Links was organized around the new model of charity care, in which people in need of medical care are referred to practitioners who have committed themselves in advance to providing some free or reduced-fee services.4 The program was initiated in 1993 by a small, ad hoc group of hospital and human service workers who had become concerned that increasing numbers of their clients were unable to gain access to needed basic care. As a first step, they initiated informal arrangements with local physicians that enabled patients to be seen in local doctors’ offices for standard-quality care for which no fee would be charged.
Demand quickly increased, and more time was spent on the informal gatekeeping role. This became untenable when patient demand skyrocketed due to word of mouth and when local physicians began to refer all indigent patients to Health Links as a prerequisite to seeing them in the office. The community hospital sought and received federal funding for Health Links from the Rural Health Outreach Program of the Health Resources and Services Administration for 1994-1997. With this grant funding, the hospital was able to hire staff to coordinate the activities of volunteer clinicians and to train nurses and lay health advocates to offer a range of services, including nursing triage, brief treatment, referrals, med¬ical case management support, and limited prescription assistance.
Health Links was staffed by three nurses (two part-time nursing coordinators and one full-time staff nurse), a volunteer coordinator, and a program manager. Limited clerical support was also provided by the hospital. In addition, more than 60 nurses and lay health advocates volunteered to provide assessment, triage, and assistance with paperwork at the walk-in sites. Through a partnership with the University of Massachusetts School of Nursing, nurse practitioner students performed compre-hensive histories and physical exams at one of the sites. (This component of the project was discontinued after vocal community members attacked the students for ask¬ing routine questions about home firearm safety.) One internist in the community volunteered as the project’s medical director. Other physicians, myself included, also volunteered at the walk-in sites. (A few volunteered in this way as an alternative to accepting referrals in their offices.)
Face-to-face contacts occurred at the Health Links office in the hospital’s medical office building or at one of two walk-in sites: the school nurse’s office at a regional high school in the western part of the county and a church basement in the central part of the county, where Health Links was co-located with a weekly community meal program.
Patient contacts occurred either by telephone or in person at one of the walk-in sites. Nursing triage was per¬formed during all contacts, resulting more often than not in no follow-up treatment and no referral to a medical office for standard-quality medical services. Volunteer lay health workers provided assistance with completing the required paperwork (see below) and offered large amounts of social reassurance and support.
Primary care was not routinely offered through the Health Links program. Most patients were seen on an episodic problem-oriented, or urgent-care, basis. For example, those presenting with acute infections typically received self-care instructions, perhaps a prescription for antibiotics, and instructions to return to Health Links should the problem fail to resolve or a new problem appear. Patients with chronic conditions such as diabetes or asthma—not easily managed on an urgent-care basis— received referrals to family physicians or general internists.
Health Links patients’ access to preventive services such as Pap smears, mammograms, and other routine cancer screening tests as well as smoking cessation or nutrition counseling was limited according to the site and the clinician’s discretion. Gynecologic or rectal exams could only be performed at the one site that afforded adequate privacy, the high school nursing office. There fore, many medical services that would normally be pro¬vided in the primary care setting either were not offered or were arranged via “unnecessary” referrals to specialists (for example, urology referrals for patients with urinary symptoms).
Eligibility. Before receiving services, patients were required to complete a written registration form that collected the following information: age, gender, familv size, gross family income, employment status of patients ages 20—64, ethnicity, town of residence, recipient status for other benefits, and other health care access markers (whether they had health insurance, whether they had an ongoing relationship with a primary care provider, and whether they had been seen in the hospital emergency department within the previous two years.
The Health Links program designated a $22,000-per-year income for a single individual or family as the income eligibility cutoff. All those meeting this criterion who were Franklin County residents and who self-reported that they were uninsured or that their health insurance would not cover the cost of needed medical care were eligible for services through Health Links. A very small number of individuals were turned away clue to not meeting the income eligibility criterion. Ineligible individuals were not counted for statistical purposes.
Data collection. Consistent data collection activities were carried out by I lealth Links staff beginning in 1995. The staff maintained daily logs of all patient contacts with I lealth Links staff and volunteers, including telephone as well as face-to-face contacts. In addition, the Health Links staff tracked participation bv local provider offices using a monthly referral log, which identified providers but not patients.
Health Links data were aggregated monthly for reporting purposes and to protect patient confidentiality. I retrospectively analyzed monthly reports for a two-year period, September 1, 1995, through August 31, 1997, to assess quantity of care, provider participation, and costs of the program.