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How To Guide > Building a Viable Primary Care Provider Workforce
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Building a Viable Primary Care Provider Workforce
A How-To-Guide written by Mark Cruise of Free Clinic Solutions
What is the purpose of this Guide?
What does the term “free clinic” mean as it is used in this Guide?
What is the first step in establishing a successful provider recruitment program?
Who is most effective in recruiting medical providers?
What collateral should be used in recruitment?
How does a clinic address concerns about medical malpractice when recruiting?
Why is credentialing and privileging important?
What are some other avenues of building a primary care provider workforce?
What are some important factors in maintaining a strong volunteer provider workforce?
What is the prevalence of paid providers in free clinics?
What should be considered in hiring a paid provider?
What are some options for recruiting a paid provider?
Will we lose our volunteer providers when we hire a provider?
What are some effective strategies for appreciating volunteer providers?
About Free Clinic Solutions and the author
• The first step is to identify a physician “champion” to lead your recruitment efforts.
• A free clinic greatly increases its chances of success by having a physician “champion” within its ranks. Many clinics have floundered in the absence of such a leader. Often, one of the founders of a clinic is a physician of this stature.
• A physician “champion” is one who is well respected throughout the medical community, is an effective advocate for the clinic’s needs and interests, and spends considerable time working to increase and support the volunteer provider workforce.
• The physician “champion” may well be the Medical Director of the clinic, but does not have to be. There can be more than one “champion.” This would be a good thing. In fact, a clinic should have aspirations of developing a cadre of physician “champions” for its cause.
• The “champion” is someone who has strong interpersonal connections to other physicians, and through the force of his/her reputation and passion for the cause, has an inherent, natural capacity to bring other physicians along with him/her.
• So, the first of order of business is to find and recruit a physician “champion” if you do not already have one. Speak to the local hospital CEO, the administrative head of the local medical society, and physicians that you may know personally to get leads on possible candidates to become your “champion.”
• Talk to those local physicians who you know do occasional oversees mission work. They may not be aware that they can do heroic mission work without leaving town.
• Once you have your “champion,” a clinic administrator will do well to make sure the “champion” has all the organizational and logistical support and tools they need to function effectively.
• Peer-to-peer recruitment remains the tried and true method for recruiting volunteer providers. If you do not have an M.D. or D.O. after your name, do not attempt to recruit volunteer physicians by yourself! It will be a largely futile exercise.
• Physicians, like other types of health care professionals, pay closest attention to their peers in the profession. They listen and are attuned to the mores and attitudes and persuasions of their peers. It is no different with free clinic personnel. It is human nature.
• Thus, the goal of clinics in recruitment should be to organize and arrange to have physicians talk with and recruit other physicians, nurse practitioners talk with and recruit other nurse practitioners, and physician assistants talk with and recruit other physician assistants.
• The provider “champion” described above is obviously a leader in this endeavor, but does not have to be the only provider involved in recruitment.
• Existing volunteer providers, who have already experienced the joy and satisfaction of practicing in the clinic, should be strongly encouraged to reach out to their colleagues and friends in the profession. They can speak firsthand about their experiences and can persuade their peers in ways that those outside of their profession cannot.
• The clinic Executive Director or Volunteer Coordinator can provide a great resource to the provider recruiters by creating and supplying them with copies of a one-page volunteer recruitment document.
• This document is two-sided. On one side would contain a letter of invitation over the name and signature of the Medical Director or physician “champion,” and printed on the clinic’s letterhead. It is well written, with a warm tone and a personal anecdote or two from the author.
• The other side would contain information that would be of most interest to prospective volunteer providers: clinic mission and scope of service, hours of operation, process to become a volunteer, choices for frequency of volunteering, information about malpractice protection, other benefits of volunteering, and more.
• Some clinics have enumerated a list of top reasons why medical providers should consider volunteering. Among the more common ones are:
• Often the first and largest concern that prospective physician volunteers have is fear of malpractice claims. It is important to address this issue clearly and completely at the beginning of the conversation.
