Medical Model

The waiting room is empty. So are the examination rooms.

That isn’t unusual for the first day in October at the Boca Grande Health Clinic. In fact, that isn’t unusual for the tiny Gasparilla Island village of Boca Grande, where the 3,000 year-round and seasonal residents trickle north throughout the summer, leaving a barebones population of 900. The summer days stretch into the early weeks of October; many restaurants and shops close for the summer and are still a few days away from re-opening.

But even with few patients — just 6% to 7% of the clinic’s 4,500 yearly patient visits take place in September or October — the clinic is open. And its staff is working.

Nurses use the slow days to set up 1,000 charts for peak season. They’ll need them for the days when two doctors and two nurses will work side-by-side for eight hours straight, during which they will treat up to 60 patients.

This summer, the entire staff is using the off-peak season to learn a new, electronic medical-records system. (The system went live Nov. 1.)

The staff also uses the summer to tend to basics such as restocking and updating CPR certifications, so that they’ll be ready for the months of November through April — the months when snowbirds flock to the luxurious beach community, where the median home price is more than $1.4 million.

But in a community where the average income is slightly more than $127,000, a community whose exclusive 33921 ZIP code was ranked as the 118th wealthiest ZIP code in the United States in the Sept. 27 issue of Forbes magazine, the island’s sole health-care provider might not be able to operate as a for-profit, year-round business.

The clinic could sustain itself during the first three or four months of the year, according to CEO John Sielert, who estimates that between two-thirds and three-quarters of the clinic’s patient visits take place between November and April. But if the clinic were a business, it might be like the restaurants and shops that close for at least part of the summer.

Sixty miles to the north of Boca Grande, on Longboat Key, Dr. Pamela Letts’ Centre Shops Family Practice and Urgent Care has a similar ebb and flow of patients. At the height of season, she and a nurse practitioner treat about 30 patients a day at the for-profit practice; off-season, the number drops to as few as three patients. This summer, which was especially slow, Letts, 65, began to look at the long-range planning of health care on Longboat Key. Worried that someday finding a doctor to take over practicing medical care on the island could be difficult because of the seasonal fluctuations, she, along with Longboat Key, Lido Key, St. Armands Key Chamber of Commerce President Tom Aposporos and Commissioner David Brenner, began to look into the Boca Grande model, in which a foundation subsidizes a not-for-profit clinic to sustain on-island medical care year-round.

“Longboat Key is losing services,” Letts said. “And this is an essential service.”

History of health
Residents like John Kaiser can’t imagine life on Boca Grande without the clinic. Recently, Dr. Michael Steffan spent two hours with him, preparing his medical records for an upcoming move. And over the summer, when Kaiser’s wife, Dorothy, became unresponsive, Kaiser called the clinic. Because the clinic has one physician on duty 24/7 and will make house calls if necessary, Steffan arrived at the Kaiser home within five minutes and determined that Kaiser’s wife’s blood sugar had fallen.

“It’s so special,” Kaiser said. “Everybody is so nice and civilized and loving and has been for the 11 years that we’ve been coming here … It’s so small-town and personal.”

Few residents remember the days before the clinic, back when doctors rarely came to the island and local pharmacist “Doc” Fugate treated most ailments. But the plaque on the door of the clinic reminds residents of the woman who made health-care services an island institution: Louise du Pont Crowninshield, a debutante from Winterthur, Del., and heiress who began wintering on Boca Grande in 1917. According to a 1997 article published by the Boca Beacon in honor of the clinic’s 50th anniversary, Crowninshield began bringing a doctor to the remote location in the 1940s. In 1947, Crowninshield and a group of six other residents collected modest donations and established the Boca Grande Health Clinic. They paid a doctor to travel to the island once a week to practice out of a modest one-room office. By May 1948, the clinic’s newly established board took out an advertisement in Florida Medical Association’s Journal of Medicine that read: “Doctor Wanted: General Practitioner for high class tourist town. Population, summer, 400, winter, 1,000. Have clinic and could subsidize to a certain extent. Chance of a lifetime for the right man.”

That summer, according to the article, the board hired Dr. J.J. Spencer, of St. Augustine, and decided he was the man for the job. As anticipated, he would require a subsidy of $2,000 because the practice would be so small, so the board launched its first capital fund drive, asking residents to contribute at least $50 a year. Gradually, through community support, the clinic became a Boca Grande institution. By the early 1960s, residents had raised enough money to build a new facility.

A focus on patients
Although patients and staff have seen the clinic grow over the years, it still remains the same small-town health-care provider. Ask Deborah “Debby” Hahn, clinic nursing coordinator, what has changed since she began working there in 1989, and she only pauses for a second to reflect.

Sure, there was the move to the clinic’s current facility, which occurred in December 1990. There was the establishment of the clinic annex, where specialists, such as a cardiologist or an audiologist, offer services one or two days per week during season. But when it comes to patient care, Hahn says nothing has changed.

