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Service Delivery Innovation Profile

Mobile Clinic Delivers Culturally Competent Services to Underserved Neighborhoods, Leading to Identification of Untreated Chronic Conditions, Better Blood Pressure Control, and Significant Return on Investment


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Snapshot

Summary

A mobile clinic known as the Family Van provides free screening, education, coaching, and health navigation services to residents of four underserved communities in Boston who face numerous barriers to accessing care. Community members, organizations and local providers refer patients to the clinic, with no appointments needed. A health educator, dietician, and HIV counselor provide a variety of screening and counseling services in a culturally and linguistically competent manner within a welcoming physical environment. Patients in need of additional diagnostic or treatment services receive referrals to their primary care providers, community health centers, and other local providers as appropriate. The program has identified many clients with previously undetected chronic conditions; improved blood pressure control and reduced the risk of heart attack and stroke among those with hypertension; and generated a significant return on investment (estimated at 30 to 1).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of blood pressure in patents with hypertension and the associated impact of such changes on the risk of heart attack and stroke. Additional evidence includes post-implementation data on the proportion of clients with previously undetected chronic conditions and estimates of the return on investment generated by the program.
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Developing Organizations

Beth Israel Deaconess Medical Center; Harvard Medical School
Beth Israel Hospital (now part of Beth Israel Deaconess Medical Center) is located in Boston, MA. Since 2001, the Family Van has been operated by Harvard Medical School.end do

Date First Implemented

1992
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Patient Population

Race and Ethnicity > Black or african american; Hispanic/latino-latina; Vulnerable Populations > Impoverished; Racial minoritiesend pp

Problem Addressed

Low-income racial/ethnic minorities often lack access to high-quality health care and consequently suffer disproportionately from chronic health conditions. Although mobile health units offer the potential to provide culturally competent, convenient care to these individuals, few organizations emphasize use of these vans as a source of care for vulnerable populations.
  • Limited access to high-quality care: Low-income minorities are significantly less likely than other populations to receive needed preventive health services.1,2,3 For example, the 2012 National Healthcare Disparities Report found that African Americans were significantly less likely than Whites—and Hispanics significantly less likely than non-Hispanic Whites—to receive evidence-based services, as suggested by lower scores on approximately 40 percent of process-of-care quality measures included in the report.1 Factors driving this disparity include lower levels of health literacy and trust in providers, financial and logistical challenges, and difficulties communicating with providers regarding health care needs.3,4
  • Greater risk of chronic conditions: Low-income minorities are more likely to suffer from a variety of chronic illnesses, including diabetes, hypertension, and high cholesterol.5
  • Failure to leverage mobile clinics: Approximately 2,000 mobile health clinics currently operate across the United States, and they have a proven record of facilitating access to care and averting emergency department (ED) visits.3,6 Yet few health systems take advantage of these mobile clinics as a vehicle for serving vulnerable populations.3 

What They Did

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Description of the Innovative Activity

A mobile clinic known as the Family Van provides free screening, education, coaching, and health navigation services to residents of four underserved communities in Boston who face numerous barriers to health and wellness. Community members, organizations and local providers refer patients to the clinic, with no appointments needed. A health educator, dietician, and HIV counselor provide a variety of screening and counseling services in a culturally and linguistically competent, nonthreatening manner within a welcoming physical environment. Patients in need of additional diagnostic or treatment services receive referrals to their primary care providers, community health centers, and other local providers as appropriate. Key program elements are described below: 
    Mother outside of Family Van health screening clinic.

    Figure 1. A mom visits the Family Van in East Boston. Click the image to enlarge. Image courtesy of Mim Adkins. Used with permission.

  • Regular visits to four underserved communities: The Family Van regularly visits five locations in four underserved communities (Dorchester, Roxbury, Mattapan, and East Boston), according to an established schedule that operates 50 weeks a year. These communities were chosen because of the high prevalence of preventable chronic conditions (e.g., cardiovascular disease, diabetes, obesity, HIV, glaucoma) and related hospitalizations and ED visits among residents. (The Context of the Innovation section provides more details on the four communities.) The van parks in central locations (such as shopping centers and major intersections) so that it can easily be seen and visited by residents (see Figure 1).
  • Referrals from multiple sources: Community organizations such as community health centers, rehabilitation facilities, social service agencies, the Women, Infants and Children (WIC) program, churches, and childcare facilities post flyers about the Family Van and its schedule. Staff at these organizations also refer people to the van. Program staff generate referrals by bringing the van to local health fairs and other community events and by participating in local radio and cable television shows. Referrals also come via word-of-mouth advertising from residents who receive services from the van. 
  • Free culturally competent, nonjudgmental services in a welcoming environment: The Family Van offers free screening, education, coaching, and health navigation support, with no appointment necessary. As detailed below, services are provided in a welcoming, culturally competent, linguistically appropriate, nonjudgmental manner by trained staff from the local community who understand the challenges their patients are facing.
    Patients are seen inside the Family Van

    Figure 2. The Family Van provides a comfortable environment. Click the image to enlarge. Image courtesy of Mim Adkins. Used with permission.

