Mobile health clinic model in the COVID-19 pandemic: lessons learned and opportunities for policy changes and innovation.

BACKGROUND: Mobile Clinics represent an untapped resource for our healthcare system. The COVID-19 pandemic has exacerbated its limitations. Mobile health clinic programs in the US already play important, albeit under-appreciated roles in the healthcare system. They provide access to healthcare especially for displaced or isolated individuals; they offer versatility in the setting of a damaged or inadequate healthcare infrastructure; and, as a longstanding community-based service delivery model, they fill gaps in the healthcare safety-net, reaching social-economically underserved populations in both urban and rural areas. Despite an increasing body of evidence of the unique value of this highly adaptable model of care, mobile clinics are not widely supported. This has resulted in a missed opportunity to deploy mobile clinics during national emergencies such as the COVID-19 pandemic, as well as using these already existing, and trusted programs to overcome barriers to access that are experienced by under-resourced communities. MAIN TEXT: In March, the Mobile Healthcare Association and Mobile Health Map, a program of Harvard Medical School's Family Van, hosted a webinar of over 300 mobile health providers, sharing their experiences, challenges and best practices of responding to COVID 19. They demonstrated the untapped potential of this sector of the healthcare system in responding to healthcare crises. A Call to Action: The flexibility and adaptability of mobile clinics make them ideal partners in responding to pandemics, such as COVID-19. In this commentary we propose three approaches to support further expansion and integration of mobile health clinics into the healthcare system: First, demonstrate the economic contribution of mobile clinics to the healthcare system. Second, expand the number of mobile clinic programs and integrate them into the healthcare infrastructure and emergency preparedness. Third, expand their use of technology to facilitate this integration. CONCLUSIONS: Understanding the economic and social impact that mobile clinics are having in our communities should provide the evidence to justify policies that will enable expansion and optimal integration of mobile clinics into our healthcare delivery system, and help us address current and future health crises.

Mobile health clinics in the United States.

BACKGROUND: Mobile health clinics serve an important role in the health care system, providing care to some of the most vulnerable populations. Mobile Health Map is the only comprehensive database of mobile clinics in the United States. Members of this collaborative research network and learning community supply information about their location, services, target populations, and costs. They also have access to tools to measure, improve, and communicate their impact. METHODS: We analyzed data from 811 clinics that participated in Mobile Health Map between 2007 and 2017 to describe the demographics of the clients these clinics serve, the services they provide, and mobile clinics' affiliated institutions and funding sources. RESULTS: Mobile clinics provide a median number of 3491 visits annually. More than half of their clients are women (55%) and racial/ethnic minorities (59%). Of the 146 clinics that reported insurance data, 41% of clients were uninsured while 44% had some form of public insurance. The most common service models were primary care (41%) and prevention (47%). With regards to organizational affiliations, they vary from independent (33%) to university affiliated (24%), while some (29%) are part of a hospital or health care system. Most mobile clinics receive some financial support from philanthropy (52%), while slightly less than half (45%) receive federal funds. CONCLUSION: Mobile health care delivery is an innovative model of health services delivery that provides a wide variety of services to vulnerable populations. The clinics vary in service mix, patient demographics, and relationships with the fixed health system. Although access to care has increased in recent years through the Affordable Care Act, barriers continue to persist, particularly among populations living in resource-limited areas. Mobile clinics can improve access by serving as a vital link between the community and clinical facilities. Additional work is needed to advance availability of this important resource.

"Road to Empathy": A Qualitative Exploratory Study of Trainee Experiences on a Mobile Health Clinic.

INTRODUCTION: Mobile health clinics often deliver care in medically underserved communities and train student volunteers to support service delivery, but little is known about how these clinics affect trainees. METHODS: We conducted a qualitative analysis of over 100 trainees' experiences volunteering with a mobile health clinic, to explore the training experience's impact on personal and professional development. RESULTS: Volunteers' training experiences involved learning how to deliver compassionate, non-judgmental health care. They developed competencies necessary to deliver effective, understandable, and respectful care. Their understanding of the health care system and patient-provider relationships deepened, and they expressed stronger empathy for people different from themselves. Over time, trainees progressed from initial apprehension towards confidence and competence, mediated by practice and staff expertise. DISCUSSION: Mobile clinics should support trainees in understanding community-based services for clients, in addition to cultivating patient-care skills.

