key: cord-0877939-s1yt3g07 authors: Leibowitz, Abigail; Livaditis, Laura; Daftary, Genevieve; Pelton-Cairns, Leslie; Regis, Craig; Taveras, Elsie title: Using mobile clinics to deliver care to difficult-to-reach populations: A COVID-19 practice we should keep date: 2021-09-08 journal: Prev Med Rep DOI: 10.1016/j.pmedr.2021.101551 sha: 5b8bce9a36480c54432966c8cf75f57652db77f5 doc_id: 877939 cord_uid: s1yt3g07 In the United States, mobile health clinics are an important method for delivering care to medically underserved populations. Mobile clinics have long been used in pediatric primary care, but there is little published to help pediatricians disseminate this practice more widely. During the COVID-19 pandemic, reduced in-person medical visits and subsequent declines in routine pediatric vaccination rates highlighted the importance of using a variety of care delivery models to reach patients. To improve vaccination coverage among young children in Boston during summer 2020, Mattapan Community Health Center and Codman Square Health Center deployed mobile clinics as an adjunct to their in-person preventive pediatric clinical services. In total, the health centers completed 17 mobile clinic sessions and served 50 unique patients, 77% of whom were African-American/Black and 75% of whom were under the age of two. A total of 146 vaccine injections were administered. A quality improvement survey of participating families demonstrated high levels of patient satisfaction and a high likelihood of using mobile services again in the future. The mobile clinic model was most valuable in reaching families who avoided in-person care due to COVID-19 transmission concerns or faced barriers to in-person care. The health centers fostered trust and demonstrated cultural competency during this novel initiative by leveraging established patient-provider relationships, using interpreters, and involving staff who reflected the diversity of the communities. Although there are challenges to implementing mobile health clinics, this initiative demonstrates the value of mobile clinics in delivering high quality pediatric preventive care to difficult-to-reach populations. In the United States, mobile health clinics are an important method for delivering care to medically underserved populations. Mobile clinics have long been used in pediatric primary care, but there is little published to help pediatricians disseminate this practice more widely. During the COVID-19 pandemic, reduced in-person medical visits and subsequent declines in routine pediatric vaccination rates highlighted the importance of using a variety of care delivery models to reach patients. To improve vaccination coverage among young children in Boston during summer 2020, Mattapan Community Health Center and Codman Square Health Center deployed mobile clinics as an adjunct to their in-person preventive pediatric clinical services. In total, the health centers completed 17 mobile clinic sessions and served 50 unique patients, 77% of whom were African-American/Black and 75% of whom were under the age of two. A total of 146 vaccine injections were administered. A quality improvement survey of participating families demonstrated high levels of patient satisfaction and a high likelihood of using mobile services again in the future. The mobile clinic model was most valuable in reaching families who avoided in-person care due to COVID-19 transmission concerns or faced barriers to in-person care. The health centers fostered trust and demonstrated cultural competency during this novel initiative by leveraging established patient-provider relationships, using interpreters, and involving staff who reflected the diversity of the communities. Although there are challenges to implementing mobile health clinics, this initiative demonstrates the value of mobile clinics in delivering high quality pediatric preventive care to difficult-to-reach populations. Keywords: Pediatric vaccination; Mobile clinics; Mobile health clinics; COVID-19 pandemic; Health inequities; Community health centers Introduction: In the United States, mobile health clinics are an important method for delivering high quality care to medically underserved populations. Mobile health clinics have been employed to reach people who are homeless (Knight et al., 1990; Nuttbrock et al., 2003) , seasonal farmworkers (Luque et al., 2013) , in disaster zones (Brito, 2011) , and more (Hill et al., 2014; Regis et al., 2020) . Studies have shown that these clinics can produce both cost savings and improved outcomes (Chen et al., 2020; Hill et al., 2014; Song et al., 2013; Yu et al., 2017) . In pediatrics, mobile health clinics providing primary care are common (Children's Health Fund, n.d.; Ronald McDonald House Charities, n.d.) , but published studies have focused on children requiring specialty care (Abdel-Aleem et al., 2016; Diao et al., 2016; Jones et al. 2005; Mulligan et al., 2010) . There is little published to help general pediatricians disseminate this practice more widely. During the COVID-19 pandemic, routine office visits dwindled due to parental concerns about viral transmission as well as the pandemic's economic and social impacts. Although telehealth provided a viable, temporary alternative for adult care (U.S. Department of Health & Human Services, 2020; U.S. Department of Health & Human Services 2021; Koonin et al., 2020; Mehrotra et al., 2020) , pediatric preventive care declined and routine vaccination rates decreased nationally (Santoli et al., 2020; Bramer et al., 2020) . After the final mobile health session was completed, Mattapan invited participating families to complete a modified quality improvement survey. Outreach and interviews were conducted via telephone by an affiliated staff member who was not involved in patient care. Staff members from both Mattapan and Codman Square also participated in a debrief to discuss their experiences with the mobile health initiative. During July -September 2020, Mattapan held 9 mobile health clinics and Codman Square held 8 mobile health clinics, together serving 50 unique patients. Approximately half (48%) of the patients were male, and 75% were two years old or younger. 77% of patients were Black/African-American, 21% of patients were Hispanic, and 2% of patients were White, according to medical records. 