Arianna Fischer

Health policy conversations often revolve around access to health insurance, often as to how health insurance can be reformed to be made more affordable or assessing the quality of health care. However, health insurance isn’t universally accessible in the United States. In 2019, 10.9 percent of the nonelderly population was uninsured. That is 28.9 million individuals who did not have health coverage, oftentimes foregoing or delaying access to health care providers when needed.

I started working on this project to gain exposure to a free clinic serving a need in rural North Carolina. Hope Clinic is a free and charitable clinic serving the uninsured and underinsured in the county. The opportunity to work on a project for this clinic has allowed me to get exposure into how to actually expand access to health services and essential care at the community level for one of the most vulnerable populations in this country.

The opportunity to continue engaging with Hope Clinic has been extremely rewarding in terms of how to expand health care access. As I have not engaged with a free and charitable clinic in my previous experience, it was eye-opening to see the services that this clinic is able to provide given their resource constraints. Hope Clinic staff work tirelessly to fill a need in their community. And during a pandemic, no less, their services were crucial.

The main purpose of this project was to provide diabetic patients at the clinic with opportunities to help them manage their diabetes. This project uncovered that even at the most basic level of chronic care management, peer and community support is crucial. Just providing patients with opportunities to engage with and support one another can go a long way. When an individual is living with and managing a chronic condition on a daily basis, it can be tiresome to keep up with their demanding health needs. Having a peer or community member to rely on for support when times get tough is invaluable.

The main legacy of this project in my mind has been to connect Hope Clinic with other organizations and resources in the county that their patients would benefit from. Even though Pamlico is rural and the resources that exist are scattered in the county, there are so many people willing to help in any way they can. For example, a community task force has started during the COVID-19 pandemic to serve as a resource for community members. The COVID-19 Community Task Force (CCTF) has been an effective volunteer effort over the past year, connecting Pamlico residents to resources and supports when needed as well as disseminating resources on the importance of masking, vaccine dissemination efforts, and other COVID019 related topics. Never underestimate the power of volunteers.

The more services that are offered through the clinic, the more the topic of long-term sustainability comes up. One of the long-term goals that came from this project was the idea of implementing Community Health Workers (CHWs) in Pamlico County. CHWs health workers that are recruited from the community to aid their community members in a variety of things such as health education, support, and mentoring, to name a few. CHWs often bridge the gap between formal health care providers and patients, providing patients with an opportunity for more-frequent care. In a rural community like Pamlico, they can also address access to transportation by conducting home visits for patients. For a resource-constrained organization like Hope Clinic, it would be beneficial to have health extension workers out in the community, providing ongoing support to patients in need.

While I do not have the answer at this time as to how to bring CHWs to Pamlico County, this is an effort that others in Pamlico are going to continue to explore and hope to carry out. CHWs are an innovative form of health care that should be explored in other settings as well, particularly in rural areas of the country where the hope is to expand access to care but where there are limited resources. My hope for Hope Clinic, and the future of this project, moving forward is that they will continue to utilize the network of willing volunteers in the county to assist their patients in their journey to managing their chronic conditions.

An exciting update from my last blog post – my team has completed the patient survey! This process has been so much more difficult than my team and I imagined it would be, yet I know the results with provide invaluable insight into which elements of our proposed pilot program will work. The survey results will be extremely beneficial to my community partner, Hope Clinic, as they plan for ways to enhance their services to better serve their patient population.

The purpose of the survey was to gain patient insight and gauge their interest in various elements of the pilot program that we proposed for the Hope Clinic. Key lessons learned from survey development to survey dissemination are outlined below.

Development

When developing the survey, question phrasing and question design were the main elements to think through. For question phrasing, my team and I went through multiple rounds of edits to ensure that the wording was specific and unambiguous. Part of this process was ensuring that the patient population would understand the wording of the questions we were posing and that we were not using technical language that those outside of our research team would not be able to understand. Additionally, we wanted to be mindful of the language used for questions gauging interest to clinic survey expansion. While the clinic is interested in expanding services, they’re unsure if they will have the capacity or funding to do so at this time. As such, we didn’t want question wording to come across as a promise for scaled up services in the future.

