With an emphasis on mobility and innovation, mobile health clinics are helping to tackle care gaps, reach underserved populations, and give hospitals a new access point.

Editor's note: This article appears in the September/October 2022 edition of HealthLeaders magazine.

Healthcare organizations are realizing that some services need to be brought to the consumer, rather than waiting for that person to visit a doctor. And they're using mobile health clinics to make that connection.

Mobile health clinics come in many shapes and sizes, from fully equipped, customized RVs or trailers offering a range of primary and specialty care services, to small vans with the supplies and resources needed to address one particular goal, such as sexual health education, mammography screenings, or vaccinations. They're designed to go into communities that lack brick-and-mortar healthcare resources or have populations that won't or can't access healthcare services.

"They are becoming more prevalent, in part because of the pandemic," says Mollie Williams, DrPH, MPH, a lecturer on global health and social medicine at Harvard Medical School and executive director of The Family Van and the Mobile Health Map, a resource for mobile health clinics with more than 700 members.

Mollie Williams, DrPH, MPH, executive director of The Family Van and the Mobile Health Map and a lecturer on global health and social medicine at Harvard Medical School. Photo courtesy of Harvard Medical School.

"One of the benefits of mobile health clinics is their adaptability," adds Elizabeth Wallace, executive director of the Mobile Healthcare Association (MHA), the leading membership organization for mobile health professionals in the US and Canada. "They're designed to turn the traditional healthcare relationship on its head … and create a new model of care."

Williams and Wallace were part of a team that put together The Case for Mobile, a report recently released by the Mobile Health Map and the MHA that examines how mobile health clinics support the business objectives of health systems and impact community health and health equity initiatives.

A surge in popularity as healthcare goes mobile

Williams estimates a few hundred mobile health clinics were in operation prior to the pandemic, and that number has increased to about 2,000 as healthcare organizations look at new ways to deliver care that meets consumers where they are. In addition, they're as popular in urban areas, such as inner cities, as in rural regions.

"The pandemic has sparked innovation in healthcare, including greater interest in mobile programs," the Case for Mobile report states. "Healthcare providers have adopted or scaled up other innovations, including telemedicine, drive-through testing and vaccination sites, and 'pop-up' clinics. It is very likely that innovations sparked by the pandemic will continue in various forms long after the crisis has ended. For example, many mobile clinics that began as a way to expand access to COVID testing or vaccinations are planning to continue operating and adjusting their service offerings to meet other community needs."

[See also: Upstate NY Health System Finds Strong Demand for Mobile Healthcare.]

"Because of the pandemic, everyone had to think creatively," says Williams. "Now [healthcare executives] are thinking about new ways to use mobile clinics. Some are using them to expand business lines, while others want to expand capacity or reach new communities."

And while some have classified mobile health clinics as "alternatives" to healthcare models, a 2017 study published in the National Library of Medicine and authored by researchers at Harvard Medical School indicates these vehicles can also serve as entry points to a health system, helping consumers navigate the complexities of healthcare access, and paving the way for future in-person and virtual connections.

"In many contexts, [mobile health clinics] can and do play an integral part in a healthcare system, providing accessible and sustainable care with quality that matches traditional healthcare settings," that study concluded.

These mobile access points "can identify pressures that a hospital is facing and address them in a different way," Wallace says. They can be located next to a retail center, like a mall or supermarket, or alongside a library or town offices, even next to a theater, park, beach, or motel, attracting people who might need care but are wary of going to a crowded ER or urgent care clinic.

Finding the right use case for a mobile health clinic

Williams says a common misperception about mobile health clinics is that they have to be expensive or filled with the latest in digital health technology. A health system can spend as little as $150,000 or $200,000 in startup costs for a mobile health program and see success, as long as the program reaches and engages its target population with services that meet a gap in care.

"Those costs don't have to be substantial compared to what you're probably spending" to address the care needs of that population, she says.

And they can be flexible. If one approach or one location isn't working, pull up stakes and move, or redesign the mobile clinic to address a different healthcare concern.

