Mobile Health Clinics: Improving Access To Care For The .

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Population Health AdvisorMobile Health Clinics: ImprovingAccess to Care for the UnderservedMarch 2017

LEGAL CAVEATAdvisory Board is a division of The Advisory Board Company. AdvisoryBoard has made efforts to verify the accuracy of the information itprovides to members. This report relies on data obtained from manysources, however, and Advisory Board cannot guarantee the accuracyof the information provided or any analysis based thereon. In addition,Advisory Board is not in the business of giving legal, medical,accounting, or other professional advice, and its reports should not beconstrued as professional advice. In particular, members should notrely on any legal commentary in this report as a basis for action, orassume that any tactics described herein would be permitted byapplicable law or appropriate for a given member’s situation. Membersare advised to consult with appropriate professionals concerning legal,medical, tax, or accounting issues, before implementing any of thesetactics. Neither Advisory Board nor its officers, directors, trustees,employees, and agents shall be liable for any claims, liabilities, orexpenses relating to (a) any errors or omissions in this report, whethercaused by Advisory Board or any of its employees or agents, orsources or other third parties, (b) any recommendation or gradedranking by Advisory Board, or (c) failure of member and its employeesand agents to abide by the terms set forth herein.Population Health AdvisorProject DirectorRebecca Tyrrell, MSContributing ConsultantsDarby SullivanThe Advisory Board Company and the “A” logo are registeredtrademarks of The Advisory Board Company in the United States andother countries. Members are not permitted to use these trademarks,or any other trademark, product name, service name, trade name, andlogo of Advisory Board without prior written consent of Advisory Board.All other trademarks, product names, service names, trade names,and logos used within these pages are the property of their respectiveholders. Use of other company trademarks, product names, servicenames, trade names, and logos or images of the same does notnecessarily constitute (a) an endorsement by such company ofAdvisory Board and its products and services, or (b) an endorsementof the company or its products or services by Advisory Board.Advisory Board is not affiliated with any such company.Clare WirthPractice ManagerTomi OgundimuDedicated AdvisorMonica YasunagaIMPORTANT: Please read the y Board has prepared this report for the exclusive use of itsmembers. Each member acknowledges and agrees that this reportand the information contained herein (collectively, the “Report”) areconfidential and proprietary to Advisory Board. By accepting deliveryof this Report, each member agrees to abide by the terms as statedherein, including the following:1. Advisory Board owns all right, title, and interest in and to thisReport. Except as stated herein, no right, license, permission, orinterest of any kind in this Report is intended to be given,transferred to, or acquired by a member. Each member isauthorized to use this Report only to the extent expresslyauthorized herein.Introduction and PurposeThis brief provides best practice models for employing a mobile clinic to improve accessto care for vulnerable populations, including detail on: National mobile health clinic trends Profiles of successful mobile health clinics with an emphasis on operationalconsiderations such as staffing and funding Action steps for developing a program2. Each member shall not sell, license, republish, or post online orotherwise this Report, in part or in whole. Each member shall notdisseminate or permit the use of, and shall take reasonableprecautions to prevent such dissemination or use of, this Report by(a) any of its employees and agents (except as stated below), or(b) any third party.3. Each member may make this Report available solely to those of itsemployees and agents who (a) are registered for the workshop ormembership program of which this Report is a part, (b) requireaccess to this Report in order to learn from the informationdescribed herein, and (c) agree not to disclose this Report to otheremployees or agents or any third party. Each member shall use,and shall ensure that its employees and agents use, this Reportfor its internal use only. Each member may make a limited numberof copies, solely as adequate for use by its employees and agentsin accordance with the terms herein.4. Each member shall not remove from this Report any confidentialmarkings, copyright notices, and/or other similar indicia herein.5. Each member is responsible for any breach of its obligations asstated herein by any of its employees or agents.6. If a member is unwilling to abide by any of the foregoingobligations, then such member shall promptly return this Reportand all copies thereof to Advisory Board. 2017 Advisory Board All Rights Reserved2advisory.com

Background:Defining theMobile Clinic Market 2017 Advisory Board All Rights Reserved3advisory.com

