Diversity & Equality in Health and Care Open Access

Keywords

Free clinics; Patient satisfaction; Continuity of care; USA

Introduction

Free clinics provide free or reduced fee health care services to un- or under- insured individuals in the United States (US) [1]. In 2015, nearly 30 million people lived without health insurance [2]. The main reason for un- or under- insurance is poverty [2]. Uninsured individuals experience lack of access to regular outpatient care [2]. Thus, free clinics are important resources for those who do not have access to health care other than emergency room services [1]. While free clinics contribute to increasing access to healthcare for underserved populations, there are some under studied issues in free clinic care, such as: 1) continuity of care; and 2) patient satisfaction. Continuity of care is defined as a continuous relationship between patients and providers [3]. Continuity of care can increase the amount of preventive care and diabetes care, and reduce hospitalization [4,5]. However, continuity of care is challenging for free clinics because free clinics often rely on volunteer providers [6,7]. Volunteer providers may be available in irregular shifts or leave due to life changes or relocation. Yet little is known about the issue of continuity of care at free clinics.

Patient satisfaction that can be improved by continuity of care may be challenging for free clinics. In general, free clinic patients are highly satisfied with care provided at free clinics [8,9]. However, the fact that free clinic patients may not have access to other health care sources or do not have other choices for health care facilities should be considered. Free clinic patients may have unmet needs which have not yet been addressed [10]. Since continuity of care and patient satisfaction are often related, but have not been examined together in a free clinic setting, this study aimed at exploring continuity of care and patient satisfaction from the perspectives of free clinic patients.

Methods

Overview

This qualitative study was conducted at a free clinic located in the Intermountain West. The clinic mainly provides routine health procedures, preventative care and health education programs, and has been open five days a week since 2005. Patients of the clinic do not have any health insurance and live below 150% of the federal poverty level. The clinic is staffed by 10 paid personnel and over 400 volunteers. The patients of the clinic are from over 50 countries. Approximately half of clinic patients are Spanish speakers.

Study procedure

The study was approved by the University of Utah Institutional Review Board (IRB). Data were collected from five focus groups which were held in June 2017. The clinic staff developed a draft of focus group questions based on the clinic’s experiences and needs. The research team finalized the questions (Appendix). A two-page demographic questionnaire was used to gather information about focus group participants. Participants were patients of the clinic, ages 18 or older, and spoke English or Spanish. Fliers were distributed to recruit participants in the waiting room of the clinic. Consent was obtained from each participant. At least three Spanish speaking research assistants were at each focus group. One of the Spanish speakers facilitated a group in English. Another Spanish speaker helped Spanish speaking participants as an interpreter. The third Spanish speaker took field notes. In addition, several other team members assisted the groups. All focus groups were audio-recorded by several devices. The clinic staff and volunteers were not present at any focus groups to ensure that participants felt free to express their opinions about the clinic. Participants received a $20 gift card upon their participation in a focus group.

Data analysis

The audio recordings of the focus groups were transcribed. The transcriptions were analyzed to ensure validity and reliability. The transcripts were organized to identify themes and patterns within and across the groups, independently by two study team members (JC and GA), who developed initial codes separately. The third team member (AK) checked for agreement between the two coders. AK explored discrepancies between the two members and reconciled the discrepancies. Finally, all members of the study team agreed with the interpretations.

Results

Participant characteristics

Table 1 describes the characteristics of participants (N=25). Fifteen participants were Spanish speakers. The focus groups had long-term patients and relatively short-term patients as well as new patients (Table 1). The majority of the participants were women. Only one-quarter of the participants were US born. The majority of other participants were from Mexico or Latin America. Less than half of the participants reported high school or less educational attainment. Approximately one-third of the participants had a full- or part-time job. Half of the participants were married. The average age of the participants was 52 with a large range from 24 to 77 years old. Among non-US born participants, the average duration of residence in the US was 9.2 years.

