The non-profit clinic's administrative staff and board hosted a meeting on Monday, April 14 to address concerns. For the past decade, the Health Center has funded an on-call provider 24 hours a day, 7 days a week. Beginning June 2, after hours calls to 928-SICK will be handled by a nurse triage line, which will help patients decide if their concern is a 911 emergency, or can be managed until office hours at the clinic. A fax will be sent for all calls, and follow-up will be handled by Ocracoke Health Center.

The clinic is adding office hours to better serve the community, and will be open until 7 pm on weekdays, and from 9 am to 1 pm on Saturday. An on-call provider will be available through Sunday afternoon. Ocracoke Health Center is a family practice clinic, and emergency calls are the responsibility of EMS.

If you have chest pain, call 911. If you are having trouble breathing, call 911. If you are concerned for your life, call 911.

Displeasure may be too mild a word to describe the tone of the residents who rose to speak at the meeting. People questioned the allocation of funds; the manner in which the information was delivered; the role of Obamacare in the decision; who answers 911 calls; the training levels of EMS on Ocracoke; the reasons for not providing EMS access to the clinic facilities; and what will happen if they, or a loved one, has a life-threatening condition when the clinic is closed.

"What's frightening is the feeling that we're stuck, and there may not be any help," said Martha Garrish.

"If we had a choice, we would stick with after hours," said OHC board member Amy Hilton, who was emphatically seconded by OHC board member Jason Wells. "None of us wanted to do this," he said.

The private, non-profit clinic was incorporated in 1981 and has never been able to cover its costs with patient fees. As a designated Rural Health Center, it received grant funding from North Carolina, and was the only Rural Health Center in NC to receive operational support. In 2009, those state funds dried up. Payroll was often tight, and senior staff sometimes delayed their own paychecks so the center could remain open. Last year, the clinic held a bake sale.

Closing the clinic was discussed as a possibly unavoidable option.

"There was no choice. We weren't going to tell you we're going to change after hours, or our service. We were going to say there is no more operating money. We're done," said board chair Sue Pentz. "This was a business decision. Dollars in, dollars spent."

The board and staff considered turning the facility into a Critical Care Emergency Hospital, or an Urgent Care facility. Every insurance co-pay would be at ER or Urgent Care levels, meaning even a routine visit, or an appointment to pick up blood pressure meds, would require co-pay of about $500, said Health Center CEO Cheryl Ballance. The decision was made instead to pursue federal funds, and the clinic entered a partnership with the Engelhard Medical Center, which serves a large migrant population. The two facilities have been one business, with two branches, since 2010.

In November 2013, the staff received word that they had been approved as a Federally Qualified Health Center. They were the only new clinics in the state of North Carolina to earn the designation. FQHC funding "was a lifesaver," said Ballance. "FQHC means sustainability for the clinic, practically forever." It also designates funds for pharmacy, dental, and specialist services, and allows the clinic to recover more costs of treating the uninsured.

"We took three years seeking this out, with the advice of Rural Health, to find an avenue, to find these funds, so we could keep a clinic open. We have been fortunate here with our providers who care about coverage, who care about these small communities," said Pentz.

While FQHC money means the clinic can remain open, it also means the end of a twenty four hour on call provider who is on Ocracoke, unless other funds can be found.

Will there be a doctor on call after clinic hours? asked Kathleen O'Neal.

"We're not saying 'No.' We're saying there's no money," said CFO Chris Salerno, whose position is mandated by FQHC guidelines.

Most FQHCs operate with four or five administrative staff, Salerno said in response to a question of whether the budget favored administration. Ocracoke has Ballance and Salerno. Even administrative salaries support health care, said Ballance.

Providers on call 24 hours a day was no longer feasible from a risk management standpoint, nor was it financially sustainable, and the number of patients utilizing the service has decreased significantly with more consistent office hour care, said Ballance. When she sat down to look at the numbers, "it was shocking how low after hours visits were, relative to the cost of providing the service."

Roughly 7% – about 200 per year – of clinic visits classified as after hours in the past three years. Those visits include lunch time and visits that go later than the previous 5 pm closing time. The service cost $242,767 last year, said Salerno. $140,000 of that cost was ameliorated by occupancy tax funds the clinic received. With federal guidelines that require a chaperone to accompany after hours visits, the cost of providing 24/7 care rises to over $400,000.

$400,000 is more than the yearly occupancy tax budget. While the clinic was always grateful for the money provided by that board, they always knew those funds were a temporary solution, said Ballance. Occupancy tax board member Frank Brown said the board prioritized health care, but continually encouraged the Health Center to seek long-term sustainable funds from other sources.

The clinic generates an average of $22,000 a month in patient fees.

