North Carolina
Student Rural
Health Coalition
UNC Chapter
Operations Manual
I.)
Mission Statement:
The Community Health Initiative is the UNC School of Medicine chapter of the
North Carolina Student Rural Health Coalition. The NCSRHC is a group of mostly
university-related individuals and organizations working in partnership with
communities to promote accessible health care and a healthier society in rural North
Carolina.
We hold that access to health care is a basic human right and that denial of that
right is unjust. We hold that promotion of good health requires educational, social,
political, spiritual, occupational and environmental approaches, in addition to
traditional health care approaches.
We hold that the organization and operation of a just and effective health
movement must take direction from and be accountable to the community it serves.
We believe our first responsibility is to the community, and the health care priorities
established by that community.
We are also committed to assuring the Coalition members learn about the
conditions that contribute to poor health, develop the skills and sensitivities needed
to address these conditions, and learn career options that will enable them to
continue to address these problems in the future.
We are also committed to assisting those programs leading to improved
indigenous health resources. It is with these commitments that we help to help
North Carolina’s teaching institutions fulfill their mission to improve health care
access to all North Carolina.
Specifically our chapter is responsible for the operation of two clinics – Bloomer
Hill and Garysburg – which are both rural communities in Eastern North Carolina.
We are unique among organizations at UNC SOM in that we provide free medical
services to rural communities in the state. Not only do we provide care to these
communities, but we also expose students to rural health care and community-based
medicine.
We run the Bloomer Hill clinic one Saturday every month for twelve months. In
addition, we provide 4 special clinics throughout the year. We run the Garysburg
clinic once every month for twelve months. These clinics provide approximately
450 encounters per year.
In addition to running the clinic, CHI sponsors a monthly seminar to review the
patients seen at the clinic that month, and to learn about primary care topics relevant
to our work. This provides an opportunity for our physician preceptor to work with
students on reviewing and presenting patient information. This is a valuable
experience in that it gives students a chance to develop some of the skills they will
need for the rest of their career.
II.)
Organization Bylaws:
See Appendix
III.) Clinic Organization (some of this applies to the Bloomer Hill
People’s Clinic that is currently closed and as such would not directly
apply when we are practicing out of Dr. Hughes’ clinic):
On arrival to the clinic at 9:00am, there is a team meeting to introduce all of the
volunteers and clarify the responsibilities and objectives for the day. This meeting
typically lasts for five to ten minutes. After the meeting, the first task is to organize
the supplies need to run the clinic. This includes educational materials, vital sign
equipment, laboratory materials, and exam room supplies.
The Patient Education posters are stored in the storage closet and placed in the
waiting rooms for patients to review. The posters can be placed in the alter area or
on the pews, anywhere where they are in the patient’s sight. There is also a
television and VCR on a cart that can be wheeled out from the storage area and
shown to the patients. There are a series of VCR tapes on the cart that the patients
can watch.
The equipment for vital signs is located in the lab cabinets and in the storage
closet. The blood pressure cuffs and thermometers are located in the lab cabinet.
The eye chart and scale are located in the storage closet. The eye chart is hung on
the wall separating the lab from the main examination room. The 20-foot mark is
marked on the floor.
The laboratory supplies are kept in the lab cabinet. There are extra supplies for
much of the dry supplies in the storage closet.
The exam room caddies are kept in the storage closet. They contain all of the
materials that the physician routinely needs to perform an exam.
The community representative, Princess or Ethel, is responsible for checking in
the patient, taking a one-dollar donation to cover operation cost, and preparing the
patient’s charts. Then, a medical student (1st year students are encouraged to follow
a 2nd, 3rd, or 4th year student) takes the patient to an exam room, interviews the
patient, takes vitals and performs a physical exam. Once complete, the examiner
will leave the patient in the room, and discuss their findings with the attending
physician. Once a course of action has been discussed and chosen, the physician
and the medical student will enter the room and finish the visit. If any laboratory
tests are needed, the patient will be sent to the laboratory. If any patient education is
necessary, the volunteers can perform this either in the rooms, or in the main
examination room. If the patient needs to enroll in the patient assistance program or
see the pharmacy volunteer, these services are provided at this time.