• Free clinics in the U.S. have flourished through the years in part because volunteer immunity laws have been enacted in many states, protecting free clinic providers from malpractice lawsuits. Check to see whether your state has such a law and if so, what protection it provides.
• The incidence of lawsuits against the nation’s free clinics and their providers is statistically insignificant.2 Part of the reason has been that state immunity laws – and the high bar set for successful claims – have had a chilling effect on trial lawyers’ consideration of potential lawsuits.
• In addition, clinics have enjoyed the participation of a high-caliber group of providers who typically provide high quality care to patients. It is also well known that patients are less likely to sue a provider they like, and free clinic providers are generally a very likeable group.
• Nevertheless, the threat of just one lawsuit weighs heavily on the minds of potential volunteer providers.
• A clinic needs to provide volunteer prospects with clear, accurate, and complete information about how it assures or facilitates malpractice protection for its health care providers.
• One effective strategy is to have a pro bono attorney who specializes in health law to prepare a letter explaining the state volunteer immunity statute and to offer an opinion about its protections. A state association of clinics may arrange to have such a letter prepared on behalf of all its member clinics.
• Clinics in states that do not have a robust volunteer immunity statute may elect to pursue the free malpractice protection available through the Federal Tort Claims Act (FTCA). To qualify for FTCA coverage, free clinics must develop and implement a credentialing and privileging system, a risk management plan, and a quality assurance program.
• Under FTCA, a “deemed” health care professional (whether paid, volunteer, or contracted) practicing in an approved clinic may not be sued under any circumstances. The claimant instead must sue the United States Government, and the Justice Department will handle the case if it reaches the courts. For further information about FTCA, go to http://bphc.hrsa.gov/ftca/freeclinics/.
• As a last resort a clinic can purchase a private medical liability policy to cover its staff and volunteer providers, and perhaps also the entity. This can be expensive, but if your state does not have a volunteer immunity statute and since FTCA does not include entity coverage, it can be worthwhile protection.
• It is good practice for a clinic to perform credentialing and privileging on all of its health care professionals, especially those who are independent practitioners such as physicians. It not only protects patients and the clinic by lowering the risk of medical errors that may be caused by incompetent providers, but it also enhances the reputation and credibility of the clinic in the eyes of providers and the wider health care community.
• Credentialing and privileging are common in many other practice settings. The Federal Tort Claims Act noted above requires it, among other things.
• Credentialing ensures that clinic practitioners are duly qualified, licensed, and board certified, and do not have a lengthy history of malpractice claims, state-instituted sanctions, or other undesirable professional circumstances. Clinics should not only obtain a copy of a provider’s state license, DEA certificate, and board certification, but should also verify those credentials directly with the issuing bodies.
• Clinics can register to perform queries of the National Practitioner Data Bank in order to view the malpractice claims history of their providers. It currently costs $4.75 per query. For more information, go to http://www.npdb-hipdb.hrsa.gov/.
• Retired physicians should have recent practice experience. Being away from medicine for five or more years is too long. Some clinics require no more than two years away from practice, with exceptions done on case-by-case basis.
• In communities where a number of the clinic’s providers have privileges at a local hospital, it may be desirable to use the hospital’s credentialing as a proxy for the clinic’s. In such cases, there should be an agreement between the clinic and the hospital, and the hospital should provide some form of official documentation of each provider privileges for the clinic’s files.
• If a hospital is not available or willing to serve as a credentials verification organization (CVO), a clinic might consider accessing the American Medical Association’s Physician MasterFile to obtain credentialing information. For further information, go to http://www.ama-assn.org/ama/pub/about-ama/physician-data-resources/physician-masterfile.page.
• If a physician is not on the staff of a local hospital, consider requiring a professional reference from a recent supervisor or colleague.
• Privileging ensures that clinicians are not only properly credentialed but are in fact competent to practice within a specified scope at the clinic. Each provider should be reviewed on a periodic basis (e.g. every two years), and be issued specific privileges in writing.
• As was stated at the beginning of this Guide, active-practicing primary care providers are facing increasing challenges and frustrations in their professional lives. In the coming years, clinics will lose some of these providers and will have an uphill struggle replacing them with other active-practicing providers.
