While youth advocates have successfully lobbied in recent years for programs to expand health insurance coverage for poor children, insurance is not always the major barrier to good health care for kids. Many times, the problem is access.
“In many places, there aren’t enough resources available,” says Karen Redlener, executive director of the Children’s Health Fund (CHF) and of the New York Children’s Health Project. As a result, “kids often receive care at emergency rooms.”
But many poor kids in cities – especially homeless and runaway youth – never see doctors or nurses for routine health care. In remote rural areas, even hospital emergency rooms are often a distant option.
That’s one reason some organizations bring health care to kids, with mobile medical units.
CHF started its first such unit in New York in 1987 and now helps to coordinate a national network of 21 pediatric projects, all of which have mobile units. They include programs in rural West Virginia and Mississippi. In Massachusetts, Bridge Over Troubled Waters, a nonprofit that serves homeless and runaway youth, started operating a mobile medical unit 30 years ago to reach kids on city streets.
That’s not to say that mobile units are always the best way to provide health services. On the one hand, they reach underserved youth and tend to draw gushing publicity from the local news media. But they can be expensive and complicated to operate, and some observers say health clinics are often a more cost-efficient option.
The units are often run by hospitals, but perhaps the biggest single force behind their proliferation is the CHF. The fund’s roots trace back to the start of the Children’s Health Project in New York in 1987, which was established by pediatrician Dr. Irwin Redlener, his wife, Karen, and singer Paul Simon. Redlener and Simon worked on the USA for Africa relief project in the 1980s, and decided to do something to provide health care and nutrition education to homeless people in the United Sates.
Karen Redlener, who took over program management for the New York project, decided to use a mobile medical unit to bring health services to poor children, often by parking at homeless and domestic violence shelters.
Other projects have since been established around the country with various amounts of funding from CHF. Every project in the network is affiliated with an academic medical center or community health clinic, which helps provide staff, funding and other resources.
Is that money well-spent? “Medical vans can make use of scarce resources and spread them around,” says Julia Lear, director for the Center for Health and Health Care in Schools at George Washington University, in Washington.
But in many cases, Lear says, medical vans aren’t the most cost-effective or easiest way to meet the health care needs of underserved kids. With school-based clinics, she says, “you have the capacity to not just do one-on-one care, but to work with teachers and the school community to make the whole school environment healthier for kids.”
She contends that if an organization can afford to outfit a medical van, it would probably do better with a stationary clinic. “You don’t have to keep up with the van, insurance, hire a driver, pay people to wait with kids, or find a safe place to store and park it,” she says. “If you’re where the kids are, you’ve solved the transportation issue.”
On the other hand, outfitting and staffing one mobile unit might cost less than creating and running a half-dozen or more clinics.
In Massachusetts, Bridge Over Troubled Water estimates that its unit cost $13 per patient last year. Its medical staff is all volunteer, unlike many, if not most, mobile units.
Lear notes that the units make economic sense in many rural areas and for “populations of kids who don’t go to school.”
Consider Mississippi, the nation’s poorest state, where many families live 15 to 20 miles from any type of health care provider and don’t have their own transportation. The poverty is often so dire, says Dr. Rhonda Boles of the Mississippi Children’s Health Project, that “well-child care just isn’t a priority.” Concerns about housing, keeping the utilities on, problematic and unstable domestic relationships, and legal troubles make for a full plate. Health care is often left on the back burner.
Following are examples of how several organizations fund and operate mobile health units for various types of populations.
Healthy Kids Express Mobile Health Vans
St. Louis Children’s Hospital
St. Louis, Mo.
The Approach: Two Healthy Kids Express Mobile Health Vans provide preventive care to thousands of children at low-income schools and day care centers throughout St. Louis. They visit sites all over the city four days a week, reaching each site two or three times a year and providing preventive care, such as vision, hearing, dental, scoliosis, lead poisoning and anemia screenings, as well as immunizations and standard physicals. “We go to districts where kids are underserved,” says Greta Todd, director of Healthy Kids Express.
The vans employ the services of social workers and nurses who make tracking follow-up care a major priority. “When we identify children who have a medical problem, our nurses contact their parents and their pediatrician, if they have one,” Todd says.
Their work thus takes on one of the central challenges of medical vans: going beyond just finding health problems. “It doesn’t mean much to just identify a problem,” Todd says. “It’s helping families get a resolution that makes the difference.”
For that reason, she says, the nurses and social workers are especially persistent. They not only help kids and parents schedule appointments for follow-up care, they also help arrange transportation through Medicaid or use funds from the program to pay cab fare. “These families are worried about paying the rent and keeping the lights on,” Todd says.
Unlike many mobile units, the Kids Express van keeps tabs on what health services the children use after their visits. “If we conduct vision tests and find kids who need glasses, we track the number of kids who actually get glasses,” Todd says. “We track the number of kids with hearing problems who see an audiologist.”
It’s not unusual for social workers who run into a dead end with parents to call pediatricians until a problem is solved. “A lot of it [the work] is just plain persistence,” Todd says.
