompressed clinics with those eligible for care receiving proper resources. One element that can be defined as either a barrier or a facilitator would be public opinion, which could be dependent on the current political climate. While some communities may applaud and support the decision to restrict care, it may be met with resistance in others.
  • To implement the new policy, a consensus must be established among the VIM national officers and board to agree on the change to the care model. Forming a dedicated team to present the policy change to the clinic network and manage the transition will be crucial. Volunteers will need reassurance that VIM’s mission and care considerations will not be compromised using the new eligibility requirements. Pilot programs can be used in community clinics serving large immigrant populations with volunteer and patient feedback essential to determining success rate and acceptance. The target goal would be permanent implementation within current associated clinics by 12 to 18 months nationwide, with all future clinics set up according to the revised VIM model. Ongoing guideline development would need to take into account legal changes and may need to be flexible initially
  • To evaluate the decision , VIM could compare the clinics locally and nationally, partner with the PHDept for statistics, and collaborate with community care partners . All these components could help determine if the policy change had negative or positive impact on VIM and the community it serves.
  • If clinics feel the need to continue care, future considerations and solutions could include providing interventional care via telemedicine- this could be culturally sensitive ,yet anonymous and serve to uphold both the civil and ethical obligations of care givers; use immigrant specialists or nurse navigators to assist patients in securing needed care;
  • mobile units for community outreach, and limited negotiated agreements with various groups to secure financial reimbursement for costs of providing care. These efforts would address the major issues and concerns raised as well as relieve legal quandaries and ethical dilemmas.
  • Noted anthropologist Margaret Mead said…………….Such is the case with Volunteers in Medicine. Their unique mission is to bring relief to a population that has fallen through the cracks of the system. The decision to restrict access to care nationwide based on residency status is difficult but in this case, the right one. It is the only way for the VIM organization and clinics to continue their mission and stay viable. A solution for providing quality health care to the uninsured is not easy, and finding creative ways to serve all needs of U.S. residents—both documented and undocumented— will continue to challenge resources and resolve.
  • N587 Redmond

    1. 1. Case study: A health care clinic for the uninsured faces the problem of treating illegal immigrants Laura Redmond Nursing 587 Drexel University
    2. 2. A Challenge to the System <ul><li>In September 2008, The Stuart Clinic choose to change policy and ask for citizenship status prior to treatment </li></ul><ul><li>Driven by increased costs and potential of losing secondary care agreements with hospital, local care offices </li></ul><ul><ul><li>Found it could not afford to provide the tests previously paid by Martin Memorial </li></ul></ul><ul><li>Both agreed to restrict care to legalized residents only </li></ul>
    3. 3. A Challenge to the System <ul><li>Decision has far-reaching implications </li></ul><ul><li>Has the potential to influence the non-profit health care landscape </li></ul><ul><li>Should VIM institute a national policy change restricting care for illegal immigrants using additional eligibility requirements based on residency status </li></ul>
    4. 4. Volunteers in Medicine (VIM) <ul><li>Started in 1992 in Hilton Head, SC </li></ul><ul><li>Currently, 200+ VIM clinics nationwide </li></ul><ul><li>Relies on donated time from volunteers and retired health care professionals </li></ul><ul><li>Provide primary and preventative health care exclusively for : </li></ul><ul><ul><li>Those who cannot afford private insurance and do not qualify for federal or state aid </li></ul></ul>
    5. 5. Volunteers in Medicine (VIM) <ul><li>Accepts no federal or state funds, thrives through private philanthropy </li></ul><ul><li>Partners with secondary care centers (hospitals, offices) </li></ul><ul><ul><li>Provides diagnostic services and treatments </li></ul></ul><ul><ul><li>Given as charity care </li></ul></ul><ul><li>VIM is not a safety-net program </li></ul><ul><li>Prevention is key concept </li></ul>
    6. 6. The Problem <ul><li>Estimate 45.7 million people without insurance </li></ul><ul><ul><li>over 12 million illegal immigrants </li></ul></ul><ul><li>May overwhelm clinics and absorb resources </li></ul><ul><li>VIM has strict eligibility requirements, but not on status </li></ul><ul><li>Decision can have financial, legal, and ethical ramifications and may threaten the public health </li></ul>
    7. 7. Decision <ul><li>VIM should institute a national organizational policy change based on: </li></ul><ul><ul><li>Societal and marketplace demands </li></ul></ul><ul><ul><li>Financial risk involved </li></ul></ul><ul><ul><li>Threat to VIM mission </li></ul></ul><ul><ul><li>Risk to not being able to serve intended population </li></ul></ul><ul><li>Fragility of current U.S. health care system makes delay inadvisable </li></ul><ul><ul><li>Added eligibility requirements ensures VIM viability </li></ul></ul>