• According to a national survey of physicians in 2010, 40% indicated they would be leaving patient care in the next one to three years. Retirement was cited as the primary reason for this, but frustration with the business of medicine was also a leading factor.3
• This looming retirement of many physicians provides a great opportunity for clinics looking to replace lost capacity due to declining numbers of active-practicing physicians and other medical providers.
• Physicians are not content retirees. After a year or two of golf, or travel, or other “bucket list” activities, they get bored. They get antsy. It is not easy for them to practice medicine for 30-40 years and simply walk away. Eventually they long to get “back in the game.” Free clinics can give them that opportunity.
• Identify and make a concerted effort to reach out to retired, semi-retired, and near-retired physicians in your community. Get to know them, find out if they are interested in volunteering, and if so, make sure their license is active, and take steps to get them involved in your clinic. Most hospitals have a list of recently retired physicians and often they gather on a monthly basis for lunch at the hospital – a good forum for recruitment.
• In addition, clinics do well to build partnerships with family medicine residency programs, medical schools, nurse practitioner schools, and physician assistant schools in their region, to create interest in opportunities for residents, interns, and students to do rotations at their clinic, under the supervision of faculty providers where applicable.
• These programs are receiving large infusions of public and private sector funding as the nation seeks to address growing shortages of primary care providers. The heads of programs will not come to your clinic looking for a partnership. You must go to them! The rewards can be very handsome. In exchange for some added effort at ensuring a good training experience, you get the benefit of additional providers to deliver quality care to more patients.
• Provide a quality volunteer experience. This goes without saying, and yet is often overlooked and under-estimated. For medical providers, a quality experience means giving them an opportunity to practice in a clinic that is clean, well organized, well-equipped, professionally managed, and committed to quality care.
• A clinic should have systems in place to make sure provider’s orders are followed, tests are scheduled, and results are reviewed in a timely manner, with abnormal test results receiving immediate follow up. This is often a concern of providers who are accustomed to handling these matters themselves, but who are forced to turn this responsibility over to others following their volunteer shift.
• Require that volunteer providers receive a thorough orientation and introduction to the clinic and its operations BEFORE they begin volunteering. Often clinics are just so happy to have a new volunteer provider that they neglect to give them a proper orientation. They deserve this and should be required to have it, just like all your other new volunteers. However, consider doing a more individualized orientation and clinic introduction for your providers, as they will appreciate the personal attention and will feel free to ask questions relevant to the work they will perform.
• Feed them, literally! Provide wholesome, plentiful food and beverages for your volunteer providers, especially when you are conducting evening clinics for which your providers are coming straight from their “day jobs.” A church women’s circle, or a group of them, can be a great resource for providing meals for your volunteers on a rotating basis. Restaurants, too, often are happy to provide a monthly carry-out buffet in exchange for a small amount of recognition.
• Train staff to be “volunteer-friendly.” Do not assume that all employees understand and appreciate the value of volunteers and the proper techniques in managing and working with volunteers. Consider bringing in a seasoned volunteer administrator to do an in-service workshop on this topic.
• Provide pre-printed nametags for your providers – and indeed all of your volunteer and paid staff – to wear during clinic hours. This will enhance name recognition, identify to the patients who the providers are, and facilitate a greater sense of unity and teamwork among all who are participating in the clinic.
• Consider using a volunteer management software program, such as Volgistics (www.volgistics.com) which is gaining in popularity among free clinics, to enable your volunteer providers to create a volunteer record of their own, view the upcoming calendar of clinics and schedule themselves, and check in and out to record their volunteer service.
• Deliver or facilitate continuing education or other professional development opportunities for your providers. Clinicians need Continuing Education Units (CEUs) in order to maintain their licensure and to remain up-to-date in the practice of their profession. Consider partnering with a state or local medical society, or area health education center, to sponsor a continuing education program. Some states offer CEU credits for volunteer service in a free clinic.
