Contributor to Health Progress
At 6:45 a.m. on a recent day at the nonprofit Surgery on Sunday, an energetic team of volunteer nurses and medically certified Spanish-English interpreters buzzed about taking vitals, explaining procedures and ensuring patient consent forms had been completed correctly. Nearby, volunteer surgeons and anesthesiologists changed into scrubs and prepared for the busy morning ahead, which included two hernia repairs and two gall bladder removals, plus one tonsillectomy, one cornea repair and one retina repair.
The scene looked like any other surgery center in America with one key difference: the seven patients waiting their turn in clean, orderly pre-op bays would not face any out-of-pocket bills for their surgical procedures.
Since its launch in 2005, Lexington, Kentucky-based Surgery on Sunday has performed nearly 6,000 free, medically necessary outpatient operations for low-income patients — everything from simple hernia repairs and cataract removals to more specialized orthopedic operations.
At its core, the unique care collaboration model behind Surgery on Sunday is simple: providers volunteer their time and services one Sunday each month to perform these procedures at no cost to qualifying patients, using untapped weekend hours at the Lexington Surgery Center, a physician-owned facility affiliated with SCA Health.
But for patients, the effect is anything but simple — it's life-changing.
"I feel like, honest to God, they have saved my life," says Randall Winford of Lebanon, Tennessee, who made the roughly three-hour drive to Lexington multiple times to undergo three separate operations at Surgery on Sunday — two to repair severe cataracts on each of his eyes and one to remove melanoma on his right hand. "My vision was so poor I was running into trees. I couldn't drive. I couldn't work. You can't understand how hard it was for me not to be able to provide for my family."
Since having his vision restored, Winford has returned to his job remodeling houses — a second chance he does not take for granted. "I'm not an emotional guy," he says. "But when I was able to return to work that first day, I bawled my eyes out. The people at Surgery on Sunday are the greatest people I've ever dealt with. They make everything so comfortable — and they don't make you feel bad for needing help."
PROVIDING CARE WHERE IT'S NEEDED
While seven patients underwent operations at Surgery on Sunday one day this past June, on a more typical surgery day, usually held the third Sunday of each month, the care team performs 10 to 15 operations. A standard day's case load requires between 70 to 80 volunteers, including nurses, anesthesiologists, surgeons, interpreters and intake staff. Most volunteers arrive around 6:15 a.m. and work until all patients are ready to be sent home, usually around 2 p.m.
The program currently has around 275 active clinical volunteers on its roster, among them roughly 50 surgeons — representing every health care system in Lexington as well as those from many surrounding communities — who offer their services on a rotating basis as needed. Volunteers have donated more than 100,000 hours of service since Surgery on Sunday's inception. This number grows monthly.1
"When volunteers come in and see that they're getting a chance to do good, it's easy to hook them and keep them coming back," says Dr. Andrew "Andy" Moore II, founder and chair of the board of directors of Surgery on Sunday. "This work gives us all purpose. It energizes me every time I go in."
"The nurses and the doctors and other volunteers at Surgery on Sunday are about providing care to those who need it," agrees Dr. Paul Kearney, the nonprofit's medical director and a longtime volunteer surgeon. "I personally don't care about where you come from or if you're documented or not. If you need help, I'm going to help you."
Currently, roughly 30% of Surgery on Sunday's patients speak little or no English. While the majority of patients come from Kentucky, in recent years, roughly 30% have come from Tennessee — an influx stemming from the state's decision not to expand Medicaid access under the Affordable Care Act,2 while Kentucky did.
Patients who qualify for Surgery on Sunday services make too much to qualify for Medicaid but not enough to pay for expensive health care deductibles. Specifically, Surgery on Sunday works with patients whose household income is below two-and-a-half times the federal poverty level who either have no health insurance or have policies with deductibles that are 10% or more of their total income.
Patients, whether pediatric or adult, are often referred to Surgery on Sunday by a provider at a free health clinic or local health department. The Surgery on Sunday care team reviews patient care records carefully to ensure each surgery is medically necessary. When needed, volunteers with the agency can help patients locate or secure pertinent medical records — a process that can be challenging for patients who have had limited access to health care and who may not have seen a primary care provider in years.
