Patient Advisory Board Internship

Patient Advisory Board Internship at Zuckerberg San Francisco General Hospital

For this cooperative education project I have chosen to write about my internship at Zuckerberg San Francisco General Hospital (ZSFGH). I was chosen for this internship from a pool of pre-medical student applicants based on my resume, letter of interest and in person interview. The work was advertised as needing someone to run the formal Patient Advisory Board Council (PAC). I wasn’t aware until my interview with the Medical Director and Floor Manager that I would be doing much more than running a once a month meeting. I would also be in charge of recruiting new members to the PAC, seeking out presenters and providers wishing for patient input, enrolling patients in and training them to use the online SF Health Network Patient Portal, running the monthly Diabetes in Motion Clinic, and doing various other small duties around the hospital. I had to commit to being available 30 hours a week that were flexible but must include Fridays. I was excited to be chosen for this opportunity to have great potential in improving patient health and satisfaction at ZSFGH, San Francisco’s community safety net hospital; while also growing my own knowledge of what it takes to provide high quality health services to underserved populations.

Before being allowed to start my volunteering duties there were many steps I needed to tackle to be eligible to work with patients, both for my own safety as well as theirs. I had to find time to go to the hospital to procure blood work and testing to be sure I didn’t have Tuberculosis or a list of other communicable diseases. I was required to take just over 10 hours of training geared to helping familiarize myself with the layout of the hospital; in addition to how to safely interact on a daily basis with the unique population at ZSFGH. My learning objectives were to understand what I would need to do in my daily work to knowledgably comply within HIPAA rules and NIH safety protocols.

Method

For my content for this report I performed research on site at my Internship. ZSFGH has an extensive medical library that is free and open to the public. The librarians are well versed in what is available in the event that I had any questions arise during my time there. The Volunteer Services Office also stocks many resources that are available for learning about how best to care for patients’ wellbeing and properly protecting their personal information online and in daily hospital interactions. I utilized both of these resources in my off-volunteer hours either before or after doing internship qualifying hours.

Discussion & Literature Review

Initial Onboarding

In order to be able to be an official volunteer at ZSFGH, I had to complete their online Volunteer Orientation Course. This took about 2 hours and was helpful in walking me through the layout of the SF Health Network as well as the buildings where I would be working. Also outlined were the health requirements of all volunteers in the network requiring blood work and vaccinations. After completing those steps I was assigned a volunteer identification number to be able to log my Internship hours and a badge identifying me as a Volunteer that also shows which clinic I am a part of, my flu-shot status and lists the hospital wide emergency response codes for easy reference.

In order to be useful in my positions I needed to learn about the San Francisco Health Network Primary Care’s missions and vision for providing the highest quality primary and preventative care to adults, regardless of ability to pay. There are 4 main aims of the clinic that follow from building a foundation of healthy, engaged, and sustained primary care workforce. To ensure an excellent patient experience, optimize access, operations and cost-effectiveness, have sustainable patient centered care and finally, to improve the health of the patients served.

The specific clinic I was hired to do my internship with was the Richard Fine People’s Clinic – General Medicine Clinic (RFPC-GMC). This is a clinic consisting of mostly low income, homeless and immigrant patients. The Volunteer Services Office at ZSFGH assisted my learning about patient information security by providing some short video training from the SF Department of Public Health. (Public Welfare, 2009) This helped me learn what information qualifies as needing to be private and secured; treated as sensitive and protected health information. There is an established national set of standards for identifying protected patient health information (PHI) such as a patient’s demographic data relating to past, present or future medical needs. (The Health Insurance Portability and Accountability Act of 1996) It is anything that can be used to identify patients such as their first or last name, medical record number, phone numbers, email addresses, date of birth, Social Security Number or address. Rules for handling such information is that you must never store PHI on an unencrypted computer, a flash-drive or take home files with PHI. If necessary for an email this information must be encrypted and titled as “Secure.” Written information must be disposed of in the locked “to be shredded” bins when no longer needed. Information can be stored on the provided work computer server only accessible by UCSF ward computers. (Burnap, 2012)

Unlike a Kaiser or Sutter insurance network hospital or clinic, the SF Health Network is part of the city’s health system that provides a significant level of care to low-income, uninsured, and vulnerable patient populations. ZSFGH is a unique in that it is also a training hospital tied with UCSF. Patients benefit from cutting edge training for their Doctors and Residents as well as generous philanthropic funding that the University benefits from annually. A large part of ensuring patient self-empowerment lies in building their networks and increasing accessibility to services, which this funding can bring. (Corburn, 2007)

