Implementing a Teaching Rural Mobile Health Clinic: Challenges and Adaptations

Summary

In 2022, Penn State College of Medicine launched the LION Mobile Clinic, a teaching mobile health clinic offering preventive health services in rural Snow Shoe, Pennsylvania. We outline four challenges the clinic team faced in implementation, along with adaptations made to tailor the model to Snow Shoe's needs and opportunities.

The U.S. urban-rural mortality disparity has been growing since the 1980s.^1–3 While urban life expectancy continues to increase, rural life expectancy has stagnated since 1999.⁴ Lack of access to health care due to hospital closures and primary care provider shortages is a major contributor to the rural health penalty.^5–7 Mobile health clinics (MHCs) offer one potential solution to bolster health care access in places with limited infrastructure. They allow providers to physically bring their practices to communities, reducing patients' needs to travel long distances to brick-and-mortar clinics.^8–10 While MHCs are promising, there are several challenges that health care organizations may face during implementation, and few public accounts describe best practices for overcoming these challenges.

In this article, we describe our experience implementing and evaluating a MHC in Snow Shoe Township, Pennsylvania, a mostly-White, rural community of 1,700 people in central Pennsylvania. As a former coal mining community, Snow Shoe has long faced declining economic prospects and an aging population, two challenges that plague many rural U.S. communities; Snow Shoe Township has a median household income of $53,125 and median age of 47.2. However, Snow Shoe's outlook quickly became even more grim in 2020. In the span of two years, Snow Shoe lost its grocery store, hardware store, bank, federally qualified health center (FQHC), and pharmacy.

In 2021, a team of clinicians at Penn State College of Medicine (PSCOM) initiated conversations with local, state, federal, university, and health system leaders to discuss emerging health needs in Snow Shoe. These conversations revealed that primary barriers to health care access included transportation needs and time constraints rather than lack of insurance (only 2% of the township is uninsured). While Snow Shoe lies only 30 miles from State College, a large university town with ample health care resources, this distance can pose a challenge for older adult residents, particularly those with low incomes or disabilities. Local stakeholders and clinicians discussed that this distance could be easily traveled by a MHC to bring State College's health care resources to Snow Shoe. They envisioned a pilot program through which clinicians would visit Snow Shoe biweekly, parking at a central location in the Township.

These conversations led PSCOM to launch the LION Mobile Clinic in May 2022. In addition to increasing health care access for Snow Shoe residents, the MHC serves as a clinical immersion site for medical students. The LION clinic has two exam rooms and is typically staffed by one physician and four to five medical students. Penn State College of Medicine provided start-up capital to launch the LION Clinic; to keep initial costs lower, PSCOM signed a lease with a nearby hospital that owned an existing mobile medical unit.¹¹ The arrangement was mutually beneficial as it engaged the unit on days when it would otherwise go unused. Using this pilot arrangement to show proof of concept, the LION clinic staff used early success to secure Congressional Community Project Funding to purchase their own mobile medical unit.

From the outset of implementation, the clinic team embedded a research team into clinic operations, and the researchers collected and analyzed qualitative data to provide the clinicians prompt feedback on Snow Shoe residents' perceptions and needs. Drawing on these data, we describe here four major challenges the clinic team faced during their first year and highlight the adaptations they made to tailor their model to Snow Shoe's needs and opportunities.

Gaining Visibility

Leading up to the clinic's launch, the clinic team visited a Snow Shoe Township Council meeting, the Township Council shared a flyer on their official Facebook page, and the clinic team made an announcement on a local radio station. Yet at the first two clinic events, a crew of eager medical students were met with disappointment, as zero patients showed up. Through early interviews with community members, the research team quickly learned that none of the clinic team's initial marketing strategies matched the primary ways that people learn about events. One community member told us, "It used to be the grocery store Hall's that was the focal point for the community. If you wanted to know anything, go to Hall's because it was on a [bulletin board]. And now that it's not there, it's really hard [to get information out]." Respondents emphasized that, without Hall's, word of mouth was critical.

Our research efforts facilitated the initial spread of information about the clinic. Interviews not only provided a meaningful opportunity for community members to share their thoughts with researchers; they also provided an opportunity for researchers to tell community members more about the clinic. After their interviews, several respondents shared information about the clinic on a private, local Facebook group that is used by many residents, but on which the clinic team could not post themselves. As patients began to trickle in, they were given flyers to share with others in the community, leading to a snowball effect that began to increase patient flows. We learned that visibility takes time and likely requires an organic, bottom-up approach. Ultimately, word of mouth did work, but it took both patience and insider support to access the private channels where information was shared.