"I was speaking to the family member of an eastern Tennessee patient recently who said he hadn't been off their mountain in three years," says Amanda Ferguson, who served as Surgery on Sunday's full-time paid executive director for five years until resigning at the end of June to pursue other professional interests. "Our patients represent a population that doesn't routinely access care. They aren't getting routine screenings or having annual wellness visits because they don't have insurance and simply cannot afford it," Ferguson says.
Photo courtesy of Surgery on Sunday
Surgery on Sunday volunteers remove a submandibular neck mass from a female patient. Shown left to right are Corey Lindsay, SRNA; scrub nurse Rebecca Roberts (reaching over patient); Francesca Spirito, SRNA; otolaryngologist Dr. Tad Hughes; and Daryl Bauer, CRNA. Hughes is a Surgery on Sunday board member.
The brainchild of Moore — a plastic surgeon who practiced primarily at CHI St. Joseph Health until his retirement — the nonprofit's initial launch was funded through $200,000 in grants from Catholic Health Initiatives and the Sisters of Charity of Nazareth, both of which continue to support the agency. The Surgery on Sunday headquarters, in fact, is housed in office space donated by CHI St. Joseph Health, which is part of CommonSpirit Health.
"We still get grant money from the Sisters of Charity of Nazareth almost on an annual basis, and also St. Joe — through their foundation — continues to support us through various efforts and through sponsoring various events that we do as fundraisers," Moore says. Two popular annual fundraisers — a local Dancing With the Stars-themed event and a 25-hour fitness marathon — have raised hundreds of thousands of dollars for Surgery on Sunday over the years.
The original idea for Surgery on Sunday stemmed from volunteer work Moore was doing in the early 2000s through St. Joseph's nonprofit Northside Clinic, no longer operating, which had provided free medical care to economically disadvantaged neighborhoods in Lexington.
"I was on the board of Northside Clinic, and we kept hearing complaints from an ER doctor on the board that there were all these patients needing surgery with nowhere to go," Moore says. "I threw my idea [for Surgery on Sunday] out there, and there happened to be others on the Northside board — including a lawyer and a grant writer — who had the skill set to help us get Surgery on Sunday off the ground."
STRENGTH IN PARTNERSHIPS
Surgery on Sunday operates completely through private grants and donations from corporations, religious and secular nonprofits and individuals; it receives no government or taxpayer support. It has just one paid staff position — for its executive director — while everyone else operates as a volunteer.
The agency's operational costs are relatively low, since service hours are donated, and it leases its Sunday usage of the Lexington Surgery Center for just $1 a year. "That way, if anything bad happens, it's on us, not them, because we 'own' the building that day," Moore explains.
Surgery on Sunday has its own Ambulatory Surgery Center license and reports its operational data to the Office of the Inspector General of Kentucky, just as any other ambulatory surgery center would.
To cover supply costs on surgery days, Surgery on Sunday pays the Lexington Surgery Center an additional flat fee of roughly $350 per patient. It also occasionally receives donated supplies and surgical instruments from surgical supply partners, many of whom contribute thanks to preexisting professional relationships with Surgery on Sunday surgeons.
Having the partnership of the Lexington Surgery Center has been key to the agency's success, Moore says. When other cities have tried to replicate Surgery on Sunday's model, one stumbling block has been the reluctance of area surgery facilities to get on board.
"Louisville had a similar program going for three years, but they were bouncing all over the community to different places because no surgery center would commit to it, and their program didn't last," Moore says.
While securing a surgery facility partner is important, so, too, is getting investment from its staff, Moore adds. "You have to get personnel at the surgery center invested as well, because you have all these volunteers coming in who don't know the facility, and it's so helpful to have at least one or two volunteers coming each month who do know the building and know how the usual processes take place there."
Surgery on Sunday has also forged strong partnerships with area hospital systems, diagnostic offices, labs and physical therapy centers, which routinely provide lab tests, pathology, physical therapy and other health services for free or reduced rates. When testing or diagnostics are not available for free, Surgery on Sunday covers these costs. Its patients do not receive a bill for any services provided.