	Frequency
Language – Spanish	15
Patients of the clinic 2+ years	13
Female	20
Country of origin
Mexico	7
US	6
Venezuela	3
Peru	2
Iran	2
Guatemala	1
Brazil	1
Tonga	1
Uruguay	1
Spain	1
Educational attainment – high school or less	12
Employed	9
Married	13
Age Years in the US (Non-US born only)	Mean , SD (range) 52.0, 14.9 (24-77) 9.2, 9.6 (<1-27)

Table 1: Participant characteristics.

Continuity of care

The majority of the participants had recognized that the clinic was trying to improve the continuity of care. One participant said, “Now I know they are trying to make my appointment with the same provider because when they did my appointment by phones,…reception ask if I want to see the same provider.” Some participants liked the idea that patients see the same provider each time mainly because of improved communications with providers. One participant said:

When a person gets to know you, it is more personal and comfortable for you. You feel like that person knows you. When you meet a new doctor, there is really uncomfortableness and you don’t always warm up to that (new) doctor and you are embarrassed to tell (the new doctor) things or you just don’t remember (what to tell)(laugh), but if you see the same one, then (the doctor) knows a lot more about you.

However, continuity of care was not important or was not necessarily positive for some participants. One participant said, “This is a free clinic and I accept all the providers that see me, especially if they are general practitioners.” Another participant said:

We have to accept that each physician who comes to the clinic won’t be (with the clinic) forever…The most important (thing) is the record of the patient which is left for other physicians. The next doctors are going to come. They come (do) a good follow up. And they provide good treatment and solution for the problem.

Some participants did not believe it was important to see the same provider each time. For them, the priority is seeing the first available physician so they would not need to wait. One participant said:

They (providers) are not here every day or maybe not every week or once a week. That would be a problem if you would stick to the same doctor. If it’s emergency or you need a follow up right away, why not see another provider.

The potential negative impacts of seeing the same provider include: 1) A patient may continue seeing a provider who provides poor quality of care (e.g. “Yeah, but if it was the past doctor, I would not like having to stick with him. I did not feel like he had the best interest. So it depends on the doctor you get”); and 2) Patients may not have an opportunity to seek second or third opinion (e.g. “At minimum, having two doctors is a good thing to have a second opinion”).

Patient satisfaction

The majority of important factors for patient satisfaction were related to receptionists or making an appointment. While most participants were satisfied with receptionists and the appointment process, there were some problems. Receptionists were sometimes not accessible by phone. One participant said, “(Are) you open Monday to Friday over here? Because on Monday I called from the morning to the evening. No answers...” Other participants agreed that there were times when they were told incorrect appointment dates (e.g. “There were now two times that I came over here (the clinic) on a wrong day of an appointment, though when they called me, I repeated it (the appointment date) over.”) Participants pointed out that receptionists may not be able to handle both answering phone calls and doing front desk tasks (e.g. “I believe that the person who is at the front desk doesn’t have enough time to do both jobs to answer the phone and to the deal with the patients in the lobby”).

Participants also pointed out that appointment reminder were very important (e.g. “I would like them (receptionists) to always send me a reminder. They sometimes do not send reminders...I sometimes got a reminder but sometimes I did not.” Making appointments at earlier dates was also important (e.g. “The only thing which can be improved is, for example, I would appreciate if I can make an appointment sooner rather than two weeks later.” Some participants shared their experiences in miscommunications with receptionists. One participant said: “I had two appointments that I came all the way out here and they (receptionists) said that they cancelled (the appointment) because the doctor had to leave for an emergency. Nobody ever told me…” Another participant said “For two months and a half, I don’t receive any call. We’re gonna check (today). But they didn’t give me an appointment.

Facility

Some participants expressed concerns about the size of the facility (too small) and the narrow entrance of the parking lot. In addition, one participant pointed out that the sign of the clinic was not visible from the street because it was covered by a tree: “I drove past it (the clinic) twice. Until the clinic has a bigger sign (laugh), you know, you couldn’t see it.” The small size of the facility was not necessarily negative. One participant said “I think this is a nice place. I like it also because it’s small. I don’t like big places, like hospitals, very scary (laughs).” Some participants noted that patient capacity, rather than the size of the facility, was important because they would like to increase the clinic’s ability to treat more patients (e.g. “It (the facility) should be a little bigger. I am not referring any portion of (the) facility. But more about (the) number of patients that the clinic can accept each day.”