Refining the question design included deciding between asking questions on a scale versus free response questions versus multiple choice questions. The first draft of the survey largely included questions that were asked on a scale, such as “On a scale of 1 to 10, how equipped do you feel to manage your chronic condition?” After talking through the questions with a survey expert at Duke and our course instructors, we decided this question design was not well-suited for our survey population. The clinic’s patients were likely not familiar with such a scale, and so their responses would vary greatly and be difficult to compare across patients. The next round of the survey included multiple choice questions with free-response follow-up questions based on each yes or no selection. When the revised survey was close to final, we tested the survey among classmates and community members and realized the survey was too burdensome due to the number of questions that were being asked and the extent to which we were asking for the free-response follow-up questions. In order to cut down on the time it would take to complete the survey, the final survey included mostly multiple-choices, yes or no questions with an ‘other’ option for patients who wished to elaborate more. We also ensured we were only asking the essential questions for the scope of this project.

Sampling

Early on in the process, my team and I knew we would not reach a 100% response rate, even if the survey was disseminated digitally. When the final decision was to conduct the patient survey via phone calls, our goal became surveying 10 to 15 percent of the patient population. To ensure that the patients we surveyed were representative of the full patient population, we sampled the list of patients based on the demographics of age, sex, race/ethnicity, health condition, and language. The original sample that we randomly pulled to survey matched the demographics of the full patient population in every category. While we had to sample additional patients along the way to account for non-responses, the final list of patients surveyed still matches the overall demographics of the patient population nicely.

Dissemination

As we conducted the survey via phone calls, each member on our team created a Google Voice phone number with an area code that matched the Pamlico County region. This was a necessary step, as we hoped having a similar area code to the patients we were calling would encourage a better phone call pick-up rate. Additionally, the clinic posted a notice on their social media accounts, notifying patients that they may receive a phone call asking them survey questions for the clinic.

Conducting the survey calls was a process of trial and error. After conducting initial calls, we began recognizing patterns in availability during the day that patients had and strategically tried calling around those times. My team and I held weekly check-ins during this time to assess progress and determine if we were on track for wrapping up the survey. The survey took 5 weeks in total to reach the goal of sampling 15 percent of the patient population. As we have now closed the survey, we have begun cleaning the survey responses and analyzing the results.

My project entails developing and piloting a diabetes management program for patients at Hope Clinic in Pamlico County, North Carolina. Progress to date has included developing a proposal for the pilot program, which my team and I completed Fall semester 2020. In recent weeks, we received buy-in from stakeholders at Hope Clinic on the proposal and the go-ahead to continue planning and implementing the pilot program.

The next phase of the project has been reaching out to patients. I developed a survey to distribute to a sample of patients to gauge their interest in various elements of the pilot program that my team and I proposed. We developed the pilot program based on a thorough literature review and interviews with experts and innovators who have experience with diabetes management, and more broadly chronic care management, programs. However, the patient population is the most important to get input from before we can finalize the pilot proposal.

This piece of the project has been challenging, as there have been logistical barriers to overcome to distribute the survey. With technological barriers, such as limited access to broadband internet in the county, my team and I ultimately decided the best way to connect with patients would be via phone calls. This month we will be working on calling a sample of the patients, randomly selected in line with the overall demographics of patients at Hope Clinic.

The patient survey is crucial because the pilot will only be useful for patients if it’s in line with their needs and the activities that they are interested in participating in. The survey closes with the question ‘Is there anything that you would like to see in your community that could improve your health or quality of life?’ connecting directly with people that will engage with this program is crucial. I am not a resident of Pamlico County, nor do I have a chronic health condition that requires ongoing care. While the pilot program was developed based on research and talking to stakeholders who have developed similar programs in other locations, getting the input from those who would be using the program is crucial.

If all goes as planned, the patient survey will be complete by the end of the month and the pilot program can be refined and finalized. Once finalized, the program will be rolled out in three different phases based on level of effort and funding required to start the phase. There are two more urgent elements of the pilot that my team and I want to pursue as soon as possible.

The first element includes increasing opportunities for physical fitness for patients, as well as their families and friends, to engage in in the community. As Spring approaches and the weather is nicer, this is soon to be the perfect time for outdoor, socially-distanced fitness classes. We are in contact with various fitness instructors in the area to arrange outdoor classes and take advantage of this optimal timing.

The second element includes coordinating access to food resources for individuals experiencing food insecurity. Food insecurity has increased nationwide as a result of the COVID-19 pandemic and the rise in unemployment that we saw nationwide as a result. At the close of 2020, North Carolina Central University (NCCU) studied the effect of COVID-19 on lost income and increased food insecurity in North Carolina. The study found an increasing number of North Carolinians are relying on friends, family, and charity resources for food.

