CareWay Mobile Health

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Executive Summary

CareWay Mobile Health is a nonprofit in Kentucky that brings primary care to the neighborhoods and small towns where getting to a doctor is hardest. Our mobile health clinic is a fully accessible van with a private exam room, staffed by a nurse practitioner, a medical assistant and a community health worker. It parks each week at the same trusted places, such as a church lot, a library, a food pantry and a housing complex, and sees anyone who walks up, whether or not they have insurance.

Many people in our region go without care because the nearest clinic is a long drive away, they have no car, they cannot take time off work, or they cannot pay. They wait until a problem is serious, and then go to an emergency room. High blood pressure goes unchecked. Diabetes goes undiagnosed. Children fall behind on vaccines. A mobile clinic closes the distance and, just as important, builds trust over time.

With this grant we will put the clinic on the road and serve about 1,100 different people in Year 1, in about 2,400 visits at six regular sites, four days a week. Visits include checkups, care for common illnesses and minor injuries, blood pressure and diabetes checks and care, vaccines, school and work physicals, and screening and referral for other needs. Our community health worker helps patients sign up for coverage, get to specialists and find a regular doctor. Every patient who wants one is connected to a medical home, and we work with local clinics and the hospital, not against them.

Our Year 1 budget is about $481,500, growing to about $705,500 by Year 5 as we add a second clinical team, evening and Saturday clinics and two more sites. Each year's budget is planned to balance, with a small surplus each year. We have 5 paid staff in Year 1 and 8 by Year 4. Patient service payments from Medicaid and insurance grow from about $40,000 in Year 1 to about $180,000 in Year 5, and a regional health system partner and local donors add steady support.

We are asking the Heritage Health Fund for $160,000 for our Nurse Practitioner, medical supplies and vaccines, the medical director agreement, vehicle operating costs and our health records and billing system. The mobile unit and its equipment are bought with startup funds from a hospital foundation, a regional health system and our board. Other grants, health system payments and donors cover the rest.

I am Samuel Whitaker, the Executive Director. The numbers in this proposal are estimates based on the assumptions listed at the end, not promises.

Company Description

CareWay Mobile Health is a nonprofit organization in Kentucky. We are a 501(c)(3) public charity (or a program of one, through a fiscal sponsor), governed by a volunteer board of directors. We will provide our IRS determination letter, board list and most recent financial statements with this proposal.

Our mission. To bring health care to the people and places that other health services do not reach, with respect and without judgment.

What we believe. Health care should come to people as often as people go to health care. Trust is built by showing up in the same place every week. A neighbor who is a community health worker can do what a pamphlet cannot. A mobile clinic should make local clinics stronger, not replace them, and every patient deserves a regular doctor if they want one.

How we started. CareWay began three years ago as a volunteer health table at a food pantry, where a retired nurse and two nursing students checked blood pressure and blood sugar. Every week people told us they had not seen a doctor in years. We began tracking the results: nearly half the people we screened had a reading that should be followed up with a clinician, and many did not have a doctor to call. Local clinic leaders, the county health department and a hospital community benefit team asked whether we could provide real care, not just screenings. This proposal asks for support to put a licensed mobile clinic on the road for a full year.

What we offer:
- Primary care visits on the van. Checkups, care for common illnesses and minor injuries, school, sports and work physicals, and follow-up visits.
- Chronic disease checks and care. Blood pressure, blood sugar and A1C checks, cholesterol screening, medication review and coaching for people with conditions such as high blood pressure and diabetes.
- Vaccines. Childhood and adult vaccines, including flu and other routine vaccines, with careful storage and records.
- Screening and referral. Screening for depression, tobacco use and other health risks, and referrals for cancer screenings, women's health and prenatal care, dental care, vision and specialists.
- Community health worker support. Help signing up for Medicaid and other coverage, finding a regular doctor, arranging rides and getting prescriptions filled.
- Health education. Short, plain-language talks at each site on topics such as blood pressure, diabetes, healthy eating and vaccines.