    • Culturally competent staff in welcoming physical environment: All staff have been trained in how to uncover each client's particular social circumstances and cultural beliefs and how to tailor services accordingly. Following the “Knowledgeable Neighbor” model of care,3 Family Van personnel often live in the communities they serve and always strive to cultivate a friendly, nonjudgmental, comfortable, and warm atmosphere that invites local residents to seek care. To that end, they do not wear white coats, and the van itself is outfitted with carpeting and comfortable chairs so that it does not look or feel like a clinic (see Figure 2). Whenever someone arrives, staff ask about the purpose of the visit and describe the services available, letting the client decide which services they would like to receive.
    • Screening, education, coaching, and health navigation support: The van has a health educator, dietician, and HIV counselor. Van staff can provide screenings for blood pressure, serum cholesterol, blood glucose, obesity, HIV, depression, and vision, along with pregnancy testing, family planning services, and HIV counseling. Based on findings from any tests given, staff offer oral and written health education and conduct motivational interviewing and coaching related to diet, exercise, medications, health risks, and medical treatment. Through discussions, staff evaluate clients' health literacy and tailor discussions accordingly to ensure that clients understand the nature of their conditions and possible treatments. Staff also support clients in navigating the health system, including making appointments for followup care. Uninsured clients who may be eligible for public programs are referred to a city government office that can help them apply for coverage.
  • Referrals for diagnosis and treatment: All clients with positive screening results receive referrals to their primary care physician (if they have one) or a local community health center for formal diagnosis and ongoing treatment. These clients receive a card listing their screening results to share with other providers. For those with immediate needs, staff may recommend a visit to the ED or even call an ambulance. For those with less pressing acute care needs, they refer patients to local providers who can offer the needed services. At the end of each visit, staff encourage clients to return to the Family Van for additional education and coaching.

Context of the Innovation

Family Van staff provide information to residents.

Figure 3. Family Van staff provide outreach to potential patients. Click the image to enlarge. Image courtesy of Mim Adkins. Used with permission.

Located in Boston, Beth Israel Hospital is part of Beth Israel Deaconess Medical Center, which serves as the teaching hospital for Harvard Medical School. The impetus for this program began in the late 1980s, when a Beth Israel Hospital anesthesiologist (Nancy Oriol, MD) became concerned about Boston’s poor birth outcomes (above-average rates for both infant mortality and low–birth-weight babies) and the high incidence of preventable conditions among her patients. In an effort to bring better prenatal care to underserved populations, Dr. Oriol interviewed her patients to learn about the financial, language-related, and emotional barriers they face to accessing care. Later, she and a medical student (Cheryl Dorsey, MD, now president of the Echoing Green Foundation) interviewed residents in underserved Boston neighborhoods over a 2-year period about their preventive care needs. Based on these interviews, Dr. Oriol created the Family Van mobile health clinic (see Figure 3). As noted, the van serves four neighborhoods that are home to low-income, minority (often immigrant) populations with high rates of chronic disease. These neighborhoods include the following:
  • Roxbury: Half of residents are African American and 20 percent are Hispanic/Latino. The median household income is under $20,000, and many residents suffer from heart disease.
  • Dorchester: This ethnically diverse neighborhood has the highest rate of obesity in the Boston metropolitan area.
  • East Boston: Just under half of this area's residents are of Latino descent. The area is home to many uninsured immigrants and is characterized by high rates of substance abuse and sexually transmitted diseases.
  • Mattapan: The vast majority—over 90 percent—of residents are people of color (84 percent are African American, 7 percent are Latino, 3 percent are White, and 1 percent are Asian). Per capita income in this neighborhood is $14,800; the neighborhood has the highest rate of diabetes in Boston.

Did It Work?