Systemic Barriers Restrict Access to Care for Already-Vulnerable PopulationsLack of Consistent Care Drives High-Cost Emergency Department Visits and HospitalizationsMost Frequently Cited Barriers to Health Care UtilizationDistrust of the Health Care SystemLack of Transportation53%25%Low-income Americans whoagreed that U.S. doctorscannot be trustedLow income patients whohave missed or rescheduledappointments due to lackof transportationOther Common Barriers:Individual Race, ethnicity Gender, sexual orientation Age Socioeconomic status Legal status Employment statusHigh Cost of CareLack of Insurance CoverageInterpersonal20%11% Linguistic and cultural barriersUninsured patients who wentwithout needed care due tocost; 8% for publicallyinsured patientsNonelderly uninsured rate Personal safety Psychological barriers Intimidation by healthcare settings Anonymity concernsNonelderly Patients Without Usual Source of Health Care by Insurance TypeSystemicKaiser Family Foundation Location, hours of operation2015More than half ofuninsured nonelderlypatients lack a usualsource of health care54%UninsuredUninsured13%12%Medicaidor OtherMedicaidorPublicOther PublicEmployeror OtherEmployerorPrivateOther Private Health care provider shortages Food insecurity Literacy, education Housing qualitySource: Blendon R, et al., “Public Trust in Physicians– U.S. Medicine in International Perspective,” New England Journal of Medicine, 371, (2014): 15701572; Cronk I, “The Transportation Barrier,” The Atlantic, /the-transportation-barrier/399728/; “KeyFacts about the Uninsured Population,” The Henry J. Kaiser Family Foundation, t-the-uninsuredpopulation/#endnote link 198942-19; Hill C, et al., “A Literature Review of the Scope & Impact of Mobile Health Clinics 2016,” Mobile Health ics%202016.pdf; Population Health Advisor research and analysis. 2017 Advisory Board All Rights Reserved4advisory.com

Mobile Health Clinics Costly but Effective Method for Reaching the UnderservedMost Common Offerings Include Preventive Screenings, Primary Care, and Dental ServicesPurpose of Mobile Health ClinicsMost Common Services Offered by Mobile Health ClinicsTo provide accessible health care services for vulnerablepopulations by reducing traditional barriers to access (e.g.,transportation, time constraints, distrust of health care system)Survey by Harvard Medical School’s Mobile Health Map45%42%National Trends Identified by Harvard’s Mobile Health Map30%Services: preventive screenings, primary care, and dental servicesare most common; others include disease management, behavioralhealth care, prenatal careTarget populations: primarily the uninsured and publically insured,as well as children under 18; of patients currently served by mobileclinics, 60% are uninsured, 31% are publically insured, and 9% areprivately insured; 42% are under age 18PreventiveScreeningsPrimary CareDental ServicesLocations: both rural and urban communities with 39% servingcities, 14% serving rural areas, and 47% serving bothMobile Health Clinic Patients’ Insurance CoverageSurvey by Harvard Medical School’s Mobile Health Maphealth2,000 Mobileclinics in the U.S. 429KAverage operationalcost of a mobileprogram per yearPrivatelyInsured9%mobile6.5M Estimatedhealth clinic visitsannually 12PublicallyInsuredAverage return forevery dollar investedin mobile health31%60%UninsuredSource: “Impact Report” Mobile Health Map, http://www.mobilehealthmap.org/impact-report; Hill C, et al., “A LiteratureReview of the Scope & Impact of Mobile Health Clinics 2016,” Mobile Health ics%202016.pdf; Population Health Advisor research and analysis. 2017 Advisory Board All Rights Reserved5advisory.com

Analyze Non-Clinical, Clinical, Utilization Trends to Inform Mobile InterventionSupplement Data Analytics with Community Input to Fulfill Demonstrated Need in MarketTrends Suggesting Opportunity for Mobile Health Clinic Intervention:Non-Clinical Signals Presence of logistical barriers to health care (e.g., transportation access, insurance)Sources to Determine Population Needs: Discussions or survey of community-basedorganizations, residents Shortage of dental, behavioral health, specialty, or primary care providers incommunity Community Health Needs Assessment Patients disconnected from health care system (e.g., lack of primary care visits) County-level insurance rates Public transportation scheduled routes Distrust between population and providers Community resource utilization (e.g., housing services, SNAP benefits)Clinical Signals to Further Segment by Patient Populations (e.g., payer type, location,disease state) Repeat symptoms presented in the emergency department (e.g., asthma attacks) Hospital claims data Centers for Disease Control and Preventiondata and statistics (e.g., diabetes, oral health) High chronic disease prevalence (e.g., diabetes, asthma)Utilization Signals Demographic Profiler Tool High hospital readmission rates Avoidable Emergency Department Tool Low outpatient visit rates High inpatient costs High emergency department utilization and costsSource: Hill C, et al., “A Literature Review of the Scope & Impact of Mobile Health Clinics 2016,” Mobile Health ics%202016.pdf; Population Health Advisor research and analysis. 2017 Advisory Board All Rights Reserved6advisory.com