What we do not do. The van is not an emergency room. We do not stock or prescribe controlled substances on the van. We do not perform surgery or offer X-rays. Anyone who needs urgent or emergency care is sent to a hospital, and we call 911 when needed.

How we are run. A seven-member volunteer board of directors oversees the organization and approves the budget each year. The board includes a physician, a retired nurse, a hospital community benefit director, a county health department nurse, a pastor, a rural business owner and a certified public accountant. A licensed physician serves as our Medical Director under a written agreement. The Executive Director manages the organization and operations, the Nurse Practitioner leads the clinical team, and an outside accountant reviews our books every year.

Where things stand today. A hospital foundation has committed a capital gift for the mobile unit, and a regional health system has agreed in principle to a yearly partnership payment. We have signed letters from six host sites that have offered a parking area, power and a private spot at no cost. We have a letter of intent with a local physician to serve as Medical Director. Before we begin, we will confirm all required state registrations and enrollments, sign a short agreement with each host site and complete the credentialing steps listed in the Operations section.

Problem & Opportunity

Why this clinic is needed.

Where a person lives affects how long they live. In many of our communities, the nearest primary care office is a long drive away, public transportation is limited or does not exist, and many families have one car or none. People who do not have a regular doctor are more likely to skip checkups and treatment, to have conditions that go undetected until they become serious, and to use the emergency department for care that could have been given earlier and at lower cost.

The gaps we see:
1. Distance and transportation. A visit to a clinic can mean an hour or more of driving, or no ride at all. Missing a day of work for a checkup is not possible for many families.
2. Cost and coverage. Many people are uninsured, have Medicaid but do not know how to use it, or have insurance with deductibles they cannot meet. Some do not know they qualify for coverage.
3. Too few providers. Large parts of our region have too few primary care providers for the number of residents. The federal government identifies these places as Health Professional Shortage Areas. Before we submit, we will check our service area using the federal Health Resources and Services Administration's shortage area finder and add what we find.
4. Chronic conditions go unmanaged. High blood pressure, diabetes and high cholesterol are common, and they can often be managed with regular care. Without it, people can face serious problems such as heart disease, kidney disease and stroke.
5. Children fall behind. Missed checkups and vaccines mean children start school without required immunizations or physicals, and sports and school forms go unsigned.
6. Trust. Some people have had bad experiences with the health system, feel judged about cost, immigration or substance use, or simply do not know what to expect. A familiar van in a familiar place, with staff who return every week, lowers that barrier.
7. The system is hard to navigate. Insurance enrollment, referrals, prior approvals and prescriptions are confusing, and people give up.

How we know people want this. In our volunteer health table, we saw more than 900 people last year at five sites, and more than 300 asked if we could see them again for ongoing care. Six host sites and three clinics have asked for us to expand.

How we will show the need. Before we submit this proposal, we will add the population of our service area, the share with no health insurance or with Medicaid, the distance to the nearest primary care clinic, the number of primary care providers per resident from the county health rankings and the state health department, the share of adults with high blood pressure and diabetes, and the rate of emergency department visits for conditions that primary care can manage. We will also add our own results from the health table: how many people we screened and how many had a reading that needed follow-up.

Who benefits first. Adults and children who live in our service area and have no regular doctor, no insurance, Medicaid they have not been able to use, or no way to reach a clinic during the day, including older adults, farm and shift workers, families with children and people in housing without transportation.

Products & Services

What the grant will pay for and what we will do.

1. Put a licensed mobile clinic on the road. The van is a refurbished mobile clinic with a private exam room, a wheelchair lift, climate control, a generator and a sink, set up to serve patients privately and safely. It is purchased with startup funds from a hospital foundation, a regional health system and our board, and staffed from the day it opens by a Nurse Practitioner, a Medical Assistant, a Community Health Worker and a Clinic Coordinator and Driver.

