Providing occupational and physical therapy services in a free community-based interprofessional primary care clinic

ABSTRACT Interprofessional care provided in a free community-based clinic that focuses on chronic health conditions and health promotion provides an innovative solution to improve societal health. Many existing clinics provide a range of professions, but few include allied health services such as occupational and physical therapy. This paper provides a description of the development and implementation of an expanded faculty-guided student-led community-based primary care clinic that includes occupational and physical therapists as part of an interprofessional collaborative practice model. A detailed description and explanation of the partners involved, the institutional missions that drive this work, the logistics completed that enabled the ‘doors to open,’ faculty and student roles, and initial outcomes will be provided. A review of the service delivery model, lessons learned, and future directions for the clinic will also be offered.


Introduction
There are approximately 1400 free and charitable clinics providing care to medically underserved patients in the United States (National Association of Free and Charitable Clinics, 2021). In addition, there are 152 student-run free clinics (SRFC) providing low-to no-cost care and providing critical training for healthcare students (Society of Student Run Free Clinics, 2020). Both have existed in the United States since the 1960s as a safety net for uninsured or underinsured patients (Meah et al., 2009;National Association of Free and Charitable Clinics, 2021). Frequently, SRFCs are community-based with sponsorship, staffing, and supervision provided through medical schools, while free and charitable clinics are philanthropically funded and staffed with volunteers and professionals from the community. Services vary from clinic to clinic and often include primary medical and dental care, mental health, wellness, prescription consultation, and nutrition (National Association of Free and Charitable Clinics, 2021; Society of Student Run Free Clinics, 2020). While interprofessional models of care are increasing, few clinics provide allied health services, such as occupational (OT) and physical therapy (PT) (Simpson & Long, 2007;Smith et al., 2014;Swartz, 2012). These professions, in addition to medical services, are integral to quality, low-cost patient care, particularly in communitybased clinics that provide primary care (Bolt et al., 2019;Bornhöft et al., 2019;Institute of Medicine, 2017) Occupational therapists address prevention, health management, and wellness while focusing on promotion of healthy routines and habits, engagement in 'occupations' supportive of healthy lifestyles, and prevention of complications as a result of chronic disease progression or poor chronic disease management. "Occupations" are activities that people want and need to do, including everyday activities like preparing a meal and getting dressed, to more complex activities like managing their health and pursuing leisure and social activities. OT interventions remediate barriers to allow greater participation in work, social, educational, sleep, and instrumental activities of daily living (ADLs/IADLs) (American Occupational Therapy Association, 2020a).
Similarly, PTs evaluate and treat individuals across the lifespan who have a medical diagnosis or other health-related condition(s) that limit their ability to move and perform functional activities in their daily lives. PTs develop treatment plans designed to optimize the patient/client's ability to move, reduce their pain, restore function, enhance their health, wellness and fitness, and prevent disability (American Physical Therapy Association, 2020).
As members of an interprofessional allied healthcare team, OTs and PTs work together in preventative and maintenance activities related to primary care, e.g., falls and injury prevention, exercise, ergonomics, and completion of ADLs and IADLs. Working in concert with the primary care team, OTs and PTs integrate the primary care goals with patient goals and create a treatment plan to optimize both (Bolt et al., 2019;Gray et al., 2018;Peranich et al., 2010). Other interprofessional team members may also include other allied health professionals such as dieticians, social workers, community health workers, and interpreters. This paper describes the development and implementation of an expanded faculty-guided student-led community-based primary care clinic that includes OTs and PTs as part of an interprofessional collaborative practice model. The genesis for the development of this clinic came from the congruent missions and visions of an existing nonprofit community healthcare organization (St. Mary's Health Clinics [SMHC]) and an educational institution (St. Catherine University) that focuses on educating socially responsible allied healthcare professionals. The goals of this free clinic are to provide highquality clinical services to Spanish-speaking patients without health insurance and student learning opportunities through interprofessional practice. The similarities in institutional missions and the development of the clinic collaboration between SMHC and St. Catherine University will be reviewed, including faculty and student roles, and service delivery. Finally, lessons learned and future directions for the clinic will be offered.

