This post provides an in-depth discussion about the question: “how does diversity, age and gender issues impact the Get Well Clinic (GWC).”  It also discusses some of the critical areas in terms of culture and age-related issues that should be addressed in the organization.

Get Well Clinic (GWC) (General Information)

Use information presented here to answer the questions for the cases indicated below and in your consulting report.   Apply course information on each organizational frame as you analyze the cases. You are also encouraged to research and apply evidence-based strategies that can help save the GWC.

The Organization

(This is a real organization and a faculty member at FNU “past” consulted on and helped save this clinic)

In 1985, Dr. Lona Sings, PhD, CNP, a nurse practitioner from a rural area began to have her friends and neighbors line up at her door for primary care. She realized access to primary care in the community in which she lived was limited. Since she was employed full-time as a professor at a local university, she was only available eight to sixteen hours a week for private practice. Dr. Sings conducted a needs assessment of the surrounding community which indicated the area was medically under-served. To fill this gap, Dr. Sings put together a plan and enlisted other faculty to join the practice. She enlisted the help of four faculty member colleagues that were licensed as nurse practitioners (NPs). Together the NPs made one FTE. She also hired a collaborating physician for the practitioner’s controlled substance prescriptive authority as required in her state at that time. The providers worked with three major hospitals in the area, two community hospitals and one tertiary care hospital to find avenues to admit and care for patients in need of acute care. The providers were credentialed by a major Medicaid insurer in the county and a major private insurer in the area.

As the practice grew, Dr. Sings invested $100,000 of her own money via a second mortgage on her home to expand and continue to grow the practice.

For ten years she was successful at running the practice, however, the limited reimbursement for NPs kept her profit margin low and many of the patients did not pay for their care. In 2000, she wrote a proposal to have the clinic become a Federally Funded Community Health Center. Under this plan she would improve her reimbursement, have a sliding scale fee for patients with no insurance and offer laboratory services. In order to form this type of clinic, community involvement was necessary.  A board of directors (BOD), primarily male, was formed from community citizens and a business manager (BM) was hired.

The staff include a receptionist, two medical assistants (MA), early – mid 20s), a registered nurse (RN), a counselor and one FTE of NPs (four part time NPs, varying ages, all female, which covered the clinic Monday – Thursday 9am – 6pm and Fridays 9am-1pm) and the business manager (female). Dr. Sings served as the clinical director. The RN served as a liaison between the NPs, providing knowledge of the patients and treatment plans. The RN was also the lab supervisor. The counselor provided social work services and mental health counseling and referrals. The business manager hired a biller.  The BM was also responsible for acquiring additional credentialing with insurers to increase the patient numbers. The biller was responsible for billing and coding and the BM was to check and submit the billing to the proper agencies for reimbursement. The receptionist answered the phones and scheduled appointments. The medical assistants took patients to the rooms, assessed vital signs, drew labs, and handled patient questions and phone calls.

All seemed to be going well, until some of the NPs were no longer able to continue to practice at the site due to other obligations. Dr. Sings tried to hire a new NP but the lack of health insurance coverage for employees was a major factor, limiting the pool of NPs. A new NP, Dr. Laura New came to the clinic one day a week. The business manager complained to Dr. New that the clinic was not making money.

Dr. New could not understand how the clinic was not making money in light of the reimbursement and the number of patients cared for daily. She noted the following: On Monday the NP saw 28 patients; most were walk-ins for acute illness, (15 were walk-ins, 4 were annual women’s health exams, three were CDL physicals and six were chronic illness patients). On Tuesday the NP saw 20 patients; three EPSDT (early and periodic screening, diagnosis and treatment), two physical exams for work, 10 acute care and 5 chronic care visits. On Wednesday the NP saw 7 acute care, 3 follow- up visits, 3 women’s health annual exams and 3 EPSDT exams. Dr. Sings practiced on Thursdays, since she has the largest patient following, she saw 32 patients: 15 chronic illness, ten acute illness, 5 CDL physicals and 2 women’s health visits. Also on Thursday, Dr. New saw 20 patients: 10 acute care, 5 women’s health and 5 chronic care. The counselor was on-site three days a week and saw 5-6 patients per day and two home visits for social services. While talking to the business manager, Dr. New discovered that the clinic did not have to pay the electric, gas or water and did not pay a mortgage. The major overhead costs included: the telephone service, the electronic medical record service and support, computer services, supplies and the salaries of the personnel. Since the clinic was a federal program, the MAs and receptionists were paid federal minimum wage which was lower than the state minimum. The collaborating physician charged a nominal fee for his services and the malpractice costs were low compared to a physician run practice.