2. Park at the same trusted places every week. In Year 1 the clinic serves six regular sites four days a week, such as a church parking lot, a library, a food pantry, a senior housing complex, a community center and a school lot. Sites are chosen with community partners, based on need and a safe place to park, power and a private area. The schedule is posted in advance and rarely changes, so people know where to find us.

3. See people in person, with or without an appointment. Patients can walk up, call or text, or book through a partner. The Medical Assistant checks in each patient, gets their history and vital signs, and the Nurse Practitioner provides care within their license and the Medical Director's protocols. A typical clinic day sees about 12 to 13 patients, about 190 clinic days a year and about 2,400 visits in Year 1.

4. Care for the whole person.
- Checkups and school, sports and work physicals.
- Care for common illnesses and minor injuries, such as colds, ear infections, rashes and sprains.
- Blood pressure, blood sugar and A1C checks and cholesterol screening using point-of-care tests, with follow-up visits and medication review for chronic conditions.
- Childhood and adult vaccines.
- Screening for depression, tobacco use and other health risks, and brief counseling or referral.
- Family planning and women's health referrals, and referrals for prenatal care.
- Referrals for dental, vision, specialist, mental health and substance use care, and help getting to those appointments.

5. Connect every patient to a medical home. The Community Health Worker helps each patient enroll in coverage, find a regular doctor or health center, make and keep the first appointment and get prescriptions filled. We share records with the patient's permission so care is not repeated. We want people to have a regular doctor, and we welcome it when they no longer need us.

6. Follow up. The Community Health Worker calls or visits patients with abnormal readings, missed follow-ups or new diagnoses, and checks that they got the care they needed.

7. Teach, briefly. A five-minute talk or handout at each site on a health topic that matters locally.

How we will measure results. For every patient we record the visit, the reason, key readings such as blood pressure and A1C, referrals and whether they were completed, vaccines given and whether a patient has a medical home. We track how many people return and how their readings change over time. With patient permission, we look at emergency room use through partner hospitals. We survey patients about how they were treated.

Our Year 1 goals:
- About 1,100 different patients and about 2,400 visits.
- At least 60% of patients with a high blood pressure reading return for a follow-up visit within 60 days.
- Among patients with high blood pressure who return at least twice, at least 50% have a lower reading than at their first visit.
- At least 70% of patients who are not already connected to a regular doctor are connected to one or are scheduled for a first appointment within 90 days.
- At least 90% of children seen are up to date on required vaccines or are given a plan to catch up.
- At least 90% of patients say they were treated with respect.
These are goals, and we will report our real results to the Fund, including where we fall short. We do not promise that any patient's health will improve.

Market Analysis

Who we serve and how many.

The people. Anyone who walks up, regardless of age, insurance or ability to pay. We reach out especially to adults and children with no regular doctor, people with chronic conditions that are not under control, older adults, farm and shift workers, families with children, and people living in housing without easy transportation. We welcome people of every background and offer Spanish-language care and interpreters.

Where we work. Three counties in rural Kentucky and two small-town neighborhoods, with six regular clinic sites in Year 1. In Year 3 we add a second clinical team, evening and Saturday clinics and two more sites, for eight sites in all.

How many we will reach:
- Year 1: about 1,100 different patients and about 2,400 visits at six sites.
- Year 2: about 1,400 patients and about 3,000 visits at six sites.
- Year 3: about 1,900 patients and about 4,200 visits at eight sites, with a second clinical team and evening and Saturday clinics.
- Year 4: about 2,200 patients and about 4,800 visits, with a second Community Health Worker.
- Year 5: about 2,300 patients and about 5,000 visits.
Over five years we expect about 19,400 visits. Many patients come back several times in a year, so we count visits and different patients separately.