Check-in

The majority of participants believed check-in was very easy and were satisfied with the check-in process. A few participants pointed out a long waiting time or miscommunications at checkin. One participant said:

I came over here (the clinic) about 30 min before (an appointment) and I checked in. And I thought he (a receptionist) checked me in. But then I waited and waited and then, you know, 15 min passed by time of my appointment...I knew I wasn’t check(ed) in at that time, but he didn’t even give me a warning.

Waiting-room

Some participants raised problems concerning the waiting room. Participants complained about noisy music (e.g. “It is ok to play the music but no so loud”). Long waiting times were another concern. For example, one participant said, “Something that they could improve is being able to go quicker in the morning. One time we had an appointment at 9:00 and we had to wait until 11:00…” Some participants felt the waiting room was too small: “Sometime, we do feel like, a little squeeze in there when there are little kids running around.” However, other participants indicated that a small waiting room was fine: “If it (the waiting room) is bigger, there are more toys and mess and more accidents. One lady fell down on one of the toys. Toys can be problems.” Some other important issues included accommodations for patients with disabilities by providing more chairs or establishing a section for children (e.g. a play area for children). Some participants would like the clinic to install a TV and/or Wi- Fi capabilities in the waiting room, given the common experience of long waits.

Providers

Overall, participants were highly satisfied with providers (e.g. “I think they (providers) are very impressive with the nicest smile and the way they say everything is nice.”). However, some patient-provider communication issues were raised. Participants felt that the commonly used phrase, “What brings you in today?” implied that the providers were ignorant of the patient’s condition and thus inadequately prepared for the consultation. The facilitator of the focus group was a medical student and indicated that medical students are taught to begin the consultation with an open ended question, such as “What brings you in today?” so that patients have an opportunity to express their concerns before the provider takes control of the visit. However, participants interpreted the question differently and thought that it was an indicator that providers did not thoroughly review their records beforehand and therefore did not understand their needs. For example, when asked “What brings you in today?” by a provider, one participant thought, “Don’t you know why I am here today? I’m sick.”

Participants noticed that unforeseen interruptions associated with the volunteer status of a provider may have implications in the continuity of care model, such that they would like to know the duration that volunteer providers would remain at the clinic. For example, one participant said:

I have a question. Is there any way we can know how long the doctor…want to be here…I chose a doctor, right. But, I want to know how long he’s going to (be) working (as) a volunteer here. Then I (can) know when I have to try to look for some other doctors – which one I want to change before he leaves.”

One participant indicated that she would be willing to contribute a small fee if that helped improve care at the clinic: “I know that the providers are volunteers. But maybe if we pay a symbolic amount, about $15, maybe they can improve the services. Not only for the doctors, but also for the general services.” Other participants agreed with the idea.

Interpreters

Participants whose native language was not English rated interpreter services very positively (e.g. “I’m very satisfied with the job that they are doing…I see that they know the terminology. And they let the doctor know why I am here.)” Bilingual receptionists were also found to be important for patient satisfaction, particularly because many patients are foreign-born. One participant noted:

The language component is important. It’s important for the receptionists to be able to speak with us. For example, for me, I only speak Spanish. I only know a few words in English. So for me, it’s very important for the receptionists to be able to understand what I am saying.

Health education programs

Participants who had participated in health education programs were satisfied with health education programs (e.g. “I’ve been to the diabetes class. One hundred percent (satisfied)! Very nice”). One participant wanted the program to be weekly so that she and her husband could stay motivated (biweekly was not enough): “I don’t want to wait for a long time. You know, after two weeks we didn’t see our coach and didn’t come to the class, when we had to wait for another week, we lost interest.” The main problem in participants who had never attended health education programs was awareness (e.g. “It seems the biggest problem (is) that most of us didn’t know about all these things.”). Some participants suggested potential ways to advertise the health promotion programs such as making a monthly calendar, an information board, a sign on the wall, and flyers. Interestingly, although the clinic has an information board about the programs at the entrance, the majority of the participants had never noticed it.

