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Point-of-Care Assessment at a Free, Out-of-Hours Orthopedic Clinic 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019 

 
 

Point-of-Care Assessment at a Free, Out-of-Hours Orthopedic Clinic  
Whitney M. Graves, DAT, LAT, ATC1; Zachary K. Winkelmann, PhD, SCAT, ATC2; Kenneth E. Games, PhD, 
LAT, ATC1 

1Cumberland University, Lebanon, TN; 2University of South Carolina, Columbia, SC; 3Indiana State University, Terre Haute, IN 
 

 
ABSTRACT 

Access to healthcare is a challenge for many Americans living 
in rural communities. Hospital systems have created programs 
and developed models to improve access to care. However, 
documentation of the role of these clinics serving different 
populations and various types of communities is quite scarce. 
The purpose of this article is to describe the patient 
satisfaction and procedures assessed at the point-of-care 
during a 14-week, out-of-hours free orthopedic clinic in the 
Southeastern United States. One hundred and twenty-nine 
patients attended the orthopedic clinic and completed a 
patient satisfaction survey following their patient encounter. 
At the end of the 14-week, 89% (n=115/129) of the 
patients were highly satisfied with the staff and physician 
politeness and 100% (n=129/129) of patient encounters 
were highly satisfied with staff and physician professional 
manner. During this study, 72% (n=93/129) of patients 
reported that their injury and treatment plan was explained 
in an understandable manner, and 75% (n=97/129) of 
patient encounters reported that staff and physicians 
answered all of their questions in an understandable way. Of 
those surveyed, 95% (n=123/129) of patients reported that 
they were highly satisfied with the free clinic and the service 
that was provided. Overall, 96% (n=124/129) of patients 
reported that they would come back to the free, out-of-hours 
orthopedic clinic outside of just the fall football season. The 
point-of-care assessment described the number of x-rays 
taken, MRI’s ordered, follow-up appointments scheduled, and 
potential revenue generated through surgeries scheduled 
during the 14-week time period. Moreover, the access to 
specialized sports medicine care has expanded to reach 
underserved populations such as pediatrics and those unable 
to miss work to seek healthcare. The results of this assessment 
have provided the orthopedic clinic staff and patients with 
data to support changes to improving patient-centered and 
low-cost healthcare visits. 

Key Phrases 
Clinic and Hospital Patient Population, Healthcare Economics 
(Value and Worth), Organizational and Personal Outcomes 
 
Correspondence 
Dr. Whitney Graves, Indiana State University, 3200 Belotes 
Ferry Road, Lebanon, TN 37087. 
E-mail: wgraves@cumberland.edu  
Twitter: @Whit_graves 
 
 
 

Full Citation 
Graves WM, Winkelmann ZK, Games KE. Point-of-Care 
Assessment at a Free, Out-of-Hours Orthopedic Clinic. Clin 
Pract Athl Train. 2019;2(3):16-21. 
https://doi.org/10.31622/2019/0003.2  
 
Submitted: March 3, 2019 Accepted: August 7, 2019 
 

INTRODUCTION 

In the United States, a lack of insurance and 
underinsurance composes a significant national 
public health problem.1 As of 2014, in the United 
States, 50.7 million individuals, 16.7% of the 
population, were uninsured and many more 
experienced barriers to obtaining health care.1 
Some of these barriers include: means/cost of 
transportation, lack of understanding with medical 
terminology, and wait time in the waiting room. 
Despite large gains in health coverage, some 
people continued to lack coverage, and the 
Affordable Care Act (ACA) remained the subject 
of political debate.7 Attempts to repeal and 
replace the ACA stalled in summer 2017, but 
there have been several changes to 
implementation of the ACA under the Trump 
Administration that affect coverage.7 In 2017, the 
number of uninsured rose for the first time since 
implementation of the ACA to 27.4 million.7 

Certain population subgroups have a low amount 
of health insurance coverage, including ethnic 
minorities, residents of southern and urban 
locations, and low-income households.1 
Specifically in the southern state of Alabama, 
33% of its population is uninsured and the highest 
uninsured rate for the state is in southern Alabama 
near Birmingham.2 There is a substantial need to 
provide health care for uninsured individuals in the 
United States and southern states such as 
Alabama in particular. Previous research has 
shown that one method to improve access to care 
is through free medical clinics, which has been 
cited to have high patient satisfaction feedback 

https://doi.org/10.31622/2019/0003.2


Point-of-Care Assessment at a Free, Out-of-Hours Orthopedic Clinic 

 

 
 