Who else benefits:
- Local clinics and health centers. We send them new patients who have already been checked, enrolled in coverage and motivated to follow up, which makes their work easier.
- Hospitals. When patients have a regular source of care, there may be fewer visits for problems that could have been handled earlier, though we do not promise this.
- Employers and schools. Healthier workers and children miss fewer days.
- Families and communities. A trusted health presence in the neighborhood supports everyone.

How we will size the need before we submit. We will add the population, insurance status and chronic disease rates for each host site's area, the distance to the nearest clinic and the number of visits we expect from each site, based on our health table counts. These come from the U.S. Census Bureau, the Kentucky Department for Public Health, the County Health Rankings and our own records.

Competitive Landscape

Other places people can go, and how we fit.

- Community health centers and rural health clinics. These are the backbone of primary care for many families, and they offer a sliding fee. But many are a long drive from the people we serve and have limited hours. We work with them. Our goal is to send our patients to them for ongoing care when it is reachable.
- Hospital emergency departments and urgent care. Essential for emergencies, but expensive and not designed for ongoing care. We send emergencies there and help patients find a better first stop next time.
- Private doctors' offices. Many are excellent, but some are full, some do not take Medicaid and few have evening hours or outreach.
- Pharmacy clinics and telehealth. Convenient for some, but they require transportation, a smartphone and good internet, which many of our patients do not have.
- Health department clinics. They provide vaccines and some services, usually at set locations and times. We coordinate with them and avoid duplicating what they offer.
- Other mobile units. Some regional units focus on a single service, such as dental, vision or screenings. We share schedules and refer patients to each other.

The gap we fill. In our service area, no program brings full primary care, chronic disease follow-up, vaccines and community health worker support to the same trusted places every week, without regard to insurance.

Our partners:
- A regional health system and its hospital foundation, which fund the mobile unit and a yearly partnership payment.
- Two community health centers and a rural health clinic, which take referrals and share records with patient permission.
- The county health department, which shares vaccines and outreach and coordinates schedules.
- Six host sites, including churches, a library, a food pantry, a senior housing complex and a community center.
- A local physician who serves as Medical Director.
- A nursing school, which places students for supervised clinical experience in later years.

Marketing & Sales Strategy

How people will find us and how we keep them engaged.

Reaching people who need us:
- A fixed weekly schedule. The van is at the same place on the same day, so people learn when to find us. The schedule is posted on the van, at each host site, on a simple website and on a text line.
- Host sites. Churches, the library, the food pantry and the housing complex tell their members and neighbors, and often announce us at services and events.
- Community health workers. Our Community Health Worker visits food pantries, laundromats and school events, and talks with people one on one.
- Referrals. Clinics, schools, hospitals and the county health department send people who need us.
- Flyers, posters, radio and local newspaper notices in English and Spanish.
- Word of mouth. Many patients tell a neighbor the first time they feel they were treated with respect.

Making it easy to come:
- No appointment is required, and no one is asked for insurance first.
- Fees are explained in plain words, with a sliding fee based on income. No one is turned away because they cannot pay.
- Patients can bring family members, and a quiet waiting area under a canopy is available at each site.
- Rides to follow-up appointments can be arranged through our Community Health Worker.

Keeping patients engaged:
- The same clinical team returns to the same sites, so patients see familiar faces.
- With the patient's permission, we send text or call reminders about follow-ups and vaccines.
- The Community Health Worker follows up with patients who miss a follow-up.
- Patient feedback is gathered every quarter, and what we hear changes the schedule and the services.

Reaching supporters. We invite hospitals, clinics, businesses, churches and individuals to sponsor a clinic day or a site. We share results twice a year with funders and partners, with no patient names or details.

Outreach budget. Site partnerships, outreach and evaluation are about $8,000 a year in Year 1, growing about 4% a year. The vehicle wrap, brochures and website are paid for once from startup money ($9,000).

Operations Plan

How the clinic will operate.