This process continues until all of the patients have been seen. All patients must
be seen in this fashion, even if they are there only to fill out paperwork. The clinics
can see a maximum of 22 patients each Saturday. The clinic will remain open from
10:00am until 3:00pm. Once the patients have been seen, the yellow copies of the
charts are collected, the supplies are returned to the storage area, and the patient’s
charts are replaced in the filing cabinet.
IV.) Organization Outline & Responsibilities
Flow Coordinator (2):
 Work with the community to insure the success of the organization
 Make sure that the clinic is working smoothly
 Attend NCSRHC Board meetings
 Organize the meeting times and sites for the rural health elective
 Maintain the NCSRHC Web-page
 Make sure that recognition forms have been updated
 Attend the Saturday clinics and assure that they are running smoothly
 Answer questions from the attending physicians, ensure that the attending
physicians know where and what time we are meeting Saturday morning
 Decide on special clinic dates
 Serve at Bloomer Hill as interviewer
 Contact patients for follow-up
 Get volunteers for the clinic (1 attending, 2 3rd or 4th years, at least 2 1st
years)
 Collect the demographic information about the patients that visit the
clinics
Treasurer (1):
 Make sure that the Whitehead Budget is turned in
 Organize the budget and finances of the organization
 Fill out the Whitehead funding form and turn it in
 Apply for other sources of funding
 Write any updates for acquired grants
 Organize special fundraising events
Patient Educator (2-3):
 Keep the Patient Education Materials at the clinic up to date
 Serve as an interviewer at the Saturday clinics
 Organize 4 extra clinics that will focus on special screening issues
 Serve at Bloomer Hill as interviewer
Community Outreach (2-3):
 Organize screens and Patient Education at sites outside of clinics
 Get volunteers for these screening sessions
 Serve at Bloomer Hill as interviewer
 Work with community members to publicize the clinic and extra clinics
Lab Coordinator (4-6):
 Organize the lab at the clinic and keep it well stocked
 Be proficient in all of the lab tests
 Serve at Bloomer Hill as interviewer
 Transport the materials for the lab to and from the lab


Send patient’s lab results
Turn in samples to the Core laboratories at UNC-Chapel Hill Hospital and
send off Pap smears to ECU laboratory
V.) Positions and Responsibilities:
A.) Overall Coordinator (this position is part of Flow Coordination):
1.) Rural Health Elective Responsibilities: The rural health elective is a
year-long class that gives 2 weeks of 4th year credit for all those who
apply. For details, see the following section on this topic. The
overall coordinator has the responsibility of reserving a room for the
class. The class takes place on the first Friday after the Bloomer Hill
clinic at 12:30. Of course, if the class and Dr. Pignone agree upon
another time, the class time can be changed. In order to reserve a
room, you must request a room in writing to Julie Ciosmak on the
third floor of Berryhill in mid March of the semester before. In
addition, complete the Medical Sciences Teaching Laboratories
Request Form, which is located in the Appendix. In the letter,
include:
a.) The semester you need the room for (Fall and Spring
Semester)
b.) What room you would like (403 or 503)
c.) When you would like the room reserved (Fridays at 12:30
till 1:30) – I would recommend reserving it for every
Friday, because the time may occasionally need to be
changed.
d.) The name of the elective (Rural Health Elective)
e.) Professor (Dr. Michael Pignone)
f.) Number of Students
2.) Meetings:
a.) Whitehead Funding Meetings: during these meetings, all
of the deadlines will be discussed and requirements for
funding and recognition will be listed. These change from
year to year, so be sure to attend.
b.) Rural Health Elective: These meetings will be described in
Section V.
c.) NCSRHC Board Meetings: In order to keep all of the
clinics up to date, one representative must attend each of
the monthly NCSRHC meetings. These meetings are
supposed to happen every month, but often they will not
happen for several months out of the year. The meetings
will be announced via mail, so watch out for them. At
these meetings, be prepared to discuss clinic business and
any fundraising ideas for the organization. At these
meetings, the budget and community business is also
discussed.
