CHHMP was founded in November 2004 by a small group of first and second year medical students interested in starting a clinic for the homeless in Northern Manhattan. It was decided that clinical services would be initiated only after a thorough site search and needs assessment. From the start, a faculty supervisor (J.S.) was identified from the Center for Family and Community Medicine to provide advice and feedback during the planning stages and to eventually supervise clinical care as described below. The site search began in December 2004, during which approximately 40 clinic spaces were evaluated for appropriateness both of patient population and potential clinic space. Potential sites, including food pantries, churches, and outreach stations, were identified through online databases, manuals of homeless services providers, direct calls to known service organizations, and word-of-mouth. Each potential site was visited in person by at least one CHHMP student. If a site warranted further consideration, meetings with all major organizational stakeholders were organized. Thus, site selection took several months. Sites up to four miles away from the Columbia University Medical Center (CUMC) were evaluated.
The first site, a transitional housing center in central Harlem, was selected in March 2005, and a needs assessment was begun. However, despite successful completion of the needs assessment and purchasing of basic supplies, the start date was postponed several times, and the site was eventually abandoned due to logistical constraints. The second site, St. Mary's Episcopal Church in West Harlem, was chosen in July 2006 after a second 6-month site search. The particular strengths of this site included a community involved in public service; a large, clean basement with bathrooms; and, most importantly, a daytime drop-in center for the chronically homeless operated by the Center for Urban Community Services (CUCS). This site was a “safe space” for the local homeless community, and both the church and CUCS were enthusiastic and supportive. Legal negotiations regarding liability and institutional relationships, logistical planning, and a second needs assessment took an additional 10 months, and the clinic opened its doors on May 1, 2007.
CHHMP was to develop in three stages. In stage 1, the “pilot phase,” the goals were to finalize the finer points of the clinical model and operating procedures, build trust within the local community, and begin to deliver basic care. A comprehensive chart review was carried out and a plan for outreach was developed and finalized during this phase. The second phase of clinical operations, the “implementation phase,” consisted of implementing chart review findings and expanding services given project resources. This phase was anticipated to last 12 to 18 months and is the current phase of operations. The third phase of clinic operations was termed “expansion.” The overriding goal of this phase will be to firmly establish continuous and comprehensive care by meeting additional needs, monitoring health outcomes, and potentially establishing a satellite location.
While the target population of the clinic was the homeless population of West and Central Harlem, the decision was made to open the clinic to all patients seeking health services. However, we expected the bulk of our patients to be homeless and felt our focus on this population called for a clinical model that maximally promoted continuous, trusted care. To ensure continuity, the same medical students are required to commit to working at CHHMP on a weekly basis throughout the duration of medical school. Based on our review of published reports of student-run medical clinics and conversations with student leaders around the country, we believe that this model of care with a weekly student commitment is unique. While we conceived of CHHMP as primarily an extracurricular volunteer activity for only the most committed students, we have been able to secure limited course credit for participants—it counts as a “clinical clerkship” for volunteer preclinical students, and fourth year students can sign up for a 1-month “CHHMP elective.”
As a “medical home” for clients, CHHMP provides comprehensive primary care services: history and physical exam, point of care testing (i.e., blood glucose, pregnancy tests, urine dipstick, fecal occult blood), written prescriptions, disbursement of some medications free of charge, counseling on lifestyle and health care maintenance, psychiatric screening, and a system for direct referrals to physicians at CUMC for further care. Medical students also began outreach projects to promote CHHMP to our target homeless population. These included weekly trips with church volunteers to deliver food parcels and announcements at local soup kitchens and food pantries.
At a typical weekly session, teams of one clinical student and one preclinical student obtain histories and conduct physical exams. Repeat patients are matched to their original care team whenever possible. An attending physician from the Center for Family and Community Medicine (J.S.) and family medicine residents (when available) provide direct student supervision at all clinic session. Students present clinical assessments to the attending physician (or an occasional substitute from his department) who reviews all cases, sees patients, signs off on treatment plans, writes prescriptions, and provides instruction in caring for this unique population. A record of participating students is kept and annual written reflections are collected from students.
Relevant patient chart data gathered for internal clinic review were entered into a standard Excel spreadsheet. Patient data was then de-identified and imported into SAS, version 9.1 for descriptive analyses.15
The Columbia University Institutional Review Board granted this investigation exempted status because it uses previously gathered, de-identified chart data.