Wallace says healthcare organizations looking to launch a mobile health program should first conduct a community needs assessment. This gives the organization an opportunity to talk to the community about what it wants and needs, as well as identifying partners in the project. That may include health systems and local doctors, charitable groups, civic organizations, and even local government. The idea is to create a group of stakeholders who can help guide the program as it launches and evolves and identify any issues it may have to address.

Elizabeth Wallace, executive director of the Mobile Healthcare Association. Photo courtesy of the MHA.

"It shouldn't be thought of as a pilot project," she adds. That evokes images of a test, or something that's being tried out and can be cancelled at any moment. This, instead, is a program that aims to stay in the community and foster a lasting relationship.

In addition, mobile health clinics don’t have to be dependent on technology to be effective.

"Technology and mobile healthcare, they're not in the same universe," Williams says. "I would say they can complement each other and stimulate each other … but they don’t have to both be there."

"We've found, in some cases, that technology doesn't resonate with them," she says of the typical mobile health clinic visitor. "They don't seek out [healthcare services] like you or I. They are coming to a mobile clinic, in many cases, for that personal touch."

This, in turn, can help a health system connect with its surrounding communities. That point was made by a health clinic operator interviewed for the MHA/Mobile Health Map report.

"For communities that have been disinvested or marginalized by our healthcare system through generations, being able to go to them, make the effort to get right where they are-say here I am," the clinic operator said. "I’m here to respond to you. It’s a good way to be able to bring them into a healthcare system that maybe they are distrustful of."

Sowing the seeds for sustainability

The challenge for many mobile health programs lies in finding a means of continuing past the loan, grant, or award used to get the program up and running.

"The launch is just the beginning," says Williams. "You need to establish a plan for getting support, especially from payers."

The key, as with any new healthcare program, is to gather evidence that the program works. That may be in reduced ER visits, which help a hospital's bottom line and lessens the pressure on 911, ambulance and EMS services, or an improvement in screenings, public health education, chronic care management, and other services that boost clinical outcomes down the line. The unmeasured effect, meanwhile, lies in an improved community.

The drawbacks? It's hard to find any.

"We worked really hard to find people who would disagree with us," Williams chuckles. "We tried really hard to find people to tell us that mobile clinics were a bad idea, and that just didn't play out."

New York City's Mount Sinai Health System is launching a digital health program aimed at relaying teenager-friendly messaging for teenagers at risk of type 2 diabetes.

It's never easy to communicate with a teenager—just ask any parent. But care providers at the Mount Sinai Health System are making that connection with a new digital health platform aimed at young adult at risk of developing type 2 diabetes.

The New York City-based health system is partnering with digital health company mPulse Mobile on a digital health engagement platform that meets teens where they want to be met and gives them access to resources focused on education and prevention.

The key to engagement, say researchers, is involving teens in the planning process.

"We did a lot of the buy-in work early on," says Nita Vangeepuram, MD, MPH, a pediatrician, clinical researcher, and assistant professor at Mount Sinai's Icahn School of Medicine. "We turned the program on its head a little bit and decided, why not ask them for their thoughts and how to make this work? I don't know if that's been done before."

Type 2 diabetes was once thought to be an older person's disease, while Type 1 diabetes was called pediatric diabetes. Type 1 is genetic, while type 2 develops over time, often due to a predisposition toward diabetes combined with bad diet and exercise habits. More and more teens and young adults, however, are becoming type 2 diabetic. According to the National Health and Nutrition Examination Survey (NHANES), one in every five teens and one in every four young adults can now be classified as  prediabetic.

Put those teens and young adults in an underserved population, such as East Harlem, and the risk increases. Between one-third and one-half of the teens in that area are prediabetic. Access to health resources, including digital literacy education, telehealth technology, and even in-person primary care services, is more complicated.

"We actually don’t know what's going to work," says Vangeepuram, who's been working on the program for the past few years and is eager to start collecting and analyzing engagement data. "We know that what's been tried in the past hasn't worked, and pediatricians are struggling. It's time to recognize that the patients here are the experts."

Making the Message Matter

Those experts are telling Mount Sinai's care teams how they want to communicate. For example, Vangeepuram says the teens involved in the early part of the program prefer texts, rather than either an mHealth app or social media. And while automated messages are good to get certain points across, they still want to talk to real, live care providers, either in person or virtually.