Earning Trust

Our research also taught us of a perceived social divide that clouded some residents' perceptions of Penn State efforts. There were longstanding feelings that Snow Shoe got short shrift relative to nearby State College, where Penn State is located. Other State College-based organizations had brought initiatives to Snow Shoe in the past, but these organizations did not stay long-term. As a result, there was skepticism about the clinic team's intentions and suspicion that the clinic might not stay. One community member told us, "[Snow Shoe] is a very tough crowd. Most people are skeptical, and the best you can do is show consistency, even if it doesn't immediately pay off. It's almost like they've been scorned too many times. They need that consistency to show that somebody cares."

To gain local trust and demonstrate their sincere intentions and investment, the clinic team launched a series of events called Coffee Talks with Future Docs at the local senior center, one of the few remaining town establishments. The team asked the women who frequent the center what health-related topics they would like to learn about, and medical students prepared short presentations on requested topics, such as diabetes. These presentations were paired with an activity that the seniors and students could engage in together, such as preparing a healthy dessert. The women warmed up to the students, especially seeing them in a non-clinical setting. One student told us, "It feels like you're kind of seeing old friends at this point now." Because these women are central in local social circles, earning their trust meant they would also communicate these positive impressions to other residents.

Meeting Community Needs

The clinic's initial goal was to provide preventive care such as blood pressure screenings and influenza vaccinations. The rationale was that residents would more likely make the 30-mile drive to State College for acute health issues than for regular preventive care; additionally, an initiative providing preventive services could be more quickly approved by PSCOM and implemented. However, given the recent infrastructure losses in the area, residents had more pressing needs. One community member relayed, "Everybody I talked to [about the clinic], I'm like, 'Well, did you get your flu shot? You know, you can get a COVID vaccine now.' Or, I've said to them, 'You can go there and have your blood pressure checked or talk about your medication.' But a lot of them come back to me with, 'That's not enough.'"

In our interviews, we asked "If you could wave a magic wand and recruit one business to town, what would it be?" Due to the recent loss of the town's grocery store, every single respondent told us they wanted a new food supplier. The loss of Hall's brought increased food insecurity and lack of access to fresh fruits and vegetables. To address this need and make it worthwhile for residents to visit the clinic, the clinic team worked together with the local YMCA's mobile food pantry. The MHC and mobile food pantry showed up in tandem, and after the pantry director asked a local contact to post an announcement on the town's private Facebook group, droves of residents came out for the food distribution. Medical students went from car to car to engage residents, and several sought care at the MHC after receiving food boxes. The adaptation was successful in serving the intended dual purpose. One woman, for example, had her blood pressure checked after picking up a food box. Upon learning that her blood pressure was elevated, she made an appointment with her primary care provider to follow up. Had she not come to the food distribution and stopped at the clinic, she likely would not have recognized her health issue until it had become more severe.

Improving Accessibility

By bringing care directly to Snow Shoe, the MHC significantly reduced the distance that residents needed to travel to see a physician. However, there are still major transportation barriers within Snow Shoe, and those residents most in need are often older adults who are homebound. For these residents, getting to the MHC, even in a central location in town, could still pose a challenge. One respondent who worked for the local emergency medical services warned us, "Some of our people can't get [to the MHC]. They don't have a way there. They don't have the ability to get there. If you had someone available who could be like, 'Yeah, I can go to someone's home…' I think that would be awesome."

To address this issue, the clinic team made a crucial change to the model, beginning home visits. Operating the MHC as a hub-and-spoke system, the team would park the MHC at a central location in town, where most residents would be seen. Clinic staff could then use personal vehicles to travel short distances to homebound patients. The first resident the team served at home was a woman in her 90s who could not leave without assistance. The team brought her an influenza vaccine, and she later told us, "I was so elated. I just could not believe that they would come to the house."

Conclusion

The LION Clinic continues to adapt and expand. Most notably, following community members' suggestions, the clinic team will begin providing more full-service primary care in 2024. While the LION Clinic continues to visit Snow Shoe on a biweekly basis, the clinic team is expanding to other rural, underserved communities across Central Pennsylvania on different days.

We believe our experience provides a set of cross-cutting lessons that may inform the development of rural MHCs elsewhere. Further, we hope that laying out these challenges and adaptations highlights the importance of embedding data collection into implementation. Our experience shows that acquiring prompt feedback can motivate necessary changes to recognize communities' opportunities and needs.