PHILADELPHIA — Under a white tent about four blocks north of Temple Hospital, a nurse checked Robert White’s blood pressure, as cars and delivery trucks rumbled past.
“You’re doing well,” said Barbara Hitchens, a nurse practitioner, suggesting she’ll see him again in another a week.
Instead of a doctor’s office, the 62-year-old White relies on an outdoor mobile clinic at Germantown Avenue and Broad Street. Three months ago he started visiting the clinic run by Temple University Medical School’s Center for Urban Bioethics to get a COVID-19 booster.
“It’s convenient, it’s right there, so I got nothing to lose,” said White, who visits every Monday during a break or after work as a custodial ambassador at Call to Serve, a nearby neighborhood community development corporation.
The mobile clinic, one of three affiliated with Temple, launched four months ago as a vaccination clinic. But as Philadelphia’s COVID-19 vaccination rates have stagnated, the service has added other ways to stay essential — and build on the trust providers have garnered by taking COVID-19 care directly to people. It’s now offering chronic disease monitoring every Monday at the busy North Philadelphia intersection.
“There are a lot of folks out there who are afraid to see their doctors,” because they don’t trust medical professionals or are anxious about going to large medical facilities, said Cornelius Pitts Director of COVID-19 Vaccinaton Response Project at a Center for Urban Bioethics, Lewis Katz School of Medicine Temple University. Others may be embarrassed that they’ve gone so long without an appointment and scared their doctor will chastise them. “We wanted to create an access point for people who had that fear.”
Mobile clinics rose in popularity during the pandemic as a minimal-contact way to deliver health services, such as needed COVID-19 tests and vaccines to undervaccinated communities, said Mollie Williams, executive director of Harvard’s Mobile Health Map. Questions from health care providers about starting their own mobile clinics have steadily increased since the pandemic began, she said.
“In the beginning, the questions were about starting new clinics and now, more are about sustaining those new clinics as they shift their services to address health issues beyond COVID,” Williams said.
Philadelphia doesn’t track mobile health services in the city, but the Harvard map showed a dozen in Philadelphia and the surrounding Pennsylvania and New Jersey counties.
It’s not surprising that many of the mobile units created to dispense COVID-19 vaccines have evolved to offer other services. Nonprofit hospitals rely on funding that requires community outreach —and mobile clinics fill that need.
“They have this great new asset in the mobile clinic and this relationship in the community,” Williams said.
Pandemic lessons
Mobile health is nothing new in Philadelphia, but mobile clinics’ effective vaccination outreach to underserved communities made providers appreciate the use of health care vans.
“What we learned from this is you truly could do a clinic-in-a-box model,” said Heather Klusaritz, associate director of University of Pennsylvania Health System’s Center for Community and Population Health. That model stocks a vehicle with medical supplies and brings along two or three people who can provide the same care as a doctor, without requiring people to walk farther than the end of their block.
Studies conducted before the pandemic found mobile clinics are effective at providing urgent care, preventative health screenings, and managing chronic illness. They allow people to sidestep transportation, scheduling, and administrative obstacles to health care, one 2017 review found, and help overcome racial barriers. About 60% of people using the service are uninsured, and 31% are covered by Medicare or Medicaid, according to Harvard’s Mobile Health Map.
Penn was among the health systems nationwide that invested in a mobile clinic for COVID-19 vaccinations. That’s still the van’s primary purpose.
The mobile clinic vehicles can be adapted for mammograms, to test for hepatitis B or skin cancer, or private patient consultations.
“There was this massive movement to centralize health care systems and the personalized home visits went away,” said Amy Leader, associate professor of population science at Jefferson’s Sidney Kimmel Cancer Center at Jefferson, who works with a regional mobile mammography clinic. “Now we’re sort of back into the model of bringing things in to people and in their communities and meeting them where they are.”
Empowering health care
Pat Imms, a clinical supervisor with Miriam Medical Clinics, was on duty at Temple’s mobile clinic a recent morning when Lenise Miller stopped by for a blood pressure check. Imms talked to her about how high blood pressure can harm the renal artery, eventually leading to kidney dialysis.
“I didn’t know it was elevated until she just took my pressure,” said Miller, 66.
“Will you come next week and we’ll check it again?” Imms asked. Miller said she would.
Nicetown-Tioga, where Temple’s clinic sets up shop, has about one primary care physician for every 1,314 residents. That’s better than the city’s overall ratio of 1 to 1,460, according to a 2019 city report on neighborhood health, but far worse than places like Center City East, where there’s a primary care doctor for every 312 people.
Even people who have doctors struggle to book appointments at offices overwhelmed by patients who had put off care during the worst of the pandemic, which means people missed out on routine screenings, like blood pressure checks.
Ethel Kellum, 55, was on the way to the post office when she decided to get checked for a recent sensation of tingling in her toes that she feared was diabetes.
“People are walking around with high blood pressure and diabetes and don’t even know it,” she said. A blood sugar test assuaged her fears. “I feel better,” she said, “knowing I don’t have diabetes.”
Almost 20% of people in Nicetown-Tioga have diabetes, compared with just over 12% citywide, according to that 2019 report. Rates of hypertension, high cholesterol, and chronic kidney disease are also more common there than citywide.
Sometimes, nurses at the clinic just converse with passersby. A few times, the clinic has helped people in urgent need of treatment. Pitts recalled one patient whose blood pressure was so high a nurse escorted him from the mobile clinic to Temple Hospital.
Limited funding, limited reach
Mobile clinics also have inherent limitations. They can only be at one location at a time, and often attract small crowds. About a dozen people typically visit Temple’s van during the clinic’s four-hour Monday window. About half are there to get vaccinated.
The services are intended to connect people to primary care, not take the place of a primary care physician, Pitts said.
“It’s all about connections and relationships, and that’s where health care a lot of times falls down,” Pitts said.
Ideally, interactions with the mobile clinic will be a catalyst for people to seek more routine health care. The visibility of seeing health care in a community is a benefit too.
“We’re here, our doors are open when you need us. We’re creating an access point whether you come or not,” Klusaritz said.
There is also the issue of cost. Temple’s mobile clinic doesn’t rely on federal funding, but others, including Penn’s service, has been paid for through emergency funds made available because of the pandemic. One alternative is to bill patients who have insurance, but offering free health care is one of the missions of outreach clinics, Klusaritz said.
The shift to chronic disease management at Temple’s mobile clinic is to some extent a source of frustration for its organizers, who say there is still a need for COVID-19 vaccination. More than two-thirds of Philadelphians ages 5 to 11 are unvaccinated, and more than 20% of adults are not fully immunized.
Pitts, of Temple, noted that distrust of health care providers and government has played a part in driving vaccine hesitancy nationally, something mobile clinics can combat.
“There’s an undercurrent of people who don’t want any part of the health care system,” Pitts said. “We’re learning who those people are.”
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