"We're seeing that there's some balance that needs to happen," she says. "Not all of the interactions can be automated; there has to be some interaction."

Vangeepuram and her colleagues are being specific in how they tailor the program. Choose the wrong medium or message, and teens won’t be interested in collaborating with the care providers on better lifestyle choices, and the advice will fall on deaf ears. They also won’t be interested in a generic, cookie-cutter approach that uses the same message for everyone.

"This is why research and behavioral science are important," Vangeepuram says. "You have to understand what works and what doesn't. And you do it by telling a story … that engages them."

Teens helping to develop this platform preferring texting over social media and apps surprised her in a way. So much of today's teen culture is wrapped around social media and apps that it just seemed natural to follow that route. They weren't interested in sharing photos, either.

"They prefer messaging, and goal-setting is extremely important," she says. "They want to be involved in the process."

Making Prevention a Priority

Programs like Mount Sinai's hold significant promise for value-based care because they target chronic disease prevention, alongside health and wellness. According to the Centers for Disease Control and Prevention's National Diabetes Statistics Report, some 37.3 million Americans, or more than 11% of the population, have been diagnosed with diabetes, while another 96 million people aged 18 and older are classified as prediabetic.

The American Diabetes Association, meanwhile, notes 1.4 million Americans are diagnosed with diabetes each year, and that number is going up. Also increasing are the costs to treat people living with diabetes: $327 billion in 2017, with $237 billion tied to direct medical costs. This means a person living with diabetes spends 2.3 times more on healthcare than someone without diabetes.

Due to the nature of type 2 diabetes, which can be avoided through better diet and exercise, healthcare organizations are planning and launching diabetes prevention programs (DPPs), which funnel in-person and group counseling with targeted resources aimed at helping people live a healthier lifestyle.

Federal officials have also gotten involved. The National Institutes of Health's National Institute of Diabetes and Digestive and Kidney Disease (NIDDK) developed a DPP model in the 1990s. The Centers for Medicare & Medicaid Services (CMS) used that model to create the Medicare Diabetes Prevention Program (MDPP) in 2018, enabling care providers to qualify for Medicare reimbursement for diabetes prevention services.

The program has been met with skepticism, with critics arguing that it isn't reducing costs or keeping a measurable amount of the prediabetic population from developing diabetes. The main problem is that few health systems are launching or supporting DPP programs, and despite intense lobbying, CMS has not expanded coverage to include virtual programs.

Proving the Program's Value

Vangeepuram says Mount Sinai will be looking at engagement metrics with this program. She wants to see that teens are getting these messages and responding to them and interacting with their care providers, and she wants to see that these actions help teens improve their health and reduce the chances of developing diabetes.

For now, they'll be rolling out the digital health platform, looking for engagement, and making any tweaks necessary to improve the process. They'll be working closely with not only primary care providers and diabetes educators, but with the teens, themselves.

Eventually, Vangeepuram says, they'll launch a clinical study, which will look to tie engagement into clinical outcomes. Those numbers might help state and federal payers, like CMS, to show more support for the program. They could also be the catalyst to scale the program out to other populations and target other chronic disease or health concerns.

After all, if you can connect with a teenager, you've made quite an accomplishment.

"It's better to teach them to be healthy, and that part isn't really complicated," she says. "You have to make sure that they're listening. That's the hard part."

Rice County District Hospital, a 25-bed critical access hospital in the heart of Kansas, is improving inpatient care and critical patient transfers with technology. Officials say the platform is a life-saver and a crucial cog to staying open.

When you're the only critical access hospital around for hundreds of miles, you'd better have the resources for treating patients in need of emergency care—or the means for quickly and effectively getting patients to the care they need.

At Rice County District Hospital in Lyons, Kansas, staff are using patient placement technology to coordinate care for both patients inside the 25-bed, level 4 hospital, and those needing to be transferred to another facility. The platform integrates local EMS and other transport services, such as helicopters and planes, with health systems hundreds of miles away who have the specialists necessary to treat a critically injured patient.