Shared mission
The creation and development of the clinic stems from the shared history and healthcare missions of the Sisters of Saint Joseph of Carondelet (CSJ) through SMHC and St. Catherine University. SMHC was founded by the CSJs based on the belief that healthcare is a basic human right (St. Mary's Health Clinics, 2020). St. Catherine University was also founded by the CSJs with a commitment to create an inclusive environment of excellence emphasizing intellectual inquiry and social teaching within the Catholic tradition (St. Catherine University, 2020). The charism emphasized by the CSJs, to help the "dear neighbor without distinction" (CSJ, 2020), continues in both the work of SMHC and St. Catherine University. SMHC's current community-based structure and initiatives represent a continuation of this charism in providing quality health services to individuals without healthcare insurance.
The Saint Catherine University's Henrietta Schmoll School of Health (HSSH) "educates diverse learners and engages clinical and community partners to influence health, health systems, and health policy" (St. Catherine University, 2020). Team-oriented healthcare education, interprofessional education, and a commitment to promote health among underserved and immigrant communities are emphasized. To meet the needs of diverse people, SMHC and HSSH place a premium on working for justice in health and education. Each values the education and involvement of students as a way to serve those in need and enrich students' lives as they engage in professional activities and studies. Given this, community healthcare programs providing interprofessional patient-centered care that addresses social justice and healthcare disparities created an excellent foundation for St. Catherine University OT and PT students to work with patients of SMHC.
Building successful collaborations requires a sense of mutual respect and trust, and a strong commitment to a shared mission (Parkinson, 2006). In addition, clear roles/ responsibilities and excellent communication are key to both implementation and sustainability of a clinic collaboration (Seaton et al., 2018). To enhance this collaborative relationship and guide the services provided, the mission of the clinic is "to advance social justice through transformative, holistic healthcare." The vision is to reduce healthcare disparities among the underserved through accessibility to high quality, patientcentered health services; develop compassionate and culturally fluent healthcare professionals in an interprofessional environment; engage in community partnerships that promote health and well-being; and advocate for wellness for all.

Role of interprofessional team
Initial planning for the addition of OT and PT services at SMHC included communication between the Director of the University's Student Health and Wellness Center, the Executive Director of SMHC, and OT and PT faculty leadership as they considered opening a satellite clinic on the St. Catherine University campus. Given the importance of organizational leadership support when developing formal relationships with other organizations (Seaton et al., 2018), the Director of the Student Health and Wellness Center met with the University Administration to confirm administrative support for this community-based venture. With positive responses, the Director of the Student Health and Wellness Center formed the Clinic Expansion Committee (CEC). This is a small group of faculty and staff interested in the collaboration and includes the OT and PT faculty preceptors. A small group of committee members attended the annual conference hosted by NAFCC (National Association of Free and Charitable Clinics, 2021) to learn more about free and charitable clinics, and several committee members visited the University of California-San Diego SRFC (University of California School of Medicine, 2021) to observe a working interprofessional model in practice. Additionally, several committee members visited each of the existing SMHC sites to understand the current operational flow (St. Mary's Health Clinics, 2020).

Student recruitment and role
Students from St. Catherine University are well-prepared to successfully provide interprofessional care from a social justice perspective and have been introduced to curriculum related to interprofessional care and social justice. Many students have also taken undergraduate coursework founded on interprofessional education principles, have participated in TeamSTEPPS (Agency for Healthcare Research and Quality, 2020) and/or attend the University due to a longstanding commitment to social justice (St. Catherine University, 2020). Similar to other university and college healthcare programs, students are often eager to participate in experiential learning during their academic training (Schutte et al., 2015), and thus, student recruitment was not a barrier. Students attracted to this type of work often possess a genuine level of empathy, kindness, respect, and passion for the work (Shabbir & Santos, 2015;Weaver et al., 2019).