Timeline for Year 1:
- Months 1 to 3: Purchase and outfit the mobile unit, hire the Nurse Practitioner, Medical Assistant, Community Health Worker and Clinic Coordinator and Driver, sign the Medical Director agreement, sign host site agreements, and set up the health records and billing system.
- Months 2 to 4: Complete registrations and enrollments, including the state mobile unit approvals, a CLIA certificate of waiver for point-of-care tests, vaccine program enrollment, Medicaid and insurer enrollment, and a pharmacy or supplier agreement for medications and vaccines.
- Month 4: Staff training on infection control, emergency response, privacy and the van's equipment. Practice clinic days at each site without patients.
- Months 5 to 12: Open to patients at six sites, four days a week. The first Medicaid and insurance payments arrive late in the year. We review each site's numbers every quarter and adjust the schedule.

The van and equipment. We buy a refurbished mobile clinic van with an exam room, wheelchair lift, climate control and a generator ($118,000). Medical equipment, such as an exam table, vaccine refrigerator, point-of-care testing devices, an EKG and vital signs equipment, costs $22,000. Tablets, a mobile hotspot and a secure printer for records on the road cost $4,500. A portable canopy, tables, chairs and signage for outdoor sites cost $5,500. That is $150,000 of equipment in all, paid once from startup money. After Year 1, we set aside about $4,000 to $6,000 a year to replace and add equipment, and we plan to replace the van after about 10 years.

Staffing. In Year 1: an Executive Director, a Nurse Practitioner, a Medical Assistant, a Community Health Worker and a Clinic Coordinator and Driver. On clinic days, a clinical team of three (the Nurse Practitioner, Medical Assistant and Community Health Worker) is on the van, with the Coordinator and Driver. A second Nurse Practitioner and Medical Assistant join in Year 3, and a second Community Health Worker in Year 4.

Medical oversight. A licensed physician serves as our Medical Director under a written agreement, at about $18,000 a year in Year 1. The Medical Director approves clinical protocols, reviews a sample of charts each month and is available by phone during clinic hours. Nurse practitioners' authority to diagnose, treat and prescribe differs by state, so we confirm Kentucky's current rules and any required collaborative agreement with a physician before we see patients.

Clinical quality and safety. All clinicians hold current Kentucky licenses and complete background checks and credentialing. The van follows infection control and cleaning protocols after every patient, and we dispose of medical waste through a licensed vendor. Vaccines are stored in a refrigerator with a continuous temperature monitor and recorded in the state immunization registry. Point-of-care tests are performed under a CLIA certificate of waiver, and staff are trained on every test.

Emergency plan. The van carries basic emergency equipment, and staff are trained in basic life support. If a patient needs emergency care, staff call 911, begin care and stay with the patient until help arrives. Clinic sites have a location and cell signal plan. We carry no controlled substances on the van, so no one has a reason to target it.

Privacy. Every patient record is kept in a secure electronic health records system that follows HIPAA, the federal health privacy law. Tablets are locked and encrypted, exam room conversations are private, and we share information with other providers only with the patient's written permission or as the law requires. We report results to funders only as totals. The health records and billing system costs about $16,000 a year in Year 1.

Fees and billing. We bill Medicaid and insurers for covered patients. Whether we bill under our own enrollment or under a partner health center's depends on the state's rules, so we confirm this with the state Medicaid agency and our partner health centers before we start. A sliding fee scale based on income and family size is posted on the van, and no one is turned away because they cannot pay. Medicaid and insurance rules change, so our billing staff checks current rules each year.

Insurance. We carry medical malpractice and general liability insurance, commercial auto insurance for the van, property insurance and workers' compensation. Malpractice and liability insurance is about $14,000 a year in Year 1, and vehicle fuel, maintenance and insurance are about $30,000.

Records and reporting. Grant money is tracked separately so we can show each funder how their money was spent, and an outside accountant reviews our books every year.

Management & Organization

Who leads the organization.

Samuel Whitaker, Executive Director. Samuel leads the organization, raises money, manages grants and partnerships, supervises operations and reports to the board. He spent 15 years in rural hospital administration and co-founded our volunteer health table. Planned salary: $66,000 a year.