3.) Preparing Recognition Forms: Examples of old recognition forms
are available in the appendix. The form is due in September. The
form can simply be copied, with the names changed to reflect current
leadership. It needs to be signed by Dr. Pignone, and submitted to
227 MacNider with a copy of the mission statement. These letters
can be obtained at 227 MacNider or a copy will be sent to Dr.
Pignone. It is crucial that this form be submitted, otherwise the
organization is not recognized by the university and would not be
eligible for funding.
4.) Web Site Maintenance: Each year, the website needs to be updated
in order to reflect the new leadership and any changes in the
organization. Make sure that the information is accurate, as
interested volunteers and patients use this page. In order to gain
access to the page, do the following: go to the medical student
resource page and click on student organizations, under this heading
you should find the North Carolina Student Rural Health Coalition
link that will take you to our web page.
5.) Maintain Listserve: At the end of each term in office, the Overall
Coordinator needs to sign over the control of the listserve. This is
accomplished the following way:
6.) Organize Other Positions: One of the most important functions of
the Overall Coordinator is to make sure that all of the other positions
stay on task and make sure that all projects are running smoothly and
on time. It is the overall coordinators responsibility to report to Dr.
Pignone the progress of the clinic and discuss any changes that need
to be made.
7.) Serve as Flow Coordinator: See Below in Flow Coordinator: Clinic
Activities section.
B.) Treasurer:
1.) Preparing a Budget: Sample budgets are available in the Appendix
Section. In order to prepare a budget, ask each position holder for a
list of materials that will be needed for clinic or other operations.
Ask for them to research how much these items would cost down to
the dollars and cents. A more complete budget is much more
effective than one full of estimations. If a new project is being
proposed, ask the proposing individual to include a description of the
new program and explain the funds needed. The rules for applying
for Whitehead funding change from year to year, so contact the
Whitehead treasurer for more details on the how and when the
budget is submitted. Currently, the budget must be submitted in
March so the funds are ready when the following year begins.
2.) Maintaining the Budget: Whitehead does not like to tell you the
balance of your account, so be sure to keep a record of the amount of
money that you have left in the account. It is of paramount
importance that all funds be used before the end of the year (in May)
so that more funding will be given the next year.
3.) The Student Activities Fund Office: Most grants must be kept in a
account housed in the Student Activities Fund Office. This is
located on the second floor of the student union. The funds are
under the account name “Rural Health Coalition.” In order to take
out funds, you must take a receipt to the office and get a check
written to you to reimburse.
4.) Organizing Fundraising: When the organization is adding new
projects, it becomes necessary to search out new sources of funding.
Contacting the Whitehead representatives is a good first step to
determine any sources of funding. The Graduate Professionals
Student Foundation is a regular contributor to the organization to
help start new programs.
5.) Taking care of Updates for any Grants: Some of the grants require
that regular updates must be submitted to maintain the grant. These
updates are explained within the grant materials. It is the
responsibility of the treasurer to prepare these updates.
C.) Flow Coordinator:
1.) Organize volunteers:
a.) Getting Volunteers: The two flow coordinators share the
task of organizing volunteers for each clinic. There should
be 2 lab personnel, 2 1st years, 1 extra 2nd year, 2 3rd or 4th
years (3 examiners total – 3rd or 4th years preferable, but 2nd
years can do so when comfortable), and 1 attending. 1st
year volunteers can be arranged by emailing the forums,
emailing individual people who signed the interest sheet at
the student organization day (or any other interest meeting),
or from sign ups at meetings. 3rd and 4th years can be
arranged in similar ways. An easy way to get volunteers
for 3rd and 4th years is to contact MD-PhD’s and MDMPH’s. Because of their schedule, they find it much easier
to make the clinics and they can serve as 3rd or 4th year
students. Past officers are also a good resource. Most of
the time, the attending list has already been made due to
Dr. Pignone’s efforts. If new attendings are needed, Dr.
