Daniel Prude's family knew he needed psychiatric care and tried to get it for him. Instead, his encounter with police hours after he was released from Strong Memorial Hospital in Rochester, New York, proved fatal.

This article was published on Tuesday, September 29, 2020 in Kaiser Health News.

By Brett Dahlberg, WXXI September 29, 2020

When Joe Prude called Rochester, New York, police to report his brother missing, he was struggling to understand why Daniel Prude had been released from the hospital hours earlier. Joe Prude described his brother's suicidal behavior.

"He jumped 21 stairs down to my basement, headfirst," Joe said in a video recorded by the responding officer's body camera in the early hours of March 23. Joe's wife, Valerie, described Daniel nearly jumping in front of a train on the tracks that run behind their house the previous day.

"The train missed him by this much," Joe said, holding his thumb and pointer finger a few inches apart.

"When the doctor called me and told me that they released him, I'm saying, 'How you going to sit here and tell me you're going to release him when he was hurting himself? Come on. You weren't sworn to do that,'" he said on the body camera footage.

At the point of this recorded conversation just after 3 a.m., Joe and Valerie Prude knew only that Daniel was missing, delusional and vulnerable. They didn't know his next encounter with the police would be fatal.

Police would find Daniel minutes later ― naked, acting irrationally. Because he spat in the direction of officers and allegedly said he had the novel coronavirus, officers placed a white hood, called a "spit hood," over his head. When he started trying to stand up, despite being restrained by handcuffs, an officer placed much of his body weight over Daniel's head and pushed it into the pavement.

Daniel died a week later when his family took him off life support. The county medical examiner's autopsy described his death as a homicide and listed the immediate cause of death as "complications of asphyxia in the setting of physical restraint." The incident garnered widespread attention as another example of a Black man killed after an encounter with police.

Less attention has been paid to what happened to Daniel Prude in the preceding hours, when he was treated and released after a psychiatric assessment at Strong Memorial Hospital, run by the University of Rochester Medical Center.

Joe Prude called police at about 7 p.m. on March 22 because he needed help getting Daniel to the hospital. Daniel had been having problems with a PCP addiction, Joe told officers. Now he had begun telling Joe and Valerie that people were out to get him, and he wanted to die.

By about 11 p.m., Daniel was released from the hospital, according to Joe and police records. "He was calm as hell when he got back here," Joe told police.

That didn't last.

"He was fine for a little bit, then all of a sudden started acting crazy," Joe said. He told police that Daniel asked him for a cigarette, and when he went to get one, Daniel took off running. He was barefoot, wearing only a tank top and long johns in 30-degree weather.

"He was gone. Track star status. Hauled ass like Carl Lewis," Joe told the officer.

Around 3 a.m. the next day, four hours after his release from the hospital, emergency dispatchers started fielding calls about Daniel Prude. His brother reported him missing, and a tow truck driver spotted him, naked and bloodied, on West Main Street, police records show.

Police body camera footage shows that by 3:20 a.m., officer Mark Vaughn was pressing Daniel Prude's head into the pavement.

While restrained, Prude stopped breathing. An ambulance crew resuscitated him, but he was in critical condition. His brain was damaged after being deprived of oxygen. He died a week later at Strong Memorial after being taken off life support.

The University of Rochester Medical Center said patient privacy laws bar it from discussing the specifics of Prude's treatment and release, but, in general terms, spokesperson Chip Partner said, the hospital is bound by a New York state law that requires patients to be released within 24 hours unless they have a mental illness that is likely to result in serious harm to themselves or others and that requires immediate observation, care and hospital treatment.

The details of Prude's encounters with law enforcement and the healthcare system offer a look into the practice of emergency psychiatry, and how, as in many branches of medicine in the U.S., mistakes in that field are disproportionately borne by Black people.

Medical decisions in a case like Daniel Prude's are high-stakes, with little margin for error, said Dr. Ken Duckworth, chief medical officer of the National Alliance on Mental Illness.

"Emergency psychiatric assessment is very challenging, and the potential for catastrophic outcomes following your decision is very real," he said.