"It has been complex at times, and very stressful," says Bonnie Goans, RN, the hospital's trauma and emergency preparedness coordinator, who remembers instances where it has taken two weeks to get a patient to the right hospital. "The technology we have now is really helping to make things smoother and more efficient."

Bonnie Goans, RN, trauma and emergency preparedness director, Rice County District Hospital. Photo courtesy Rice County District Hospital.

With a population of about 3,500 in a county of only 9,500, Lyons sits right in the middle of Kansas and the Great Plains, an area that could be used as the dictionary definition of "rural." There's plenty of farmland and a few industries, including an ethanol plant. The hospital sees its fair share of farming and industrial injuries, vehicle and ATV accidents, and, like everywhere else, chronic diseases.

And it offers an ideal location to prove the value of innovative new technologies in improving healthcare access and outcomes in rural America.

Of the estimated 6,000 hospitals in the US, according to the American Hospital Association, almost 1,800, or about 30%, are in rural locations. More than 130 rural hospitals have closed over the past decade, and another 600 are at risk of closing.

Telehealth advocates have been pushing virtual technology as an avenue by which these small, remote hospitals can keep more patients in-house and improve access to services and specialists, and Goans says Rice County District Hospital has been using telehealth for a variety of services, including cardiac, pulmonary, and neurological care. But there's only so much a 25-bed hospital with a staff of about 150 can accommodate, and some patients need care that the hospital just doesn't have.

That's where technology comes in—and one's neighbors.

"That's the good thing about being in a small community," Goans says. "Everyone pitches in. Everyone helps when they can."

The hospital has one EMS crew on hand and one backup, as well as access to a few helicopters and fixed-wing aircraft. There's a level 3 trauma center 30 miles away, and a pair of level 1 hospitals in Wichita, roughly 80 miles away. But anything that takes three hours or more "is a no-go," Goans says, because it leaves the community short of resources in case of an emergency.

The old process of arranging transports focused on the telephone, and it basically meant that anyone with hands free would place calls to (a) find the necessary transport and (b) find the right location. Now the information is pulled out of the electronic health record and fed into a platform that scans available health systems for the right clinicians and an available bed, while making sure transportation is available.

"A lot of times in the past it was your doctor making the phone calls because the nurses were busy doing something," Goans recalls. "And there were lots of calls to make. You needed the right doctor at the right hospital, and you needed a room available, and you didn't stop until you had the room. Then it was a race to get the patient on the road" to get to that hospital before that room was taken.

'We were used to being accepted. And suddenly that went away.'

The catalyst for change was the pandemic. That, combined with a nationwide shortage of staff, created a crisis.

Suddenly every hospital was at or near capacity, and everyone was scrambling to find a bed. Hospitals across the state (and the nation) struggled not only to support and care for patients with the virus, but also to care for patients with other health concerns who had to be kept separate from infected patients, while also taking steps to shield doctors and nurses from COVID-19. One news report estimated that nearly 80 patients in Kansas alone died waiting for a hospital bed.

"We were used to being accepted" for a patient transfer, Goans says. "And suddenly that went away."

The pandemic pushed state officials to invest in technology and resources allowing health systems to coordinate care. The state's Department of Health and Environment and Department of Emergency Medicine signed and then extended a contract with digital health company Motient to create a network enabling more than 110 of the state's hospitals and correctional facilities to use the company's Mission Control platform to coordinate transfers.

"In terms of preventative healthcare and resource redeployment, the wealth of data that will come out of a statewide program like this will be invaluable in a few years," Alana Longwell, MD, the chief medical officer at Newman Regional Hospital, a 25-bed critical access hospital in Emporia, about 160 miles from Rice County District Hospital, said in a 2021 press release announcing the contract extension. "We started using the platform to find beds, and now we use it for more than 90% of our transfer patients. The platform lets us slice and dice our data around time-critical diagnoses to help us increase efficiency and improve our transport processes."

At Rice County District Hospital, Goans says the platform reduced the frustration level of staff almost instantly. Doctors are now able to spend more of their time with patients, while nurses handle all of the transportation details, while phone calls are only made to make sure everything is in place.