Patient Advisory Council

Prior to working within the SF Health Network I was not aware that there were 26 clinics across the city. This aids in vastly improving patient’s access to care in or near their own neighborhoods. Each clinic was challenged with starting their own PAC in 2016. There are now 21 PAC’s across the city for various different types of clinics and patient populations including 2 in Spanish and 1 in Mandarin languages. Prior to instating these PAC’s much of the average provider’s knowledge of patient satisfaction was just word of mouth. The main motivating force behind coordinating clinic PAC’s is aimed at inviting longtime and new patients to provide input for quality improvement projects from the ground floor. Assessing involvement at the direct patient level can lead to fast strides in community health improvement. (Dannenberg, 2008)

I was responsible for the outcome of the Richard Fine People’s Clinic PAC. I needed to work on recruiting new and diverse members to the team and learn how to lead a group of people that is outside of my everyday socio-economic peer group toward a common goal. I looked to resources for what has worked for other projects for medical recruiting methods prior to mine. (Dannenberg, 2006) I had to coordinate presenters and inquiring providers to ensure that the board provides helpful information to both patients at the clinic and those within the larger health care network. While the focus was on our individual clinic, there is also a hospital wide PAC that was able to push forward any ideas we might have that would benefit the entire hospital population at ZSFGH. In addition to organizing the agenda for the PAC meetings, my duties involved gathering information from patients and providers that generated from our meetings to then enter them into other systems and/or up-channeling ideas involving specific patient populations and their recommendations and desires. Some more recent accounts of improving health at one community level have shown to have a positive impact on the entire city. (Bhatie,Corburn, 2011) I kept meticulous records of all agendas and minutes of every meeting for all attendees’ records as well as past and future reference needs of progress.

I was also assigned to help the RFPC Residents on their new project concerning the SF Health Network’s Patient Portal. They tasked me with recruiting current patients to enroll in the waiting room. The Patient Portal is a tool for empowering patients to be proactive regarding their own health. Most of my patients are housing insecure so I had to seek out examples of positive outcomes of patients evolving from homeless to housed and how to be aid those in transition. (Kessell, 2006) A few strategies for recruiting new patient advisors, portal users and clinic class attendees were given to me by the previous Intern that I was replacing. I had to meet quota goals for portal enrollees, training and tracking; recruit new patient users in clinic for the online Patient Portal and do some data entry for tracking contacts, new enrollees and demographics. I had to figure out the best way to narrow down how best to contact clinic patients to arrange one on one training sessions for the online Patient Portal. I looked into ways in which your immediate surroundings can shape your ideas of your own perceived ability to achieve healthy outcomes as guiding the ways I would approach patients. (Cummins, 2005)

To keep the PAC running, I needed to also book conference rooms for upcoming meetings and was able to book a nice meeting room through December 2017 for ease of transition for the next intern. I made reminder calls and sent out an agenda one week prior to meetings to those members with access to email. I collaborated with members to see what topics they are interested in learning more about for upcoming meetings as I was responsible for coordinating them with presenters. (Dearing, 1996) I surveyed members about what their favorite snack foods were so I could best provide for our meetings. I was allowed to spend $50 for each meeting so we had quite an assortment of foods, all within reason of course as we are promoting healthy lifestyles after all. I guided the meetings but also recorded notes for action items to follow up on as well as to write minutes for future reference as available to the public.

Diabetes in Motion Clinic

The SF Health Network also has a Community Wellness Program branch that allows for patient learning on a variety of fronts from smoking cessation lectures to Zumba classes and nature walks. The Wellness Programs are offered at several clinics across the city and aim to provide and promote innovative services to staff, patients, their families and all San Franciscans. They are designed to be accessible culturally and linguistically as well as to all physical ability and/or limitation levels. The classes that are part of the Working on Wellness (WOW) Healing Moves, Active Living Initiative are open to all and free of charge. Another important part of my duties was to also work on chronic disease group visits in the diabetes clinic. It was important to help try and understand the unique hurdles specific to this particular patient population. (Bhatia, Seto, 2011)