Photo courtesy of Surgery on Sunday
Nurses in Surgery on Sunday's Post Anesthesia Care Unit discuss and assign patients coming out of the operating room for recovery. From left to right, Babs Ernest, RN; Charmayne Brown, RN; Holly Moore, RN; and Mary Todd, RN.
"We put on our social worker hat to help patients find the cheapest options for X-rays or MRIs or whatever else they may need presurgery," Ferguson explains. "We have strong partnerships in place in Lexington, but if we're dealing with a patient from outside of Lexington who may need services before or after surgery, we'll call around to advocate for our patients and say, 'Here's the deal. Here is who we are and what we're about. Can you help us help this patient?'"
Relationship-building helps drive Surgery on Sunday's success, agrees Nancy Johnson, RN, BSN, a trained ICU and transplant team nurse who volunteers as the agency's clinical coordinator.
"Work like ours has to be a community effort," Johnson says. "I recently had a patient who needed medical clearance to have general anesthesia, for example, so I called a free clinic who sends us patients frequently and said, 'Hey, this is Nancy. I need a favor back in return. Could one of your physicians see and clear this patient?' And they said, 'Absolutely.' We're all willing to work together so we can make sure all these patients get taken care of."
All Surgery on Sunday patients are seen at their surgeon's home office for a no-cost preoperative evaluation and for a free postoperative follow-up — an arrangement that has been a bit tricky at times to navigate from a health administration standpoint.
"Most hospital-based clinics do not have a way to register a patient visit in their systems without a payment mechanism associated with it," Ferguson explains. "We have so many surgeons who tell us they'd be glad to come volunteer to perform surgeries, but then they face this obstacle from the administrative side," she adds. Sometimes, surgeons work out the logistics of how to either bill or not bill those visits with their health systems themselves. At other times, Surgery on Sunday leadership has put in calls to health system administrators to mutually carve out plans for handling these specialized cases.
Some volunteers also initially wonder about the professional liability implications of working with Surgery on Sunday. But because the nonprofit is a free clinic certified with the Health Resources and Services Administration, federal law exempts its volunteers from malpractice and personal liability claims.
From a patient perspective, sometimes simply getting to Lexington can be the biggest hurdle. "Transportation is a big stumbling block for our patients," Johnson says. "Especially as we have more patients coming from out of state on limited incomes. The number one reason we may lose a patient is that they can't find a ride to get to us."
To ease this burden for patients, Surgery on Sunday routinely draws on its fundraising proceeds to provide gas cards or Uber or Lyft gift cards to help patients make it to their appointments. If out-of-town patients need to stay in Lexington overnight, the nonprofit offers to cover the cost of their hotel accommodations. "We try to be as resourceful as possible," Johnson says. "The longer we do this, the more tricks we learn."
Because so many of its patients are now coming from Tennessee, Surgery on Sunday is trying to start a second location in Knoxville, but the process will take time. "When you're running one of these programs, everything comes down to building personal connections," Kearney says. "A lot of it comes down to building bonds in the community before you try to launch. You have to find enough people wanting to make it work."
For those willing to embrace the model, the work is endlessly fulfilling, says Tony Reyes, a certified medical interpreter who has volunteered to communicate in Spanish and English with Surgery on Sunday since its beginnings. "This work changes patients' lives forever," says Reyes, who was particularly struck by the successful postsurgery turnaround of a patient who had been facing homelessness when his hernia pain had left him unable to work. "There is so much joy in being part of helping patients in such a profound way."
ROBIN ROENKER is a freelance writer based in Lexington, Kentucky. She has more than 15 years of experience reporting on health and wellness, higher education and business trends.
- "About Us," Surgery on Sunday, https://www.surgeryonsunday.org/about-us.
- Louise Norris, "Tennessee and the ACA's Medicaid Expansion," healthinsurance.org, April 18, 2022, https://www.healthinsurance.org/medicaid/tennessee.
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