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Quality: Health on Wheels

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Mobile outreach efforts promote quality outcomes and reduce costs.

For the past 17 years, the Family Van, a mobile health clinic sponsored by Harvard Medical School, has made scheduled stops at several medically distressed sections of the Boston area—providing healthcare screening and education services. Its goal has not been to replace traditional healthcare services found behind four walls but to help bridge a path to better care—via four wheels, says Family Van Cofounder Nancy Oriol, MD.

The Family Van—and the approximately 2,000 other mobile health vans operating across the country—have provided a variety of important services to many communities. However, their contributions to quality care, while praised locally, often have been overlooked by the healthcare community as a whole, says Oriol, who is the dean of students at Harvard Medical School and an obstetric anesthesiologist at Beth Israel Deaconess Medical Center, which has 621 licensed beds.

"It's not just a sweet little corner of the universe. It's actually an important component of the healthcare system . . . that is completely outside of anyone's awareness," she says. To put a new light on quantifying the value of nontraditional preventive care, the idea of developing a prototype "return on investment" calculator was born.

"We can't expect people to see, respect, or value our role in the healthcare system if they don't even know who we are and what we are doing," she says of mobile health clinics. "We need to know that the services we provide are bringing in value."

Each year, the Family Van has more than 5,000 visits. Under Massachusetts law, which mandates health insurance coverage, these patients should have access to primary care providers. However, many initially may have trouble getting appointments with those providers or even with community health centers.

"It's very difficult for [the providers] to accommodate the increased demand," says Jennifer Bennet, executive director of the Family Van program. Other visitors may be unclear about how to initially enter and navigate a confusing healthcare system.

The Family Van—with its staff of health educators, nurses, medical school students, and other health professionals—provides health counseling and education to these patients, along with medical services such as screenings and tests for hypertension, cholesterol, blood glucose, glaucoma, pregnancy, HIV/AIDS, and body mass index assessments.

No physicians are on board, though. "It is our belief that for these kinds of interventions, people other than physicians can provide these services as well—that's part of the cost benefit," Oriol says. "We're just doing risk assessment. We're identifying issues and then we're referring folks into care."

Bennet notes that the number of repeat visits by individuals using the van services has increased from about 33% to 56% during the past five years. There is no cost to them for services. "Many of the repeat folks are the ones that we either helped diagnose [with a chronic illness] or they know they have that diagnosis and they're working with us on managing the illness," Bennet says.

Approximately 30% of their first-time visitors have undiagnosed illnesses such as diabetes, hypertension, or HIV, or they may be pregnant. Of those with chronic conditions, more than half are likely to have multiple chronic illnesses.

So how can value of these services be determined? Oriol and Bennet teamed up with Mobile Health Clinics Network, a membership-based organization of mobile health clinics and other experts. Using published data from the National Commission on Prevention Priorities (NCPP), which assigns values to preventive practices, and published data on cost savings related to avoidable emergency room visits, the team created an algorithm that "calculates" an ROI ratio.

For 2008, they calculated that the ratio was 36:1—or $36 saved for every dollar invested for care provided by the Family Van. While the ratio is helpful in "proving our value" to program donors, it underscores how mobile health has a niche in the greater healthcare system.

"We're only one component of the nontraditional healthcare system that has a finger on the pulse of all these people," Oriol says. "When people talk about the healthcare system, they talk about people who choose to come to the emergency room at the last minute. The people we serve are the great unknown. We know them, and we have the opportunity to form relationships with them."

Filling the healthcare gaps
Since Hurricane Katrina in 2005, delivering healthcare services has been difficult in New Orleans and the surrounding Gulf Coast area. Even years later, healthcare providers are scattered and various facilities that were damaged remain closed: Four out of nine hospitals are still closed in nearby Orleans Parish, and none has reopened in St. Bernard Parish.

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