The Diabetes in Motion (DIM) Class was an extra duty inherited by me as the previous Practice Manager moved to Hawaii and requested that the incoming PAC Coordinator (me) adopt the class. This 2 hour class was held once a month and tasked with helping those with Diabetes, the pre-Diabetic and their caregivers better understand how to help improve their conditions. I noticed immediately that there might be low attendance, only 5-10 attendees, due to a lack of a unified agenda across the year of these classes. I researched ideas of how living in an urban environment can impact health and wellness differently than a more rural setting for insight into health problems. (Bodea, 2009) I decided that we would try breaking the class into 2 portions, a movement portion (due to the title) and a healthy eating portion. There was no dedicated staff and, as we had plenty of funding left in the available grant I was able to hire 2 local instructors. I hired Sylvie Minot, leader of the Syzygy Dance Project as an Exercise Instructor and Catherine McConkie, Founder of The Caregivers Table as our Nutritionist. Ms. Minot was able to lead progressive movement exercises that were accessible to all levels of mobility incorporating yoga, stretching and dance movements. The importance of exercise is shown across the lifespan. (Bauman, 2007) During the exercising portion of the class she would lead a discussion about the importance of incorporating movement throughout daily life. (Saelens, 2003) Ms. McConkie would follow for the second half of class with easy and affordable food ideas that she made during the class so the attendees could participate. In addition to making healthy options accessible, she would also pass around ingredients that might be new or unusual for the patients and discuss why certain foods are good or bad to eat. Eat Better, Feel Better! Colorful Choices is a San Francisco Health Service System program aimed at adding more fruits and vegetables to daily routines. I was able to team up with them for our classes to provide free fruits and vegetables to attendees. (Drewnowski, 2004) A $25 Safeway gift card was given to the first 22 participants that stayed for the entire class. Participants were able to take home a bag of food to make the recipe presented in class, for any who could not afford them on their own. (Kim, 2006) I created and distributed English and Spanish language flyers throughout the hospital as well as purchased the patient incentives, organized an agenda with the instructors and ensured 2 interpreters (Spanish and Mandarin language) could attend. Following each class I gathered receipts from all 5 of us leading the course to submit to our grant overseer for documentation and reimbursement. Our attendance went from a low average to roughly 30 patients per class in just 3 months.

Patient Portal

In addition to putting together the DIM and PAC monthly meetings I was assigned to work with the RFPC Residents that were writing a research paper on empowering patients to improve their own care knowledge. The biggest aspect of this was increasing patient awareness, enrollment and use of the SF Health Network’s Patient Portal. This online tool enables patients to see all of their most recent and up to date data from any meetings with providers as well as testing and results. Not only can this aid individual improvement through expanded knowledge of care but it also provides an easily accessible list to give to out-of-network providers. The system also newly rolled out the ability to email your assigned provider. The system self regulates to ease provider burden by immediately rerouting easily accomplished tasks such as appointment scheduling or refill requests before any emails actually go to the provider.

Initially, I was tasked with 10 hours per week of recruiting new enrollments in the Patient Portal system by visiting with people in the waiting room. With an iPad in one hand and flyers in multiple languages in the other, I spoke with each patient on hand to see if they were aware of the program and would like to enroll if not already. I tracked demographics for the residents as well as number enrolled by me or already. I also had proxy forms available if someone wanted their child or spouse etcetera to have access to their information due to any learning disabilities or language differences as the system is only currently in English. I was able to use Google Translate as well as my flyers in 6 different languages to “speak” with everyone in the room one by one. After doing this for 2 months the residents decided I should transition to training users to increase the amount of actual users of the system once enrolled. I utilized the electronic Clinical Works application (eCW) to research which patients were already enrolled in the Portal. I would then call patients with appointments on a particular day for the next week as determined by the Residents until I found about 10 people willing to meet with me before or after their appointments. Together, we would then walk through accessing the system and what benefits and uses it provides to the patient. I would send training videos to anyone I spoke with that wasn’t interested in meeting in person that they could view on their own if they so wished and they had access to my UCSF email if they had any further questions arise.

The largest barrier to increasing user numbers or active users for the Patient Portal ended up being access to electronics and language barriers. The specific patient population at RFPC has phones that may or may not be web-enabled and a lot of them do not have computers or are computer savvy. In meeting with patients I was able to teach them how to recover their login information and perform simple computer navigation. I provided introductions to the hospital library where free computers are available all day that I had never seen full. The system is eventually scheduled to be accessible in Spanish and Mandarin sometime next year.

Extra Tasks

There were some one time tasks on my plate as well. I needed to accomplish the yearly update of the Clinic Care Team Boards. All of the providers are divided into one of three color care teams to help ensure that, even if you cannot visit your assigned Doctor, you will see someone familiar with them and your file. The previous boards were on a small black and white listing with a few pictures. I used the Adobe program InDesign to organize everyone by provider type, team, procured color head shots of all providers and found a local print shop to print each team board on a 3′ x 5′ color poster. I also needed to keep the waiting room stocked of specific informational flyers and magazines every few days.

Results

Participants

Adult patients I was able to add to the PAC were recruited through various methods. Informational flyers were posted in the waiting room and at the pre-appointment health screening station. Providers were encouraged to mention the Council to patients they felt were well informed and/or had the desire to work on quality improvement projects for the Clinic. Most respondents that became full time members of the Council were older adults, 45-72 year old, 4 women and 6 men. Participants were compensated $10 and offered free food (cheese, meat, crackers, fruit, veggies, cookies and water) for their 90 minute participation at each meeting. 3 of the members additionally qualified for free Muni transportation vouchers and 1 for free parking passes. All participants were asked to read the agenda sent to them one week prior to each meeting to prepare any questions or ideas they might have on each topic scheduled to be addressed.