17 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

due to access to care.3 At East Alabama 
Orthopaedics & Sports Medicine in Opelika, 
Alabama, the staff provided athletic training 
services to local secondary schools in the Lee 
County which includes Auburn, Alabama. Lee 
County, Alabama has a vast array of current 
socioeconomic status among residents with the 
2016 median household income being $45,056 
and predominantly White residents (67.9%).4  
 

In the East Alabama Orthopaedics & Sports 
Medicine clinic, the patient panel is predominately 
lower and middle-class income status, and a high 
number of self-pay patients. According to the U.S. 
Census Bureau, the majority of patients seen in the 
East Alabama Orthopaedics & Sports Medicine 
clinic would be considered underserved. Opelika, 
Alabama is considered a rural area with about 
15% of the population speak a language other 
than English. There is a 3.5% Hispanic population 
and 11.5% Korean population. About 15% of the 
population under the age of 65 has a disability, 
and about 15-20% of people under the age of 
65 have no form of health insurance.4 The poverty 
rate is at 30%. Twenty-three percent of the 
population for whom poverty status is determined 
in Lee County, AL (34,085 out of 148,121 people) 
live below the poverty line.4 This number is higher 
than the national average of 14%. The largest 
demographic living in poverty is male between 
the ages of 18-24, followed by female between 
the ages of 18-24, and finally female between 
the ages of 25-35.4 Additionally, the clinic serves 
an estimated 2,000 veterans from Lee County, 
Alabama. The cost of healthcare is sometimes a 
burden on the patients, and especially the student-
athletes that the staff provides healthcare to. The 
student-athletes that we provide medical care 
make up a large percentage of the underserved 
community and often times these patients will not 
come in to see the physician to receive medical 
treatment due to the office visit or insurance co-
pay costs. At East Alabama Orthopaedics & 
Sports Medicine, a patient’s continuity of care is a 
concern as some patients abandon care due to 
outstanding balances or them not having the funds 
to come in and see the doctor. 

East Alabama Orthopaedics & Sports Medicine 
clinic currently has a free orthopedic clinic outside 
of business hours. The facility serves patients on 
Saturday mornings outside of the normal clinic 
hours for 2-4 hours during the fall school semester 
as it aligns with football season. A typical patient 
load during one Saturday session is 20 to 25 
student-athletes. The free orthopedic clinic runs for 
14-weeks beginning the first Saturday following 
the start of football season and ending the 
Saturday after the Alabama state championship 
football game. The services provided at the 
orthopedic clinic include diagnostic imaging (x-
rays), bracing, scheduling of MRIs at East 
Alabama Orthopaedics & Sports Medicine, full 
orthopedic evaluations, and concussion 
assessment. These services are provided and 
performed at no cost to the student-athlete or their 
family regardless of insurance status. The staff for 
the free orthopedic clinic included two orthopedic 
surgeons, one sports medicine physician with 
training in neurology, seven athletic trainers, an 
outreach coordinator, and administrative 
personnel. The staff was paid as part of their 
contracts for their services meaning that there 
were no upfront or recurring costs for stipends or 
salaries. Currently, the out-of-hours free 
orthopedic clinic lacks any form of patient survey 
or satisfaction assessment regarding the services 
provided from the staff. As such, the purpose of 
this point-of-care assessment was to explore the 
patient satisfaction, access to sports medicine 
services, and potential cost-benefit for the 
community.    

METHODS 

Prior to the start of the 2018 football season, the 
lead athletic trainer for the free, out-of-hours 
orthopedic clinic implemented a patient 
satisfaction survey for patients to complete 
following their visit. The patient satisfaction survey 
consisted of five questions measured using 5-point 
Likert scale with one additional yes/no item. This 
six-question instrument aimed to determine each 
patient’s perception of the following constructs: (1) 
politeness and professionalism of personnel, (2) 
explanation and understanding of injury and  



Point-of-Care Assessment at a Free, Out-of-Hours Orthopedic Clinic 

 

 
 

18 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

 

treatment, (3) satisfaction of the free orthopedic 
clinic, and (4) if the patient would seek healthcare 
again from the facility. Table 1 provides the items 
from the patient satisfaction survey. 

Throughout the 14-weeks that the free orthopedic 
clinic was open, the lead athletic trainer 
administered a paper survey to each patient as 
they checked out. The patient satisfaction 
assessment was collected anonymously. Once the 
patient completed the survey, the patient placed 
their survey into a locked drop box near the exit 
of the East Alabama Orthopaedics & Sports 
Medicine clinic. This survey was given and 
completed by 129 patients. Following the 14 
week data collection period, the lead athletic 
trainer compiled patient responses from the 
survey using Microsoft Excel. Concurrently, the 
lead athletic trainer also tracked all patient data 
and procedures during the office visit that the 
patient received. The patient data and 
procedures included the (1) reason for office visit, 
(2) body region being evaluated, (3) type of 
evaluation, (3) evaluation complexity, (4) 
radiographs taken, (5) MRI ordered, (6) surgery 
scheduled, (7) follow-up appointment scheduled, 
and (8) if the patient was a football player or 
non-football player. Upon completion of collecting 
patient data and procedures, along with the 
satisfaction surveys, the leader athletic trainer 
analyzed the data and compiled the findings for  

 

 

a presentation to physicians and East Alabama 
Orthopaedics & Sports Medicine stakeholders.  