History & Organization: St. Louis Children’s Hospital started the Healthy Kids Express Mobile Health Van program six years ago to provide a way for children eligible to enroll in Head Start programs to get dental, vision and hearing screenings, as well as immunizations. The program started with one van and has added another, and has expanded to serve not only Head Start programs but day care centers and elementary schools in low-income areas.
Youth Served: The vans serve approximately 10,000 children each year, ranging in age from preschool through elementary school. There are no income requirements for children to use the vans’ services.
Staff: Ten full-time and part-time staff run the two vans, with a medical director supervising the program. The staff consists of nurses, nurse practitioners, administrative assistants and two social workers.
Funding: Todd says it costs just under $1 million a year to operate the vans, including salaries and supplies. All funding comes from the St. Louis Children’s Hospital Foundation, which gets most of its funding from private donors, as well as from the Missouri Foundation for Health.
Indicators of Success: The program reports that of the 10,000 kids served last year, only 200 had cases that were not “closed.” If a case isn’t closed, it often means referrals were not followed up, a medical problem was not resolved, or Healthy Kids Express lost track of a child who moved.
Todd is particularly proud of the asthma program that Healthy Kids Express runs at two schools the vans visit each month. The program involves monitoring asthma sufferers and working with their pediatricians to control the symptoms. “We’ve seen asthma-related absenteeism drop 40 percent in these two schools,” she says.
Bridge Over Troubled Waters
The Approach: Bridge Over Troubled Waters offers a variety of services to at-risk and homeless teenagers and early 20-somethings, including providing health care to the underserved. Its Mobile Medical Van has served Boston and Cambridge for more than 35 years. It makes seven stops in the two cities, serving some every week night.
The van originally provided primary care services, but as the area’s homeless have gained more access to health care, it evolved to focus more on urgent care services and monitoring chronic conditions such as diabetes and high blood pressure, says Carol Phillips-Rimpas, Bridge’s development director.
Peter Ducharmes, who manages Bridge’s medical program, says that although Bridge was established as a youth support organization, “the medical van will see anybody, regardless of age or medical situation.” He says 80 percent of the young people who visit the van are homeless, meaning they live on the street, in a shelter or in unstable arrangements with friends or family.
While many people use the van without being prompted, Ducharmes says that each night outreach workers accompany the vehicle and fan out to find youth in the community, encouraging them to use the van and other Bridge services.
Ducharmes admits that providing health care through a medical van is not ideal. “You can always do more in a clinic than on a medical van,” he says. He says workers on the van try to refer patients to community health clinics or the clinic at Bridge’s Boston facility.
But for people who can’t or won’t go to a clinic, he says, getting some medical care through the van is better than getting none at all.
History and Organization: Bridge Over Troubled Waters was founded in 1970 by outreach workers affiliated with the Catholic Church who wanted to address the problem of Boston-area runaways and kids living on the streets. Today the nonprofit offers educational, health and housing assistance to more than 4,000 youth each year.
Youth Served: Bridge says that last year it provided medical services to 1,442 “unique” patients in the Boston and Cambridge areas. Ducharmes says about one-third of the van’s patients are under age 25, and many of them have mental health problems or substance-abuse issues. More than 80 percent of them lack health insurance.
Staff: Bridge has 48 paid staff, but most of the people who work with the organization’s medical services are volunteers. Ducharmes says he has 46 medical volunteers, including doctors and nurses. Medical staff members come from a variety of backgrounds and settings, including emergency rooms, hospitals, family practices and health clinics.
Because he has so many volunteers, many of whom work rotating schedules at their paid jobs, Ducharmes says staffing the van can be challenging.
Funding: Bridge’s annual budget is $3.6 million. About $300,000 of that is earmarked for medical services, with $100,000 going toward the van. The Mass Bay United Way provides most of the funding for the medical program. Other funding sources include the Massachusetts departments of Education and Public Health, and a transitional day programs grant from the U.S. Department of Housing and Urban Development, which comes through the Boston Department of Neighborhood Development.
Indicators of Success: Ducharmes admits it’s hard to track success when dealing with transient populations, but the van does track emergency room referrals. Ducharmes says 80 percent of referred patients make it to the emergency room for care.
West Virginia Children’s Health Project
The Joan C. Edwards School of Medicine
The Approach: The West Virginia Children’s Health Project is designed to serve an extremely isolated rural population that suffers from lack of access to pediatric care. “In some areas, there may be a doctor’s office 10 to 15 miles away, but not necessarily a pediatrician,” says the project’s medical director, Dr. Isabel Pino.
Making matters worse, residents have little access to public transportation, and low-income families often don’t have reliable vehicles of their own or can’t afford the gas. That’s the major reason the project’s medical van visits elementary and high schools, where kids are easily reachable. When the services of a specialist are required, the program tries to help arrange for transportation. One of the rural counties it serves has a bus service, and Medicaid covers transportation to health care. The problem is that many parents aren’t aware of the service or can’t wait the three days often required to get the transportation.