Accomplishments

We’ve been able to get funding to remodel the waiting room with more comfortable furniture, a new color of paint on one wall (blue instead of white) and wall hangers to provide information of free local services available throughout the month. We’ve also spearheaded projects such as surveys to fill out prior to your appointment while you wait in the waiting room and converting the waiting room television from daytime drama shows to clinic specific informational ticker that rotates from a video documentary about the namesake of the clinic to various free or affordable services offered throughout the city for the current month. Starting in April, we will be part of the coordinated effort to have Food Pharmacies across the network. In partnership with the SF Marin Food Bank, patients will be able to get a bag of free and healthy food after their appointments. PAC members will be available once a week to assist.

Another issue raised was of transit safety. One of our members was on disability due to having been run over by a vehicle while she was legally using a crosswalk. The incident left her unable to work for over a year while undergoing multiple surgeries and a lengthy recovery. We had several presenters come to a meeting to get insight from our patients in regard to possible pedestrian improvements. (Mejia, 2017)

The PAC raised money to have a portrait painted of our Clinic’s namesake, Dr. Richard H. Fine that it is to be hung in the waiting room. We are waiting on the display box that is being made to keep it displayed securely. Dr. Fine founded the General Medicine Clinic at ZSFGH, one of the first outpatient clinics in the nation at a Public Hospital that provides health care to underserved populations. He ran it for 25 years. To recognize and thank Dr. Fine for his acute discernment of patient needs, the General Medicine Clinic (GMC) was renamed as the Richard H. Fine People’s Clinic (RFPC) in August of 2015 three months before his death. There is a wonderful documentary about his life that I was able to show the PAC members at the end of one of our meetings. (“Biker with a Moral Compas: Dr. Dick Fine and the Evolving Culture of SFGH” http://mission-healthequity.blogspot.com/2015/07/moral-compass.html)

I was able to establish more clear and concise PAC values and guidelines as none had been expressed in writing prior to my tenure as leader. We were to work in partnership and collaboration to address systemic issues versus individual situations. We would do so by working in partnership with the clinic management to support the clinic mission and vision. We would represent the diverse socioeconomic and cultural needs and perspectives of RFPC’s patients. We would seek the input of other patients to broaden perspectives. We also established term limits to facilitate turn over and diverse patient representation. Our meetings would create and maintain a safe environment for all members and guests to share ideas and points of view. Respect would be given to the confidential nature of information received at the meetings and we would review and sign HIPAA confidentiality agreements and release forms annually as opposed to only upon initial recruitment. As the PAC coordinator I worked hand in hand with the Clinic Champion, Mr. Michael McGuire who, as the Practice Manager of RFPC was the link between the PAC and clinic leadership. He was able to provide some assistance to help me coordinate with staff and providers to ensure successful collaboration on PAC initiatives help me ensure progress was being made on PAC projects.

DIM

The grant to fund the DIM Clinic was picked up for renewal for next year and the instructors I chose were invited to stay and wished to do so. The dramatic increase in attendee numbers rose from 5 or 10 to upwards of 30 under my tenure. We received a lot of positive feedback from patients with successful weight loss and blood sugar stabilization.

Patient Portal Recruiting & Training

I was able to interact with 815 patients in the waiting room and successfully enrolled 230 new Portal users. For online, in person training I spoke with 87 patients over the phone and met one on one with 34 for individualized training. This data will be included in the Residents’ research paper as well as my experiences with what the patient population specific challenges were for our Clinic.

Conclusion

I was able to impart some positive change within the community of ZSFGH during my Internship. I also learned several important lessons such as how communication can be difficult at times but it’s helpful to try to display an open and approachable demeanor. Patients may be upset when they do not receive what they have requested from staff, but remaining clam and expressing compassion can help diffuse and redirect the situation. Because of Dr. Fine’s close connections to the community, he was able to hear about subsets of people who were not seeking health care and make visible what was invisible to many. I am happy to have been a part of so many diverse projects to assist disenfranchised and marginalized populations of San Francisco.

Empowering patients to be proactive about their own care and the outcomes they wish to see has been my main take away from this internship. Helping patients to see ways to incrementally improve their own physical and mental health can not only save money in treatments not needed down the line but also be the first steps towards becoming more independent and being well enough to provide their own income and stable housing.

While the community wellness programs in San Francisco promote interventions aimed at addressing lifestyle issues such as diet and smoking, they also recognize the ways in which social determinants of health such as housing status, neighborhood safety, and access to affordable healthy food play a critical role in wellness promotion and encouraging healthy lifestyle choices. With this in mind, I worked to incorporate strategies such as public health education and advocacy in addressing poor health outcomes during my Internship.

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