Nurse Practitioner. Leads clinical care on the van, sees patients, orders point-of-care tests, manages chronic conditions and coordinates with the Medical Director. Must hold a current Kentucky advanced practice license and complete a background check. One in Years 1 and 2 and two from Year 3, at a planned salary of $110,000 each. The Heritage Health Fund grant would support part of the first Nurse Practitioner's salary.

Medical Assistant. Checks in patients, takes vital signs, performs point-of-care tests, gives vaccines under the clinician's orders and cleans and stocks the van. One in Years 1 and 2 and two from Year 3, at a planned salary of $40,000 each.

Community Health Worker. A trusted member of the community who helps patients with coverage, follow-up, rides and resources, and leads health talks. One in Years 1 to 3 and two from Year 4, at a planned salary of $42,000 each.

Clinic Coordinator and Driver. Drives the van, sets it up at each site, manages schedules, supplies and host sites, and handles safety and maintenance. Must hold the required driver's license and a clean driving record. Planned salary: $36,000 a year.

Pay figures include payroll taxes and workers' compensation insurance.

Staff in each year: 5 paid staff in Years 1 and 2, 7 in Year 3 and 8 from Year 4 on.

The Medical Director. A licensed physician under a written agreement, who approves protocols and reviews charts.

The board. A seven-member volunteer board approves the budget, reviews results twice a year and helps raise money. Board members serve three-year terms. The board's certified public accountant chairs the finance committee. The board's physician and nurse advise on quality and safety.

People who help us. An outside accountant who reviews our books every year, an attorney who reviews our agreements and privacy policies, a billing consultant for payer enrollment, an insurance agent who understands mobile health, a fleet mechanic for the van, and an advisory group of patients, pastors and community leaders who meet each semester to tell us what is working.

Training. All staff complete training in infection control, privacy, emergency response and cultural humility before starting. Clinicians complete continuing education as their licenses require.

Money management. Grant money is tracked separately for each funder. The Executive Director and a board member must both approve any payment over $2,500.

Milestones Narrative

Our goals for each year and how we will measure them.

- Year 1: Put the clinic on the road at six regular sites, serving about 1,100 different patients in about 2,400 visits. Complete all registrations and enrollments. A balanced budget of about $481,500, with a small surplus of about $13,500. 5 paid staff.
- Year 2: Serve about 1,400 patients in about 3,000 visits, with a growing share of follow-up visits and more patients connected to a regular doctor. A balanced budget of about $488,000, with a small surplus of about $12,800. 5 paid staff.
- Year 3: Add a second clinical team, evening and Saturday clinics and two more sites, serving about 1,900 patients in about 4,200 visits. A balanced budget of about $648,000, with a small surplus of about $15,000. 7 paid staff.
- Year 4: Add a second Community Health Worker, serving about 2,200 patients in about 4,800 visits. A balanced budget of about $698,000, with a small surplus of about $15,200. 8 paid staff.
- Year 5: Serve about 2,300 patients in about 5,000 visits, with patient service payments covering about 26% of our budget. A balanced budget of about $705,500, with a small surplus of about $14,200. 8 paid staff.

What we measure:
- Patients and visits, by site and by month.
- Blood pressure, A1C and other key readings, and how they change for patients who return.
- Follow-up visits kept, referrals completed and patients connected to a regular doctor.
- Vaccines given and children up to date.
- Patient satisfaction and whether patients felt respected.
- Sliding fee amounts, Medicaid and insurance payments, and the cost of care per visit.

How we review results. The Nurse Practitioner and Medical Director review clinical quality every month. Each quarter, staff review each site's numbers, patient feedback and safety reports and change the schedule or services. Twice a year, the board reviews results and we share them with funders and partners as totals. Every number in this plan is a goal, and we will report what really happens.