The hospital where Prude died has faced scrutiny over its treatment of psychiatric patients and discharge procedures before.

In April 2018, federal inspectors found security officers at the hospital had used law enforcement restraint techniques against a pediatric psychiatry patient, breaking her arm and sending her to the emergency room.

Months later, inspectors found the hospital discharged a patient who was in the emergency room with a history of dementia and multiple medical problems despite a discrepancy in her address between her medical record and the information she gave hospital staff.

Two years earlier, inspectors found that hospital staff had placed patients in ankle and wrist restraints without an order to do so, and placed another patient in restraints without documenting when the restraints were released. Restraints are meant to be used only with a physician's order, and federal rules require precise documentation of their use.

None of these incidents at Strong Memorial Hospital garnered media attention at the time they happened or at the time the reports were made public.

Strong spokesperson Partner said that immediately after the April 2018 inspection the hospital changed its public safety protocol to eliminate the use of law enforcement techniques to manage a violent patient unless that patient is being arrested.

He said updated staff training and discharge protocol after these incidents now mitigates the risk of discharging someone who was not ready to be released. "These protocols were well established in 2020 and had absolutely no bearing on the evaluation or treatment of Daniel Prude on March 22," Partner said.

Prude's case is unusual because the consequences of the decision by doctors to release him have played out so publicly, said Duckworth. Usually, emergency room psychiatrists never find out what happened to their patients.

"You make a very big decision, which usually has no known outcome. You put this person in the hospital, you go on to the next patient. You send this person home, you go on to the next patient," he said.

Duckworth said he would not second-guess the actions of Prude's hospital team in the moment, but with the benefit of hindsight, "there's overwhelming evidence that he had a psychotic illness and was quite vulnerable," he said. "He didn't need to die."

In a statement, URMC said its treatment of Prude was "medically appropriate and compassionate."

Several oversight organizations are investigating.

The Joint Commission, which certifies hospitals to receive federal funding, said it's reviewing Prude's treatment at Strong. New York state's Justice Center is investigating on behalf of the state Office of Mental Health.

The university medical center itself is still conducting an internal clinical review.

In response to questions from NPR and KHN about whether the hospital's treatment of Prude could have been affected by his race, Partner said the medical center asked Dr. Altha Stewart, past president of the American Psychiatric Association, "to conduct a third-party independent review through her lens as a national expert on racism and bias in psychiatric care."

In a separate interview before the request from URMC, she described how unconscious bias can cloud clinicians' judgment and make it difficult for them to make the best possible decisions for their patients.

"It is very clear that in today's healthcare system, bias is built in structurally," Stewart said. "Seeing a tall, imposing Black man who is behaving aggressively puts in place a series of ideas and thoughts and assumptions that direct decision-making."

Psychiatric disorders in Black patients are less likely to be taken seriously than in white patients, Stewart said. Unequal treatment starts early.

Black boys are viewed as adults more often than white boys of the same age, said Stewart, who is also the director of the Center for Health in Justice Involved Youth.

"So a Black child with a meltdown is described as aggressive, obstinate, oppositional," she said, "as opposed to traumatized, depressed, anxious."

Those expectations follow Black boys through adulthood and in the healthcare system, increasing the odds that doctors will view Black men as a lost cause and provide subpar care, Stewart said.

She stressed that she does not have any direct knowledge of deficiencies in the care of Daniel Prude, but she said that Black men, like Prude, are disproportionately likely to be misdiagnosed, mistreated and written off as a result of structural bias and unconscious racism.

A group of medical students at the University of Rochester wrote in an open letter that Daniel Prude was "sentenced to death by our failed healthcare system."

"Not only do our current models of healthcare leave gaping holes for individuals such as Daniel to fall through, but they do so in manners which are fraught with racism," the students wrote.

Partner, the medical center spokesperson, said the psychiatry department's Office of Diversity, Inclusion, Culture and Equity will evaluate Daniel's treatment for potential bias. He said the medical center "recognizes that we have a long way to go before we can confidently say that our policies and practices are universally culturally appropriate to the populations we serve."

