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Service Delivery Innovation Profile

Mobile Clinic Provides Comprehensive Medical Home for Homeless and At-Risk Youth, Reducing Emergency Department Visits and Increasing Followup Care


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Snapshot

Summary

A collaborative partnership between Phoenix Children's Hospital, UMOM New Day Center, and Children's Health Fund, Crews'n Healthmobile Homeless Youth Program operates a free-standing clinic and a mobile medical unit that provide hope and holistic health care to Arizona's homeless and at-risk youth and young families. Preventive and comprehensive services include medical and health education services at numerous sites where homeless and other at-risk youth gather in the Phoenix metropolitan area. Through partnerships with community agencies, the clinic also provides referrals for needed follow up services, including medical and dental care and social services. Regular program participants utilize the emergency department less frequently and are more likely to receive follow-up care, while both patients and providers report high levels of satisfaction with the program.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data on emergency department use and attendance at follow up care appointments, along with anecdotal reports from patients and providers.
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Developing Organizations

Children's Health Fund; HomeBase Youth Services; Phoenix Children's Hospital
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Date First Implemented

2000
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Patient Population

Vulnerable Populations > Children; Homeless; Impoverished; Urban populationsend pp

Problem Addressed

Thousands of American youth are currently homeless, often living alone and/or without adequate food, shelter, clothing, and medical attention. Homelessness has serious health-related consequences for young people, causing many to suffer from physical and mental ailments.
  • Many youth affected: According to the National Alliance to End Homelessness, between 5 and 7.7 percent of youth in America experience periods of homelessness each year.1 Unaccompanied youth account for 3 percent of the urban homeless population.2 In 2010, 6,087 children under age 18 and 3,016 youth ages 18-24 experienced homelessness and accessed services through non-profit organizations in Arizona alone.3
  • Risky behaviors: Homeless youth are more likely to become involved in prostitution, use and abuse drugs, and engage in other dangerous behaviors, putting them at increased risk of physical harm due to violence and infectious diseases such as human immunodeficiency virus/acquired immunodeficiency syndrome.1
  • Illness prevalent, with little access to care: Homeless youth often suffer from depression and anxiety, poor health and nutrition, and posttraumatic stress disorder.2 The lack of financial and other resources makes it difficult for these youth to receive the care and treatment they need.

What They Did

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Description of the Innovative Activity

Crews'n Healthmobile is a mobile medical unit that offers a full range of medical and health education services at numerous sites where homeless and other at-risk youth gather. Through partnerships with community agencies, the clinic also provides referrals for needed follow up services, including medical and dental care and social services. Key elements of the program include the following:
  • Target population: Crews'n Healthmobile provides services to individuals 24 years of age or younger who are homeless or considered "at risk." Among others, at-risk groups include those living in shelters, group homes, hotels, or cars, and those being evicted from their homes. Services are free to homeless and at-risk youth, children, and young families. Patients receive eligibility screening and assistance with insurance acquisition through Arizona Health Care Cost Containment System, the state's Medicaid program.
  • Fixed site and mobile services at easy-to-access community sites: The program provides services from a fixed site and a mobile medical unit. The fixed site clinic offers care 3 days a week at partner agency UMOM New Day Center, Arizona's largest family shelter. Medical street outreach provides services from a 38-foot van that houses three fully-equipped examination rooms, a registration area, and a bathroom. At any given time, the van is staffed by a team composed of a physician, a nurse, and a case manager. The van parks Monday through Thursday at numerous Phoenix-area sites where homeless and other at-risk youth are known to gather. Current sites include Children First Academy, Watkins Shelter for the Homeless, HomeBase Youth Services, three Tumbleweed Center for Youth locations, and an undisclosed group home for children with significant mental health issues. The program currently offers sixteen medical clinics and one immunization clinic.
  • Comprehensive medical home: The clinic provides a comprehensive medical home, with program staff and partnering agencies working together to coordinate medical and nonmedical services needed by each patient. The Crews'n clinics not only provide care but also serve as an entry point for additional services to help youth and young families get off the streets and live healthy lives. Core components of the medical home include the following:
    • Medical care: The mobile clinic provides patients with a full array of medical services, including but not limited to full physical examinations and well-child care, immunizations, medications, acute care, primary and preventive care, and minor surgical procedures. Medical practitioners from Phoenix Children's Hospital staff the clinic at all times, with residents and medical students from Phoenix Children's, St. Joseph's Hospital, and Banner Good Samaritan Medical Center rotating through on a periodic basis.
    • Behavioral health screening and counseling: New patients between 12 and 24 years old are screened for behavioral health issues using the HEADSS (Home, Education, Activities, Drug use and abuse, Sexual behavior, Suicidality and depression) interview tool,4 with all staff—including case managers, nurses, nurse practitioners, and physicians—being trained to conduct this screening. Patients identified with behavioral health issues, such as depression or a history of abuse receive referrals to local mental health centers.
    • Referrals to partner agencies: Crews'n Healthmobile partners with a number of community agencies to provide holistic and comprehensive care. Mobile clinic staff refer patients to these agencies based on individual needs and will assist patients in making and keeping appointments as necessary. For example, HomeBase Youth Services provides case management services, educational assistance, and transitional and independent living facilities for youth 18 to 21 years old. The United Methodist Outreach Ministries New Day Centers provides bilingual shelter and services to women and children affected by family violence and to families without a home. The Tumbleweeds Center offers emergency shelter, transitional living, and case management services to younger patients (up to 17 years old). Patients receive comprehensive routine and emergency dental care through the dental clinic at downtown Phoenix's Human Services Campus and a mobile program known as Community Dental.
    • Health education: Mobile clinic staff educate and counsel patients on a variety of issues, including drug, alcohol, and tobacco use, sexually transmitted diseases, depression, anxiety, pregnancy, smoking cessation, nutrition, safety, relationships, and self-care. In addition, program staff train staff at partner agencies to provide similar services. For example, Crews'n staff teach classes on sexually transmitted diseases at a diversion program for males and females involved in prostitution. They also offer classes on blood-borne pathogens and medication training for HomeBase Youth Services and the Tumbleweed Center for Youth Development.
  • Up-to-date technology: The mobile clinic has a satellite tracking dish, wireless Internet access, and a fully operational electronic medical records system that uses laptop computers and hand-held devices, thus allowing program staff to maintain secure and detailed medical records without transporting cumbersome paper files. The system is maintained jointly with the Children's Health Fund, a partner agency. The mobile clinic's wireless capability also allows patients to apply onsite for Medicaid coverage via an online application process.

