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HCA411 Case Study
Background:
Jacob Heights Health Clinic is located in what is now a poor neighbor of the city surrounded by vacant lots, large but run down houses that house multiple families, and a homeless shelter. Few stores or restaurants are located now in the area. However, when Jacob Heights Health Clinic was first opened it was a private health center run by several doctors. The doctors lived in the area that was at one time a very well off area sitting on a hill overlooking the city. Over time, however, the area declined, as the wealthy families moved further into the suburbs and left the city. What was once a thriving area of town with many shops and restaurants, became the victim of vandals and thefts. The owners slowly moved out and the stores were abandoned. A few shops have since attempted to establish themselves in the area to provide mostly food and necessary services. Two such services are a homeless shelter and foodbank.
When the doctors moved out of the area, they sold the clinic to a hospital group who would continue to run it. However, the doctors took their paying patients with them. The hospital insisted that they could meet the needs of the area and attract paying patients and therefore decided to continue with the policies and procedures that existed originally. In fact, a number of the staff that were not taken by the doctor remained to run the clinic. Other medical personnel came from the hospital periodically to work the clinic. These medical personnel did not live in the area and had thriving practices elsewhere in the hospital.
The equipment and furniture in the clinic have not been updated since the doctors left. Many of the exam tables do not recline to lie a patient flat, instruments and equipment is in poor repair, and hazards are present in the form of extension cords across the floor, poor lighting, and frayed rugs. The front door is kept locked during office hours and patients have to ring to be admitted. They speak to the receptionist through a hole in the glass partition that separates the reception desk and the waiting room. There are often not enough chairs in the waiting room for all patients so some sit on the floor.
Management
The day to day operation of the clinic is handled by Ms Keets who previously worked for the doctors. She has been with the clinic for 25 years. Ms Keets oversees the hiring, staffing, and management of all non medical staff. She does not have a degree in healthcare administration but was trained as a bookkeeper and receptionist. The management of the clinic is carried out by the hospital board of directors. However, they have little concern for the clinic and outside of sending some medical personnel to the clinic, they do not become involved. Hospital policies are not extended to the clinic.
Hours of operation of the clinic have been shortened partly due to lack of medical personnel who will come to the area, and partly due to Ms Keets insistence that all staff must be out of the area before dark. The clinic is currently open from 9 am until 5pm five days a week. There are no evening or weekend hours.
Specialization and Clients
While the clinic was still run by the private doctors, they specialized in providing primary care to families. Over the years, particularly close to the time that they moved out of the area, they had seen a change in the type of patients. Where they originally dealt with common colds, flu, cardiac disease, and preventive care, the doctors began to see an increasing number of patients with chronic diseases such as diabetes, STIs, pneumonia, and alcohol and drug addiction related issues. It was at this point that they sold the clinic to the hospital.
Unfortunately, under the administration of Ms Keets, the clinic did not adapt its policies and procedures to address this change in clients or care. Because the hospital board has remained disconnected from the clinic, there has been no oversight that would help refocus the clinic to meet the needs of current residents of the area. Ms Keets believes that the same type and level of care should be maintained, keeping the clinic as if it was 25 years ago. She has a dislike for dirt and poverty and insists that staff have as little contact with the clients as possible, wipe down all surfaces including door handles as soon as the patient leaves, and prevent individuals from entering the clinic if they do not have an appointment. Families are not allowed into the exam rooms with patients except in the infrequent case of a child.
The clinic has family practice nurse practioners that come from the hospital twice a week to treat patients. Other days the clinic is staffed with nurses and non medical personnel. The family practice nurse practitioners are provided back up by hospital doctors but patients have to go to the hospital if they need further care that cannot be provided at the clinic.
Current Clients consist of individuals from the immediate area of the clinic, a mixture of ethnicities, including recent immigrants from Africa and Central America along with elderly Caucasians, African Americans, and Hispanics. The clients are mainly of two groups, the elderly and those who are addicted to drugs or alcohol. In the areas there are, however, many families with small children and teenagers. There is a high rate of STIs and teenage pregnancy in the area. These patients often do not receive prenatal care and show up at the hospital only when they are in labor. A number of these patients are also on drugs and have STIs. Many of the children are either not vaccinated or are behind in their vaccinations.