Both Stewart and Duckworth said reducing the role that police play in addressing mental health crises would increase the odds of survival for a person released too early from psychiatric care.

Federal inspection reports show that hospitals across the country have released patients who, like Prude, ended up in grave danger only shortly thereafter.

In March 2018, a patient with a history of schizophrenia, post-traumatic stress disorder and suicide attempts arrived at Russell County Hospital in Kentucky complaining of alcohol withdrawal, depression, anxiety and pain. An hour and a half later, the patient was discharged with instructions to "follow up with his/her primary care provider and take medications as prescribed." Two hours later, the patient was back in the same hospital. A physician's notes said the patient had drunk a bottle of Benadryl "in effort to kill self."

In August 2018, federal inspectors found that UT Health East Texas Pittsburg Hospital discharged a patient who had verbalized a plan for suicide. The patient got a ride to his truck from the county sheriff. Later that day, the patient was found dead in the truck from a self-inflicted gunshot wound.

Last summer at Stafford County Hospital in Kansas, a patient arrived in the emergency room saying she had drunk half a liter of vodka because she was upset and wanted to die. She told hospital staff that she started drinking that day after two years of sobriety and that she "did not feel safe to go home due to the presence of alcohol." The hospital discharged her 11 minutes later.

Earlier this year, inspectors found that a patient with a history of psychosis went to the emergency room at Mercy Hospital in St. Louis and told staff she needed to get back on her medication. She was delusional, disoriented, homeless and unable to give her name. She was discharged with a voucher for cab fare but no follow-up appointments or services and no plan to ensure she got her medication.

A spokesperson for UT Health East Texas said the health system has since implemented a process for staff to more thoroughly document mental health concerns in patient records. Mercy Hospital in St. Louis said it takes the health and safety of each patient very seriously "regardless of race, ethnicity or ability to pay."

Neither of the other hospitals responded to emails or calls seeking comment.

This story is part of a partnership that includes Side Effects Public Media, NPR and KHN.

"No Mercy" is Season One of "Where It Hurts," a podcast about overlooked parts of the country where cracks in the health system leave people without the care they need. Our first destination is Fort Scott, Kansas.

This podcast was released on Tuesday, September 29, 2020 in Kaiser Health News, and was produced in partnership with St. Louis Public Radio.

By Sarah Jane Tribble

Click here to listen.

Each season, "Where It Hurts" takes you somewhere new —  to an overlooked part of the country to explore cracks in the American health system that leave people frustrated — and without the care they need. The story begins in Fort Scott, Kansas. Rural. Deeply Christian. And sicker than other parts of the state. When Mercy Hospital shut its doors, the town's sense of identity wavered.

Season One "No Mercy" is about the people who remain, surviving the best way they know how. Host and investigative journalist Sarah Jane Tribble spent more than a year revisiting southeastern Kansas, where she grew up, to document the sparking tensions, anger and fear many people felt as they struggled to come to terms with the hospital's closure.

Chapter 1: 'It Is What It Is'

Midwesterners aren't known for complaining. But after Mercy Hospital Fort Scott closed, hardship trickled down to people whose lives were already hard. Pat Wheeler has emphysema. Her husband, Ralph, has end-stage kidney failure, and the couple are barely making ends meet as they raise their teenage grandson. Pat is angry with hospital executives who she said yanked a lifeline from residents. "They took more than a hospital from us," she said.

Click here to read the episode transcript.

"Where It Hurts" is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble's award-winning series, "No Mercy."

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

And to hear all KHN podcasts, click here.

In an effort to raise his approval rating on an issue on which he trails Democrat Joe Biden in most polls, Trump on Thursday unveiled his "America First Healthcare Plan."

This article was published on Monday, September 28, 2020 in Kaiser Health News.

By Julie Rovner and Phil Galewitz September 28, 2020

When it comes to healthcare, President Donald Trump has promised far more than he has delivered. But that doesn't mean his administration has had no impact on health issues — including the operation of the Affordable Care Act, prescription drug prices and women's access to reproductive health services.