“Working here is the way I was taught nursing,” Hahn says. “It was always about the patient.”
Dr. Gordon Nidiffer is one of two full-time doctors at the clinic and had a Sarasota obstetrics and gynecology practice from 1979 to 2003. According to Nidiffer, the clinic allows doctors to practice medicine without focusing on insurance companies and hospitals. (See sidebar below.)

“You get to know patients both medically and personally,” he said. “It’s a very rewarding experience.”

Because the clinic is a non-profit, staff can spend more time with patients, providing services that are increasingly rare in private practice. They perform two-hour physicals when needed and will spend time counseling a patient who feels depressed. The clinic offers various health screenings throughout the year and requires each patient to bring every medication — both prescription and over-the-counter — to their appointments. Frequently, staff finds that patients are taking medications that aren’t compatible.

In 2003, the clinic’s board voted to establish the Boca Grande Health Care Foundation to raise money while clinic staff focused exclusively on health care.

Mary Anne Hastings, managing director of the clinic’s foundation, frequently hears residents describe the clinic’s role.

Without the clinic, they say, they wouldn’t be able to stay on the island.

When it comes to fundraising, Hastings emphasizes the key role that the clinic plays among local non-profits.

“We like to think that we are the most important,” Hastings said. “Because of us, people can live here.”

The alternative of driving off the island for health care may seem obvious, but for the 53% of clinic visits in which the patient is 65 or over, that option presents a challenge. According to Sielert, the general U.S. population averages 3.1 doctor visits per year; but for an elderly patient, 10 to 12 visits a year aren’t uncommon — which becomes difficult if the patient’s driving capabilities are limited.

Local care
Letts has witnessed first-hand the problem with not having a doctor on Longboat Key. Like Boca Grande, Longboat Key supported a single health-care provider, a practice owned by Dr. William Carter. But when Carter died suddenly in 1993, the island was left without a doctor. According to Letts, hospital doctors began seeing Longboat residents in local emergency rooms for common colds and coughs.

Shortly thereafter, a group of Sarasota Memorial Hospital physicians opened the Bay Isles Medical Center. Letts, a Staten Island, N.Y., native who practiced for 15 years in Canada, came to the area to be closer to family and began working at the Bay Isles clinic in 1996. When that clinic closed in 2002, Letts temporarily began practicing in Sarasota. Again, she saw the problems that arose without a primary-care doctor on the island. One patient canceled her visit to Longboat Key that year because she only drove on the island and finding transportation to frequent doctor appointments in mainland Sarasota would be too difficult. Another patient asked for an eye-drop prescription over the phone and said that she couldn’t make the drive off the island. Only when Letts insisted on an examination did the patient come to Letts’ Sarasota office; at that appointment she learned that she had a case of shingles that required immediate treatment.

Laying the foundation
The Boca Grande Health Clinic Foundation continues to work toward a goal of a $20 million endowment, according to Hastings. At that point, the clinic could generate from interest on investments the $1.5 million needed each year to operate, and the foundation could focus less on fundraising and more on money management.

But, like any non-profit, the foundation felt the pinch of the Great Recession. Currently, the endowment — which even in tough times the clinic has never touched — is around $15 million.

According to Hastings, the foundation has also benefited from the fact that during tough times, donors are more likely to keep their money within their communities.

This year, donations have ranged all the way from $25 checks to a $600,000 remainder trust that a supporter willed to the foundation. The foundation generates about $1 million per year through fundraising, $300,000 to $400,000 of which comes from an annual giving campaign. Throughout the year, the clinic holds fundraising events, including the Hank Wright Golf Tournament, which brings in around $130,000 per year.

Despite the economic downturn, donations have continued to come in.

“We’ve been a little bit more aggressive with smaller donations,” Hastings said. “We’re still looking for those $25 checks.”

Letts, along with Longboat leaders, plans to explore the idea of creating a health-care foundation on Longboat Key and will hold meetings in the early months of 2011. But she said that she is encouraged by what she saw during the summer, when she visited the Boca Grande Health Clinic: a health-care provider who is successful in treating patients despite large seasonal fluctuations.

Both Sielert and Hastings believe that Longboat Key could follow Boca Grande’s model. It has a larger patient base than Boca Grande and a strong financial base.

But both advised that defining any future organization’s mission must be clear.

With a strong core group of donors, Sielert said, the larger community can become a part of the foundation.

“If that core group of people is behind it,” Sielert said, “it is conceivable.”

Health Stats
Here’s a look at the Boca Grande Health Clinic by the numbers:
 $15 million The approximate amount currently in the clinic foundation’s endowment
 $1.5 million The amount of money the clinic needs each year to operate
 $130,000 The cost of the clinic’s new electronic medical records system that went live Nov. 1
 4,500 The number of patient visits in an average year at the clinic
 60 to 70 The percentage of people who own homes on Boca Grande that the clinic estimates have used the clinic
 30 The percentage of Boca Grande homeowners who donate regularly to the clinic
 11 The number of clinic staff members, including physicians
 2.5 The number of clinic physicians

Contact Robin Hartill at [email protected].