Pignone will tell you where and who to ask.
b.) Getting them to the clinic: Email is by far the easiest way
to get all of the volunteers to the clinic. Sample emails can
be found in the Appendix. Physicians should be contacted
one month before the clinic, and be sure to contact the
physicians and other volunteers a week in advance.
2.) Maintain Flow at the Clinics: It is critical that a flow coordinator is
present at all clinics.
a.) Setup: Upon arrival, the flow coordinator instructs
volunteers what needs to be done to prepare the clinic to
see patients. This includes lab, patient education and vital
statistics instruments. See Section III.) Clinic Operations
for the location of these instruments.
b.) Clinic Flow: One flow coordinator should be available at
all times for questions. They must track the patients, know
what rooms are open, and know the order of patients. They
organize the charts, and tell the interviewers when to go
into what rooms. They should also fill in when necessary,
but make sure that someone has the responsibility to
organize the flow. The flow is explained in Section III.)
Clinic Organization.
c.) Maintaining Clinic Policies and Algorithms: At the
beginning of each clinic, the flow coordinator is
responsible for letting the attending know that there are
established policies and algorithms for a majority of the
common illnesses that the clinic sees (Section VI).
Whenever there is a question about how a patient should be
treated, the flow coordinator is responsible for informing
the physician about these drug algorithms and clinic
policies.
d.) Changing the Sign (does not apply to Dr. Hughes’ office):
At some point during the clinic, the flow coordinator is
responsible for changing the sign in front of the clinic so
that it has the date for the next clinic on it. The hammer,
nails, and pieces for the sign are located in the storage room
in the smaller file cabinet.
e.) Clean up: After the clinic is over, the flow coordinator is
responsible for seeing that the clinic is cleaned up properly.
All materials are returned to their original places. After
making sure that the interviewers and physician sign all of
the charts, the charts are organized, and the yellow copies
of the record are taken from all of the charts. If the patient
is visiting the clinic for the first time, also make a copy of
the patient information form. Additionally, all Patient Data
is collected and taken back to UNC.
3.) Communicate to the Lab Coordinator or Overall Coordinator the
needs of the clinic: If you run out of a supply at the clinic, make
sure that the Lab coordinator or Overall coordinator knows so that
they can get it before the next clinic.
4.) Organize/Clean the clinic: One a year, it is the responsibility of the
Flow Coordinators to organize a clean up of the storage area and the
lab, so that out of date materials can be discarded. Before throwing
away any materials that may be used for another function within the
clinic, please check with the community representative.
5.) Arrange follow-up for any patients: Following the Friday Rural
Health Meeting, it is the responsibility of the Flow coordinator to
arrange any follow up for the patients. If a patient needs to come
back the following week, it is your responsibility to make sure that
the patient is notified. It is also the responsibility of the flow
coordinator to make sure that the lab personnel make sure that the
patients receive a copy of their test results. This contact can either
be through the mail or by phone.
D.) Patient Educator:
1.) Patient Education Materials: The patient educator is responsible for
obtaining and maintenance of educational materials.
a.) Obtaining Materials: Education materials can be obtained
through many avenues. There are many Internet sites
where you can ask for materials to be sent
(www.healthfinder.org and MDConsult are good
resources). The American societies are a great resource for
this purpose, such as the American Cancer Society.
b.) Maintenance: It is critical that the clinic is stocked with
current pamphlets for patients. The pamphlets can be
organized either in the storage area or in the organizer in
the main examination room.
c.) Patient Education Posters: The posters must be maintained
in good condition and show current information.