Faculty role
Student guidance from faculty preceptors is necessary, particularly with students at various levels of preparation (Ng & Hu, 2017). Accreditation and state licensing standards require students to have faculty guidance in the initial chart review process to understand medications, diagnoses, tests and procedures, and past medical histories; identify a plan for the initial patient contact, e.g., phrases to elicit the patient's history, motivational interviewing techniques, prioritizing multiple and complex issues, differential diagnoses; and in the provision of care, e.g., palpation/provocative/special tests, resources, and guidance on the home programs, frequency and duration of services, and discharge planning (American Occupational Therapy Association, 2020a; American Physical Therapy Association, 2014). Additionally, faculty provide consultation and recommendations to students and provision of care that may be beyond a student's current knowledge and skill level (i.e., custom orthotics and complex patient care instruction related to cancer). Ultimately, students provide the majority of handson patient care, with OT or PT faculty assisting as needed, similar to other SRFC models (Society of Student Run Free Clinics, 2020).

Models for student participation
Processes to coordinate OT and PT student volunteers were put into place from the onset. OT students were initially recruited through the Master's Seminar and Master's Project courses, occurring during their last year of the OT program. Three students were initially selected based on interest and skills and were instrumental in completing literature reviews on topics related to caring for patients in this setting, including topics of chronic health conditions in Spanish-speaking populations. These students also conducted a needs assessment with SMHC and provided education for the providers and staff at SMHC. This fostered a better understanding of OT and PT in primary care and the types of patients that could best be served. The initial three OT students also provided care during the first 4 months of clinic operations.
Sustainability played a factor in recognizing that the clinic would be better served by OT students as part of level I Fieldwork, a standard, credited course within the OT curriculum. Level I Fieldwork is one of the two layers of Fieldwork required of all students matriculating in an entry-level occupational therapy program. AOTA defines Level I Fieldwork as "an experience designed to introduce students to the concept of fieldwork education, amplify and build on didactic material in the program's coursework, and provide a beginning level of clinical skills while under close supervision of qualified personnel including program faculty" (American Occupational Therapy Association, 2020b). Experiences can occur in all OT practice areas including community and emerging OT practice settings. To date, there have been six groups of level I Fieldwork students engaged in clinical activities. Each group of three students commits to a 4-month period, allowing the clinic to be staffed with consistent OT students 12 months per year. Overlap between incoming and outgoing students is intentional and provides orientation and peer mentorship. In this model, OT students can be firstor second-year students.
Doctor of Physical Therapy (DPT) students, due to an existing DPT program model of serving community-based pro bono clinics, staff the clinic on a volunteer basis. Lead PT students were selected and responsible for recruiting consistent PT student volunteers to staff each clinic session. This model allows second year DPT students to develop their leadership and communication skills ensure ensure a consistent number of DPT students available for each clinic session. In both OT and PT models of care, students are encouraged to follow a patient from an initial visit through discharge of services, in an effort to provide consistent patient care and to allow the student to understand the spectrum of rehabilitation services.