RESULTS 

The study consisted of male and female middle to 
high school aged patients who participated in 
football, cheer, volleyball, tennis, and baseball. 
The major body regions evaluated during the 
data collection period were knee and shoulder. 
There were 121 musculoskeletal-based 
encounters and seven reported concussions. 
Overall, the majority of evaluation complexity 
that each physician documented was considered 
moderate level. Medicare defines an evaluation 
complexity of moderate level as face to face time 
spent with a patient requiring 20-25 minutes of 
care.6 Ninety-six radiographs were taken in the 
clinic and thirty-three patient encounters required 
an MRI to be ordered. Ninety-four encounters 
deemed a follow up appointment was necessary 
and 38 re-check evaluations were documented. 
Seven surgical procedures were generated during 
this time frame. 

Overall, the results from this study presented a 
positive effect and an increase in the number of 
radiographs taken, MRI’s ordered, follow-up 
appointments made, and surgeries each physician 
obtained during that time period compared to not 
having a Saturday non- business hours clinic. The 
results also showed that overall patients were 
highly satisfied from the healthcare they were  

Table 1. Patient Satisfaction Survey  
Question 

Were our personnel polite and courteous?* 

Did our personnel take care of you in a professional manner?* 

Did we explain your injury and treatment plan in an understandable manner?* 

Did we answer all of your questions in an understandable way?* 

Overall, how satisfied were you with the free service you received from us?* 

Would you come to a Saturday morning clinic outside of football season? # 

* = Measured using Likert scale of 5=Highly Satisfied, 4=Satisfied, 3=Adequate, 2=Unsatisfied, 1=Very 
Unsatisfied, # = Yes/No item 



Point-of-Care Assessment at a Free, Out-of-Hours Orthopedic Clinic 

 

 
 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

  

receiving. The patient satisfaction survey results 
identified that 89% (n=115/129) of patient 
encounters were highly satisfied with staff and 
physician politeness, and 100% (n=129/129) of 
patients were highly satisfied with the AT and 
physician professional manner. 95% 
(n=123/129) of patients reported that they were 
highly satisfied with the free injury clinic and 
services that were provided. Overall, 96% 
(n=124/129) of patients reported that they 
would come back to a Saturday morning clinic 
outside of the fall football season.  

Moreover, the clinic potentially saved patients 
anywhere from $9,400 to $14,200, or $75 to 
$113 per patient (n=125).This was based on clinic 
procedure fees. In addition, the out-of-hours clinic 
could serve as a revenue stream for East Alabama 
Orthopaedics & Sports Medicine through 
referrals. In order to analyze if the free services 
performed to potential revenue from follow-up 
appointments, we calculated the potential 
revenue using the East Alabama Orthopaedics & 
Sports Medicine clinic costs for an MRI, surgical 
procedure, or a follow-up appointment in the 
clinic. In total, East Alabama Orthopaedics & 
Sports Medicine generated $32,900 to $39,900 
from the 94 patients, or $350 to $424 per 
patient. To present this data to stakeholders, a 
cost-benefit ratio is recommended. For the specific 
out-of-hours clinic, a total benefit per patient on 
the low end of procedure fee estimate would be 
$350 and the cost was $75 which gives a positive 
benefit-to-cost ratio of 4.667.  

 

We calculated this cost-benefit ratio by dividing 
the total benefit per patient (low end- $350) by 
the cost ($75). Table 2 and Table 3 provide 
details related to the procedures performed 
during the period, and the follow-up services 
scheduled with the potential revenue generated 
for East Alabama Orthopaedics & Sports 
Medicine, respectively.  

