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G&H For what types of liver and gastroenterologic disorders are outreach clinics needed?
RG In the fields of hepatology and gastroenterology, areas that may be in need of outreach clinics include liver diseases (of all types), pre- and post-transplant care, and complex gastrointestinal diseases such as inflammatory bowel disease, gut motility disorders, and pancreatitis. There are a variety of patients with more unusual abdominal disorders who might benefit from outreach services, but these would comprise a much smaller proportion of patients seen or referred.
G&H What considerations are needed when setting up an outreach clinic?
RG There are several issues to take into account when one is considering setting up an outreach clinic, as well as a medical center–based referral/complex medical care program. The first and most important step is to do one’s homework by actively researching a particular community’s needs. It is essential to take the time to visit communities in person, to meet local residents, patients, and healthcare professionals, to provide lectures, and to find out what services are missing in the community. Specifically, it should be determined what services are unavailable in the community setting that people need to travel in order to obtain. If people are not traveling to obtain these unavailable services, why not? Such a needs assessment is the first step one must take when considering setting up an outreach clinic and a tertiary care referral program.
G&H How should a clinician approach the community in which the outreach clinic is to be started?
RG It is very important to think about the message that one is bringing to the community in which an outreach clinic is being started. The clinic is not there to compete with healthcare services already established in the area and is not seeking to remove patients from their local care environment. Rather, the outreach clinic is there to complement the services already being provided and to partner with the community. The arrangement needs to benefit both sides equally; an outreach clinic manager or practitioner cannot insist on controlling all services.
It is crucial to perform regular “community maintenance.” The outreach clinic physician should meet with local doctors and small groups of people every month and give talks. There should be an ongoing dynamic between the practitioners in the clinic and the community. Many programs fail because those in charge do not develop and maintain these relationships.
G&H What kinds of financial considerations are necessary in setting up an outreach clinic?
RG Outreach clinics typically lose money in their daily operation. Travel time can be extensive; also, because the clinic may be used just a few times each month, there may be overhead costs on equipment that is not used full time. Outreach sites do not generally create much revenue directly. However, clinics can generate dollars for the institution with which they are affiliated, and so it is best to work in partnership with a hospital/medical center. The hospital will benefit from the finances generated by patients coming from the outreach clinic, and in turn, the outreach clinic will be supported by a stable resource. The hospital/medical center must reimburse/pay the practitioners for all of their outreach time, travel time, and administrative time, fairly and at market value, or the program is doomed to fail.
G&H Why are outreach clinics needed?
RG Traveling from a distant area to an urban center for medical care can be a complex issue for many people. There are many reasons why people do not travel, which can be associated with fear and/or lack of knowledge about services and benefits available at a large medical center. People also do not travel because it is expensive and troublesome, and there is no guarantee that they will meet with the expert that they have been recommended to see; they may be seen instead by a staff member or resident, or when travelling in an unfamiliar area, they may be late for or miss their appointment. Having an outreach clinic in the community can be extremely beneficial because it can mean the difference between traveling for several hours and traveling for 15 minutes.
G&H What are other considerations?
RG A major factor in the success of an outreach program and tertiary care program is the participation of experts in their fields—individuals with community, regional, national, and international presence who write, lead trials, and publish in peer-reviewed publications. The community asks and demands such a level of expertise. The medical center and practitioners therefore need to recognize and fully support this notion with an ongoing active clinical trials programs, research, and communications.
G&H Could you provide an example of a successful outreach clinic with which you are involved? What factors have contributed to its success?
RG Through more than 15 hepatology and complex gastroenterology outreach clinics in Northern California and Nevada, we bring our specialist partners to local communities and support comprehensive patient care with the latest advances and research. Since the liver program’s inception in 1988 at the California Pacific Medical Center, we have performed more than 1,200 liver transplants with excellent survival benefit both during the liver transplant listing stage and after transplantation is performed. We presently evaluate nearly 400 patients each year and perform more than 75 transplants annually, and continue to grow as a result of our excellent results and patient-friendly services provided in the community.
The following Web sites may be useful for physicians who are considering setting up a gastroenterology/hepatology outreach clinic.
• A listing of liver disease and transplant outreach clinics associated with the California Pacific Medical Center
• A listing of gastroenterology and hepatology outreach clinics associated with the Lucile Packard Children’s Hospital at Stanford
• SLU Care of St. Louis University