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Service Delivery Innovation Profile

Mobile Clinics Increase Access to Screening Services in Rural and Frontier Communities


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Snapshot

Summary

The Improving Health Among Rural Montanans (IPHARM) program works with local partners in rural and frontier communities to identify and train pharmacists and students from various disciplines on how to administer screening tests for osteoporosis, diabetes, hyperlipidemia, hypertension, and lung function and then transports screening equipment to these areas to be used during screening clinics that are held for low-income and underserved populations. Data suggest that the program has enhanced access to health care screenings, identified unmet health needs, and increased the number of trained professionals in remote locations.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the amount and type of screening services provided and the number of professionals trained. The underlying assumption is that, in the absence of this program, many participants (who generally live in remote, underserved areas) would not have had access to these services.
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Developing Organizations

University of Montana School of Pharmacy and Allied Health Sciences, Missoula, Montana
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Use By Other Organizations

The University of Minnesota College of Pharmacy-Duluth has employed a similar model of providing screening services to geographically and/or economically underserved populations living in northeast Minnesota and northern Wisconsin in its "Wellness Initiative of the Northland" project. Initiated in 2005, College of Pharmacy faculty partnered with local Federally Qualified Health Centers, critical access hospitals, parish nurses, and Rotary Club International chapters to plan and conduct approximately 15 to 20 screening clinics each year, half of which are conducted in remote rural communities, serving 30 to 90 people per session. The partnership obtained funding for equipment through a private foundation, and received continued funding through donations from philanthropic organizations and patient donations.

Date First Implemented

2002
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Patient Population

Vulnerable Populations > Impoverished; Rural populationsend pp

Problem Addressed

Individuals who live in rural areas are at higher risk for specific illnesses and have more limited access to care than do those who live in less remote locations. Rural health care systems, challenged by the size of the area they serve and chronic physician shortages, often struggle to provide all the services that residents need and consequently must rely on referrals to nonphysician providers for services that they cannot easily offer.1,2,3,4
  • Increased risk of illness: Rural residents are generally older, more restricted in their activities, and more likely to report being in fair or poor health than are residents of less remote locations. In rural areas where agriculture, mining, forestry, and/or fishing are central to the economy, residents are exposed to health hazards such as pesticides and potentially dangerous machinery, leading to higher rates of injury and illness.1,2
  • Less access to care: Rural residents have less access to regular primary care providers and are less likely to receive timely care. Rural residents are also more likely to be uninsured than are urban residents.1,2,3
  • Need for external support: Rural health care systems frequently depend on external support to address difficulties associated with delivering health care.2 For example, using community pharmacists to provide screening services has been found to increase access in these areas.4

What They Did

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Description of the Innovative Activity

The IPHARM program works with local partners in rural and frontier communities to identify and train pharmacists and students from various disciplines on how to administer screening tests for osteoporosis, diabetes, hyperlipidemia, hypertension, and lung function and then transports screening equipment to these areas to be used during screening clinics that are held for low-income and underserved populations. Key elements of the program are described below:
  • Local collaborations to identify needs and recruit volunteers: IPHARM staff partner with county health departments, Federally Qualified Health Centers, area health education centers, and local pharmacies to identify screening needs, coordinate logistical arrangements for screening clinics, and recruit volunteer providers (e.g., local pharmacists and students) to staff the clinics.
  • Ongoing training and supervision: In the first year of the program, onsite training on use of the screening equipment was negotiated into the equipment's purchase price. Currently, new volunteers attend a full-day training session on how to conduct screenings and how to counsel patients before and after the tests. Onsite supervision during the clinics supplements this training. To ensure that supervision is rigorous, the program assigns one supervisor for every two volunteers.
  • Screenings in diverse community locations: In its first year, the program conducted screenings in selected areas of northwest Montana, using a motor home purchased for the IPHARM program. The program now holds screening clinics across the state, using university vehicles to transport the equipment to locations identified by stakeholders in the communities.
    • Marketing and logistics: Partners in the host community advertise upcoming clinics, identify interested participants, and schedule appointments. Although the clinics accept walk-ins, scheduling helps IPHARM arrange the necessary staffing and supplies in advance.
    • Individualized services: The length of screening clinics and the number of individuals screened varies according to community needs and interests. The number of individuals served in a given clinic has ranged from 20 to 150, with approximately 15 minutes allotted per test and the typical patient receiving two or more tests.
    • Multiple stations to deliver screenings: Up to five stations provide services during the screening clinics. Individuals first come to the intake station for a short history and to determine which tests might be appropriate. For example, staff typically do not offer screening for osteoporosis to women under the age of 40 years unless special circumstances exist that justify the test. After identifying which tests the patient needs and is interested in receiving, staff note the tests on an intake form that patients then take to the appropriate stations. At each station, trained volunteers conduct the specific screening test and immediately provide the patient with results. Patients whose screening results are outside of the normal range are referred to their primary health care provider for followup, and/or are given recommendations to address the issue (e.g., increasing calcium intake to reduce the risk of osteoporosis).
    • Patient privacy: Staff at the intake station review privacy issues with patients and obtain a signed release form before conducting screening tests. A unique identifier is generated for each patient. The IPHARM program keeps a confidential record of each patient's age, gender, type of tests administered, and whether the results were within the expected range.

