Mobile Clinic Provides Comprehensive Medical Home for Homeless and At-Risk Youth, Reducing Use of Emergency Department and More Followup Care

Problem Addressed

• Many youth affected: According to the National Alliance to End Homelessness, between 5 and 7.7 percent of youth in America experience periods of homelessness each year.¹ Unaccompanied youth account for 1 percent of the urban homeless population.² An estimated 1,780 Arizona residents under the age of 18 are homeless and live on their own.³
• Risky behaviors: Homeless youth are more likely to become involved in prostitution, use and abuse drugs, and engage in other dangerous behaviors, putting them at increased risk of physical harm due to violence and infectious diseases such as HIV/AIDS.¹
• Illness prevalent, with little access to care: Homeless youth often suffer from depression and anxiety, poor health and nutrition, and post-traumatic stress disorder.² The lack of financial and other resources make it difficult for these youth to receive the care and treatment they need.

Description of the Innovative Activity

• Target population: Crews’n Healthmobile provides services to individuals 24 years of age or younger who are homeless or considered “at risk.” Among others, at-risk groups include those living in shelters, group homes, hotels, or cars, and those being evicted from their homes. Services are free to homeless and at-risk youth, children, and young families. Patients receive eligibility screening and assistance with insurance acquisition through Arizona Health Care Cost Containment System, the state's Medicaid program. 
• Fixed site and mobile services at easy-to-access community sites: The program provides services from a fixed site and a mobile medical unit. The fixed site clinic offers care 4 days a week at partner agency HomeBase Youth Services. Medical street outreach provides services from a 38-foot van that houses two fully-equipped exam rooms, a registration area, and a bathroom. At any given time, the van is staffed by a team comprised of a physician or nurse practitioner, a nurse, and a case manager. The van parks Monday through Friday at numerous Phoenix-area sites where homeless and other at-risk youth are known to gather. Potential sites include the United Methodist Outreach Ministry Shelters, the Church for the Nations, New Foundations, Watkins Shelter for the Homeless, Children First Academy, and on the streets in Tempe, Arizona. The program currently offers eight medical clinics, one psychiatric clinic, one immunization clinic, one developmental/ behavioral assessment clinic, and one vision and hearing screening clinic per week. 
• Comprehensive medical home: The clinic provides a comprehensive medical home, with program staff and partnering agencies working together to coordinate medical and nonmedical services needed by each patient. The Crews'n clinics not only provide care, but also serve as an entry point for additional services to help youth and young families get off the streets and live healthy lives. Core components of the medical home include the following:
  • Medical care: The mobile clinic provides patients with a full array of medical services, including but not limited to full physical examinations and well-child care, immunizations, medications, acute care, primary and preventive care, and minor surgical procedures. Medical practitioners from Phoenix Children’s Hospital staff the clinic at all times, with residents and medical students from Phoenix Children’s, St. Joseph’s Hospital, and Banner Good Samaritan Medical Center rotating through on a periodic basis.
  • Behavioral health screening and counseling: New patients between the ages of 12 and 24 are screened for behavioral health issues using the HEADSS (Home, Education, Activities, Drug use and abuse, Sexual behavior, Suicidality and depression) interview tool,⁴ with all staff—including case managers, nurses, nurse practitioners, and physicians—being trained to conduct this screening. Patients identified with behavioral health issues, such as depression or a history of abuse, can receive evaluations, treatment, and medications from the program’s Psychiatric Nurse Practitioner.
  • Referrals to partner agencies: Crews’n Healthmobile partners with a number of community agencies to provide holistic and comprehensive care. Mobile clinic staff refer patients to these agencies based on individual needs and will assist patients in making and keeping appointments as necessary. For example, HomeBase Youth Services provides case management services, educational assistance, and transitional and independent living facilities for youth 18-21 years old. The United Methodist Outreach Ministries New Day Centers provides bilingual shelter and services to women and children affected by family violence and to families without a home. The Tumbleweeds Center offers emergency shelter, transitional living, and case management services to younger patients (up to age 17). Patients receive comprehensive routine and emergency dental care through the dental clinic at downtown Phoenix’s Human Services Campus and a mobile program known as Community Dental.
  • Health education: Mobile clinic staff educate and counsel patients on a variety of issues including drug, alcohol, and tobacco use, sexually transmitted diseases, depression, anxiety, pregnancy, smoking cessation, nutrition, safety, relationships, and self care. In addition, program staff train staff at partner agencies to provide similar services. For example, Crews'n staff teach classes on sexually transmitted diseases at a diversion program for males and females involved in prostitution. They also offer classes on blood-borne pathogens and medication training for HomeBase Youth Services and the Tumbleweed Center for Youth Development. 
• Up-to-date technology: The mobile clinic has a satellite tracking dish, wireless Internet access, and a fully operational electronic medical records system that uses laptop computers and handheld devices, thus allowing program staff to maintain secure and detailed medical records without transporting cumbersome paper files. The system is maintained jointly with the Children's Health Fund, a partner agency. The mobile clinic’s wireless capability also allows patients to apply onsite for Medicaid coverage via an online application process.

