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Comparative Analysis

Mobile Clinics: Optimizing Access to Preventive CareMICKELDER KERCY, MD

TEACHERS COLLEGE COLUMBIA UNIVERSITY

Key Issues in the U.S.

Haitian Population

Evaluation Plan

Access to Preventive and Coordinated Care

•Kings County Hospital Center: Plan to acquire a mobile van that will increase

access to health screenings and health education services as well as direct referrals for

additional care in the hospital setting.

•Literature: Mobile clinics are unequivocally successful at increasing access to preventive

health care services and routine management of certain health conditions. Even when care

is readily accessible, mobile clinics present an opportunity to seek services from unfamiliar

faces, which eliminates the fear of potential disease related discrimination.

Cost Containment

•Kings County Hospital Center: Potential health care savings due to the mobile clinic.

•Literature: Estimated return on investment is 2.1 (Hill et al., 2014).

Quality Care & Sustainability

•Kings County Hospital Center: No clear evidence of the long-term goal of the mobile clinic

to accommodate the needs of community members to receive assistance on how to be

empowered to prevent disease and manage their health in their own living environment.

•Literature: Mobile clinics has been resourceful to community members of underserved

communities, especially the male population who does not typically seek health care services

at hospital or in clinical settings. The Knowledgeable Neighbor Model is an ideal framework

to accomplish these goals.

In the capacity of a Community Health Educator and Researcher Consultant:

•Collaborate on a 3 year health equity project with the Kings County Hospital leadership

team members, the pastors of the churches located in the zip codes with the highest

agglomeration of Haitians and Haitian-Americans (18 years and older), and the

stakeholders at organizations such as the Haitian-American Community Coalition

(HCC) (n.d.) and the Haitian-American Caucus (n.d.).

•Assist in creating the logic model, planning the budget, and formalizing the hiring

process of the personnel and volunteers.

•Facilitate the training of community-based staff members in cultural competence and

motivational interviewing, based on the Knowledgeable Neighbor Model.

Workforce

•One program manager, one physician, two nurses, two health educators, one social

worker, and one medical assistant would be providing services to be reimbursed mainly

based on performance and quality measures.

•Volunteer students in public or community health reaching out to the population using

social marketing principles and delivering health education activities.

•Volunteer international medical graduates, medical students, and or nursing students

would primarily be screening community members for their medical and non-medical

concerns, and enabling them to use their blood pressure machines and glucometers.

Description of

Organization/ProgramNew Program Plan

Kings County Hospital Center

•University-affiliated hospital providing a wide range of simple to highly complex care

services to vulnerable populations in Brooklyn.

•A) Emergency department visits: 35% uninsured versus 40% Medicaid patients.

•B) Clinic visits: 39% uninsured versus 39% Medicaid patients.

•Member of the New York Health Hospital Health (HH) group – The Uninsured account

for $698 million in uncompensated care annually at HH.

•Report (2013) – Top priorities: Preventing and managing chronic diseases.

Program

•Hospital: Streamline patient appointment process, infrastructure expansion and remodeling,

increase patient visits frequency, employ more dieticians, and decrease readmission.

•Mobile health van: Health screenings, health education, and hospital referrals.

Literature Review

Study 1: Hill et al. (2012)

•Introduction: Low-income populations need preventive and cost-beneficiary services.

•Methods: Knowledgeable Neighbor Model - Staff members are integral members of the

community; and trained in cultural competency, and motivational interviewing.

•Results: Family Van Mobile Clinic - From 2006 to 2009, 5898 community members

(Massachusetts) received care, 65% self-identified as blacks, 82% were uninsured, 6%

spoke Haitian Creole, 23% screened for High blood pressure, 11% with pre-diabetes, and

3% with high blood sugar.

•Conclusion: Increased access to cost-effective and high-quality preventive care to

insured male who typically do not seek health care.

Study 2: Luke and Castañeda (2013)

•Introduction: Farmworkers are “a medically underserved population in the U.S”. What are the best partnership practices to successfully reach out to them using mobile clinics?

•Methods: Literature review (January 1, 1990 – July 24, 2012) – PubMed and CINAHL

•Results: 18 articles. Based on the Community Coalition Action theory, successful mobile

clinic efforts are due to strategic partnerships between the nursing or medical school

leading the project with a variety of stakeholders; community-based engagement; and the

formal development, implementation, and evaluation of projects.

•Conclusion: Mobile clinics sustainability results from strong collaboration between the

lead agency and stakeholders such as academic institutions and local organizations.

Study 3: Gibson et al. (2014)

•Introduction: The literature is scarce about “the spatial distribution of MMC [mobile

medical clinics] clients, healthcare service utilization, and frequency of MMC usage”.

•Methods: The statistical software ArcGIS 10.1 was used to map the distribution of the

people served at the Community Health Care Van in New Haven (Connecticut). The

distribution data was compared to the services they were receiving. The relationship

between the distribution data and the frequency of visits to the van was estimated.

•Results: In total, 8404 people with documented addresses received some care at the

mobile clinic (January 2004 - December 2012). Most people (300-500 per census tract)

were living within 8 to 10 miles from the van, congruent with the theory of distant decay.

However, “most frequent visitations occurred between 11 and 20 miles”. Based on a

novel framework combining the Health Behavior Model, the theories of health

geography, and the Penchansky’s and Thomas’ five domains of health care access, need

factors were linked with the higher-frequency usage of services from distant clients.

•Conclusion: Proximity was a major determinant in accessing the van for some people.

Individuals who lived far away sought health care services at the van because of need

factor and to potentially avoid stigma and discrimination.

Implementation Plan

First 6 months

•Recruitment and training of the personnel and volunteers to deliver service exclusively to

local church members.

Following 6 months

•Beginning of the neighborhood community outreach on 3-5 days per week, based on

available human capital, workload, and budget capacity. The mobile clinic is stationed in

areas of high traffic such as the Nostrand avenue in the Flatbush neighborhood.

Policy Recommendations

Formative and Summative Evaluation Processes

(Access to care, Perception of quality of care, Cost-Effectiveness, and Sustainability)

•Quarterly analysis of the management information data to inform the logic model revision.

•HCAHPS-like surveys in different languages administered to each participant.

•Random sample of 40% of participants - Perception of the quality of care at the van

•Proportionate stratified random sampling of church members - Workshops assessments

•Amend the sponsor’s affidavit of support (USCI form I- 864) (Scherzer et al., 2010). •Enact laws making immigrants eligible for Medicaid within the first 5 years of residency.

Thanks to Dr. Nicole Harris-Hollinsworth for her instructional support on this project.

Acknowledgment