On the Road Again: Rural Residents Rely on Mobile Services

September-October 2010
By: Mark Crawford

BY: MARK CRAWFORD

Providing mobile health services to underserved areas in rural eastern Kentucky has special meaning for Rose Rexroat, RN, manager of community services for Saint Joseph Hospital in Lexington, a member of the Catholic Health Initiatives (CHI) system.

"I grew up in Morgan County," she said. "Being part of providing service to communities that I know, to friends and even family members, is priceless to me. To be able to give back to the area where I grew up is very meaningful. I never thought I would have the opportunity to be involved in a program that cared for people in that area of Kentucky that is totally motivated out of mission — I feel blessed every day to be doing this."

Rexroat is administrator for Saint Joseph Hospital's Eastern Kentucky Mobile Health Service. The hospital modeled its mobile service on a successful mission clinic it opened in 1997 to serve the uninsured in Lexington and Fayette counties. To bring health care access to residents in more remote rural communities, Saint Joseph launched the mobile service in May 2003.

Access to health care is a serious issue in Kentucky, because the state just doesn't have enough doctors. According to a 2007 Kentucky Institute of Medicine report (kyiom.org/KMAWorkforceReport9-24-07.html), the shortage is chronic. At the time of the study, Kentucky needed over 2,000 more active physicians, notably in primary care specialties, just to match the U.S. average ratio of physicians to population.

What's more, the difficulty of recruiting and retaining physicians in rural communities leaves little hope of replacing practitioners as they retire, much less significantly adding to their numbers.

Rexroat's mobile clinic operates in Morgan, Wolfe and Lawrence counties, three of the state's most underserved areas that also have some of the highest health-professional shortages. People who live in these counties have higher rates for cardiovascular death, cancer death and total mortality compared to state and national averages. This is especially true for Wolfe County, which the Kentucky Institute of Medicine ranked the least healthy in its assessment of the state's 120 counties (kyiom.org/assessment.html).

TELEHEALTH MAKES IT ALL POSSIBLE
Managed by an advanced registered nurse practitioner(ARNP), the Eastern Kentucky Mobile Health Service provides primary health care services and is staffed by a registered nurse, social worker and a driver cross-trained for data entry and other duties. Dr. Joseph Richardson, an emergency department physician in Lexington, is the medical director for the clinic and is available for consultation 24/7, thanks to phone and video conferencing.

"We have had telehealth technology since 2004," said Rexroat. "The technology is primarily used for access to specialty and mental health consultations. We can also provide primary care to patients of the mental health network using the telehealth equipment."

The clinic follows a scheduled weekly route, setting up in a different community each day in the three-county area. At each location, the clinic connects to the Saint Joseph Health System through phone and T1 land lines. As a member of the Kentucky TeleHealth Network, the Saint Joseph Health System can access any facility on the state network.

More than 3,000 patients a year use the mobile clinic, often traveling from neighboring counties to receive health services. No one is turned away for lack of ability to pay. If patients have Medicare, Medicaid or third-party insurance, the clinic bills for its services. Uninsured patients go through financial counseling and screening to see if they can pay on a scale or qualify for charity care.

"Without [the mobile clinic], many of these individuals and families would be without treatment," said Rexroat. "For example, we have one couple where the wife receives about $280 of medications per month for a bladder disorder, high cholesterol and high blood pressure. The husband also has high blood pressure, for which he obtains care and medications, and also had a malignant melanoma diagnosed and removed from his arm for free. They are both uninsured and cannot afford $62 each for a physician office visit. They rely on us for their health care and medications. Without the clinic, their conditions would remain untreated."

Indeed, the mobile clinic has dispensed about $6.9 million in medications to patients since 2003 when the service began. The drugs are subsidized by pharmaceutical company medication programs, and patients aren't charged. The average wholesale cost of medications per patient visit (using the same pricing that Saint Joseph Health System would pay to purchase the same medications) is $623.45.