In a last-ditch effort to raise his approval rating on an issue on which he trails Democrat Joe Biden in most polls, Trump on Thursday unveiled his "America First Healthcare Plan," which includes a number of promises with no details and pumps some minor achievements into what the administration calls "monumental steps to improve the efficiency and quality of healthcare in the United States."

As the election nears, here is a brief breakdown of what Trump has done — and has not done — on some key health issues.

Affordable Care Act

Trump has not managed to repeal and replace the Affordable Care Act, despite his claims that the law is dead.

But his administration, and Republicans in Congress, have made changes to weaken the law while not dramatically affecting enrollment in marketplace plans.

Congress failed to rewrite the law in summer 2017, but Republicans who controlled both the House and Senate at the time included in their year-end tax cut bill a provision that reduced the penalty for failing to have health insurance to zero. That change eliminated what was by far the most unpopular provision of the law.

It also sparked a lawsuit by Republican state attorneys general and governors arguing that the tax change undercuts the law and thus should invalidate it. The case is set to be heard by the Supreme Court the week after the Nov. 3 election. The Trump administration is formally supporting the GOP plaintiffs in that suit.

The administration also used executive and regulatory action to chip away at the law's efficacy. Trump ended disputed cost-sharing subsidies to help insurers lower out-of-pocket costs for policyholders with low incomes. And the administration shortened the open enrollment period by half and slashed the budget for promoting the plans and paying people to help others navigate the often-confusing process of signing up.

Administration officials have complained that plans sold on the ACA marketplaces are not affordable, so they set new rules that allowed companies to sell competing "short-term" policies that were less expensive than ACA-sanctioned plans. But those plans are not required to provide comprehensive benefits or cover preexisting conditions.

Now, weeks before the election, federal officials are taking credit for premiums coming down, slightly, on ACA plans. "Premiums have gone down across all of our programs, including in healthcare.gov, which had been previously seeing double-digit rate increases," Seema Verma, who runs Medicare, Medicaid and the ACA exchanges, told reporters in a Sept. 24 conference call.

Premiums have come down this past year, confirmed Sabrina Corlette, who tracks the ACA as co-director of the Center on Health Insurance Reforms at Georgetown University, but only after many of the Trump administration's changes had driven them even higher. Insurers were spooked by the uncertainty — particularly in 2017, about whether the law would be repealed — and Trump's cutoff of federal funding for subsidies.

"The bottom line is, rates have gone up under Trump," Corlette said.

Women's Reproductive Health

Before he was elected, Trump pledged his allegiance to anti-abortion activists, who in turn urged their supporters to vote for him. But unlike many previous GOP presidents who called themselves "pro-life" but pushed the issue to the back burner, Trump has delivered on many of his promises to abortion foes.

Foremost, Trump has nominated two justices to the Supreme Court who were supported by anti-abortion advocates. With the help of the GOP Senate, Trump has also placed 200 conservative judges on federal district and appeals courts.

While many of the policy proposals advanced by the Trump administration are tied up in court, the sheer volume of activity has been notable, outstripping in less than four years efforts by Presidents Ronald Reagan and George W. Bush over each of their two-term presidencies.

Among those actions is a re-implementation and broadening of the "Mexico City Policy" that restricts foreign aid funding to organizations that "perform or promote" abortion. The administration has also moved to push Planned Parenthood out of the federal family planning program and Medicaid program. In addition, it has moved to make private insurance that covers abortion harder to purchase under the Affordable Care Act.

Trump's efforts on women's reproductive health reach beyond abortion to birth control. New rules would make it easier for employers with a "moral or religious objection" to decline to offer birth control as a health insurance benefit. Other rules would make it easier for health workers to decline to participate in any procedure to which they personally object.

COVID-19

Trump often claims that his decision in February to stop most travel from China was a critical factor in keeping the coronavirus pandemic in the U.S. from being worse than it has been. But the "travel ban" not only failed to stop many people from entering the U.S. from China anyway, scientists would later determine that the virus that spread widely in New York and other cities on the East Coast most likely came from Europe.