CLINICAL APPLICATION 

Providing patient-centered care is one of the most 
important things we can do in health care. The 
patient has options and can choose where to seek 
services to meet their healthcare needs. 
Measurement and understanding of the patient, 
caregiver, and family experience of healthcare 
provides the opportunity for reflection and 
improvement of healthcare and patient outcomes. 
Often times we, as healthcare providers, seem to 
forget what is really important for patient 
satisfaction. It is vital to review and reflect on 
Picker’s Eight Principles of Patient-Centered Care 
in relation to our own practice.5 It is important to 
involve patients in decision making, recognizing 
they are individuals with their own unique values 
and preferences.5 Proper coordination of care 
can alleviate patients feeling vulnerable and 
powerless in the face of an illness or injury5 In 
healthcare, patients expressed their worries that 
they were not being completely informed about 
their condition or prognosis. 5 Physical comfort will 
come after healthcare providers enhance patient 
education and information.5 The level of physical 
comfort that patients report has a significant  

Table 2. Procedures Performed During the Free Clinic 

Procedure Count Cost Total Costs Saved 
Initial evaluation 
   Low 
   Moderate 
   High 

 
0 
72 
17 

 
$50 
$75 
$100 

 
$ 0 

$5,400 
$1,700 

Re-Evaluation 
    Low 
   Moderate 
   High 

 
0 
36 
2 

 
$50 
$75 
$100 

 
$ 0 

$2,700 
$200 

Radiographs taken 96 $50 - $100 $4,800 - $9,600 



Point-of-Care Assessment at a Free, Out-of-Hours Orthopedic Clinic 

 

 
 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

 

 impact on their experience with us as providers. 
Providing accommodation for family and friends 
and involving them in the decision-making process 
can enhance patient care and ease the overall 
patient experience for everyone. Providing 
patients with understandable information 
regarding medications, ongoing treatment, 
physical limitations and access to physical or 
financial support will supply patients a better 
continuity and transition to care. Finally, patients 
need to know they can access care when it is 
needed.5 The ease and availability of scheduling 
appointments, accessibility to specialists and 
providing clear instructions on how and when to 
get referrals are all great examples of how we 
can enhance patients access to care. 

Gaining a better understanding of patient 
satisfaction, while measuring actual care provided 
our clinic with greater insight on what areas of 
patient care need to be strengthened and what 
areas of patient care we are excelling in. After 
reflecting on Picker’s Eight Principles of Patient 
Centered Care and our patient satisfaction survey 
results that was completed in this study, we were 
pleased to see that our clinic was on the right tract 
for providing optimal patient centered care. This 
project has opened opportunities to reach the 
underserved population, student athletes, and 
working men and women who cannot get away 
from their job during the Monday thru Friday work 
week; and also allow for quality healthcare visits. 
The result of the cost-benefit ratio demonstrates 
that the potential revenue generated from 75% 
(n=94/125) patients (age 18-24) that referred 
to the East Alabama Orthopaedics & Sports 
Medicine clinic for follow-up services will be  

 

greater than any “lost” costs incurred by offering 
the out-of-hours free clinic. As such, the clinic has 
not only brought a reduced healthcare option to 
the student-athletes in the county, it also provides 
a valuable revenue stream to the clinic. In 
addition, the gains from this project has 
demonstrated that East Alabama Orthopaedics & 
Sports Medicine provides an experience that is 
highly satisfied by the patients.  

After compiling all of the data, the report was 
presented to East Alabama Orthopaedics & 
Sports Medicine stakeholders and physicians. 
During the presentation, the possibility of 
extending the free Saturday morning clinics 
beyond the football season was proposed. During 
the collaborative discussion, the stakeholders and 
lead athletic trainer discussed the pros and cons 
of an extension of providing the out-of-hours clinic 
during the spring and summer months. After 
reviewing the results and patient satisfaction 
responses, the group came to an agreement that 
the community would greatly benefit from 
extending the out-of-hour clinic services, while 
providing East Alabama Orthopaedics & Sports 
Medicine an opportunity for community outreach. 
The increased volume of patients from opening a 
clinic on Saturday also increases the surgical load 
and patient visits for physicians, which in turns 
increases potential revenue to the clinic. We do 
acknowledge that there are still barriers to care 
for patients with no insurance regarding follow-up 
care. Future research should look at different 
models to continue follow-up patient care for 
those with no insurance in order to better educate 
clinics on how to provide the best patient centered 
care for this population. We suggest that clinics 

Table 3. Potential Revenue for Follow-Up Appointments 

Procedure Count Cost Potential Revenue 

MRI 33 $500 $16,500 

Surgical procedure 7 $1,000 - $2,000 $7,000 - $14,000 

In Clinic Appointment with 
Physician 94 $100 $9,400 



Point-of-Care Assessment at a Free, Out-of-Hours Orthopedic Clinic 

 

 
 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                      Volume 2 – Issue 3 – November 2019  

providing outreach and per diem athletic training 
services consider creating an out-of-hours clinic 
using a similar model to improve the access to care 
for the population, which improves the chance that 
patients come back for further care in turn 
generating in increased revenue stream.  

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