The new office hours were designed after looking at the utilization of after hours time for the past three years, said Ballance. In addition to full time physician Dr. Erin Baker, an additional provider will work Thursday afternoon until Sunday afternoon, staffed on a rotating basis. Many former island health care workers, including Dr. John Moore, and Jolene Jernigan, may be hired for this coverage. The staff to cover the additional hours is budgeted to cost $185,000, and is within the guidelines of the federal grant, said Salerno.

There is no grant money for after hours care, said Ballance. The (252) 928-SICK line is a resource people are encouraged to use for after hours medical questions. Emergency? Call 911.

"There is paramedic level service at every call on the island," said Hyde EMS Director Justin Gibbs. One ambulance is adequate the majority of the year, given the call volume, said Gibbs. He schedules a second ambulance and crew during busy summer holidays and weeks. Ocracoke Volunteer Firefighters are First Responders, and provide support on all EMS calls.

Gibbs is planning to have thrombolytics – medicines which can break up clots and interrupt heart attack and stroke –available on Hyde ambulances by July 1.

Ocracoke EMT Julia O'Neal said that twice during the past few months a second ambulance has been needed. She is concerned that when the ambulance is off the island, EMTs won't have a place to stabilize a patient.

When Ocracoke Health Center contracted with Hyde to provide EMS service on the island, emergency crews were able to utilize the clinic. Hyde now provides its own EMS service, and leases the building behind the clinic.

The clinic cannot make its facilities available after hours because it is liable for all the medicine that is practiced there, and would lose its funding, said Ballance. The Ocracoke Health Center is not the end point for emergent situations, she said, and ambulances have the equipment to stabilize a patient while getting them closer to a treatment facility. EMS also has real time access to an ER physician, and mobile field reporting so the hospital is prepared to treat when they arrive, said Ballance.

While a physician has more experience with diagnostics, paramedics have "the important nuts and bolts of patient care, like IV placement. They have oxygen. They know how to use fluids, they know the rates to use fluids. A lot of the medications they have on the truck are the same ones I have here. In terms of acute stabilization, they have all of this," said Dr. Baker, in an interview separate from the meeting.

Medical Director Baker recognizes that not having a back-up crew for the paramedics is a major concern. "It will be exceedingly uncommon to have two incidences requiring EMS at the same time, but I have been here when that happened. For something that is treatable and manageable, that is time sensitive, it is concerning."

There is an opportunity for islanders to to have salaried, full time jobs as paramedics and EMTs.

Gibbs and Hyde County Manager Bill Rich share the concern, and may ask the occupancy tax board to provide funds for an additional EMS crew on Ocracoke.

Any major incident with multiple casualties will be an "all hands on deck" situation, when every medically trained person on Ocracoke will respond, said Baker.

All of us need to be aware of where we live, said OVFD member William Howard.

Patients that aren't critical but need to be seen can be treated by EMS between midnight and 5 am – or any other time the ferries aren't running –, released and referred to the clinic, said Gibbs. Present protocols and training do not allow EMS to suture wounds, but Gibbs is exploring that option. A clean cut can wait up to 12 hours before being stitched.

Meeting attendees were curious about the discretion of funds. A full time provider, Nurse Practitioner Gail Covington, was recently let go, and is now practicing at the Hatteras Health Center. She was valued, and will be missed, said Pentz. The perception that the Health Center has come into a windfall and yet is cutting twenty four hour coverage has been drifting around the island.

The guidelines define practitioner, said Pentz. The Health Center would like to add a medical assistant (ever want to be more like Kenny Ballance? Here's your chance!) and a phlebotomist (are you into drawing blood?) to their staff to free up more highly trained providers to focus on long term case management and patient care.

"The system that's going into effect in June is, I think, going to do very well," said Baker. "I know right now it's not being widely received, but it is going to do well." Baker has been talking with every patient she sees to help them better manage potential concerns that may crop up after clinic hours.

"We don't want anyone to feel that there is no plan for them," said Ballance.

There is a sense on Ocracoke that a number of services – from ferries with a dredged channel to lifeguards to education funds for rural schools – are being taken away. "I recognize that," said Ballance, "None of this was taken lightly." The new system is fluid, and will be continually assessed and adapted to meet the needs of Ocracoke residents and visitors, she said.

"This was a significant decision put into place with no input from the community," said physical therapist Kris Harris.

"Posting the financial numbers would be helpful," so that the community could understand the basis for this decision, said DeAnna Locke.

"I'm hearing that we need to keep a line of communication open," said Pentz. Working more closely with EMS and keeping the community apprised of decision making at the Health Center are the next steps. The clinic plans to have a website to assist in this.

"You know who is on the board. Tell us things. We're here," said Pentz, reiterating that the new system is just that: new, and open for discussion. The Ocracoke board members are Sue Pentz, Benji Hart, Howard Bennink, Ann Borland, Amy Hilton, Kathy Perez and Jason Wells. The mainland board members are Mike Adams, Alice Keeney, Art Keeney, Earl Pugh, Alice McCabe and RS Spencer.