• In light of the $600 million cut in federal discretionary funding for health centers in Fiscal Year 2011, policymakers who want to expand access to care might consider tax incentives that reward volunteering or provisions that encourage retired healthcare professionals to volunteer in free clinics.4 At least one state (Virginia) offers state income tax credits for volunteer service in a free clinic by health care professionals.
• As a free clinic grows, develops additional financial resources, and becomes more sophisticated in its approach, it may reach the point where it becomes possible and advantageous to hire one or more providers.
• Hiring a provider may not only augment the capacity of the volunteer providers, but also provide greater continuity of care and enhance the overall quality of care the clinic provides.
• Clinics that have decided to hire a provider often opt to hire a “mid-level” provider, i.e., a nurse practitioner or physician assistant, rather than a physician. Nationally 30.3% of free medical clinics have at least a part-time paid mid-level provider, while 19.4% have at least a part-time paid physician.1
• Hiring a mid-level provider can be a cost-effective way to increase clinic capacity, including hours of operation, the number of patients served, and the number of visits provided. It can also help improve the availability and quality of health education for patients.
• A clinic should engage in careful and deliberate planning before it hires a provider. This begins with a needs assessment to determine areas of critical • need in the clinic and in the community, and to identify those areas that can best be addressed with the addition of a paid clinical provider.
• The planning group generally consists of the Executive Director, Medical Director, Clinical Coordinator (or lead nurse), and any others whom the Executive Director deems necessary. Depending on the Board’s style of governance and how it handles delegation of authority and responsibility for allocating resources, hiring staff, etc., there may be representation from the Board of Directors.
• The planning group should look at issues such as current clinic capacity versus demand for services, whether there is a waiting list and how long it is, what gaps may exist in care delivery (e.g. referrals, follow-up, patient education), to what extent the medical community has been tapped for volunteers, and what needs or opportunities exist for improving quality care and overall impact.
• Hiring a paid provider is not simply adding another employee to the clinic. It will have ripple effects in all aspects of free clinic operations. In hiring a provider, a free clinic must be ready to move to a new level of service activity across the board.5 Examples include more prescriptions written, more labs and diagnostic procedures ordered, more need for care coordination and follow-up, and perhaps moving from a walk-in model to an appointment-based model.
• The clinic should be very clear about what it wants the paid provider to do. To what extent is the provider expected to see patients and meet service delivery targets? To what extent may the clinic expect the provider to help coordinate care for patients seen by other providers? To what extent is the clinic expecting the provider to manage clinical operations and other staff involved in patient care? The answers to those questions and others will vary from clinic to clinic, depending on needs. The job description should be built around those expectations very clearly and thoroughly.
• For more information on relevant issues to consider and how a free clinic can plan and make effective use of a paid mid-level provider, see Virginia Health Care Foundation publication on this topic at http://www.vhcf.org/wp-content/uploads/2010/09/Free-Clinic-Mid-Level-Provider-Initiative1.pdf.
• Depending on the relative number of primary care providers in your area, it can be more or less of a challenge in recruiting one to become a paid provider at your clinic.
• The competitiveness of the compensation and benefits package will be a major factor in attracting quality candidates.
• Clinics can circulate a position announcement among their existing volunteer providers, as well as through the local medical society or association. They can also post and/or announce a position opening on its website, or the websites of its state association of clinics, state association of nonprofits, or other local or community organizations.
Advertising in the local newspaper (including its website) should be considered, though the costs can be significant in some areas, and there may be plenty of other free channels available to ensure a strong pool of candidates.
• Clinics that are located in federally-designated medically underserved areas and that wish to hire a provider for at least 32 hours a week may qualify to seek candidates through the National Health Service Corps. Through this program, providers can qualify for loan repayment in exchange for service in a medically underserved area. The clinic must still pay a competitive salary, but the NHSC program can be an effective recruitment and retention tool. For more information, go to http://nhsc.hrsa.gov/ or contact your state office of primary care. To determine if your clinic is in a medically underserved area, visit: http://muafind.hrsa.gov/.
• When faced with the prospect of hiring a provider, clinics often ask whether this will have an adverse effect on the continued volunteerism of existing medical providers.