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Results

The program has identified many clients with previously undetected chronic conditions, improved blood pressure control and reduced the risk of heart attack and stroke among those with hypertension, and generated an estimated return on investment (ROI) of 30 to 1.
  • Many previously undetected conditions: A study of 13,272 Family Van clients served between 2006 and 2009 found that many had previously undetected chronic health conditions, including hypertension (60 percent of clients), elevated blood glucose (14 percent), and high cholesterol (30 percent).   
  • Better blood pressure control, lower risk of heart attack and stroke: A study of 5,900 patients who visited the Family Van more than 10,000 times between January 2010 and June 2012 found that those who presented with high blood pressure at their initial visit experienced average reductions of 10.7 mm Hg in systolic blood pressure and 6.2 mm Hg in diastolic blood pressure, which translates into a 32.2-percent reduction in the risk of heart attack and a 44.6-percent reduction in the risk of stroke.6
  • Substantial ROI: A financial analysis of Family Van services in 2008 estimated that the van saved $3.1 million in avoided ED costs and calculated the annual value of life-years saved as a result of the van at $17.8 million, meaning that the program as a whole generated an ROI of 30 to 1.7 A separate analysis of savings from the aforementioned reductions in blood pressure equals nearly $1.6 million in avoided heart attacks, strokes, and ED visits.6

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of blood pressure in patents with hypertension and the associated impact of such changes on the risk of heart attack and stroke. Additional evidence includes post-implementation data on the proportion of clients with previously undetected chronic conditions and estimates of the return on investment generated by the program.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Partnering with community organizations: In each community, program leaders communicated with partners, including community health clinics, rehabilitation facilities, social service agencies, and food pantries, with regard to program design and implementation as well as referrals.
  • Identifying and validating need: As part of the interview process described earlier, Dr. Oriol elicited input from patients and community members about their needs and the ideal delivery model for meeting them. 
  • Obtaining and refitting van: The program initially leased a van from a community mobile mental health service. Later, program leaders raised money from corporations and foundations in Boston to purchase a van and refit it to create a welcoming environment that looks like the living room of a house, including adding carpeting and comfortable chairs.
  • Identifying convenient locations to park van: Program developers worked with local residents on designing the program and identifying convenient, easily accessible locations where the van should park within each community.
  • Pursuing grassroots marketing: Program developers visited and distributed flyers to community partners and other organizations, such as churches, schools, and childcare programs.
  • Adding services based on local needs: Program staff meet periodically to discuss any needs they may have observed and the merits and feasibility of adding new services to address them.

Resources Used and Skills Needed

  • Staffing: The program has seven staff members, including three managerial staff (an executive director, a program coordinator, and a grants manager) and four van-based staff: a manager of direct services, a health educator/certified nursing assistant (who also drives the van), a registered dietician, and an HIV tester and counselor (a rotating position staffed by local community health centers). One or two volunteers (typically medical or public health students) also work on the van.
  • Costs: Total development costs are unavailable; the van cost approximately $250,000 to purchase and refit, not including the costs of medical equipment. The annual costs of operating the program total $565,700, including staffing, disposable items needed for care, marketing materials, and gasoline.
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Funding Sources

Harvard Medical School
Harvard Medical School houses the program and pays for a portion of its costs. Other funding sources for the 2013-2014 fiscal year include the American Heart Association, Bank of America (Frank W. and Carl S. Adams Memorial Fund), Blue Hills Bank Charitable Foundation, Boston Scientific, Charles and Sara Goldberg Charitable Lead Trust, the Commonwealth of Massachusetts, Friends of the Congressional Glaucoma Caucus, Genzyme Corporation, Harvard University, Health Resources and Services Administration, Office of Minority Health, Hispanic Association of Colleges, Ludcke Foundation, Massachusetts Medical Society, St. Timothy's Parish, and TUFTS Health Plan.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Highlight studies proving positive outcomes: When seeking financial and institutional support for the program, it is important to highlight the evidence base showing that mobile health clinics have generated both positive health outcomes for underserved populations and a substantial ROI.
  • Elicit input from target population: Community members should provide input at every stage of the development process to ensure that the mobile clinic addresses their needs.
  • Partner with community organizations: Program developers should explain the mission of the mobile health clinic to potential community partners, including health centers, social service agencies, and other local organizations. The goal should be to develop mutually beneficial referral relationships. In addition, programs should hire community residents and train them to be community health workers.
  • Design van to feel welcoming: Designers should make the van feel inviting and less clinical by incorporating carpeting, comfortable chairs, and other design elements. This approach helps to create a welcoming atmosphere and ensure that community members are not intimidated at the prospect of seeking services.
  • Park in easily accessible locations: It is important to choose “high-traffic” areas that are easily accessible to pedestrians and those who rely on public transportation, such as a shopping center parking lot or a major intersection.