    8. 8. Barriers <ul><li>Would face few barriers due to current legislation and public opinion </li></ul><ul><ul><li>Many already believe there should be limits in place </li></ul></ul><ul><li>Exception would be volunteers’ personal and ethical beliefs </li></ul><ul><ul><li>Staff discomfort could lead to decreased volunteer workforce </li></ul></ul><ul><ul><li>May be unable to turn those in need away </li></ul></ul><ul><ul><li>Staff could be turned into unwitting immigration watchdogs </li></ul></ul>
    9. 9. Facilitators <ul><li>Projected cost-savings to VIM clinics and secondary care centers </li></ul><ul><li>Positive impact as clinics are decompressed and those qualifying for care receive proper resources </li></ul><ul><li>Provider motivation </li></ul><ul><li>Public opinion could be both barrier or facilitator </li></ul><ul><ul><li>Some communities may support restricting care; may be met with resistance in others </li></ul></ul>
    10. 10. Implementation <ul><li>Establish a consensus </li></ul><ul><ul><li>VIM national officers and board of directors </li></ul></ul><ul><li>Transition team </li></ul><ul><ul><li>Present policy change </li></ul></ul><ul><ul><li>Reassure volunteer workforce </li></ul></ul><ul><li>Pilot programs </li></ul><ul><ul><li>For clinics serving large illegal populations </li></ul></ul><ul><ul><li>Use volunteer and patient feedback </li></ul></ul><ul><ul><li>Target goal: 12-18 months with future VIM clinics using revised policy </li></ul></ul><ul><li>Ongoing guideline development </li></ul>
    11. 11. Evaluation <ul><li>Compare VIM clinics locally and nationally </li></ul><ul><ul><li>Patient numbers </li></ul></ul><ul><ul><li>Resource usage </li></ul></ul><ul><ul><li>Financial contributions </li></ul></ul><ul><ul><li>Public Health Department </li></ul></ul><ul><ul><li>Epidemiological statistics </li></ul></ul><ul><ul><li>Morbidity </li></ul></ul><ul><ul><li>Reviews/collaboration with secondary care partners </li></ul></ul><ul><ul><li>Affect to tertiary care departments </li></ul></ul><ul><ul><li>Financial impact </li></ul></ul>
    12. 12. Future Considerations <ul><li>Interventional Care </li></ul><ul><ul><li>Internet-based treatment and telemedicine </li></ul></ul><ul><ul><li>Culturally specific, yet anonymous </li></ul></ul><ul><ul><li>Assumes access to cost-efficient technology </li></ul></ul><ul><ul><li>Upholds both civil and ethical obligations </li></ul></ul><ul><li>Use of immigrant specialists or nurse navigators </li></ul><ul><ul><li>Specifically trained in illegal immigrant issues </li></ul></ul><ul><ul><li>Assists patients in navigating the complex health care system </li></ul></ul><ul><ul><li>Serve as a resource for securing care </li></ul></ul>
    13. 13. Future Considerations <ul><li>Mobile units for community outreach </li></ul><ul><li>Negotiated partnerships to offset costs </li></ul><ul><ul><li>Immigrant activist groups </li></ul></ul><ul><ul><li>Faith-based preventative or cultural centers </li></ul></ul><ul><ul><li>Worldwide charities </li></ul></ul><ul><ul><li>Foreign consulates </li></ul></ul><ul><li>Limited collaboration could: </li></ul><ul><ul><li>Coordinate compensation agreements for reimbursement </li></ul></ul><ul><ul><li>Exempt volunteer caregivers from ethical dilemma </li></ul></ul>
    14. 14. <ul><li>“ Never doubt that a small group of thoughtful, committed citizens can change the world” </li></ul><ul><li>- Margaret Mead </li></ul>
    15. 15. THANK YOU!
    16. 16. References <ul><li>Copsey, H. (2008, October 8). Stuart clinic cuts free services for illegal immigrants, will require documentation. Florida’s Treasure Coast and Palm Beaches . Retrieved from http://www.tcpalm.com/news/2008/oct/04/clinic-cuts-free-services-for-illegal- </li></ul><ul><ul><ul><li>immigrants/ </li></ul></ul></ul><ul><li>Emergency Medical Treatment and Active Labor Act of 2003 (42 C.F.R. 489.24), amending the Consolidated Omnibus Budget Reconciliation Act of 1985 (42 U.S.C. 1395dd), section 1867 of the Social Security Act of 1935 (H.R.7260). 108 th Congress (2003). Retrieved February 4, 2009, from http://www.ssa.gov/OP_Home/ssact/title18/1867.htm#t </li></ul><ul><li>Free Clinic Federal Tort Claims Act (42 U.S.C. 233), amending section 194 of Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191), section 224 of the Public Health Service Act of 1944 (42 U.S.C. 201). 108 th Congress (2004). Retrieved February 11, 2009, from http://bphc.hrsa.gov/policy/pin0424.htm </li></ul><ul><li>Goldman, D. P., Smith, J.P., & Sood, N. (2005). Legal status and health insurance among immigrants. Health Affairs , 24 (6): 1640-53. </li></ul><ul><li>  </li></ul>
    17. 17. References <ul><li>McKeon, E. (2006). Treating illegal immigrants: the ANA aims to protect nurses against potential criminal penalties. Retrieved February 5, 2009, from http://www.nursingworld.org/ajn/2006/jun/politics.pdf </li></ul><ul><li>Mead, M. (n.d.). The Institute for Intercultural Studies. Retrieved on February 18, 2009, from http://www.interculturalstudies.org/Mead/index.html </li></ul><ul><li>Morse, A., Blott, A., Speasmaker, L., & Dwyer, L. (2006, November 17). Immigrant policy- 2006 state legislation related to immigration. National Conference of State Legislatures Immigration Policy Project. Washington, D.C. Retrieved February 5, 2009, from http://www.ncsl.org/programs/immig/6ImmigEnactedLegis3.htm </li></ul><ul><li>Sherman, A., Greenstein, R., & Parrott, S. (2007). Poverty and share of Americans without health insurance were higher in 2007 and median income for working- age households was lower than at bottom of last recession. Center on Budget and Policy Priorities , Retrieved February 2, 2009, from </li></ul><ul><ul><li> http://www.cbpp.org/8-26-08pov.pdf </li></ul></ul><ul><li>Volunteers in Medicine. (2008). Volunteers in Medicine Institute. Retrieved Jan 31, 2009, from http://www.volunteersinmedicine.org/ </li></ul>