Preventative health, diversity, and inclusion: a qualitative study of client experience aboard a mobile health clinic in Boston, Massachusetts.

BACKGROUND: There are approximately 2000 mobile health clinics operating in the United States. While researchers have established that mobile health clinics can be cost effective and improve outcomes, there is scant research examining the healthcare experience on a mobile health clinic from patients' perspectives. METHODS: Data were gathered from interviews with 25 clients receiving care on a Boston-based mobile health clinic and analyzed using grounded theory methodology. RESULTS: Emerging patterns in the data revealed three relational and three structural factors most significant to participants' experience of care on The Family Van. Relational factors include providers who 1) Communicate understandably, 2) Create a culture of respect and inclusivity, and 3) Are diverse with knowledge of the community. Structural factors include 1) A focus on preventative health and managing chronic disease, 2) Expeditious, free, and multiple services, and 3) Location. CONCLUSIONS: The participant accounts in this report serve to expand on prior research exploring mobile health clinics' role in patients' healthcare, to more clearly define the most salient aspects of the mobile health clinic model for the patients they serve, and to give voice to patients too seldom heard in the academic literature.

The scope and impact of mobile health clinics in the United States: a literature review.

As the U.S. healthcare system transforms its care delivery model to increase healthcare accessibility and improve health outcomes, it is undergoing changes in the context of ever-increasing chronic disease burdens and healthcare costs. Many illnesses disproportionately affect certain populations, due to disparities in healthcare access and social determinants of health. These disparities represent a key area to target in order to better our nation's overall health and decrease healthcare expenditures. It is thus imperative for policymakers and health professionals to develop innovative interventions that sustainably manage chronic diseases, promote preventative health, and improve outcomes among communities disenfranchised from traditional healthcare as well as among the general population. This article examines the available literature on Mobile Health Clinics (MHCs) and the role that they currently play in the U.S. healthcare system. Based on a search in the PubMed database and data from the online collaborative research network of mobile clinics MobileHealthMap.org , the authors evaluated 51 articles with evidence on the strengths and weaknesses of the mobile health sector in the United States. Current literature supports that MHCs are successful in reaching vulnerable populations, by delivering services directly at the curbside in communities of need and flexibly adapting their services based on the changing needs of the target community. As a link between clinical and community settings, MHCs address both medical and social determinants of health, tackling health issues on a community-wide level. Furthermore, evidence suggest that MHCs produce significant cost savings and represent a cost-effective care delivery model that improves health outcomes in underserved groups. Even though MHCs can fulfill many goals and mandates in alignment with our national priorities and have the potential to help combat some of the largest healthcare challenges of this era, there are limitations and challenges to this healthcare delivery model that must be addressed and overcome before they can be more broadly integrated into our healthcare system.

The Emerging Business Models and Value Proposition of Mobile Health Clinics.

Mobile health clinics are increasingly used to deliver healthcare to urban and rural populations. An estimated 2000 vehicles in the United States are now delivering between 5 and 6 million visits annually; however, despite this growth, mobile health clinics represent an underutilized resource that could transform the way healthcare is delivered, especially in underserved areas. Preliminary research has shown that mobile health clinics have the potential to reduce costs and improve health outcomes. Their value lies primarily in their mobility, their ability to be flexibly deployed and customized to fit the evolving needs of populations and health systems, and their ability to link clinical and community settings. Few studies have identified how mobile health clinics can be sustainably utilized. We discuss the value proposition of mobile health clinics and propose 3 potential business models for them-adoption by accountable care organizations, payers, and employers.

Mobile health clinics in the era of reform.

OBJECTIVES: Despite the role of mobile clinics in delivering care to the full spectrum of at-risk populations, the collective impact of mobile clinics has never been assessed. This study characterizes the scope of the mobile clinic sector and its impact on access, costs, and quality. It explores the role of mobile clinics in the era of delivery reform and expanded insurance coverage. STUDY DESIGN: A synthesis of observational data collected through Mobile Health Map and published literature related to mobile clinics. METHODS: Analysis of data from the Mobile Health Map Project, an online platform that aggregates data on mobile health clinics in the United States, supplemented by a comprehensive literature review. RESULTS: Mobile clinics represent an integral component of the healthcare system that serves vulnerable populations and promotes high-quality care at low cost. There are an estimated 1500 mobile clinics receiving 5 million visits nationwide per year. Mobile clinics improve access for vulnerable populations, bolster prevention and chronic disease management, and reduce costs. Expanded coverage and delivery reform increase opportunities for mobile clinics to partner with hospitals, health systems, and insurers to improve care and lower costs. CONCLUSIONS: Mobile clinics have a critical role to play in providing high-quality, low-cost care to vulnerable populations. The postreform environment, with increasing accountability for population health management and expanded access among historically underserved populations, should strengthen the ability for mobile clinics to partner with hospitals, health systems, and payers to improve care and lower costs.