Clinic structure and service delivery
Patients are provided with a prescription for services from a primary care provider at one of the SMHC 8 offsite locations. Initially, providers prescribed OT and PT services for patients with common musculoskeletal issues (carpal tunnel syndrome, knee and back pain, etc.). After several months of operation, through student-led education sessions, faculty e-mails, and personal communications, providers began sending patients with orders for "OT/PT eval and treat" for many chronic health issues, e.g., obesity, chronic pain, diabetes, hypertension, and anxiety.
Scheduling is done through SMHC. Students and faculty communicate with providers via e-mail, phone, and written communication in the paper chart. Initially, patients provided their own transportation. More recently, many patients have begun to utilize a corporate ride service paid through grant funding. Rides to appointments are scheduled through SMHC, while rides home are scheduled by faculty in attendance on clinic days. Students typically escort patients as they leave the clinic to ensure the patient has located their ride. Drop off and pick up locations, signage, and campus maps for patients are intentional to ensure patients feel well cared for in a new environment.
Paper charts are picked up from th SMHC office located adjacent to campus by a faculty member. Students and faculty arrive 30-60 minutes prior to the first patient appointment for review of clinic tenets, chart review, and team formation. Students are encouraged to choose one or two scheduled patients based on interest, current course involvement, and continuity of care. Initial patient encounters are scheduled for 60 minutes with follow-up visits for 30 minutes. Students and faculty work together to review charts and focus on medications, past medical history, social history, and current diagnosis/order. Of note, with referring providers off site, patients may have to wait several days to several weeks to get an appointment at the clinic.
As patients arrive, students greet and take them to private treatment rooms. In most cases, two students (one PT and one OT student) and an interpreter participate in the initial evaluation. Students interview the patient, asking open-ended questions to determine the patient's needs, and begin the objective evaluation process. Once the students have collected this information, they consult faculty. The faculty then guide students through their clinical reasoning process by addressing students' questions regarding diagnosis, special tests, and possible interventions. In addition to faculty resources, students rely on the online learning platform for the clinic, which houses patient education materials in English and Spanish. The medical director or another medical provider is available for consultation during this time. Students then return to the patient to complete their examination and evaluation and begin to provide interventions. Faculty assist with interventions as needed.
Once the visit is complete, students complete their documentation in accordance with state practice guidelines, with oversight from faculty preceptors. Notes are printed, signed, and placed in the chart. Follow-up communication, via phone or e-mail, is completed with the patient care coordinator and/or referring provider. Clinic debriefing occurs after all patients are seen, and takes between 30 and 60 minutes. Food, provided by the St. Catherine University food shelf, is available for all patients to take home. Charts remain in a locked clinic room until a volunteer from SMHC picks them up the following day.
Excellent patient care is emphasized and demonstrated through the tenets of the clinic (see Table 1). The tenets were created by the CEC, with inspiration from the University of California-San Diego SRFC (University of California School of Medicine, 2021), as a guide for collaborative practice and patient-centered care. All students and faculty review these tenets as an interprofessional group prior to and reflect on them after every clinic session. Prior to the end of a patient session, students will ask the patient to identify health issues of importance and help the patient formulate questions to ask their primary care provider at the next visit. Encouraging patients to take greater control over actions and decisions that impact their health results in better overall health outcomes (McAllister et al., 2012). Emphasis is placed on the tenet, "Patient as Teacher," encouraging students to actively listen, learn from the patient and treat the patient as an equal in the interprofessional team.
Dedicated efforts to provide high-quality care and produce allied health professionals who will excel in today's healthcare environment require time for reflective practice (Mitchell et al., 2015). Thus, the interprofessional group is allowed time to complete chart reviews and huddle prior to patient care, and time to debrief and reflect on the overall outcomes of the clinic. Students are engaged in reflection on what went well, what could have been better, and how this will change their practice moving forward. At least two faculties, from different disciplines, facilitated the reflective components. Faculty are then able to support students with additional resources and evidence to move forward and engage students in role-playing difficult scenarios to ensure students are more confident in future patient encounters. Reflective practice is necessary to develop collaboration skills across professions and to improve individual clinical skills and reasoning (Richard et al., 2019).