Context of the Innovation

Crews'n Healthmobile is a collaborative partnership between Phoenix Children's Hospital, a comprehensive medical center offering specialty and subspecialty care to children; UMOM New Day Center, Arizona's largest family shelter; and Children's Health Fund, a national pediatric mobile program supporting direct health services and public education programs in disadvantaged rural and urban communities. After reading about the many unmet medical needs of HomeBase Youth Services' homeless clients, leaders of Phoenix Children's Hospital approached the agency in 1999 about developing a partnership to tackle this problem. Soon after, representatives from the two organizations attended a local presentation given by the Children's Health Fund. Realizing their mutual interest in reaching youth through mobile services, these representatives approached the Health Fund about the potential for further collaboration. The partner agencies sought and received funding to purchase a van and supplies, with the mobile clinic opening in the fall of 2000.

Did It Work?

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Results

Between 2001 and 2008, Crews'n Healthmobile cared for 4,547 new patients and provided 13,165 health encounters. Pre- and post-implementation data show that regular program participants utilize the emergency department (ED) less frequently and are more likely to attend follow up care. Anecdotal reports suggest high levels of satisfaction among patients and providers.
  • Less ED use: ED visits among program participants who accessed clinic services three or more times fell by 27 percent, from 1.5 visits to 1.1 visits over a 6-month period. This data was gathered from screening interviews conducted with 835 new and returning patients from 2005 to 2007.
  • More follow up care: An analysis of patient records shows that 72 percent of program participants attended follow up care appointments arranged by the clinic in 2007, up from 51 percent in 2006. This increase reflects the program's growing emphasis on case management.
  • Highly satisfied patients and providers: Patients report feeling safe and comfortable accessing services from the mobile clinic, and many have returned on multiple occasions for care, a surprising finding given the transient nature of the population served. ED physicians report high levels of satisfaction with the program, particularly its ability to reduce ED visits.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data on emergency department use and attendance at follow up care appointments, along with anecdotal reports from patients and providers.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Obtaining seed money: Partner agencies sought and received a $460,000 seed grant from the Flinn Foundation designed to cover purchase of the van and operating costs for the program's first 3 years.
  • Researching the model: Partner agencies researched national programs and best practices and gathered local data to better understand the problem. This information helped in designing clinic services to best meet the specific needs of homeless and at-risk youth in the Phoenix area.
  • Building staff: Originally staffed by several Phoenix Children's Hospital employees with the help of occasional volunteers, the clinic created job descriptions and revised program goals based on the needs of patients. Staffing levels doubled within 2 years of opening and now consist of a team of 15 Phoenix Children's Hospital employees.
  • Training: Staff initially received informal, on-the-job training. New employees, volunteers, and students now receive orientation and formal training through Phoenix Children's Hospital.
  • Updating equipment: In 2007, Children's Health Fund donated a new 38-foot medical van to the program, after the first van began having mechanical problems. In 2009, Children's Health Fund donated a new electronic medical record system.