Although the White House has a coronavirus task force, the administration primarily has allowed states and localities to determine their own restrictions and timetables for closing and opening. The administration also had difficulty distributing medical supplies from a stockpile established for exactly this purpose. The president's son-in-law and White House adviser, Jared Kushner, said at one point that the purpose of the stockpile was to supplement state supplies, not provide them.

Testing was also a problem. An early test developed by the Centers for Disease Control and Prevention turned out to be faulty, and despite continued promises by administration officials, testing remains less available six months into the pandemic than most experts recommend. Meanwhile, Trump has claimed repeatedly — and falsely — that if the U.S. did less testing there would be fewer cases of the virus.

But many public health observers say the administration's biggest failing during the pandemic has been the lack of a single national message about the coronavirus and the best ways to prevent its spread.

More than 200,000 people in this country have died. Although the United States has only 4% of the world's population, it has recorded 21% of the fatalities around the globe.

Prescription Drug Costs

Trump pledged to attack high drug costs as one of his main campaign themes in 2016 and again this year. But he has not had the success he hoped for.

In one of the administration's biggest moves, the Department of Health and Human Services approved a rule last week that allows states to set up programs to import drugs from Canada, where they are cheaper because the Canadian government limits prices. Yet, it's unclear if the program will get off the ground, given drug industry opposition and resistance from the Canadian government.

In his healthcare policy speech Thursday, Trump promised to send each Medicare beneficiary a $200 discount card over the next several months to help them buy prescription drugs. The initiative is being done under a specific innovation program and must not add to the deficit. Administration officials Friday could not answer where they will get the nearly $7 billion to pay for what is perceived by many observers as a last-ditch stunt to win votes from older Americans.

The president previously signed an executive order that seeks to tie the price Medicare pays for drugs to a lower international reference price. The administration, however, hasn't released formal regulations to implement the policy, which could take years, and the policy is expected to be challenged in court by the drug industry.

In addition, Medicare will cap the price of insulin at $35 per prescription starting in 2021 for people getting coverage through some drug plans. More than 3 million Medicare beneficiaries use insulin to control their diabetes.

Trump also signed a law banning gag clauses used by health plans and pharmacy benefit managers to bar pharmacists from telling consumers about lower-priced drug options.

The administration's plan to require drug companies to provide prices in pharmaceutical advertising has been beaten back in court.

The administration points to the increased number of generic drugs that have been approved since Trump was elected, but many of those drugs are not on the market. That's because generic companies sometimes make deals with brand-name manufacturers to delay introducing lower-cost versions of their medicines.

At the same time, several bills the president supported to lower prices have stalled in Congress because of partisan differences and industry opposition.

"I don't think there has been any meaningful action that has had meaningful effect on drug prices," said Katie Gudiksen, a senior health policy researcher at The Source on Healthcare Price and Competition, a project of UC Hastings College of the Law in San Francisco.

Yet, she said, it's possible Trump's harsh criticism of the industry has had a chilling effect that led to lower prices.

Still, out-of-pocket costs for many individuals continue to climb as private and government insurance shifts more responsibility to the patient via higher cost sharing. Good Rx, an online site that tracks drug prices, noted this month that prescription drug prices have increased by 33% since 2014, faster than any other medical service or product.

Medicaid

The Trump administration has tried — but largely failed — to make many major changes to the state-federal health insurance program that covers more than 70 million low-income Americans.

Efforts by Republicans to repeal the Affordable Care Act would have ended the federal funding for the District of Columbia and the 38 states that expanded their programs for everyone with incomes under 138% of the federal poverty level, or about $17,609 for an individual. About 15 million people have gained coverage through the expansion.

Trump administration officials have argued that Medicaid should be reserved for the most vulnerable Americans, including traditional enrollees such as children, pregnant women and the disabled, and not used for non-disabled adults who gained coverage under the ACA's expansion. Since Trump took office, seven states have expanded Medicaid — Idaho, Maine, Missouri, Oklahoma, Nebraska, Utah and Virginia.