Outcomes
The clinic has been open since January of 2016 and has provided upwards of 130 OT/PT visits. There have been 21 OT students and 12 PT students involved in providing care, along with three faulty preceptors. The simple intent of taking good care of patients has now evolved to providing intentional care led through the vision and mission statements. Clinical work has resulted in several scholarly publications and projects, along with increased student involvement and growth. Qualitative data related to student outcomes and the student experience is in progress. See Table 2 for representative student comments after participation in clinic activities.
Unsolicited feedback from SMHC providers and staff has been very positive. Verbal feedback from patients in the clinic indicates effectiveness in pain reduction, improved ability to participate in life activities such as paid employment and child rearing, improved sleep, success in weight loss endeavors, and increased activity tolerance, to name a few. Additional patient care outcomes are being developed with our partner, SMHC. See Table 3 for representative SMHC staff and patient comments.

Discussion
Organizations and resources that may be useful for those undertaking creation or expansion of free clinics, student run clinics, or a combination thereof can be found through the SSRFC, NAFCC, and the Association of Clinicians for the Underserved (https://clinicians.org/). Additionally, recommendations provided to health-care educators by the IOM have been instrumental in validating our approach in this work (Institute of Medicine, 2003). Eliminating the hierarchical barriers that often exist in healthcare and education is paramount to the provision of patient-centered care (Schottenfeld et al., 2016). Students, patients, faculty, interpreters, and supporting staff are equal members of the Interprofessional. The foundation of the clinic is an Interprofessional care model with the patient at the center of care. Holding each other in high esteem, all disciplines work together to optimize each patient's health.
Social Justice. This clinic collaboration will provide St. Kate's students the opportunity to experience and operationalize love of dear neighbor without distinction and will develop future professionals in all disciplines with a passion for social justice.
Empowerment. Students along with faculty will create an environment that supports patients' ability to self-define issues important to their health and well-being. Table 2. Representative Student Comments after Clinic Participation. "I learned the importance of working as a team." "I think it helped me to develop reasoning of why I am recommending certain interventions and helped me develop critical thinking skills. Also, interfacing with an actual client and being able to do an occupational profile and working collaboratively with the PT students and interpreter is an invaluable experience." "I would highly recommend this fieldwork experience to any student who is looking to gain more confidence in their clinical reasoning and documentation skills." "The supervisors created a phenomenal environment for learning and growing professionally." " . . . using our OT skills alongside those of a PT in order to problem-solve together." healthcare team. Patient centered care provided through interprofessional teams is integral to quality care (Institute of Medicine, 2003). Future goals of the clinic include increasing services offered, student disciplines involved and determination of appropriate outcome tools for both patient care and student learning. Plans to implement the outcomes and evaluation data are forthcoming. Student outcomes will be measured by implementation of the Interprofessional Collaborator Assessment Rubric (Curran et al., 2011). Patient-related outcome tools are under investigation with a leaning toward the PROMIS Scale v1.2-Global Health Spanish Language Version (Healthmeasures, 2017). Additionally, there is discussion on the implementation of outcome tools specific to pain and other physical issues, similar to tools used in traditional outpatient rehabilitative settings, e.g., SF-12 (Ware et al., 1998). Data collection with a focus on global health and symptom-specific issues may help strengthen efforts for inclusion of allied health professions like OT and PT in primary care and improve the likelihood of procuring additional resources to expand the current efforts at this clinic.
Key recommendations include the following: (1) Shared mission and institutional alignment: Building successful collaborations requires a sense of mutual respect and alignment at the level of the vision and mission of each organization (Parkinson, 2006;Seaton et al., 2018). As partnerships are developed, assure commonalities at the core and identify the unique contribution each partner brings to fill a gap.
(2) Student commitment: Because students are often eager to participate in experiential learning (Schutte et al., 2015) and tend to possess a genuine level of empathy, kindness, respect, and passion for the work (Shabbir & Santos, 2015;Weaver et al., 2019), student screening and assurance of foundational education in interprofessional models and principles of social justice is necessary. Student participation in free clinical work requires integration with an allied health curriculum, although this can be accomplished through credited courses or expectations for service within the allied health program.