Resources Used and Skills Needed

  • Staffing: Crews’n Healthmobile maintains a staff of 15, including one part-time and three full-time physicians, one part-time and two full-time nurses, one part-time and one full-time case manager, one full-time program manager, one part-time volunteer coordinator, and one full-time financial advocate. All 15 are employees of Phoenix Children’s Hospital. Numerous residents and medical students also provide services on a rotating basis at the clinic, while staff from partner agencies throughout Phoenix also contribute hours to the project.
  • Costs: In 2010, the program had an operating budget of just over $1 million to cover staff salaries and benefits, supplies (including information technology, medical, nonmedical, and office), licensing fees, medicine, equipment, fuel, van repairs and maintenance, and outside services for radiology, vision, and hearing.
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Funding Sources

Medtronic; Phoenix Children's Hospital; HomeBase Youth Services; Children's Health Fund; Virginia G. Piper Charitable Trust; Flinn Foundation; Legacy Foundation; Health Care for the Homeless; Idol Gives Back; Ellis Family Trust; McKesson; Monroe Trust Premier Cares; Kiwanis International; United Methodist Outreach Ministries; Phoenix Jaycees
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Adoption Considerations

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Getting Started with This Innovation

  • Advocate for the program: Contact and/or meet with local, State, and Federal legislators and agencies to secure funding and publicity for the program. If possible, join a local or State-level task force on homelessness to raise awareness and build community support.
  • Utilize expertise of those running similar programs: Seek the advice and counsel of those running mobile clinics elsewhere in the country, particularly with respect to logistical issues such as record-keeping and electronic systems.
  • Build community partnerships: To meet the medical and nonmedical needs of patients, seek out and partner with local service agencies that provide assistance in areas such as transitional housing, job training, and education.

Sustaining This Innovation

  • Focus on outcome measurements: Determine specific outcome targets and develop tracking and database systems that describe the target population and demonstrate the program's impact.
  • Determine essential staff roles: Identify the duties required to run the program, analyze staffing patterns, and reassign duties as needed. In the case of Crews'n Healthmobile, the program determined that maintaining a staff member whose sole responsibility was driving the mobile medical unit was not cost-effective. Instead, the driver needed to also perform patient registration, screen for insurance eligibility, manage clinics, and stock and maintain the van. In turn, the program's health care providers have also learned to drive the mobile unit.
  • Seek new sources of funding: Look beyond foundations for additional funding by leveraging staff talent and expertise. Consider creating educational modules or offering formal training sessions to other agencies as a way to raise funds. Partner with organizations requesting your services to share resources and funding.
  • Track funding flows: Keep careful records and know how every dollar is being used. Track costs per patient and determine average costs per clinic.
  • Keep open lines of communication: Holding regular meetings for staff and partnering agencies to discuss new ideas and challenges helps to keep everyone informed, engaged, and empowered as representatives of the program.

More Information

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Contact the Innovator

Randal Christensen, MD, MPH, FAAP
Medical Director
Crews'n Healthmobile
Phoenix Children's Hospital
3333 E Van Buren St.
Phoenix, AZ 85008
Phone: (602) 933-5345
Fax: (602) 651-1862
E-mail: rchriste@phoenixchildrens.com

Innovator Disclosures

Dr. Christensen has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

The Crews'n Healthmobile Web site is available at http://www.phoenixchildrens.com/community/healthcare-outreach/crewsnhealthmobile.

Footnotes

1 National Alliance to End Homelessness. America's Homeless Youth. 2009.
2 National Coalition for the Homeless. Homeless Youth [Web site]. June 2008. Available at: http://www.nationalhomeless.org/publications/facts/youth.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
3 Department of Economic Security. Homelessness in Arizona Efforts to Prevent and Alleviate Homelessness: 2010 Annual Report. December 31, 2010. Available at: https://www.azdes.gov/InternetFiles/Reports/pdf/2010_homelessness_report.pdf
4 Cohen E, MacKenzie RG, Yates GL. HEADSS, a psychosocial risk assessment instrument: implications for designing effective intervention programs for runaway youth. J Adolesc Health. 1991;12(7):539-44. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: September 02, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 23, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: January 13, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.