Mobile clinic in Massachusetts associated with cost savings from lowering blood pressure and emergency department use.

Mobile health clinics are in increasingly wide use, but evidence of their clinical impact or cost-effectiveness is limited. Using a unique data set of 5,900 patients who made a total of 10,509 visits in 2010-12 to the Family Van, an urban mobile health clinic in Massachusetts, we examined the effect of screenings and counseling provided by the clinic on blood pressure. Patients who presented with high blood pressure during their initial visit experienced average reductions of 10.7 mmHg and 6.2 mmHg in systolic and diastolic blood pressure, respectively, during their follow-up visits. These changes were associated with 32.2 percent and 44.6 percent reductions in the relative risk of myocardial infarction and stroke, respectively, which we converted into savings using estimates of the incidence and costs of these conditions over thirty months. The savings from this reduction in blood pressure and patient-reported avoided emergency department visits produced a positive lower bound for the clinic's return on investment of 1.3. All other services of the clinic-those aimed at diabetes, obesity, and maternal health, for example-were excluded from this lower-bound estimate. Policy makers should consider mobile clinics as a delivery model for underserved communities with poor health status and high use of emergency departments.

Knowledgeable Neighbors: a mobile clinic model for disease prevention and screening in underserved communities.

The Family Van mobile health clinic uses a "Knowledgeable Neighbor" model to deliver cost-effective screening and prevention activities in underserved neighborhoods in Boston, MA. We have described the Knowledgeable Neighbor model and used operational data collected from 2006 to 2009 to evaluate the service. The Family Van successfully reached mainly minority low-income men and women. Of the clients screened, 60% had previously undetected elevated blood pressure, 14% had previously undetected elevated blood glucose, and 38% had previously undetected elevated total cholesterol. This represents an important model for reaching underserved communities to deliver proven cost-effective prevention activities, both to help control health care costs and to reduce health disparities.

Calculating the return on investment of mobile healthcare.

BACKGROUND: Mobile health clinics provide an alternative portal into the healthcare system for the medically disenfranchised, that is, people who are underinsured, uninsured or who are otherwise outside of mainstream healthcare due to issues of trust, language, immigration status or simply location. Mobile health clinics as providers of last resort are an essential component of the healthcare safety net providing prevention, screening, and appropriate triage into mainstream services. Despite the face value of providing services to underserved populations, a focused analysis of the relative value of the mobile health clinic model has not been elucidated. The question that the return on investment algorithm has been designed to answer is: can the value of the services provided by mobile health programs be quantified in terms of quality adjusted life years saved and estimated emergency department expenditures avoided? METHODS: Using a sample mobile health clinic and published research that quantifies health outcomes, we developed and tested an algorithm to calculate the return on investment of a typical broad-service mobile health clinic: the relative value of mobile health clinic services = annual projected emergency department costs avoided + value of potential life years saved from the services provided. Return on investment ratio = the relative value of the mobile health clinic services/annual cost to run the mobile health clinic. RESULTS: Based on service data provided by The Family Van for 2008 we calculated the annual cost savings from preventing emergency room visits, $3,125,668 plus the relative value of providing 7 of the top 25 priority prevention services during the same period, US$17,780,000 for a total annual value of $20,339,968. Given that the annual cost to run the program was $567,700, the calculated return on investment of The Family Van was 36:1. CONCLUSION: By using published data that quantify the value of prevention practices and the value of preventing unnecessary use of emergency departments, an empirical method was developed to determine the value of a typical mobile health clinic. The Family Van, a mobile health clinic that has been serving the medically disenfranchised of Boston for 16 years, was evaluated accordingly and found to have return on investment of $36 for every $1 invested in the program.