Services to be added

The following services were mentioned by participants as services to be added in the future: mental health/psychiatric services, psychological services, dental treatment, audiology, childcare/a room for children, natural/alternative care, English language classes, exercise classes (e.g. yoga, Tai Chi, Zumba, dance), chiropractic services, a support/education group for first time mothers, and cultural classes (e.g. music class). The request for these services not only seemed to imply a call for a more wholesome approach to providing health care, but also implied that the clinic is an integral part of the community. For example, one patient said:

I come here with my husband. Everyone else is acquaintances. We’ve only been here (for) two years. Just like me, there are a lot of people here who are patients of this clinic. So having a groups or classes where we can gather would be good social things. Or things, for (example) healthy classes for exercises like Zumba - those types of groups might be good for your health and with socializing or your social development.

There were patients who expressed a desire for services that the clinic already offered (e.g. mammogram, pediatric care, eye glasses). When participants were informed that these services were already available, they indicated that they would like the clinic to better advertise its services to patients (e.g. more flyers).

Discussion

This project explored continuity of care and patient satisfaction from the perspectives of free clinic patients and has three main findings. First, continuity of care was not always perceived positively. Second, there were potential miscommunications between providers or receptionists and patients. Third, patients might not be well informed of the available resources at the clinic.

While previous studies did not report negative impacts of continuity of care on quality of care, free clinic patients may not necessarily perceive that continuity of care is always beneficial. The results of this study indicate that patients may not wish to see the same provider if the provider is not good or if the patient would like to seek second opinions. Continuity of care is not simply seeing the same provider over time. Rather, coordination and communication are important factors for continuity of care [11,12]. Since the majority of free clinic providers are volunteers and may not be with a free clinic long-term, continuity of care should not be limited to only seeing the same doctor over time, but also seeing a team of well-coordinated providers. In addition, it is very important to be sensitive about patient preferences of having the same provider over time or not.

While participants appreciated the service of providers and receptionists, they pointed out some miscommunication issues. Patient-provider communication workshops in medical education may not be always effective in communicating with patients with diverse backgrounds. Cultural competence in medical education has been increasingly important as US populations are becoming more diverse [13]. But since free clinics serve a wide variety of underserved populations, cultural competence trainings in medical education may not wholly fit the socioeconomic and/or cultural realities of free clinic patients. Further studies are necessary to identify the perceptions of communication gaps between free clinic patients and providers. The fact that the clinic serves patients with diverse backgrounds also has implications for how the clinic is perceived in the community. The request for a variety of services would provide a more wholesome approach to health care.

In addition to providers, receptionists are very important since patients interact with patients before and after visits. Clinic receptionists’ communications with patients are a series of verbal routines [14]. But task-centered communication styles may sometimes hinder resolution in problematic situations [14]. Rather, task-centered communication styles could primarily be focused on a single patient. As some of the participants noted, simultaneously performing front desk work and answering phone calls may impede receptionists’ ability to better communicate effectively with patients. If receptionists are assigned a single task, communications between receptionists and patients may be improved.

Furthermore, the results of this study indicate that free clinic patients may not be informed of available resources at the clinic, although the clinic posts such information already. This is a persistent problem in a free clinic setting [7,15]. More in-person communication would be beneficial to distribute the information about available resources for free clinic patients [7,16]. Future studies should develop and evaluate methods to better inform free clinic patients of the resources available to them.