References/Related Articles

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Results

• Less ED use: ED visits among program participants who accessed clinic services three or more times fell by 27 percent, from 1.5 visits to 1.1 visits over a 6-month period. This data was gathered from screening interviews conducted with 835 new and returning patients from 2005 to 2007.  
• More followup care: An analysis of patient records shows that 72 percent of program participants attended followup care appointments arranged by the clinic in 2007, up from 51 percent in 2006. This increase reflects the program’s growing emphasis on case management.
• Highly satisfied patients and providers: Patients report feeling safe and comfortable accessing services from the mobile clinic, and many have returned on multiple occasions for care, a surprising finding given the transient nature of the population served. ED physicians report high levels of satisfaction with the program, particularly its ability to reduce ED visits.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Obtaining seed money: Partner agencies sought and received a $460,000 seed grant from the Flinn Foundation designed to cover purchase of the van and operating costs for the program's first 3 years. 
• Researching the model: Partner agencies researched national programs and best practices and gathered local data to better understand the problem. This information helped in designing clinic services to best meet the specific needs of homeless and at-risk youth in the Phoenix area.
• Building staff: Originally staffed by several Phoenix Children’s Hospital employees with the help of occasional volunteers, the clinic created job descriptions and revised program goals based on the needs of patients. Staffing levels doubled within 2 years of opening. In 2006, after determining that nearly half of patients suffered from mental illness, clinic leaders sought grant funding to hire a part-time psychiatric nurse practitioner.
• Training: Staff initially received informal, on-the-job training. New employees, volunteers, and students now receive orientation and formal training through Phoenix Children's Hospital and HomeBase Youth Services.
• Updating equipment: In 2007, Children’s Health Fund donated a new 38-foot medical van to the program, after the first van began having mechanical problems.

Resources Used and Skills Needed

• Staffing: Crews’n Healthmobile maintains a staff of 11, including one part-time and two full-time physicians, one full-time nurse practitioner (who also serves as program director), one part-time and two full-time nurses, two part-time case managers, one full-time office manager, and one part-time Psychiatric Nurse Practitioner. All 11 are employees of Phoenix Children’s Hospital. Numerous residents and medical students also provide services on a rotating basis at the clinic, while staff from partner agencies throughout Phoenix also contribute hours to the project.
• Costs: In 2008, the program had an operating budget of just over $1,000,000 to cover staff salaries and benefits, supplies (including information technology, medical, nonmedical, and office), licensing fees, medicine, equipment, fuel, van repairs and maintenance, and outside services for radiology, vision, and hearing.

Funding Sources

Medtronic; Phoenix Children's Hospital; HomeBase Youth Services; Children's Health Fund; Virginia G. Piper Charitable Trust; Flinn Foundation; Legacy Foundation; Health Care for the Homeless; Idol Gives Back; Ellis Family Trust; McKesson; Monroe Trust Premier Cares; Kiwanis International; United Methodist Outreach Ministries; Phoenix Jaycees

Getting Started with This Innovation

• Advocate for the program: Contact and/or meet with local, state, and Federal legislators and agencies to secure funding and publicity for the program. If possible, join a local or state-level task force on homelessness to raise awareness and build community support.
• Utilize expertise of those running similar programs: Seek the advice and counsel of those running mobile clinics elsewhere in the country, particularly with respect to logistical issues such as record-keeping and electronic systems.
• Build community partnerships: To meet the medical and nonmedical needs of patients, seek out and partner with local service agencies that provide assistance in areas such as transitional housing, job training, and education.

Sustaining This Innovation

• Focus on outcome measurements: Determine specific outcome targets and develop tracking and database systems that describe the target population and demonstrate the program's impact.
• Determine essential staff roles: Identify the duties required to run the program, analyze staffing patterns, and reassign duties as needed. In the case of Crews'n Healthmobile, the program determined that maintaining a staff member whose sole responsibility was driving the mobile medical unit was not cost-effective. Instead, the driver needed to also perform patient registration, screen for insurance eligibility, manage clinics, and stock and maintain van. In turn, the program's health care providers have also learned to drive the mobile unit. 
• Seek new sources of funding: Look beyond foundations for additional funding by leveraging staff talent and expertise. Consider creating educational modules or offering formal training sessions to other agencies as a way to raise funds. Partner with organizations requesting your services to share resources and funding.
• Track funding flows: Keep careful records and know how every dollar is being used. Track costs per patient and determine average costs per clinic.
• Keep open lines of communication: Holding regular meetings for staff and partnering agencies to discuss new ideas and challenges helps to keep everyone informed, engaged, and empowered as representatives of the program.