Goans says the platform allows the hospital to run more smoothly, managing inpatient resources as well as transfers, and gives administrators the data needed to stay on top of things. For a small hospital with razor-thin margins, battling a staff shortage that's affecting the entire country, those capabilities are key to ensuring the right staff are in the right place.

"This does help us to manage care better, and in some cases, keep more of our acute care patients," she says. "Our doctors are practicing at the top of their license now, rather than making phone calls … and we are identifying delays [and gaps] in care that can be corrected more quickly."

The platform also facilitates telehealth and other digital health services, opening the door to more care opportunities on-site and collaborations with larger hospitals and health systems. That's crucial for small hospitals like Rice County District Hospital that aren't going to be expanding any time soon and need to make do with what they currently have at their disposal.

"There will always be a need to transfer patients," Goans says. "That won’t go away." But they can make sure those transports are quick, efficient, and necessary.

Goans expects to use more telehealth and digital health tools in the future to improve care in the hospital and surrounding community. And she has her eye on some new technology as well.

"I'm just waiting for some drones now," she says.

By a near unanimous vote, the US House of Representatives has passed a bill expanding telehealth access and coverage for Medicare services until the end of 2024, while making those flexibilities permanent for FQHCs and RHCs. The bill now goes to the Senate.

Congress is halfway toward extending telehealth flexibilities enacted during the pandemic until the end of 2024.

The US House of Representatives this week passed the Advancing Telehealth Beyond COVID-19 Act of 2021 (HR 4040) by a 416-12 vote, sending the issue on to the Senate. The bill, introduced more than a year ago by US Rep Liz Cheney (R-Wyoming), expands the definition of "originating site" to allow more locations to use telehealth, eliminates facility fees for new sites, expands the list of healthcare providers able to use telehealth, adds audio-only telehealth to the definition of "telecommunications system," and makes permanent the ability of federally-qualified health centers (FHQCs) and rural health clinics (RHCs) to use telehealth under the Medicare program.

These flexibilities were put into place by the Centers for Medicare & Medicaid Services (CMS) at the onset of the COVID-19 crisis to help healthcare organizations expand access to and coverage of telehealth services, with the caveat that they be terminated at the end of the public health emergency (PHE). The bill's goal is to give providers a better idea of how long they have to use those flexibilities before they either end or Congress takes more action.

The bill's passage drew immediate praise from the American Telemedicine Association (ATA) and its lobbying group, ATA Action.

“Today, we took a significant step forward in providing much needed stability in access to care for millions of Americans, with the US House vote to extend key telehealth flexibilities implemented during the COVID-19 Public Health Emergency (PHE) until the end of 2024," Kyle Zebley, the ATA's vice president of public policy and executive director of ATA Action, said in a press release. "We cannot allow patients to lose access to telehealth post-pandemic, and this bill will provide stability through 2024, while giving Congress time to address how to make the policies permanent."

“Telehealth has long been a bipartisan healthcare issue and we now turn to the Senate to ensure this important piece of legislation makes it to President Biden’s desk so he can sign it into law,” he added.

The American Medical Association also weighed in on the issue.

“Increased Medicare-covered access to telehealth has been a lifeline to patients and physicians throughout the COVID-19 pandemic, and the American Medical Association (AMA) is pleased by today’s bipartisan vote in the House," AMA President Jack Resnick Jr., MD, said in a statement. "The COVID-19 public health emergency made plain that care via telehealth should be available to all Medicare patients, especially with their own physicians, regardless of where they live or how they access these services. From continuity of care, broadened access to care, and removing geographic and originating-site restrictions, our hope is that the flexibilities afforded during the public health emergency will be made permanent."

Passage of the bill is significant not only because of the margin of victory in the House – indicating strong bipartisan support for telehealth – but because Congress has taken action on the issue. Dozens, if not hundreds, of bills have been proposed in both the House and Senate these past few years aimed at expanding telehealth access and coverage, many seeking some or all of the flexibilities outlined in the Cheney bill, but very few have seen any votes.

