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OFFICE OF MINORITY HEALTH/HHS CONVENING
Washington DC, June 26

The Value of Mobile Health

By Anthony Vavasis, MD

Convening on Mobile Health

Today was a big day for Mobile Health Clinics across the nation. The Office of Minority Health at the U.S. Department of Health and Human Services hosted a convening in which data from the collaborative research network of mobile health programs - Mobile Health Map (www.mobilehealthmap.org) - was presented. The Mobile Health Map is the product of a collaborative between Mobile Health Clinics Association (www.mobileHCA.org) and Harvard Medical School. In attendance at the convening were representative from departments within HHS, as well as other agencies such as the Institute of Medicine. The convening included brief presentations from the Co-Principal Investigators of the Mobile Health Map and providers of mobile healthcare from around the country.

Background

The importance of the convening is embedded in the history of Mobile Health Clinics (MHCs). Here's a quick review: MHC's have grown out of the dire need for health care services among the most marginalized populations in the US. From street youth to migrant farm workers to homeless veterans, these populations suffer from health disparities that leave them in poor health. By the time they seek health care, they are usually in need of far more expensive services than the ones they might have originally received, and they are much sicker than they should have ever become. MHCs have become a key source of health care for these populations because they provide care in a way that makes it accessible.

An MHC is typically a large, customized specialty vehicle designed and built as a medical clinic, a dental operatory, a counseling room or an imaging suite for mammography. It can provide most of the services that a comparable fixed-site clinic can provide. Because MHCs are on wheels, they can bring services to communities in need. There are several obvious benefits to this. In rural communities, where transportation to remote health care facilities can be costly or unavailable, MHCs eliminate the need for transportation. MHCs are typically supported through grants, so the care is free or low-cost, thus removing another key barrier to health care access. The least tangible but equally important impediment to health care is the issue of trust. Many users of MHCs report that they don't feel comfortable in fixed-site health facilities, even if they are local and affordable. Because the MHC becomes part of the community, it is usually seen as a trustworthy source of health care.

This dynamic has been a key driver of utilization of MHCs in rural and urban communities. It has also created complexity in developing standard measures of mobile health care. The majority of MHCs have grown out of a specific community need. They are therefore defined by the health care problems addressed and the communities served. On one hand, MHCs are as accessible and culturally competent as any health care provider can be. On the other hand, each MHC is unique and therefore challenged to prove its value within the context of a very diverse sector.

The Convening

The Mobile Health Map project has attempted to meet this challenge by measuring the demographics of the population(s) served and the services provided and comparing them to external data. At the convening, the presenters collectively described our current attempts to measure an elusive entity.

Co-Principal Investigator Dr. Nancy Oriol described a key concept in mobile health: boundary turbulence. By bringing health care into the field, MHC providers meet patients at the boundary where their two worlds intersect. At this boundary, both participants in the relationship have an opportunity to redefine the relationship between them. We believe this shift explains in part why people who typically don't access fixed-site health care will come to an MHC.

Co-Principal Investigator, Dr. Anthony Vavasis summarized the data from the Map and discussed next steps. We have found that the populations reached by MHCs closely mirror populations known to have poor access to health care. Additionally, we have shown that for every dollar invested in a mobile program, $23 are returned based on avoidance of emergency departments and delivery of preventive services. Finally, we estimate that 6.5 million visits take place on Mobile Health Clinics per year by the approximately 2,000 MHCs that operate in the US.

Other presenters demonstrated the impressive potential of MHCs by showing data from their programs:

• Barbara Hoffman, MD from Lower Eastside Service Center (NYC) showed how their program, Wellness in Motion, has successfully worked with high-risk populations to improve mental health status of clients while reducing their risk behaviors, both to a degree of statistical significance.
• Madge Vasquez from St. David's Foundation (TX) showed how mobile pediatric dental programs in Texas can successfully reach high risk children and how her program's services transformed from almost entirely restorative treatments to primarily preventive interventions by providing consistent care greatly reducing overall cost of care.
• Roxanne Elliot from First Health of the Carolinas (NC) offered data on how their MHC, FirstReach, identified undiagnosed diabetes in marginalized rural populations and successfully brought their diabetes under control, contributing to reduced mortality within that population.
• Leonel Lacayo, MD from The Health Hut (in rural LA) has not only identified numerous new cases of hypertension and diabetes, but how their MHC now accepts patients who are discharged from hospitals because patients have otherwise had no care post-hospitalization (and end up getting hospitalized again, a potentially avoidable outcome).
• Delaney Gracy, MD from the Children's Health Fund (NYC) showed how her network of programs has used demographics, health disparity data and community partnerships to rationally and strategically deploy new MHCs.
  

The Discussion

The meeting was structured so that participants could engage in dialogue throughout the meeting with the explicit goal of inviting new ideas from the audience and learning the best ways to move forward. There was agreement on important steps that could help the mobile health care sector to grow and reach more populations:

• Continue to work toward uniform data collection in order to make our case
• Identify creative approaches to HIT that may help us reach this goal
• Embrace the concept of 'Health Deserts' that are known to lack the basic infrastructure to provide primary medical and dental care as targets for future MHCs
• Consider who in the target population doesn't access an MHC and why
• Consider prospective controlled studies to look at the impact of an MHC on a community
• Continue to build alliances with programs within the federal government that are working toward eliminating health disparities in order to ensure that the data collected by MHCs are useful and relevant to the programs' goals
• Identify important quality measures within the MHC sector
• Identify initiatives to expand current MHCs
• Identify how MHCs can assist the Office of Minority Health and other HHS agencies in meeting their goals

Two important tensions emerged from the discussion. Neither is insoluble, but must be considered in future programming to ensure that MHCs maintain high standards of care:

1. Scalability vs. Uniqueness: part of the success of MHCs is related to their intimate relationship with their community and population. How to expand Mobile Healthcare while maintaining the organic quality of each MHC will be a challenge;
   
   
2. Data collection vs. Trust: a key way in which MHCs have succeeded is by building trust with their target populations. Clinical and demographic data collection can be seen as an act of betrayal by people in the target populations. As MHCs work to prove their value through data collection, they must do this in a way that does not undermine hard-earned trust.

Many new relationships were established at the convening and valuable information was exchanged. We are hopeful that by starting this dialogue and joining in our common goal to reduce health disparities, MHC providers and HHS staff will become partners in the expansion of MHCs as an important and vital sector of the US health care safety net.

We are grateful to the Office of Minority Health and Dr. Nadine Gracia for supporting this important convenin