While this study contributes to increasing knowledge about the continuity of care and patient satisfaction from the perspectives of free clinic patients, there are limitations. Even though the study did not intend to describe general tendency using a large sample number, it would have been ideal if the sample size were larger to obtain a broader range of perspectives. The focus groups were conducted in English with a Spanish interpreter. But since the patients of the clinic are from more than 50 countries, this study was unable to capture perspectives of immigrant patients who do not speak English or Spanish. Finally, since the majority of participants were women, the results were predominantly from female perspectives. Future research should make efforts to have more diversity in the focus groups with patients.

Conclusion

This study explored continuity of care and patient satisfaction from the perspectives of free clinic patients. Communication among patients and receptionists, providers, and interpreters seemed to be a recurring topic across groups. In addition, the communication issues of health programs and appointment reminders are areas that need improvement. Finally, current medical education regarding cultural competence and physician/ patient communication may not wholly prepare medical students for the diversity of experiences they may face in a free clinic setting. The current form of trainings may need to be improved to better serve diverse patient populations.

Ethical Approval

The University of Utah Institutional Review Board (IRB) approved this study.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Sorenson Legacy Foundation (Akiko Kamimura) and the Summer Program for Undergraduate Research, University of Utah (Mu Pye and Kai Sin).

Acknowledgement

The authors want to thank the patients who participated in this study and acknowledge the contribution of the staff of the Maliheh Free Clinic. In addition, we thank Maria Reynes for her help as a Spanish interpreter.

References

1. Darnell JS (2010) Free clinics in the United States: A nationwide survey. Arch Intern Med. 170: 946-953.
2. Kaiser Commission on Medicaid and Uninsured (2016) Key Facts about the Uninsured Populations.
3. Gulliford M, Naithani S, Morgan M (2006) What is ‘continuity of careâ€Âââ€Å¾Â¢? J Health Serv Res Policy.11: 248-250.
4. Saultz JW, Lochner J (2005) Interpersonal continuity of care and care outcomes: A critical review. Ann Fam Med. 3:159-166.
5. Younge R, Jani B, Rosenthal D, Lin SX (2012) Does continuity of care have an effect on diabetes quality measures in a teaching practice in an urban underserved community? J Health Care Poor Underserved. 23:1558-1565.
6. Isaacs SL, Jellinek P (2007) Is there a (volunteer) doctor in the house? Free clinics and volunteer physician referral networks in the United States. Health Aff. 26: 871-876.
7. Kamimura A, Ashby J, Trinh HN, et al. (2016) Uninsured free clinic patientsâ€Âââ€Å¾Â¢ experience and perceptions of healthcare services and patient education. PXJ. 3: 12-21.
8. Wetmore S, Boisvert L, Graham E, et al. (2014) Patient satisfaction with access and continuity of care in a multidisciplinary academic family medicine clinic. Can FamPhys. 60: E230-E236.
9. Ellett JD, Campbell JA, Gonsalves WC (2010) Patient satisfaction in a student-run free medical clinic. Fam Med. 42:16-18.
10. Kamimura A, Ashby J, Myers K, Nourian MM, Christensen N. (2015) Satisfaction with healthcare services among free clinic patients. J. Commun Health. 40: 62-72.
11. Cabana MD, Jee SH. (2004) Does continuity of care improves patient outcomes? J Fam Pract. 53: 974-980.
12. Haggerty JL, Roberge D, Freeman GK, Beaulieu C. (2013) Experienced continuity of care. When patients see multiple clinicians: A qualitative meta summary. Ann Fam.11: 262-271.
13. Betancourt JR (2006) Cultural competence and medical education: Many names, many perspectives, one goal. Acad Med. 81: 499-501.
14. Hewitt H, McCloughan L, McKinstry B. (2009) Front desk talk: discourse analysis of receptionist-patient interaction. Br J Gen Pract. 59: 571-577.
15. Kamimura A, Tabler J, Myers K, Ahmed F, Aguilera G, Ashby J (2017) Student-led health education programmes in the waiting room of a free clinic for uninsured patients. Health Educ J. 76: 282-292.
16. Cristancho S, Peters K, Garces M. (2014) Health information preferences among Hispanic/Latino immigrants in the US rural Midwest. Glob Health Promot. 21: 40-49.