In 2018, federal officials allowed states for the first time to require some enrollees to work as a condition for Medicaid coverage. The effort resulted in more than 18,000 Medicaid enrollees losing coverage in Arkansas before a federal judge halted implementation in that state and several others. The case has been appealed to the Supreme Court.

The administration also backed a move in Congress to change the way the federal government funds Medicaid. Since Medicaid's inception in 1966, federal funding has increased with enrollment and health costs. Republicans would like to instead offer states annual block grants that critics say would dramatically reduce state funding but that proponents say would give states more flexibility to meet their needs.

When the congressional attempt to establish block grants failed, the administration tried through executive action to implement a process allowing states to opt into a block grant. Yet only one state — Oklahoma — applied for a waiver to move to block-grant funding, and it withdrew its request in August, two weeks after voters there narrowly passed a ballot initiative to expand Medicaid to 200,000 residents.

Medicaid enrollment fell from 75 million in January 2017 to about 71 million in March 2018. Then the pandemic took hold and caused millions of people to lose jobs and their health coverage. As of May, Medicaid enrollment nationally was 73.5 million.

The administration's decision to expand the "public charge" rule, which would allow federal immigration officials to more easily deny permanent residency status to those who depend on certain public benefits, such as Medicaid, has discouraged many people from applying for Medicaid, said Judith Solomon, senior fellow with the Center on Budget and Policy Priorities, a research group based in Washington, D.C. 

Medicare

Seniors were among Trump's most loyal voters in 2016, and he has promised repeatedly to protect the popular Medicare program. But not all his proposals would help the seniors who depend on it.

For example, invalidating the Affordable Care Act would eliminate new preventive benefits for Medicare enrollees and reopen the notorious "doughnut hole" that subjects many seniors to large out-of-pocket costs for prescription drugs, even if they have insurance.

Trump also signed several pieces of legislation that accelerate the depletion of the Medicare trust fund by cutting taxes that support the program. And his budget for fiscal 2021 proposed Medicare cuts totaling $450 billion.

At the same time, however, the administration implemented policies dramatically expanding payment for telehealth services as well as a kidney care initiative for the millions of patients who qualify for Medicare as a result of advanced kidney disease.

Surprise Billing

Trump in May 2019 promised to end surprise billing, which leaves patients on the hook for often-exorbitant bills from hospitals, doctors and other professionals who provide service not covered by insurance.

The problem typically occurs when patients receive care at health facilities that are part of their insurance network but are treated by practitioners who are not. Other sources of surprise billing include ambulance companies and emergency room physicians and anesthesiologists, among other specialties.

An effort to end the practice stalled in Congress as some industry groups pushed back against legislative proposals.

"The administration was supportive of the pretty consumer-friendly approaches, but obviously it doesn't have any results to speak of," said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy in Los Angeles.

"At the end of the day, plenty of people in Congress did not really want to get something done," he said.

Taking a different route, the administration finalized a rule last November that requires hospitals to provide price information to consumers. The rule will take effect Jan. 1. A federal judge shot down an attempt by hospitals to block the rule, although appeals are expected.

Brian Blase, a former Trump adviser, said this effort could soon help consumers. "Arguably, the No. 1 problem with surprise bills is that people have no idea what prices are before they receive care," he said.

But Adler said the rule would have a "very minor effect" because most consumers don't look at prices before deciding where to seek care — especially during emergencies.

Public Health/Opioids

Obesity and the opioid addiction epidemic were two of the nation's biggest public health threats until the coronavirus pandemic hit this year.

The number of opioid deaths has shown a modest decline after a dramatic increase over the past decade. Overall, overdose death rates fell by 4% from 2017 to 2018 in the United States. New CDC data shows that, over the same period, death rates involving heroin also decreased by 4% and overdose death rates involving prescription drugs decreased by 13.5%.