Context of the Innovation

Faculty from the University of Montana School of Pharmacy and Allied Health Sciences have long been involved in initiatives to further the school's mission of training pharmacists to provide care to underserved populations in rural communities. Beginning in 1993, pharmacy faculty members established advanced clinical rotations and scheduled regular visits to pharmacies in remote locations to provide support and mentorship in rural communities. In 2001, faculty learned of Senator Conrad Burns' efforts to secure funding for a rural health initiative and approached him with the idea of developing mobile screening clinic services. The program was made possible as a result of funding secured through a Federal appropriations earmark.

Did It Work?

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Results

Post-implementation data suggests that the IPHARM program has enhanced access to health care screenings, identified unmet health needs, and increased the number of trained professionals in remote locations.5
  • Enhanced access to care in remote locations: During the first 10 months of the project, IPHARM staff conducted 36 clinics in 16 counties, providing 2,525 screening tests to 1,525 individuals. Over 70 percent of those screened lived in rural or frontier communities. Over the first 6 years, staff conducted 215 clinics, traveling 55,500 miles across Montana to provide screenings to 7,400 individuals. More than 80 percent were aged 65 years or older.
  • Identifying unmet health needs: Bone density tests were the most requested screening test, with 78.8 percent of patients undergoing the test and 36 percent of the tests showing results outside of the normal range. Because host communities could not afford the equipment needed to conduct bone density screening, it was generally not available before development of the IPHARM program.
  • More trained professionals: IPHARM has trained 228 pharmacy students. The training program has expanded to include other professions, and, thus far, eight nursing, five physical therapy, and three social work students have also been trained. Anecdotal evidence suggests that some students trained through IPHARM have started working in remote locations and include screening among the services they provide.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the amount and type of screening services provided and the number of professionals trained. The underlying assumption is that, in the absence of this program, many participants (who generally live in remote, underserved areas) would not have had access to these services.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Needs assessment: IPHARM staff examined 2002 county census data to identify eight counties most in need of screening services. Compared with other counties in Montana, those selected had more senior citizens, lower-than-average levels of education and median household and per capita income, and above-average rates of poverty. Project staff joined with the health departments in the selected counties to identify the types of screening services that were most needed. For example, high rates of tremolite asbestos exposure in the city of Libby led to the decision to offer spirometry testing of lung function to patients who had a history of respiratory disease or who reported having trouble breathing.
  • Securing screening equipment: Based on the needs assessment, project staff secured the following clinical testing equipment: an ultrasound unit to test heel bone density; diagnostic systems to test cholesterol, glucose, and lipids; blood pressure machines; and a spirometer to test lung function. Each piece of equipment allowed for the test to be conducted and interpreted with relative ease and offered patients immediate results.
  • Acquisition of motor home: During the first year of operation, the program purchased a motor home to transport screening equipment and house mobile screening clinics. The motor home was equipped with items needed to live and work, including eating utensils, office supplies, and satellite communications equipment. The program took the motor home out of use in the second year due to financial considerations, such as the rising costs of gasoline. As noted, the program now uses university vehicles to transport the equipment to clinic locations within the communities served.