2.) Special Clinics: It is the responsibility of the Patient Educator to
organize the extra clinics on the 3rd Saturday of the month. In order
to do so, first decide on a topic. This can be any of the health topics
that are covered in the rural health elective. The next step is to get a
doctor for the clinic. Dr. Pignone can help you find a physician to
volunteer for the clinic. Then, with the help of the flow
coordinators, volunteers can be assembled. Next, any education
materials or screening materials must be gathered. The last step is to
advertise the clinics. Local churches and radio stations can be
contacted to arrange for publicity. The community representatives
(Princess and Ethel) can also help in the publicity.
3.) Advertising: Local churches, radio stations, newspapers and the
county health department can all be contacted for special events. If
numbers at the clinics fall below 10 per clinic, these places can be
contacted to increase numbers.
E.) Community Outreach:
1.) Outreach Activities: Part of the mission of the Rural Health
Coalition is community outreach. The outreach can come in two
forms, health education and health screening. While both of these
activities occur within the confines of the health clinics, it is the duty
of the Community Outreach Coordinator to see that these activities
occur outside of those walls. In order for this to happen, the
coordinator must develop contacts within the community in order to
put on special screenings and health events. The Community
Representative will serve as a guide to the community.
2.) Advertising: See under Patient Educator, Number 3.
F.) Lab Coordinator:
See attached Lab Policies.
V.)
Rural Health Elective:
A.) General Information: The Rural Health Elective is based on the rural
health clinics. The purpose of this elective is to discuss topics and
diseases that are frequently seen in the rural health clinics. The class
meets once a month on the first Friday after the Bloomer Hill Clinic.
B.) Course Requirements: There are three major requirements of the
elective are (1) class attendance, (2) one topic presentation, and (3) a
journal. All of the classes are mandatory attendance. At each meeting one
of the students gives a talk on the topic of the week. Handouts are
necessary for this discussion. In addition, a poster can be made that can be
used for the presentation and at the clinic as patient education. Dr.
Pignone will determine the schedule for the topics with input from the
students. A sample is included in the Appendix. Lastly, each month, the
student must write a one or two page journal entry on either an experience
at the clinic or the student’s thought on the reading topic. At least one of
the entries should be a patient write-up similar to an ICM write-up. Half
of the journal needs to be submitted in January, and the rest in May.
C.) Meetings: The meetings run in the following manner. The Flow
Coordinators serve as the moderators of these meetings.
1.) Clinic Business
2.) Patient Presentations: All patients will be presented to Dr.
Pignone. A presentation consists of giving the name, age, CC,
Assessment and Plan.
3.) Topic Presentation: Student presents the topic of the month.
VI.) Algorithms, Lab Work Ups and Clinic Policy
A.) Diabetes mellitus
1.) Who is screened: In our clinic, any adult who requests screening and
has not been screened within 3 years plus anyone over age 40,
overweight, or a family history in a first degree relative who has not
been screened within 2 years. Also, any patient with sudden onset of
polydypsia, polyuria, or weight loss.
2.) Drug Algorithm: 1st line. glyburide
2nd line. metformin
3rd line. referral to other provider for insulin
3.) Lab Work: HbA1C (> 7 % abnormal) – lavender topped tube
Fasting glucose – fingerstick
2 readings over 126 mg/dL on separate days
B.) Mammograms
1.) Who is screened: Women over 50 every year; if women 40-49 ask
for it, we should order it, but not push it in that age group
2.) Where do they go: Nash County Hospital (need prescription for
“bilateral screening mammogram” with Dr. Pignone’s name, address
and phone number for the results to be sent to us)
C.) FOBT Cards
1.) Who is screened: Men and women over 50 once a year. High risk
patients need colonoscopy – refer to UNC through Dr. Pignone
2.) If positive: Refer to UNC for colonoscopy.