Learnfrom Your Peers:Innovative MobileHealth Clinic Models 2017 Advisory Board All Rights Reserved7advisory.com

Profiled Organizations’ Mobile Clinic Strategies Rooted in Population NeedsGoalProfiled OrganizationTarget PopulationService OfferingsStaffing ModelHarvard Medical School’sThe Family VanUninsured or underinsured patients inthe Greater Boston areaPreventive screenings, healtheducation, referrals to social servicesand community health centersHealth educator, dietician, HIV testerand counselor, assistant director, 2-3volunteers, rotating collaborators fromcommunity-based organizationsHoltz Children’s Hospital’sPediatric Mobile ClinicUninsured children in Miami, Florida,up to 21 years of age, many of whomare immigrants with legal needsClinical care (e.g., physicals,immunizations, screenings, chronicillness management, behavioral healthsupport, urgent care), legal aid andsocial services5 clinical staff (part-time pediatrician,psychologist, NPs, MAs), socialworker, 5 administrative staff,volunteer law studentsCircle Health Services’Syringe Exchange ProgramIntravenous drugs users in Cleveland,Ohio, who are at risk for contracting orspreading HIV and Hepatitis COne-for-one syringe exchange, rapidHIV and Hepatitis C screenings, fluvaccinations, health education,provision of free harm reduction kits2 outreach workers, 2 volunteers pertrip, 1 part-time RNRemoveLogisticalBarriersParkland Hospital’sHOMES ProgramHomeless adults and youth in DallasCounty, TexasMedical, dental, and behavioral healthcare; pharmaceutical assistanceRN, driver, physician or advancedpractice provider (e.g., MD, PA, NP)Fill Service GapMobile Care ChicagoChildren in Chicago, Illinois, withoutaccess to asthma specialty careMedical and preventive care,education, support2 NPs, 2 MAs, clinic technician;additional support from CHWs whohelp identify patients and conducthome visitsThe Health WagonUninsured or underinsured ruralpopulation in Southwestern VirginiaPrimary, preventive, dental, behavioralhealth, telehealth, and specialty care;pharmaceutical assistance and aidNurse-led clinical team (DNP, RNs,LPNs, NP), volunteer specialists fromstate academic institutionsIncrease TrustSource: Population Health Advisor interviews and analysis. 2017 Advisory Board All Rights Reserved8advisory.com

Successful Programs Start with a Clear, Population-Specific VisionIdentify Structural Barriers that Contribute to Health DisparitiesThree Common Goals to Guide Service DeploymentIdentify PurposeTrack Metrics thatAssess ProgressIncrease Patient TrustRemove Logistical Barriers to CareFill Service Gap in CommunityServe as a comfortable entry pointto the health system for patientswho may be disengaged ordistrustful of the health care systemBring care to consumers wherethey are to reduce burden oflogistical barriers (e.g., work hours,lack of transportation)Target highly prevalent conditionsor service lines for which there isinsufficient access Identification of undiagnosedchronic conditions Frequency of service interaction(e.g., number of visits) Number of referralsto primary care or specialtycare services New clients served Emergency departmentutilization and hospitalization fortarget condition Patients’ sense of community andsocial connectedness No-show appointments as apercentage of total scheduledappointments or sessions Frequency of acute episodes Average time to receive referralto specialistSource: Population Health Advisor interviews and analysis. 2017 Advisory Board All Rights Reserved9advisory.com

