By Amy DePaul
A guitarist plucked a folksy melody as families strolled around Irvine’s Great Park on a recent Sunday. That’s when Araceli Lopez from Lake Forest spotted the Smile Mobile, a fully equipped RV that brings dental services to locations around Orange County. She quickly volunteered her three daughters for an impromptu checkup.
Only one cavity was detected — not bad, Lopez said in an interview after the visit. And it certainly beat trying to take three children under the age of 6 to a dentist’s office.
“It’s easier on weekends when there’s no school,” Lopez said.
Lopez’s three daughters are among the thousands of medical and dental patients in Orange County who get health-care services on mobile vans. These clinics-on-wheels have long been used across the state to improve the health of hard-to-reach populations.
But experts say the mobile vans are proving valuable in the current era of managed care and the Affordable Care Act, because they can help providers establish what is known as a medical home for patients, where a single doctor or clinic manages all of their health needs. Doing so, health experts hope, will reduce hospital readmissions and shift the emphasis from medical procedures to health results.
From parks to parking lots
At least 10 vans in Orange County serve as mobile clinics, assigned to school parking lots, community venues and the streets of low-income neighborhoods. The vans are affiliated with hospitals and community clinics.
They usually have at least two exam rooms and, with Internet access, can tap into the medical or dental records of continuing patients. Some provide specialty care, such as the Breathmobile, which treats asthma patients, as well as the two Smile Mobiles operated by the nonprofit Healthy Smiles for Kids of Orange County. Other medical vans dedicate certain visits to diabetes care or Coumadin management.
A key reason for the vans is patient access.
In Orange County, lower-income patients without cars are forced to rely on a limited bus service or favors from car-owning friends. One result can be missed appointments and patchy health care.
“Basically, with the population we serve, transportation is an issue,” said John Luker, chief financial officer for the Orange County Rescue Mission, which regularly sends its medical van to underserved communities.
Further, some undocumented patients prefer to stay close to home, according to Dulce Medina, director of programs and outreach at Healthy Smiles. “The population is scared sometimes to come out,” she said, noting that for many undocumented people, neighborhood schools are safe zones.
Schools are also highly efficient locations for treating patients; during a single school visit, the Smile Mobile staff can perform 400 dental screenings. As many as 200 of those students come back within days of the initial visit for fillings or sealant.
Struggling to get by
Another reason that mobile medical care is successful, according to Luker, is that, “Most of our patients are struggling to get by. Missing work is extremely difficult.” And some of the county’s budget-strapped community clinics can’t offer late or weekend hours, so it’s especially important to be close by and available to patients during working hours.
“There are big logistical barriers to health care. Going to places where people are, such as the mobile van, is effective for at least that initial intervention,” said Anthony Wright, executive director of Health Access California in Sacramento.
Medical vans are just one way that lower-income patients in California are receiving health care outside traditional doctors’ offices. Another is through “promotoras,” a Spanish word that means promoters but that, in a medical context, refers to lay people trained to educate their communities about good health practices. Latino and Asian promotoras in Orange County have taken their health campaigns house-to-house, to Latino grocery stores and even to beauty schools serving Vietnamese immigrants preparing to work in the nail-salon industry.
In addition, community health organizations, such as Latino Health Access in Santa Ana, sponsor programs and classes on mental health and diabetes management. Such solutions are less expensive than doctor appointments and more culturally appropriate, Wright said.
“Is telling a 50-year-old Latina mom of two that visiting an older, white, non-Spanish speaking doctor once a year for 10 minutes the most effective way to provide medical advice?” he said. “It may be more effective for a diabetic to have a monthly check-in with a dietician in a support group setting.”
And just as lower-income patients are getting health services outside of doctors’ offices, they are also getting them increasingly from non-doctors. In Orange County, a clinic managed by nurse practitioners operates on the grounds of a Santa Ana school. AltaMed Health Services, a nonprofit provider in southern California, maintains a unique practice in Huntington Beach where patients can sit down with pharmacists to get help managing their numerous prescription medicines.
A response to lack of access
Latino immigrants have long sought alternatives to doctors’ offices because 60 percent of them lack health insurance, according to David Hayes-Bautista, director for the Study of Latino Health and Culture at the School of Medicine, UCLA.
Lack of access has led to buying medicines at swap meets, relying solely on teas and herbal cures and getting care at cash-only medical offices, he said. In these cases, alternative medical solutions haven’t led to long-term, consistent care.
But Orange County’s medical and dental vans act as extensions of the community clinics and hospitals they represent, which means that they can serve as a patient’s medical home, that is, a single provider that coordinates care and keeps records on patients over the long term.
Medical homes are a key provision of the Affordable Care Act, and providers believe the vans can play a role in establishing them. For example, care coordinators with Healthy Smiles refer the patients they treat to a dentist for long-term care and follow-up whenever possible. In other cases, specialists in Medi-Cal enrollment sometimes accompany the medical staffs of mobile vans.
In addition to providing preventive services and steering patients toward a medical home, mobile medical vans can target certain populations less likely to be insured or mobile themselves. These include homeless patients and homebound seniors.
The mobile medical van operated by the University of California, Irvine regularly visits assisted living homes and occasionally does house calls for incapacitated seniors. The van’s staff saw about 1,200 patients last year.
One population the van has targeted is teens in underserved communities. Teens are not very reliable in showing up at doctors’ offices for appointments; they do better stopping by a mobile clinic on school grounds, according to Kate Kassuba, a clinical program manager in UC Irvine’s School of Medicine.
While parents can make medical decisions for young children, “Once he’s 15 and says, ‘I’m not going,’ what are you going to do?” Kassuba said. “You can’t pick them up and throw them in the car.
“We try to get to teens where they are.”