• For the most part, clinics that have hired providers have not seen an appreciable decline in the number of volunteer providers.
• In many instances, volunteer providers (some or most of whom are close to being “maxed out” in their volunteer service) are relieved when they find out that the clinic is hiring a provider. They appreciate knowing that there will be someone “minding the store,” providing continuity of care, and assuring that their own clinic patients’ care needs are being attended to, coordinated, and followed up appropriately and as needed by a fellow clinician.
• It is important to communicate with your volunteer providers in advance of the decision to hire a provider, to let them know that you are considering adding a paid provider, to explain the rationale for that, to assure them that their continued volunteer service is much-needed and valued, and to invite them to share any feedback, suggestions, or concerns.
• Volunteer providers derive a lot of personal satisfaction from giving of their time and service to those who could not otherwise access health care.
• It is important to thank them each time they come to volunteer. A simple, verbal thank-you from the clinic staff goes a long way toward making them feel appreciated. Make sure this becomes a routine practice on the part of your employees.
• Another very simple but effective strategy is for the clinic Executive Director or Medical Director to hand-write a personalized thank-you note and send it to the provider. This could be timed to occur each year in conjunction with the provider’s birthday.
• For physicians and other providers who are part of a solo practice or a small or medium-sized group practice where all or most of the providers are clinic volunteers, consider taking or catering a lunch for them and their office staff once a year.
• A framed “Certificate of Appreciation” suitable for hanging on the wall in the physician’s private office setting can serve as a visible sign of the clinic’s gratitude and be a powerful reminder of the clinic’s presence in the community and the physician’s participation in it.
• Volunteer providers tend not to attend annual “volunteer appreciation” events, for a number of reasons. Many just prefer to stay out of the limelight. However, they will be more likely to attend an appreciation event with just their peers. Consider holding an annual dinner at a nice local restaurant once a year, sponsored by a corporate partner, just for the volunteer medical providers and their spouses. No need to put on a big program; just a few remarks from the clinic Medical Director or Executive Director expressing how much the clinic appreciates their support.
• Be cautious about listing all of your volunteer providers in very public ways, such as in newspaper advertisements and in websites. Some providers do not wish to have the community know they are volunteering at a free clinic for fear that their private office will be inundated with uninsured individuals seeking care. Always ask for permission before including the names of your providers in a public list.
1. Darnell, JS, Free Clinics in the United States: A Nationwide Survey. Archives of Internal Medicine, 2010.
2. Health Resources and Services Administration, Report to Congress: A Review of the Free Clinics Network. Rockville, MD: HRSA, 2005.
3. The Physicians Foundation. 2010 Survey: Physicians and Health Reform.
4. Darnell, JS, What is the Role of Free Clinics in the Safety Net? Med Care 2011;49: 978–984
5. Virginia Health Care Foundation, Free Clinic/Nurse Practitioner Model. VHCF website: http://www.vhcf.org/wp-content/uploads/2010/09/Free-Clinic-Mid-Level-Provider-Initiative1.pdf.
About Free Clinic Solutions and the author
Established in 2006, Free Clinic Solutions is a national organization that provides strategic consulting, training, coaching, research, writing, and public speaking to free clinics and charitable clinics across the U.S., their associations, and other organizations that support and partner with them. Free Clinic Solutions utilizes a team of consultants from around the country with experience in the health care safety net and subject matter expertise in a wide variety of disciplines important to effective organizational performance. For more information, visit www.freeclinicsolutions.com.
Mark R. Cruise, founder and principal of Free Clinic Solutions, is one of the nation’s leading experts on free and charitable clinics. He speaks and writes extensively about trends and issues within the sector. In 2010 he authored “A Guide to National Health Care Reform for America’s Free and Charitable Clinics.” Mark served as the first Executive Director of the Virginia Association of Free Clinics, the nation’s oldest free clinic association, from 1997-2006. Prior to that, he served as Executive Director of the Free Clinic of the New River Valley in southwestern Virginia. He received his Master of Divinity degree from Boston University School of Theology.
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