The administration increased funding to expand treatment programs for people using heroin and expanded access to naloxone, a medication that can reverse an overdose, said Dr. Georges Benjamin, executive director of the American Public Health Association.

Meanwhile, the nation's obesity epidemic is worsening. Obesity, a risk factor for severe effects of COVID-19, continues to become more common, according to the CDC.

Twelve states — Alabama, Arkansas, Indiana, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Oklahoma, South Carolina, Tennessee and West Virginia — have a self-reported adult obesity prevalence of 35% or more, up from nine states in 2018 and six in 2017.

Benjamin said some of the administration's other policies, such as reducing access to food stamps and undermining clean air and water regulations, have made improving public health more difficult.

But the pandemic has been the major public health issue this administration has faced.

"We were doing a reasonable job addressing the opioid epidemic until COVID hit," Benjamin said. "This shows the fragility of our health system, that we cannot manage these three epidemics at the same time."

Julie Rovner: jrovner@kff.org, @jrovner

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

A Colorado program has transformed six RVs into mobile clinics to reach isolated farming communities and remote mountain hamlets.

This article was published on Monday, September 28, 2020 in Kaiser Health News.

By Markian Hawryluk

STERLING, Colo. — Tonja Jimenez is far from the only person driving an RV down Colorado's rural highways. But unlike the other rigs, her 34-foot-long motor home is equipped as an addiction treatment clinic on wheels, bringing lifesaving treatment to the northeastern corner of the state, where patients with substance use disorders are often left to fend for themselves.

As in many states, access to addiction treatment remains a challenge in Colorado, so a new state program has transformed six RVs into mobile clinics to reach isolated farming communities and remote mountain hamlets. And, in recent months, they've become more crucial: During the coronavirus pandemic, even as brick-and-mortar addiction clinics have closed or stopped taking new patients, these six-wheeled clinics have kept going, except for a pit stop this summer for air conditioning repair.

Their health teams perform in-person testing and counseling. And as broadband access isn't always a given in these rural spots, the RVs also provide a telehealth bridge to the medical providers back in the big cities. Working from afar, these providers can prescribe medicine to fight addiction and the ever-present risk of overdose, an especially looming concern amid the isolation and stress of the pandemic.

Mobile health clinics have been around for years, bringing vision tests, asthma treatment and dentistry to places without adequate care. But using healthcare on wheels to treat addiction isn't as common. Nor is equipping such motor homes with telehealth capability that expands the reach of prescribing providers to treat hard-to-reach patients in these hard-to-reach rural areas.

"We really believe we bring treatment to our patients and we meet them where they're at," said Donna Goldstrom, clinical director for Front Range Clinic, a Fort Collins, Colorado, practice that operates four of the RVs. "So meeting them where they're at physically is not a long leap from meeting them where they're at motivationally and psychologically."

Each RV has a nurse, a counselor and a peer specialist who has personal experience with addiction — and all had to be trained to drive a vehicle that size.

"I never thought when I went to nursing school that I'd be doing this," Christi Couron, a licensed practical nurse, said as she pumped 52 gallons of diesel fuel into the motor home she works on with Jimenez.

The crew has driven their RV more than 30,000 miles since January, much of it viewed through a cracked windshield courtesy of a summer afternoon hailstorm. Four days a week, they ply the roads from Greeley to the smaller towns near the Nebraska border, as the view goes from mile-high to miles-wide.

Don a Mask, Pee in a Cup

On a dusty lot outside a halfway house in Sterling, Jimenez, the peer specialist, activates the leveling jacks to balance the RV, and the team readies the unit for the day's slate of patients. The passenger-side captain's chair flips around to face a table where Jimenez will check in patients. The tabletop is crowded with a printer, a scanner, a laptop and a label-maker. Underneath lie a box of specimen cups and a gallon of windshield washer fluid. The vehicle now has plenty of masks and cleaning supplies on hand, too.

After patients check in, they go to the RV's snug bathroom to provide a urine sample. With test strips built into the sides of the cup, results show instantly whether any of 13 categories of drugs — from opiates to antidepressants — are in the urine. The sample is later dropped off at a lab to confirm the results and determine which specific drug is involved. The results help the team understand how best to treat the patients and make sure they use the prescriptions they're given.