MOVING FORWARD
So far, health reform has had minimal impact in the rural areas the clinic serves. However, as the new law brings insurance coverage to more people, serving them will require improved access to quality health care. Saint Joseph's is already considering changes for the mobile health service.

"There is no question it will be a challenge to increase access for those who become newly insured, especially as the health care provider resource is diminishing," said Rexroat. "Who will take care of the approximately 200,000 more covered lives in Kentucky in 2014?"

"Four years from now the mobile clinic will be an inefficient and inadequate platform to meet these increased needs," added Daniel W. Varga, MD, chief medical officer for the Saint Joseph Health System. "We are, therefore, looking at some new models of care delivery to continue our existing service to these communities, as well as expand our service offerings. One possibility is establishing five or six fixed sites connected by telehealth technology to a virtual multispecialty group of physicians."

This telehealth scenario would provide daily services at these clinics with immediate connection to specialists when needed. Primary care services will largely be provided by physician extenders on site, in partnership with existing practices and local health departments where available.

"We envision the mobile clinic converting to a mobile diagnostic service that can bring basic ancillary services to these communities, like mammography, echocardiograms, electrocardiograms and ultrasound," said Varga. "This initiative will support our commitment to deliver exceptional care close to home, especially for some of our neediest Kentuckians."

A MODEL FOR OTHERS
A recipient of the American Hospital Association's NOVA Award in 2006, the Eastern Kentucky Mobile Health Service is an excellent example of how an ARNP-managed clinic can effectively provide care and use technology for further access to specialty consultations.

"Mobile health services increase access to health care for those in remote rural communities who have transportation or financial barriers," stated Rexroat. "We know we are making a difference in our patients' lives. Without the care we provide and the medications we dispense, they have very little power to impact their health status and care for themselves."

Health systems considering setting up a mobile clinic should be patient with results and not lose sight of longer-range goals, Rexroat advised. "Find a place to start and continue to examine ways to make a difference or expand your model to meet changing needs," she said. "Building a network of access has been a large part of our work. Examining how we can collaborate with other agencies and use them as points of access has been very rewarding.

"Success is measured by making a difference in one person, then another person and then another. The increment is 'one,' but over time it accumulates, the impact becomes much more significant."

Rexroat suggested staying flexible and not over-planning or being too rigid in laying out strategies, "because what you experience will be totally different than what you anticipated, anyway," she said. "For example, when we first got started, based on the implementation of the mobile health clinic in Lexington, we thought that the majority of the patients we'd be seeing would need episodic acute care. Our experience in the first six weeks showed how wrong we were. Chronic disease and the need for chronic disease management were the critical needs presented by the majority of the patients that came to see us."

Having a social worker on staff for a mobile clinic is a good idea. Rexroat said. In Saint Joseph's experience, care needs to be as comprehensive as possible for meeting the multiple and often complex health needs of the rural community. People often visit the mobile clinic with a challenging mix of health, social, emotional or spiritual needs.

"Our payer mix is 77.8 percent charity care, 12.2 percent Medicare, 5 percent Medicaid and the rest 12 percent," said Rexroat. "People come to the clinic with nothing, but needing everything. We work until we can get them the help they need. We use every resource and contact we have created during our entire professional careers."

Not to mention persistence.

"Never give up in the effort, and if one option does not work, keep looking and asking," she said. "Don't be afraid to ask for help. Sometimes you'll be surprised by the extent people are willing to help; but also be prepared to hear from and accept others who don't want to help, or are quick to criticize your efforts."

Making a difference in people's lives and being part of the healing ministry of the church is deeply satisfying to Rexroat. "We are a ministry to the communities we serve," she said. "A question I often ask myself and my staff is, 'Have I reflected Jesus today to someone I have cared for?' When we have done that, we have met our mission toward the healing of the mind, body and soul of another."

MARK CRAWFORD is a freelance writer based in Chicago.