Funding Request

What we are asking for, and how the money will be used. Our request: $160,000 from the Heritage Health Fund for our Nurse Practitioner, medical supplies and vaccines, the Medical Director agreement, vehicle operating costs and our health records and billing system, for July 2027 through June 2028.

The request is spread across these budget lines:
- Personnel: Nurse Practitioner salary, $82,000 (other funds add $28,000).
- Supplies: Medical supplies, vaccines and point-of-care tests, $30,000 (other funds add $6,000).
- Contractual: Medical Director agreement, $18,000.
- Other: Vehicle fuel, maintenance and insurance, $20,000 (other funds add $10,000).
- Other: Health records and billing system, $10,000 (other funds add $6,000).

Other money in the program. Other grants, patient service payments and the regional health system partner and donors pay the other $50,000 of those lines, plus the Executive Director's salary ($66,000), the Medical Assistant ($40,000), the Community Health Worker ($42,000), the Clinic Coordinator and Driver ($36,000), malpractice and liability insurance ($14,000), site partnerships, outreach and evaluation ($8,000) and administration and accounting ($22,000).

Year 1 budget: about $481,500, planned to balance with a small surplus (about $13,500 after the yearly wear on the van and equipment). Year 1 money coming in: grants $331,500 (this request plus other grants we are applying for), patient service payments from Medicaid and insurance $40,000 and health system partner payments and donations $110,000. Year 1 costs: Executive Director $66,000; Nurse Practitioner $110,000; Medical Assistant $40,000; Community Health Worker $42,000; Clinic Coordinator and Driver $36,000; medical supplies, vaccines and tests about $36,000; vehicle fuel, maintenance and insurance about $30,000; Medical Director agreement about $18,000; malpractice and liability insurance about $14,000; health records and billing system about $16,000; site partnerships, outreach and evaluation about $8,000; administration and accounting about $22,000; and about $34,000 a year for the wear on the van and equipment, which we set aside so we can replace them.

How we planned patient income. Many of our patients are uninsured and pay little or nothing, and others are covered by Medicaid or insurance. We expect to average about $17 per visit in Year 1 (about 2,400 visits), because Medicaid enrollment and billing take months to set up and many visits are not billable. We expect about $36 per visit in Year 5 (about 5,000 visits) as more patients are covered and billing improves. Payments often arrive weeks after we bill, so we plan for about $38,520 owed to us at the end of Year 1.

One-time startup costs. Startup costs of $181,000 are paid once from startup money, not from the yearly budget: $150,000 of equipment (the refurbished mobile clinic van, medical equipment, tablets and a hotspot, and a canopy and outdoor site gear), $8,000 for the opening stock of supplies, vaccines and test kits, $2,500 for state and local permits and registration of the unit, $6,500 for an attorney's review of agreements and privacy policies, credentialing and accounting setup, $9,000 for the vehicle wrap, brochures and website, and $5,000 for background checks, staff vaccinations and the first insurance payment.

How we got our startup number. The Funding Need Calculator in this plan adds the startup costs ($181,000) and a cash cushion of about $109,500, which is about three months of Year 1 costs. That comes to $290,500. We start with $40,000 of our own savings and $260,000 in startup support from a hospital foundation, a regional health system and our board, $300,000 in all, which covers that amount.

The next five years. Our budget grows from about $481,500 in Year 1 to about $705,500 in Year 5. Grants are planned at $331,500, $301,000, $397,000, $403,000 and $380,500 in Years 1 to 5. Patient service payments grow from $40,000 to $180,000, and health system partner payments and donations grow from $110,000 to $145,000. We add a second clinical team in Year 3 and a second Community Health Worker in Year 4. Grants fall from about 69% of our income in Year 1 to about 54% in Year 5.

Savings. We plan to keep several months of costs in savings. The lowest year-end balance in the plan is about $155,000, at the end of Year 1.