1. Increase Patient TrustVan Serves as Critical Community Access Point to Full Continuum of CareFocus on Prevention Preserves Role of Existing Provider Organizations in Offering Primary, Specialty CareThe Family Van Functions as “Knowledgeable Neighbor” to Connect Patients to High-Priority ServicesThe Family VanCommunity Health Centers Focus: entry point to engage vulnerable populations Provide traditional primarycare services Services: preventive screenings (e.g., blood pressure,blood glucose), education, referrals to CHCs and socialservices (e.g., food pantries, legal services) to addresspatients’ highest needs Often refer patients back toThe Family Van for ongoingeducation and care between visits 21Saved for everydollar invested inThe Family Vanreferred25% Patientsto follow-up healthor social servicesin FY2015 Staff: health educator, registered dietician, HIV tester andcounselor, assistant director, 2-3 volunteers, rotatingcollaborators (e.g., breastfeeding educator)Community-Based Organizations Address non-clinical and specialtyneeds identified by The Family Van Patient engagement: serve as “knowledgeable neighbor”– Staff speak languages common in community and aretrained in cultural sensitivitywho12% Patientslearned they had apreviouslyundiagnosedillness (e.g.,diabetes,glaucoma) Help patients overcome barriers (e.g.,food insecurity, housing andemployment needs)– Patients prioritize what they’d like support with– Community input determines service offeringsHarvard Medical School’s The Family Van Mobile clinic run by Harvard Medical School that travels to vulnerable neighborhoods in Boston, MA Services include preventive screenings, health education, and referrals to social services. The program has also developed deep, reciprocal relationshipswith local CHCs and community-based organizations who provide other clinical, non-clinical services To overcome distrust of health care system, leverage reputation as “knowledgeable neighbor” to engage community members, ensure that services providedare those identified as being highest need by patients themselves, and rely on rotating collaborators from partner organizations address specific needs ofcommunity (e.g., STD education and breastfeeding instruction) Approximately one-third of patients visit the mobile clinic two or more times in a year and one-third were referred by family or a friendSource: Population Health Advisor interviews and analysis. 2017 Advisory Board All Rights Reserved10advisory.com

Partnership Pairs Clinical and Legal Support for Children and FamiliesCultural Competency Efforts Integrated into Staffing, Marketing, and Service Delivery to Build TrustSocial Worker Serves as Liaison Connecting Patients to Legal SupportChildren with only clinical needsChildren with legal needsClinical CareSupplemental Social ServicesLegal ServicesPediatric Mobile Clinic (PMC)Social Worker LiaisonHealth Rights Clinic (HRC)Services Offers physicals, immunizations,screenings, chronic illnessmanagement, behavioral healthsupport, urgent care, referrals Connects patients with legal support,assists with Medicaid enrollment;handles 75-80% of legal issues andrefers more complex cases to HRC Provides free legal aid to PMCpatients; cases typically relate toimmigration, special educationplacements, public benefitsCulturalcompetency efforts Hiring priority given to staff whoare proficient in patients’ firstlanguages; partner with ethniccommunity groups (e.g., Centerfor Haitian Studies) Bilingual to meet needs ofSpanish-speaking patients Brands law student volunteers asUniversity of Miami staff to buildon trusted relationshipCase in Brief: Holtz Children’s Hospital’s Pediatric Mobile Clinic 126-bed children’s hospital located at the University of Miami/Jackson Memorial Medical Center in Miami, Florida; part of Jackson Health System Mobile clinic provides clinical care, preventive services, and social support to uninsured children up to 21 years of age; serves large immigrant population Developed partnership with the University of Miami School of Law’s Health Rights Clinic to pair free medical care with pro-bono legal services that targetissues related to immigration, public benefits, and special education placements Staff refer at-risk patients to social worker liaison, who triages cases to the HRC; 75-80% of cases can be handled by social worker without HRC Serve approximately 2,400 patients annually through more than 600 behavioral health encounters, 1,000 social services, and 3,000 immunizationsSource: Population Health Advisor interviews and analysis. 2017 Advisory Board All Rights Reserved11advisory.com

Syringe Exchange Program Offers Harm Reduction ServicesPrivacy of Utmost Concern to Stigmatized PopulationThree Ways Circle Health Fosters a Culture of Safety and TrustConvenient Locations Parking sites to selected to preserve privacy while remaining convenientMultiple care sites available to let clients visit where they feelmost comfortableRelatable Staff Staffed by two non-clinical outreach workers; former addicts themselvesOutreach workers trusted by clients to recommend screening services(e.g., HIV and Hepatitis C rapid tests) and recovery programs11-18 years of experience serving on the vanEmphasis on Privacy Clients provided with anonymous identification codes to track servicesprovided, frequency of usage, distance travelledCode language for syringe and testing services in sta

Survey by Harvard Medical School’s Mobile Health Map Mobile health 2,000 clinics in the U.S. Average operational cost of a mobile program per year 429K Average return for every dollar invested in mobile health Estimated mobile 12 health clinic visits annually 6.5M To provide accessible health care services for vulnerable

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