(3) Faculty commitment: Developing and sustaining a partnership between a university or a college, and a community partner requires select faculty that are dedicated to community service and student learning. Several issues must be considered when engaging faculty to participate in this type of work (Canadian Federation of Medical Students, 2018;Clark et al., 2019). Faculty workloads must be accounted for and considered relative to how faculty are evaluated by their program, school and university. For example, how will the time, energy and work that are devoted to a free clinic be calculated into the service portfolio of faculty? Will financial compensation be added to the faculty member's salary or will 'release time' from another activity be offered? (4) Faculty Fit: Involved faculty must be prepared and need to be comfortable interacting and mentoring students from other professions. (Shellenbarger & Robb, 2016;Bvumbwe, 2016). Faculty must be patient centered and team centered rather than discipline driven (Schottenfeld et al., 2016), allowing students to work under the supervision of professionals outside their discipline while meeting state practice rules and regulations (McGonigel et al., 1994). Faculty must also value and create a safe, open learning environment that enables students explore solutions to their patient care hypotheses in the context of their individual professional learning. Finally, faculty who staff a free community-based clinic need to be flexible, adaptable, possess a high energy level and be kind toward all team members and patients (Haslam, 2015). (5) Educating primary care providers: OTs and PTs can fill a gap in primary care needs and should be utilized early and often in primary care (Peranich et al., 2010). As the need for additional primary care team members increases, it is imperative that interprofessional primary care opportunities are afforded in entry-level education for OT and PT fields (Gray et al., 2018). (6) Facilitating transportation: Lack of transportation can be a significant barrier to patient healthcare needs and correlates to lower physical and mental health (Kamimura et al., 2018). Consideration and assistance in getting patients to and from appointments is best practice (American Health Lawyers Association, 2016). Lyft Business has a variety of services related to healthcare, including integration into some electronic health management systems, and is one solution to transportation barriers (Lyft Business, 2021). (7) Navigating language barriers -use of interpreters: Providing services in a patient's primary language improves overall communication, allows the patient more control to ask questions, and improves satisfaction "Just got our charts back from your PT/OT clinic last week and was so impressed not only with the PT/OT evaluation and care our patients are receiving, evidenced by the detailed chart notes, but also now the complete nutritional consultation for each patient seen last week . . . . You all do such fantastic work and we are SO very grateful!" Patient Comments -"Thank you for listening and explaining everything so well." "Thank you for being so kind and helping me understand" "Thanks for helping me understand that I do not need to be afraid of my knee pain anymore" "My pain was a 9/10; now it is 4/10" "I have been able to sleep 5 hours without pain!" with care (Karliner, 2018). SMHC provides one trained interpreter for each scheduled clinic day, and St. Catherine University utilizes volunteer Spanish-speaking students to address additional interpreting needs. (8) Establishing clinic tenets: Clinic tenets are foundational to providing patient care services. These tenets ground the team in the philosophy of the work and guide decision-making and planning processes (Schottenfeld et al., 2016). Students and faculty review the tenants before each clinic and have an opportunity at the close of the clinic to debrief on the application of the core tenets. (9) Reflective practice: Dedicate time to allow students and faculty preceptors to engage in reflective collaboration prior to and after each clinic. Clinical skills, reasoning, and interprofessional growth occur with reflective practice (Mitchell et al., 2015;Richard et al., 2019).
Reflection is completed at the end of each clinic session, and in accordance with best practice, both OT and PT faculty challenge students to connect theory to practice while modeling effective communication and collaboration between disciplines (Richard et al., 2019).

Conclusion
The planning and implementation of a free community-based clinic that is a university-clinic partnership can be a daunting process; however, the rewards far outweigh the challenges. The goal of improving societal health and well-being with willing partners is a starting point. Flexibility and patience, combined with the energy of an interprofessional collaborative team pave the way. The end results are improved community health and a well-prepared group of professionals, ready to address emerging practice areas to improve the health of all patients.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
The author(s) reported that there is no funding associated with the work featured in this article.