After the grant. Our plan is for patient service payments to cover a growing share of the clinic's cost each year, for the regional health system and other hospitals to continue paying for the community care they receive from us, and for donors and sponsors to adopt a site or a clinic day. We will also apply to state and federal programs that support rural health. A clinic that is paid for the care it provides, and valued by the hospitals around it, can last.

Risks and how we will handle them:
- The van is delayed or breaks down. We buy from a reputable refurbisher with a warranty, keep a maintenance schedule and have a plan with a partner clinic for backup days.
- Medicaid and insurer enrollment takes longer than planned. We apply early, plan low patient income in Year 1 and keep a cash cushion.
- We cannot hire a nurse practitioner quickly. We start recruiting early, offer a four-day week and work with the Medical Director and partner clinics to cover gaps.
- A host site is no longer available. We have a waiting list of other sites and a written agreement with each host.
- A patient has an emergency. The team is trained, the van is equipped for basic emergencies and staff call 911.
- A grant or a partner's payment ends. We keep savings, grow patient income and diversify donors.

If you are just starting. A new organization can begin before it has its own 501(c)(3) status through a fiscal sponsor: an established nonprofit that receives grants for you and passes them to your program, usually for a fee (commonly around 5% to 10% of the grant, sometimes more; ask before you agree). Another way is to start smaller: a weekly pop-up clinic in a donated church room or a borrowed van, staffed by a volunteer nurse practitioner and a community health worker, tracked carefully. Strong results from a small start make larger grants easier to win.

Appendix Notes

Documents to attach with this proposal:

- Your IRS 501(c)(3) determination letter, or your fiscal sponsor agreement.
- Your most recent financial statements and your current year budget.
- A list of your board members and what each one does.
- Licenses and resumes for your Nurse Practitioner and Medical Director.
- The Medical Director agreement and your written clinical protocols.
- Your quote or purchase agreement for the mobile unit, with the warranty.
- Letters of commitment from the hospital foundation and the regional health system.
- Signed agreements or letters from each host site.
- Letters of support from health centers, the health department and community partners.
- Proof of registrations and enrollments (state mobile unit approval, CLIA certificate of waiver, vaccine program, Medicaid), or proof they were submitted.
- Your privacy policy, sliding fee scale, infection control policy and emergency plan.
- Proof of malpractice, auto and general liability insurance, or quotes.
If you don't have any of this yet, no worries - let's continue.

The assumptions behind our numbers (change them in the Financials section to match your own):
- Grant Revenue: $331,500 in Year 1, then $301,000, $397,000, $403,000 and $380,500.
- Patient Service Revenue (Medicaid and Insurance): $40,000 in Year 1 (about 2,400 visits at about $17), then $72,000, $126,000, $160,000 and $180,000 (about 5,000 visits at about $36 in Year 5).
- Health System Partner Payments and Donations: $110,000 in Year 1, growing to $145,000.
- Pay (a full year, per person, including payroll taxes and workers' compensation): Executive Director $66,000, Nurse Practitioner $110,000 (one in Years 1 and 2, two from Year 3), Medical Assistant $40,000 (one in Years 1 and 2, two from Year 3), Community Health Worker $42,000 (one in Years 1 to 3, two from Year 4), Clinic Coordinator and Driver $36,000.
- Other yearly costs in Year 1: Medical Supplies, Vaccines and Point-of-Care Tests $36,000, Vehicle Fuel, Maintenance and Insurance $30,000, Medical Director Agreement $18,000, Malpractice and Liability Insurance $14,000, Health Records and Billing System $16,000, Site Partnerships, Outreach and Evaluation $8,000, Administration and Accounting $22,000. These grow between 3% and 5% a year.
- Equipment: $150,000 at the start (the van and medical equipment), then $4,000 to $6,000 a year.
- Startup costs: $181,000, paid once from $300,000 in startup money.
- About 8% of each year's income is still owed to us at year end.
- Tax: none, as a nonprofit.
- Every dollar amount is an estimate. Replace them with your own quotes and real budget.

Startup Costs