28% of visits were conducted in a language other than English. A total of 146 vaccine injections were delivered (Table 1) , and three total visits did not require vaccine administration. Mattapan clinicians saw, on average, 4 children per four-hour mobile clinic session (range 1-7 children), and mobile clinics served 4.5% of their patients 0-5 years in age. Codman Square clinicians saw, on average, 3.6 children per three-or four-hour mobile clinic session (range 2-6 children) and mobile clinics served 2.5% of their patients 0-2 years in age. Figure 1 ). Although only seven families (58%) stated that they were "very likely" or "likely" to have utilized the mobile health clinic prior to the pandemic, 100% of respondents stated that they How would you rate the following: From the provider perspective, clinicians remarked that they enjoyed the opportunity to leave the clinic, vary their work, and bring care directly to their patients. Clinicians felt that clear communication and cultural competency were crucial to the mobile initiative's success. Ultimately, providers believed that the mobile clinics enabled them to provide comprehensive preventive care to hesitant families in an innovative way. During the COVID-19 pandemic, mobile clinics proved to be a valuable tool for providing comprehensive, preventive pediatric care to families who were unlikely to seek in-person care. Prior to this initiative, Mattapan had never achieved more than 70% routine vaccination coverage among children up to two years old (excluding the influenza vaccine). After the mobile initiative, however, vaccine coverage reached 73%. The patient experience was also positive, as demonstrated by high ratings in Mattapan's quality improvement survey and the willingness of all respondents to use this service again in the future. Moreover, more than 40% of the Mattapan families in the survey reported that they had delayed or avoided care during the pandemic, suggesting that the mobile clinic provided a critical point of healthcare access. Mobile services likely improved accessibility by alleviating concerns about contracting COVID-19 and obviating the need for transportation and childcare. Providing services directly outside patients' homes was also an important factor in participation, as significantly fewer families reported that they would utilize a mobile clinic if offered in a nearby public location. This finding may be unique to the COVID-19 pandemic, as many families avoided public spaces more generally due to concerns about infection. Nevertheless, providing care directly outside patients' homes was beneficial in allowing providers to gain a deeper understanding of their patients' living conditions and social context. Furthermore, providers felt that trust and cultural competency were key to the initiative's success, which is consistent with research on patient priorities in mobile health care (de Peralta et al., 2019) . The health centers intentionally involved staff who reflected the diversity of their patient population. Interpretation services were provided to maximize effective communication. Moreover, the mobile clinic was offered as an adjunct service to established patients only, and this pre-existing relationship likely eased the deployment of an unfamiliar care delivery model. Likewise, Codman Square's use of telehealth prior to the mobile visit provided this novel service with a "stamp of approval" from the patient's trusted primary care provider. However, there are several challenges for clinics seeking to implement their own mobile health services. During the pandemic, HRSA and MDPH were able to expedite approval processes and reduce regulatory burden such that both clinics completed licensure in only four weeks. This accelerated timeline may be unique to the state of emergency. In addition, the regulatory environment in other states may present greater administrative obstacles. Moreover, financial considerations may impede expansion of mobile clinics. Codman Square utilized a unique billing model that may not be available after the pandemic. Mattapan strived to mimic a traditional clinic schedule and billing structure. However, with time required for transportation and set-up, the mobile clinic simply could not approximate the typical volume of an office session. The cost to insure the van driver may have also been prohibitive for the health centers if regional partnerships were not available. Similarly, the clinical vehicle itself may only be a reasonable investment if multiple entities can pool resources. Although a highly specialized vehicle may not be necessary, the clinical area must provide adequate patient privacy and must be appropriately outfitted for the local climate. To facilitate documentation, both health centers utilized a laptop with Wi-Fi hotspot and employed their existing down-time procedures when Wi-Fi was unavailable. Staff and equipment availability may also determine feasibility of implementation. In addition to staffing the mobile clinic itself, mobile initiatives require greater time commitment for outreach and scheduling than traditional clinic visits. Codman Square, for instance, trained specific staff members to accurately explain this new initiative and schedule both the telehealth and mobile clinic visits. Other unique scheduling challenges include designing an efficient transportation route for the vehicle to follow during the session. Despite the challenges, implementation of mobile health clinics enabled two Boston-area community health centers to maximize routine pediatric vaccination rates and enhance preventive care services during the COVID-19 pandemic. The use of mobile clinics expanded access for underserved populations and allowed these health centers to reach patients who likely would not have attended clinic otherwise. In addition to other forms of patient outreach and patient-centered care, mobile health clinics are an underutilized, valuable method for delivering comprehensive, high quality care to the most difficult-to-reach patient populations. Mobile clinics for women's and children's health Decline in child vaccination coverage during the COVID-19 pandemic -Michigan Care Improvement Registry Continuing mobile care for Katrina's children. 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