Patients then head to a small exam room in the back, where they connect via video to a nurse practitioner or physician assistant in a brick-and-mortar clinic.

If all goes well, the provider will send over a prescription for Suboxone (a combination medicine containing buprenorphine, which reduces cravings for opioids) or for Vivitrol (a monthly injectable version of naltrexone, which blocks opioid receptors). Once the staffers have the prescription in hand, the RV nurse can give those Vivitrol shots directly and distribute Narcan, a medication that will reverse an opioid overdose. Suboxone prescriptions must be called into a local pharmacy.

Patients also can drop used needles into a sharps container for disposal, but the staffers are not allowed to distribute clean needles. Some patients will talk with counselor Nicky McLean in a room just large enough to fit a table and two chairs.

Within minutes, a couple, who asked not to be identified by name because of the stigma surrounding addiction, arrive early for their appointments. They've brought the staff homemade chicken enchiladas. They had been spending $8,000 a month buying OxyContin on the street, and their lives and finances were a wreck. He lost his house. She needs clean urine tests to see her son. The couple started their addiction treatment only three weeks earlier, after he learned about the RV clinic from a friend.

They no longer have a car, so they walked a half-hour to get to their appointment.

"We would've done anything to get our drugs," she said. "Walking 30 minutes to get better, it's worth it."

Even before they've finished, another patient is at the door. Spencer Nash, 29, has been using opioids since he was 18. Nine years ago, when his wife got pregnant, the couple decided to get clean, driving two hours each way, six days a week, to a methadone clinic in Fort Collins. Now, he walks to the RV, outside the halfway house where he lives, to get his Suboxone prescription.

Filling the Gaps

A few years ago, Robert Werthwein, director of Colorado's Office of Behavioral Health, heard about a project using RVs for addiction treatment in rural upstate New York. He thought it would work in his state, too. The agency crunched the numbers to see which regions recorded the highest levels of opioid prescriptions and overdoses but lacked addiction treatment.

"We hear too often that in rural Colorado and the mountain regions of Colorado they don't have the same access to services as the Denver metro and the Front Range regions," Werthwein said. The state secured a $10 million federal grant for the program. His team brought in healthcare providers, such as Front Range Clinic, to staff and operate the RVs.

Once the RVs were ready, the staff had to be trained to drive them, which necessitated "a couple of repairs," Werthwein said. The vehicles first started rolling out in December, eventually serving six regions — and in a seventh area, a place where narrow mountain roads precluded a large RV, one of Werthwein's teams travels by SUV.

In some communities, the local doctors and others have been less than thrilled, feeling the RVs would attract drug users to their town.

"We're hoping to address stigma, not just from a public standpoint, but we're hoping to show providers 'there is a demand in your community for medication-assisted treatment,'" Werthwein said.

Once the federal grant runs out in September 2022, Front Range Clinic and the other mobile unit operators will inherit and continue to operate the RVs, billing Medicaid and private insurance as they do now for the appointments.

As the RV crew's 1 p.m. departure time in Sterling approached, one patient remained. The woman, who asked that her name not be published because she didn't want to be publicly identified as a drug user, arrived at the mobile clinic without an appointment. But they couldn't take her as a new patient without a urine sample. For two hours, she was in and out of the bathroom, drinking bottles of water, but unable to fill the little plastic cup. Through the bathroom door, the staffers could hear her crying and cursing at herself.

With the battery power on the RV winding down, they coaxed her out of the bathroom. Perhaps tomorrow would work better, they told her. She could continue to rehydrate through the night and then meet the mobile unit at its next stop, Fort Morgan, some 45 minutes away.

The next day, she was still unable to produce a urine sample, whether because of dehydration from her substance use or simply nerves. They asked her to come back again when the RV returned to Sterling the next week, but she never showed up.

Markian Hawryluk: MarkianH@kff.org, @MarkianHawryluk