Sustaining This Innovation

  • Advertise successes: Program managers should continually highlight the mobile clinic’s successes by sharing anecdotes and quantitative data. This information helps to ensure ongoing support from referral sources and funders.
  • Approach organizations with similar mission: Corporations and organizations with similar public health missions may be willing to commit ongoing funding to the program.
  • Add services based on community needs: Program managers should review the experiences of patients and pay attention to reports from community partners to identify any new care needs. Managers should then add services to address these needs as appropriate.

Additional Considerations

Leaders of the Family Van program are spearheading a mobile health clinic collaborative research network (made up of 667 programs from all 50 States) that is gathering and analyzing data to develop an evidence base for this health care delivery model. As a result of this effort and the program's other advocacy initiatives, the Massachusetts Department of Public Health designated mobile health clinics as a statewide “best practice” in clinical–to–community linkages for prevention and management of chronic diseases.

More Information

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Contact the Innovator

Jennifer Bennet
Executive Director
The Family Van
Harvard Medical School
1542 Tremont Street
Roxbury, MA 02120
(617) 442-3200
E-mail: jennifer_bennet@hms.harvard.edu

Innovator Disclosures

Ms. Bennet reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.

Recognition

The program has received several awards:
  • Heart of Our Mission Award, American Heart Association (2013): Recipient Jennifer Bennet was selected for this award, which recognizes those who demonstrate incredible passion for the mission and dedication for building healthier lives. http://www.heart.org/HEARTORG/Affiliate/Waltham/Massachusetts/Home_UCM_FDA007_AffiliatePage.jsp
  • Dean’s Community Service Award, Harvard Medical School (2013): Dr. Nancy Oriol received this award in recognition of her outstanding efforts to serve the local, national and international community. https://mfdp.med.harvard.edu/awards
  • Mobile Healthcare Leadership Award, Mobile Health Clinics Association (2011): This award was given to Jennifer Bennet in recognition of her efforts to promote and serve the mobile healthcare sector through advocacy, education and research in order to increase access to care for all. http://www.mobilehealthclinicsnetwork.org/
  • Outstanding Outreach Educators Award, Massachusetts Department of Public Health (1999).

References/Related Articles

Harvard Medical School. The family van [Web site]. Available at: http://www.familyvan.org.

Hill C, Zurakowski D, Bennet J, et al. Knowledgeable Neighbors: a mobile clinic model for disease prevention and screening in underserved communities. Am J Public Health. 2012;102(3):406-10. [PubMed]

Oriol NE, Cote PJ, Vavasis AP, et al. Calculating the return on investment of mobile healthcare. BMC Med. 2009;7:27. [PubMed]

Song Z, Hill C, Bennet J, et al. Mobile clinic in Massachusetts associated with cost savings from lowering blood pressure and emergency department use. Health Aff (Millwood). 2013;32(1):36-44. [PubMed]

Footnotes

1 Agency for Healthcare Research and Quality. 2012 National healthcare disparities report. May 2013. Available at: http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/highlights.html.
2 United States Department of Health and Human Services. Health disparities: a case for closing the gap. June 2009. Available at: https://www.csms.org/upload/files/Cultural%20Competence%20section/Reports%20and%20Standards
/HCReform%20-%20Disparities%20Report.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
3 Hill C, Zurakowski D, Bennet J, et al. Knowledgeable Neighbors: a mobile clinic model for disease prevention and screening in underserved communities. Am J Public Health. 2012;102(3):406-10. [PubMed]
4 Agency for Healthcare Research and Quality. AHRQ News and Numbers: minorities, poor find communicating with doctors more difficult. June 2009.
5 Mead H, Witkowski K, Gault B, et al. The influence of income, education, and work status on women's well being. Womens Health Issues. 2001;11(3):160-72. [PubMed]
6 Song Z, Hill C, Bennet J, et al. Mobile clinic in Massachusetts associated with cost savings from lowering blood pressure and emergency department use. Health Aff (Millwood). 2013;32(1):36-44. [PubMed]
7 Oriol NE, Cote PJ, Vavasis AP, et al. Calculating the return on investment of mobile healthcare. BMC Med. 2009;7:27. [PubMed]
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Original publication: April 23, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.