There is a serious issue of poor nutrition in the area. With very few groceries available and rampant poverty, families tend to rely on the foodbank for their nutrition. The foodbank relies on donations, mostly from local churches. However, with the decline of the area the churches have few parishioners who are not also part of the poor neighbor. Therefore, food choices are often limited to starches and few fresh vegetables or fruit.
Human Resources: Medical and Support Staff
Medical staff consists nurse practitioners are employees of the hospital and are not compensated by the clinic in any way. Other staff are hired by the clinic on a part-time basis. The clinic does not employ any staff for more than 30 hours so that they can avoid paying health insurance, and other compensation. They are paid hourly based on the lowest levels for the area. The staff includes 1 Medical Assistant (non certified) and a LPN who do the medical intake and assist the nurse practitioners, and 2 receptionists who handle all scheduling, bookkeeping, billing, and patient intake. The LPN has also been with the clinic since the time of the doctors.
Salaries
| Receptionists (2) | $8.00/hour |
| Medical Assistant (1) | $10.00/hour |
| LPN (1) | $12/hour |
| Ms Keen (only one on salary) | $36,000 per year |
A few of the nurse practitioners have made reports to the hospital board that patients are often treated poorly at the clinic by staff. This includes being culturally insensitive, speaking down to the patients, talking about patients behind their backs, and spending little time listening to their needs. So far the hospital has not taken any action. However, this behavior has caused many of the practitioners to refuse to work at the clinic. There are no cultural competency workshops or requirements for staff.
There is no Human Resources department for the clinic and while they are officially under the HR at the hospital, Ms Keen insists that she knows best how to deal with her staff and does not believe in having written policies and procedures. She states that when staff are hired they are given a list of requirements and she strictly enforces it. The list is as follows:
- No chewing gum
- Be in clean, pressed uniform with shoes clean and white
- Be on time
- Do not spend time talking to patients or family outside of obtaining the required medical information
- Wipe down all surfaces including door knobs after patients leave
- Do not receive or give gifts to/from patients
- Do not become involved in patients outside of the clinic
- Leave the clinic promptly at 5pm on closing
- Do not admit patients to the clinic who have no appointment, are drunk, or appear to be on drugs.
Financial Considerations
Other reports have suggested that the clinic is charging excess to Medicare and Medicaid for care that was not given. There are no patients now who have private insurance so most of the money comes from federal funds. It is from these funds that the hospital pays the clinic staff, and maintains the building and utilities. Patients who are homeless, without insurance or federal support, are turned away.
Ms Keen does not have a budget from the hospital. She submits bills for supplies each month to the hospital where they are paid. Other bills for utilities and rent go directly to the hospital. It appears from the state of the facility that little of the money that is obtained from Medicare and Medicaid is put back into the clinic.
Advertising and Marketing
The hospital lists the health clinic on its web page as one of its many outreaches. However, the pictures and information shown paints a very different picture from what actually occurs there or the clients served. There are several larger flyers posted on walls in the area but these are old and outdated with erroneous information.
Security
Patient records are still in paper form and are filed along the hall of the clinic where Ms Keen says they are easy to access by staff. Anyone entering the clinic past the receptionist has access to the records. When patients are called to see the medical personnel, they are shown to a room along this hall and wait there sometimes for over an hour to be seen. Staff frequently discusses patients in front of families and other patients. When calls are made to other doctors or to obtain lab reports, they are made in the presence of others. If someone calls about patient information it is freely given.
While the front door is kept locked during the day to protect staff from people on the outside, there are many other hazards both to staff and patients. In the exam rooms there are no hazardous needle containers for used needles so needles are thrown into the regular trash. While door knobs are wiped down, other preventions are not taken to curb the spread of infection. Throw rugs are used on the floors throughout the clinic. Due to poorly kept equipment there is a continuous threat for electrical shock, falls, and other injuries.
Professionalism
While Ms Keen insists on medical staff wearing clean uniforms and shoes, many other issues of professionalism exist. Staff talk about patients, talk down to patients, are not culturally sensitive, are abrupt with patients, and freely share information on social media. Their phone etiquette is poor. Their receiving of patients is non-friendly and curt. They have been directed to ask for insurance first prior to any other contact with the patient. If a patient does not have insurance (federal or private) they are turned away and told they will have to go to the hospital. Clients with alcohol or drug problems are often sent away to “sober up first.”
Summary
In the last year the clients at the clinic have declined. Only the most desperately ill, particularly the elderly go regularly to the clinic. The equipment and building is in decay, and the needs of the community are not being met.