This element of the pilot is also timely due to a recent closure of one of the county’s grocery stores. The Piggly Wiggly in Grantsboro closed at the end of February after sales plummeted last year. Residents of Pamlico may now have less access to fresh foods in the county, particularly in the particular city the Piggly Wiggly was located in.

The local church network is extensive in Pamlico. As such, this element of the pilot involves reaching out to the local churches that operate food pantries and helping to coordinate services to get food to the patients who need is. Another element involves troubleshooting transportation. There is extremely limited public transportation available in the county, and limited ride-sharing options. We are considering options for distributing gas cards or connecting patients to volunteer drivers to access food pantries that they are typically not able to access.

Arianna will be working on developing and implementing a diabetes management pilot program for patients at Hope Clinic in Pamlico County, NC.

Pamlico County is located in a rural area of Eastern North Carolina. With a population of approximately 12,800, 30 percent of the population is elderly (ages 65 years and over) and close to 16 percent of the population lives in poverty. Rural communities across the U.S. face a variety of challenges, such as limited access to healthcare, higher rates of uninsured residents, and a higher prevalence of chronic conditions. In 2019, the Pamlico County Health Department released a Community Health Needs Assessment that gave insight into the health needs that need to prioritized in the county. Access to health services and diabetes were two of the top five significant health needs that the county health department identified as priorities for Pamlico County.

Hope Clinic is one organization working to meet the health needs of the Pamlico community. Hope Clinic is a part of the North Carolina Association of Free and Charitable Clinics and offers free healthcare to low-income and uninsured individuals in Pamlico County. A large percentage of the patients Hope Clinic serves live with chronic conditions. Due to funding constraints, the clinic has a few paid staff but relies heavily on a network of volunteers to meet the needs of the community. Open one day per week, the clinic primarily focuses on clinical appointments and has limited capacity to offer many programmatic services to their patients. In hopes of developing a chronic disease management program, Hope Clinic formed a partnership with Duke University that began through a Bass Connections project in 2020.

The purpose of the year-long project was to develop and begin piloting a chronic disease management program. Through a series of conversations with Hope Clinic in the fall, my team and I honed in on developing a pilot program for the clinic’s patients that are diabetic, as a starting point to pilot the chronic disease management program. As 30 to 50 percent of the clinic’s patients are diabetic, the pilot will test the program’s effectiveness on the patient population with the greatest need at this time. Based on effectiveness of the pilot and the clinic’s capacity in the future, the pilot may be scaled up to address the needs of people living with other chronic conditions.

The initial steps that were taken in the fall of 2020 included a thorough literature review and interviews with experts and innovators who have experience with diabetes management, and more broadly chronic care management, programs. This phase of research was crucial in proposing potential elements of the pilot to Hope Clinic at the end of the fall semester. While the pilot proposal is still in draft form, pending feedback from the clinic’s leadership and patient input, this semester we plan to begin implementation and evaluation of the pilot program.

I chose to be on this project as it overlaps with my background in public policy and public health. I have a particular interest in expanding access to healthcare for the most vulnerable populations in our country, primarily low-income individuals who are uninsured and forego access to healthcare, making their health conditions worse. While the Affordable Care Act (ACA) has made healthcare more accessible for more individuals, a key piece of the ACA was expanding Medicaid eligibility so that more low-income people would qualify for free or low-cost health coverage. Left up to states to expand the program, North Carolina is one of twelve states that have not adopted Medicaid expansion. As of 2019, North Carolina’s uninsured rate was one of the highest in the country, at 13.6 percent. The services at clinics like Hope Clinic are essential, working on the ground to fill in the gaps that a lack of policy implementation has filled in North Carolina.

This project provides the opportunity to expand health services to individuals in Pamlico County who are most in need. I am interested in how to expand these services in a cost-effective and innovative way, ensuring that the program put in place is sustainable given the limited resources and funding that Hope Clinic has. This project provides the opportunity for me to apply the course work that I have learned as well as previous work experience, through implementing a program and evaluating the program’s effectiveness. Additionally, this project is beneficial for Hope Clinic as a thorough pilot program has been drafted and proposed based on extensive research conducted by my team and me. This project provides an opportunity to improve the lives of many of the patients that Hope Clinic serves.