Increasing Access to Specialized Dermatology Care: A Retrospective Study Investigating Clinical Operation and Impact of a University-Affiliated Free Clinic

The Hope@UMHS collaboration began with otolaryngology services in 2010 [25, 26] and expanded to include multiple other subspecialties, incorporating dermatology consultations in 2012. A Memorandum of Understanding was written and signed by UMHS and HC under the counsel of legal, risk management, senior administration, and facilities management. UMHS volunteers rendering professional services are eligible for medical malpractice coverage under the UMHS coverage program. Volunteers function within the limits of their licensure or under delegated authority with all necessary supervision required by law. A space or “rental” agreement is signed by a HC administrator each year. Patients referred from HC to UMHS Dermatology remain HC patients, and all subsequent care is coordinated through the greater HC infrastructure.

Uninsured patients referred to Hope@UMHS Dermatology from HC primary care providers are scheduled for a quarterly Saturday morning clinic at the UMHS outpatient dermatology facility. HC maintains a list of dermatology referrals, contacts, and schedules, and reminds patients of their appointments. Patients are mailed appointment confirmations and receive a phone call reminder 3 days prior to the clinic visit. Those who miss and do not respond to calls over the course of two specialty appointments lose their specialty referral. Patients are given parking vouchers by UMHS and assisted in transportation needs by HC. Both Hope Clinics and the UMHS specialty clinics are accessible via public transportation.

Clinics are staffed by volunteer UMHS dermatology employees. Clinic volume is dependent on HC referrals, typically capped at 12 patients per clinic session, and volunteers are recruited according to patient census. Each clinic ideally has a minimum of five volunteers: one at the front desk, one to two medical assistants, one to two medical students, one to four dermatology residents or physician’s assistants, and one to two attending physicians. Volunteers are recruited approximately 3–4 weeks prior to clinic to ensure appropriate personnel.

New patients may be referred for any dermatology concern beyond the comfort level of their primary provider. The clinic operates in the typical US dermatology setting, and patients receive on-site biopsies and procedures, including tangential and punch biopsy, potassium hydroxide (KOH) and mineral oil preparations, cryotherapy, intralesional triamcinolone injection (ILK), and electrodesiccation and curettage (ED&C). Patients may also be referred on the same day or on future clinic dates to other subspecialty services involved in the Hope@UMHS collaboration, including plastic surgery and otolaryngology, which provide care in close proximity to the dermatology clinic. Patients who require excision are referred to plastic surgery. All related costs are absorbed by UMHS. Dermatopathologic expertise is provided by another institution collaborating with HC. An online pharmaceutical coupon resource (GoodRx) is used to determine the most affordable, logistically feasible plan for obtaining any prescriptions at commercial pharmacies. In accordance with UMHS institutional policy, medication samples are not provided to Hope@UMHS patients, but occasionally HC has some basic medications available on-site for patient use. HC support staff communicate after the clinic with patients who need prescriptions to support compliance. Interpreter services are provided by phone or family members. Follow-up is primarily handled by HC providers, who have open communication with UMHS providers for any patient questions or concerns that arise. Patients who require ongoing or additional specialty care are provided counseling services by HC to obtain insurance or charity care, such as through the University of Michigan’s MSupport program; in rare cases in which dermatology follow-up is required and cannot be obtained otherwise, return visits are available.

The HC prepares patient charts for each clinic and houses patient care records permanently in its facility. Dermatology consultants complete a paper record of the visit for HC documentation.

A retrospective chart review was completed for patients referred and scheduled for a visit to the UMHS Dermatology clinic as part of the HOPE@UMHS collaboration from 21 April 2012 through to 29 February 2020. Data from 30 clinic sessions were analyzed. Availability of demographic data was limited and variable due to patients’ ability to opt out of self-reporting. Two clinics (in which 17 patients were evaluated) were excluded from the diagnosis and management analysis due to insufficient records. Level of service was determined by dermatology consultants; corresponding Current Procedural Terminology (CPT) codes were assigned to each patient encounter.

The study was deemed exempt research by the University of Michigan Institutional Review Board (IRB) (Study eResearch ID: HUM00182333; date of IRB exempt determination: 19 May 2020).

Management recommendations may not correlate with compliance and patient outcomes, which were not analyzed in this study. Although the longevity of the collaboration suggests a mutually satisfactory arrangement, we also did not formally measure patient or volunteer satisfaction. Because of the clinic schedule, delays occur between referral and evaluation. Referring primary care providers must triage consultations and consider alternative options (emergency department, close primary care physician follow-up) when waiting is not reasonable. While retrospective in design, our results provide direction for future prospective study and analyses.