“Since we’re at the schools, the parent will send the child with a note to come see us,” Pino says. Sometimes a teacher will refer a student. “Whenever we see a child without the parent present, we send a note home,” she adds. The program accepts appointments and walk-ins and serves between one and 12 children each day.
The project has partnered with Marshall University’s psychology department to provide mental health services. Mental health professionals often join the mobile unit on its runs. The program also cooperates with several schools in offering a health curriculum about nutrition to third- and fourth-graders.
While the project is designed to serve low-income families, it does not turn away any children. “I have patients who see us because parents don’t have to take off from work if their kids can get health care at school,” Pino says.
History and Organization: Pino has been with the project since it began in 1992. Affiliated with the Joan C. Edwards School of Medicine at Marshall University in Huntington, the project serves some of the most remote regions of the southern Appalachians, where pediatric care is virtually nonexistent. “There’s a great need for services here,” Pino says. “West Virginia is a small state with a small population and a lot of isolated population.”
The van traverses three southwestern West Virginia counties, often traveling 100 miles roundtrip in a day. The unit visits schools around the region on a weekly basis. “In rural areas, the school is the center of the community,” Pino says.
Youth Served: The project serves up to 700 children each year at schools in the city of Huntington as well as in Wayne, Lincoln and Cabell Counties, with the van typically spending half a day at each school site. Pino says most of the children are covered under Medicaid or S-CHIPS, the state children’s health insurance program.
Staff: A full-time staff of 10 runs the project, with four of those workers going out in the mobile medical unit each day. The pediatric residents take turns working in the mobile unit.
Funding: The project’s funds come from insurance revenue, the CHF and federal grants.
Indicators of Success: Pino says it’s difficult for a small unit like hers to measure its impact, but success of the program is evident on an individual level. “Kids who were previously suffering from asthma, for example, are not using their respirators all the time,” she says. “And we see kids that suffered from ADD and hadn’t been diagnosed before, doing better in school.” The same goes for kids who needed glasses, but didn’t have anyone to identify their vision problems before the project came along.
Mississippi Children’s Health Project
Aaron E. Henry Community Health Center
The Approach: The Mississippi Children’s Health Project serves one of the nation’s most economically depressed rural regions: the Mississippi counties south of Memphis, Tenn. Thirty-three percent of children in the counties served by the project live below the poverty line, and 42 percent have no health insurance, according to the Children’s Health Fund.
The area is so poor that the program has trouble holding on to its staff.
It manages to operate one medical mobile unit and two school-based clinics two days a week. The mobile unit visits county and city schools and a town hall on a regular weekly schedule, traveling about 80 miles a week. It also visits one public housing project, having discontinued service to another because of violent incidents in the areas where it was working.
Many of the children served by the project live 15 to 20 miles from the nearest health services, says Medical Director Dr. Rhonda Boles. She says the notice required to arrange for Medicaid transportation is sometimes too long for a child suffering from an illness that needs immediate attention.
A dentist who is affiliated with a community health center periodically travels with the mobile unit.
One of the project’s biggest challenges, Boles says, is lack of education about health care. Much of her clientele doesn’t see health care as important in the grand scheme of scraping out a living and getting by. “It takes quite a bit to change someone’s outlook” about such matters, she says.
History and Organization: The project began in 1991 as the first CHP to provide care to children in an isolated rural region. Boles says the project was started when the national CHF office approached LeBonheur Children’s Medical Center at the University of Tennessee’s Department of Pediatrics about sponsoring a rural children’s health initiative. Today, the program is based at the Aaron E. Henry Community Health Center in Clarksdale, Miss.
Youth Served: The population of Coahoma County, the main service area for the project, is about 30,000, and the CHP serves approximately 3,000 children each year. That number has been cut in half in recent years, due to the loss of health care providers and a diminishing staff.
Boles says 95 percent of the children her program serves are indigent. Most are African-American, with whites and a small percentage of Hispanics making up the rest. Seventy percent of the youth are on Medicaid, about 20 percent on CHIPS (Mississippi’s state health insurance program for kids) and the remainder have private insurance or are uninsured.
Staff: The nine full-time employees operate one mobile medical unit and two school-based clinics. Boles says staff turnover is a persistent problem: “This is a rural area. Unless a provider has ties to the community or is a student with loan obligations, it doesn’t pay to be here.” She says the area already suffers from a nursing shortage, and salaries aren’t competitive enough to attract health care providers. At its peak, the project had 13 employees and served 7,000 children each year, but declining staff numbers have led to service cutbacks.
Funding: Program Director Vicky Hearn says the project’s annual budget is about $500,000. Some revenue comes from insurance payments and the CHF, as well as through a grant program operated by the Mississippi Qualified Health Center.
Indicators of Success: The best measure is feedback from parents and teachers and the fact that patients keep coming back, Boles says. “The response of the children is the most rewarding part,” she adds. “It’s wonderful to see the difference in their health status.”