Dr. New also learned that about ¼ of the 5,000 patients in the practice are pediatric, ½ between 18 and 65 and ¼ over 65. Major illness included: Type 2 diabetes mellitus, hypertension, obesity, dental decay and gum disease, kidney disease and various mental health problems. The illnesses were a reflection of the major diseases noted in the area by Healthy People 2020. She also noted a high teenage pregnancy rate, early sexual activity and a large number of smokers in the practice.

Dr. Sings and Dr. New discussed some of the findings especially related to the finances. Dr. Sings reported that she often holds her paycheck due to the lack of funds for bills and payroll. The BM announced that there may not be enough money to make payroll one month and that she would have to borrow money from a building grant to cover the costs. Dr. Sings advised her against borrowing the money from the building fund. Dr. Sings questioned why there were no funds to cover the payroll. The BM assured her that she was doing all she could do to get the billing into the insurers and was not getting the funding back in a timely manner or stated that the claims were being denied. The BM also complained that since there was no physician on staff and that the reimbursement was too low. The BM stated that the lack of a full- time physician provider was impacting care.

The NPs started to have trouble covering the days due to other obligations. The morale of the NPs was low due to the concerns about the patient load and not reaping any profits. The NPs complained that the BM treated them like line workers instead of the professionals that brought in the patients and thus the money to run the business. The staff was also concerned that the NPs were not seeing enough patients for them to get paid. The RN felt that she had too many lab and prescription refill calls to handle daily. The MAs stated that they could not get their other duties (copying charts and making referrals for patients) completed in a timely manner. The staff wanted more help. The BM asked the NPs to do tasks such as blood draws, filing and cleaning the bathroom.

As the morale worsened, the BM began to lobby the staff to insist on a full-time provider (MD), citing that a full time provider would increase the profits and thus, she could hire more staff. The BM blamed the problems at the clinic on Dr. Sings and stopped communicating with her. She also had limited communication with the other providers and made efforts to avoid any contact. At the same time, the BM began to call board members to express her concerns about the providers. She also told them that she had to borrow money from the grant to cover payroll. She neglected to tell them that she had already done this twice before. She also began to have a relationship with one of the board members. This board member was also a township supervisor.

The finances got so bad that Dr. Sings began to look for other options to keep the clinic open. She called a meeting of the BOD, who immediately stated that a full–time provider (MD) would solve the problems. The BOD stated that the BM was so busy with billing that she did not have time to do the credentialing. The BOD also expressed concerns about “Dr. Sings” borrowing money from the grant for payroll. Dr. Sings and Dr. New became aware that there were serious flaws in the organization and considered closing the clinic.

The tension at the clinic continued to mount as the tension between the providers and the BM became more obvious. Dr. Sings lived close to the town where the clinic was located and the staff and the BM lived in the town. Rumors regarding closure of the clinic began to mount and patients began to look for other providers. The BODs were called to meet regarding issues at the clinic but came to no resolution.

Dr. Sings had a financial consultant come in to analyze the clinic. The consultant questioned the billing practices of the BM and the financial statements for the past three years. The BOD were still convinced that the problems at the clinic stemmed from the lack of a full-time provider. The BM asked the BOD to remove the providers. The BOD recognized the long standing relationships of the providers and the patients and were reluctant to make such a move. The BOD placed an ad for a provider but did not get any applicants.

The BM’s sister, a former part-time employee (fired by her sister for insubordination) threatened the RN and accused her of causing problems for the BM. The BM’s family and extended family were all patients at the clinic. The sister told one of the MAs that her sister had not completed any of the billing for months and the plan was to close the clinic rather than have anyone look into the finances.

Dr. Sings and Dr. New were aware of the multiple problems in the clinic. In order to make an effort to save the clinic, they decided to hire another consulting team, utilizing the four frames outlined by Bolman and Deal and supplemental sources to assess the organization.

You are the consulting team!  Analyze and form strategies to save the GWC.

Case One – Structure

You are asked by Dr. Sings to help analyze the structure of the organization. Describe the past and current structure. Does the current structure work? Using the information you have learned to analyze the organization and describe strategies you would use to impact the organization. How would you describe the organizational chart? Would you change the organizational chart? What else can help?

Case Two – Human Resources and Politics

Use the information in the Human Resource Frame to analyze the Organizational Change/Interpersonal Group Dynamics presented in the case. Describe the players.  Analyze actions and consequences. How does this impact the organization?  How can you strategically improve the GWC? How does this frame impact the finances of the organization and what strategies can be implemented to improve the practice?

Political frame: Many aspects of politics are in this case. Discuss the politics of the GWC. What needs to change.

Case Three – Culture

Use the symbolic frame to look at the Culture of the GWC.  How does diversity, age and gender issues impact the GWC? What are some of the critical areas in terms of culture and age-related issues that should be addressed in the organization?   How does this frame impact the organization?  Discuss strategies which can be implemented to improve the practice. How can the GWC engage the community?

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