D.) Birth Control: We will provide for any patient in whom it is deemed
medically appropriate.
E.) Hyperlipidemia
1.) Who is screened: Anyone who asks for it and has not been screened
within 5 years. Anyone with CAD risk factors: tobacco use, HTN,
DM; people with obesity, sedentary lifestyle who have not been
screened within 2 years
2.) Initial Treatment: Dietary advice for all patients
3.) Drug Algorithm: 1st line – Simvastatin (Zocor) -- Start at 10 or 20
mg per day, and throughout course of treatment, you can increase
dosage to 80 mg per day. After 3-4 months, recheck the cholesterol
level with a fasting lipid panel (GOAL = LDL < 130 mg/dl)
4.) Lab Work: For screening, use a non-fasting Serum total cholesterol
and HDL cholesterol. During special screening events, the
Cholesteck machine can be used for immediate results. Instructions
are with the machine. For patients on medication for lipids, use a
fasting lipid panel (total, HDL, triglycerides). No routine monitoring
is necessary for liver function. Check Creatinine Kinase (CK) (gel
top tube) if patients develop muscle pain on statins.
F.) Hypertension
1.) Who is screened: Everyone
2.) Drug Algorithm: 1st line – Diuretics – HCTZ – start at 12.5 or 25
mg per day, and increase as necessary up to 25 mg per day; another
alternative is Maxzide – start at 25/37.5 mg per day (In diabetics
with hypertension, ACE Inhibitors can be used as a first line
treatment). 2nd and 3rd line – Beta Blockers and ACE Inhibitors can
be used interchangeably based on physician’s judgement. Atenolol
(Beta Blocker) can be started at 25 mg per day; max dose 100 mg
per day. Enalapril (ACE Inhibitor) can be started at 5 mg per day;
max dose 40 mg per day. 4th line – Ca2+ Channel Blockers –
nifedipine XL – start at 30 mg per day; max 120 mg per day.
G.) Prostate Screening
1.) Who is screened: Potentially, men aged 40 - 70 are screened once a
year. Screening should only be ordered after adequate discussion of
the known benefits and harms of screening.
2.) Lab Work: PSA -- >4 ng/ml high risk. If abnormal, patient needs an
appointment at UNC with Dr. Pignone to arrange follow-up. They
can also follow-up at ECU, Roanoke Rapids, Halifax County
Hospital, or UNC Hospitals.
H.) Vaccinations: No vaccinations (except at specific vaccination clinic for
influenza, Pneumovax)
I.) STD Screening: Refer to county health department. STD tests
(chlamydia, GC, syphilis) will be done only as part of diagnostic work-up
for patients with dysuria, pelvic pain, etc. HIV testing can be offered only
through health department. If medically necessary, a consent form must
be signed.
Pap Smears: We can do Pap Smears. When we perform them, we can do
STD testing concurrently. The STD testing is done at UNC Hospitals,
while the rest of the PAP smear is sent to ECU.
VII.) Directions to the Clinics:
Bloomer Hill:
Take the I-40 EAST ramp towards RALEIGH. Take the Wade Avenue exit. Take the I440 NORTH/US-1 NORTH ramp towards WAKE FOREST/ROCKY
MOUNT/WILSON/INNER BELTLINE. Continue on I-440 EAST until you reach the
exit for US-64 East/US-264 East towards ROCKY MOUNT/WILSON, exit number 13B.
You are now on New Bern Avenue. Continue on US-64 EAST for ~ 50 miles. You will
pass over I-95. Take the exit for US-301-BYP towards WESLEYAN
BLVD/WILSON/BATTLEBORO. Turn a left onto US-301. Follow US-301 (NOT
Business US-301) for several miles. You will pass by Consolidated Diesel on your right.
When you reach Battleboro, there will be a four-way stop. A few hundred yards from
that stop on the right is the Bloomer Hill Clinic. It is a white, church-like building.