Resources Used and Skills Needed

  • Staffing: The IPHARM program consists of a director and full-time clinical pharmacy specialist who oversees and manages program operations. Between three and six students are recruited for each screening clinic, depending on expected participation. Along with the program manager, one or two local or university-affiliated pharmacists supervise the services provided during each clinic.
  • Costs: The program's annual operating budget is approximately $150,000, which covers staff salaries and benefits, operation of testing equipment, supplies, and travel expenses. Program development costs, including the purchase of screening equipment, cost nearly $500,000 (see below for more details on the source of this funding).
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Funding Sources

Health Resources and Services Administration; University of Montana School of Pharmacy and Allied Health Sciences, Missoula, Montana; Montana Geriatric and Education Center
This program received a 1-year grant for $488,577 from the Health Resources and Services Administration, Office for the Advancement of Telehealth to support program development, including the purchase of screening equipment. Currently, the program is partially supported by a $200,000 grant from the Montana Geriatric and Education Center and internal funding from the University of Montana. Patients who can afford to pay are charged $15 per test, with tests provided for free or on a sliding scale to those unable to pay the full amount.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Start small by focusing on gaps in services: Initially, IPHARM staff worked with key community stakeholders in eight counties to understand residents' health care needs and identify gaps in existing services. The University's Pharm.D. program initially focused on a few screening tests that the local population clearly needed; the program is careful not to duplicate existing services, which would compete with established revenue streams in the community.
  • Work closely with community representatives: Working with local representatives can help identify strategies to reach underserved populations. For example, collaborations allowed IPHARM staff to reach migrant workers and Native Americans by gaining access to community events such as Pow Wows.
  • Recruit and train volunteers, offering incentives for participation if possible: The program recruits volunteers through local community partners and the University of Montana. Students in the University's Pharm program receive credit for their participation as a part of the requirements of their clinical rotation. Students may also earn a certificate in Geriatric Health Screening by completing additional training requirements.
  • Seek administrator support: Recognizing the benefits of the IPHARM program, administrators at the University of Montana have supported the program in a number of ways, including identifying internal and external funding sources and facilitating community partnerships.

Sustaining This Innovation

  • Identify a champion to oversee the program: Securing a program manager with strong supervisory and management skills and an entrepreneurial spirit is key to the ongoing success of the program. In addition to his or her role in developing the program, an effective program manager can ensure long-term success by building strong community collaborations; effectively recruiting, training, and coordinating volunteer staff; and continually searching for ongoing support.
  • Use analyses to identify potential funding sources: For example, by analyzing service utilization data, staff recognized that 80 percent of those served are 65 years or older. This information proved useful in securing local funding from the Montana Geriatric and Education Center.

Use By Other Organizations

The University of Minnesota College of Pharmacy-Duluth has employed a similar model of providing screening services to geographically and/or economically underserved populations living in northeast Minnesota and northern Wisconsin in its "Wellness Initiative of the Northland" project. Initiated in 2005, College of Pharmacy faculty partnered with local Federally Qualified Health Centers, critical access hospitals, parish nurses, and Rotary Club International chapters to plan and conduct approximately 15 to 20 screening clinics each year, half of which are conducted in remote rural communities, serving 30 to 90 people per session. The partnership obtained funding for equipment through a private foundation, and received continued funding through donations from philanthropic organizations and patient donations.

More Information

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Contact the Innovator

Donna Beall, PharmD, BCPS
Associate Professor, Pharmacy Practice
University of Montana-Missoula
32 Campus Drive
Missoula, MT 59812-4680
Phone: (406) 243-4237
Fax: (406) 243-4353
E-mail: donna.beall@umontana.edu

Timothy Stratton, PhD, BCPS, FAPhA
formerly from University of Montana-Missoula
Professor, Department of Pharmacy Practice and Pharmaceutical Sciences
University of Minnesota
209 Life Science
Duluth, MN
(218) 726-6018
E-mail: tstratto@d.umn.edu

Innovator Disclosures

Dr. Stratton reported that the University of Minnesota received funding from the Office for the Advancement of Telehealth and reimbursement for travel-related expenses related to this profile. In addition, the Miller-Dwan Foundation also provided funding for Wellness Initiative of the Northland project.

Dr. Beall has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

Footnotes

1 Ormond BA, Wallen S, Goldenson SM. Supporting the rural health care safety net. Washington, DC: Urban Institute; 2000.
2 Ricketts TC. The changing nature of rural health care. Annu Rev Public Health. 2000;21:639-57. [PubMed]
3 Casey M, Thiede K, Klingner JM. Are rural residents less likely to obtain recommended preventive healthcare services? Am J Prev Med. 2001;21(3):182-8. [PubMed]
4 Hourihan F, Krass I, Chen T. Rural community pharmacy: a feasible site for a health promotion and screening service for cardiovascular risk factors. Aust J Rural Health. 2003;11(1):28-35. [PubMed]
5 Stratton TP, Williams R, Meine KL. Developing a mobile pharmacist-conducted wellness clinic for rural Montana communities. J Am Pharm Assoc (2003). 2005;45(3):390-9. [PubMed]
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Original publication: October 13, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 29, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: January 17, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.