Passage in the Senate is no done deal, even with the House's strong support. But Senator Joe Manchin's (D-West Virginia) recent shift to support the Inflation Reduction Act may hint at a willingness to move forward on other issues as well, including healthcare. And the bill does have the backing of the Biden Administration.

"It is important to continue the availability of expanded telehealth to meet the needs of Medicare beneficiaries and health care providers," the Executive Office wrote in a Statement of Administration Policy shortly before the House vote, noting that telehealth visits increased 63-fold in 2020, especially in rural areas and for behavioral health services. "As we emerge from the worst stages of the COVID-19 pandemic, H.R. 4040 will ensure that the Medicare program continually adapts to provide convenient, quality, accessible, and equitable healthcare."

The Senate can now vote on the House bill, vote on its own version of the bill, combine the two, or do nothing.

And while Senate passage of the bill is now top of mind, advocates will continue to push for permanent expansion for some or all of those flexibilities, arguing that telehealth has proven its value during the pandemic.

Amazon has announced plans to buy concierge care company One Medical for almost $4 billion, positioning the retail giant right in the middle of an ever-growing battleground for primary care.

Amazon is getting into the primary care business.

The retail giant has announced that it is acquiring One Medical, the concierge-styled primary care company with a telehealth platform and more than 125 brick-and-mortar locations scattered across the country. The deal, valued at roughly $3.9 billion, would be Amazon's third-largest acquisition, giving the company a physical footprint alongside Amazon Pharmacy and Amazon Care, a virtual care platform for businesses.

“We think healthcare is high on the list of experiences that need reinvention,” Neil Lindsay, Amazon's senior vice president of Amazon Health Services, said in a press release. “Booking an appointment, waiting weeks or even months to be seen, taking time off work, driving to a clinic, finding a parking spot, waiting in the waiting room then the exam room for what is too often a rushed few minutes with a doctor, then making another trip to a pharmacy – we see lots of opportunity to both improve the quality of the experience and give people back valuable time in their days.”

“There is an immense opportunity to make the health care experience more accessible, affordable, and even enjoyable for patients, providers, and payers," added One Medical CEO Amir Dan Rubin, who will continue as CEO.

The announcement fits with the idea that primary care is becoming a hotly contested battleground, featuring competition from traditional healthcare organizations as well as telehealth companies and payers with their own provider networks and retail behemoths like Amazon, Google, Walmart and Walgreens.

All are trying to lay the groundwork for on-demand primary care services, either in person or through virtual care channels. Amazon's strategy is to make that encounter as ubiquitous as buying something on its website.

Nathan Ray, a partner in the healthcare segment of national management and technology consultant West Monroe, said the deal makes Amazon a major player in the ever-shifting healthcare market.

"Amazon continues to make forward progress towards being a broad and dynamic healthcare entity with the acquisition of One Medical, their activity here and in recent past within many of the most actively evolving areas of healthcare has shown they have an evolving strategy towards developing their role in the healthcare marketplace and now entering primary care (and risk contracting) the true center of focus and change after incrementally building relevance in DME, pharmacy, virtual care and employer health," he said in an e-mail to HealthLeaders.

"Amazon and One Medical will have some great opportunities to continue to improve on today’s technology and in particular evolving digital intelligence and engagement technologies that drive intervention, clinician effectiveness, and action based on both historic and real-time data and analytics that underpin the ability to develop and scale successful care models," he added.

Ray noted further that the deal does have some concerns.

"This move tells us both that Amazon is aware of what they lack, but also that they really may not have a grand strategy as of yet but are continuing to find value buying (particularly on the downbeat of the market here) and developing both solutions and services within the healthcare space that give them options," he said.

"The biggest questions I have are when will we begin to see more of Amazon’s signature of technology enablement, easy access, low cost and service quality begin to reveal itself within healthcare through this acquisition, and how might Amazon’s skill with those design elements yield market advantage," he added. "Primary care is a highly dynamic space with payers, providers, and healthcare services and technology organizations all focused on many of the same population health and risk attribution tools and concerns and a slow war of care models, utilization, and financial performance playing out as significant capital has entered from both private and public markets over the last 3-5 years particularly motivated by growth coming from managed care, particularly Medicare Advantage."