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Abstract

Objective:

Although previous studies have assessed provider perceptions about telehealth, no prior studies have qualitatively assessed the experiences and satisfaction of health-care providers with a community mobile health clinic model within underserved urban settings.

Methods:

This study draws on the views expressed by community health workers (n = 4), registered nurses (n = 2), Grace Medical Center outreach specialists (n = 2), and physician assistants staffing LifeBridge Health’s virtual hospital (n = 3) to understand their satisfaction and experiences with a COVID-19 community mobile health clinic in underserved Baltimore neighborhoods. Thematic analysis of the interviews was used to extract themes and subthemes of our health-care providers’ experiences with the community mobile health clinic model.

Results:

These individuals shared their experiences addressing social determinants of health, the perceived impact of community mobile health clinic, satisfaction with and limitations of the pilot project, as well as future implications for the community mobile health clinic model. Finally, ideas for how the model can fit into the existing healthcare delivery framework are suggested.

Conclusion:

The context surrounding the COVID-19 pandemic has provided a unique opportunity to critically address healthcare frameworks and models. The LifeBridge community mobile health clinic served as an initiative to truly bridge together community outreach and health access. Among the many themes, health-care providers on the team applauded the model for its potential to bring preventative health care to the patient with the goal of improving patient health outcomes.

Keywords

COVID-19 telehealth community mobile health clinic qualitative experiences

Introduction

The COVID-19 pandemic has exposed many inequities embedded in the US healthcare system and has highlighted a need for preventative strategies that promote health equity by design.¹ Despite efforts to mitigate the rapid spread of the COVID-19 virus, the rise of variants around the world suggests the hard work is far from over. Hospital shortages in personal protective equipment, funding, and medical equipment have exacerbated healthcare disparities among vulnerable populations.^2,3 Across the globe, there have been calls for innovative approaches to solve these long-standing structural inequities in how health care is accessed and provided.⁴

Overwhelmed emergency departments and hospitals can negatively impact health outcomes for nearby populations.¹ New care models are needed that can remove long-standing barriers to accessing health care and reduce the risk of disease transmission among individuals who are more vulnerable to COVID-19 complications.⁵ Amid the current COVID-19 pandemic, community mobile health clinics (CMHC) have emerged as an efficient method for rapidly expanding high quality health services to medically underserved communities.¹ Historically, mobile clinics have been used to reach marginalized communities, including people who are homeless, people who inject drugs, seasonal farmworkers, and people in disaster zones.⁶ Multiple prior studies have shown the benefits of telehealth services, including an increase of favorable health outcomes, reduced transportation barriers, increased geographical accessibility, and improved patient–provider trust.^5,7 CMHC models similarly address these challenges and they can be especially useful in increasing healthcare accessibility in underserved communities and limiting avoidable patient influx into hospitals and emergency departments.^1,8 Integration of mobile health delivery models within the current medical system can complement and extend existing structures to increase patient access to efficient and prevention-oriented healthcare services.

The COVID-19 pandemic has been a catalyst for rapid and widespread implementation of telehealth and CMHCs.⁹ A program that implemented the CMHC outreach model within underserved Baltimore neighborhoods found that more than two-thirds of its clients were suffering from multiple chronic diseases and were at high risk for COVID-19-related complications.⁵ The CMHC model was used to rapidly expand COVID-19 testing, assess social determinants of health (SDOH), measure participant satisfaction, and provide necessary health services to a marginalized population who otherwise may have gone untested and undiagnosed.⁵

In addition to developing healthcare intervention methods that can better address unforeseen crises, there is an equally necessary responsibility to understand the satisfaction, acceptance, and experiences of health-care providers working within new care delivery models such as this one.^9–11 This allows us to gauge the challenges and opportunities frontline workers encounter to bridge gaps in healthcare delivery and strengthen the adoption of promising models. Although previous studies have assessed provider perspectives and perceptions about telehealth^11–13 no prior studies have qualitatively assessed health-care providers’ experiences and satisfaction with the CMHC model within a disadvantaged urban setting. This study aims to understand health-care providers’ concerns and perspectives regarding the workflow of CMHCs to determine how best to integrate them into new and more effective healthcare models.

Overview of mobile clinic operational model

LifeBridge Health used a COVID-19 Vulnerability Index as a starting point to identify by location where higher-risk inpatient and primary care patients in West Baltimore resided.⁵ It determined the zip codes with the largest proportion of vulnerable individuals and then created a mobile clinic pilot program to bring COVID-19 screening and health services to patients where they lived. We staffed a mobile health clinic with a driver, a registered nurse (RN), and a community health worker (CHW) to proactively implement preventative measures against adverse COVID-19 outcomes and bring health care to where the most vulnerable community residents lived. Our mobile clinic team called identified residents, traveled to their homes to administer COVID-19 tests, screened for SDOH, and often connected these residents to providers through virtual visits. During these encounters, the RN documented patients’ vitals, completed clinical health screenings, conducted COVID-19 testing, prepared the lab specimen, and helped patients use an iPad that linked them to a health-care provider at the health system’s “virtual hospital.” The iPad provided patients with a secured video connection with a LifeBridge Health provider, typically a physician assistant, to aid medical evaluation and determine next steps. The physician assistant led the telemedicine visit, determined the discharge disposition, and placed COVID-19 orders for processing. The CHW used the iPad to screen the patients for social needs, assessing for food availability, housing needs, and financial assistance. The CHW followed up with resources and documented their work within the health system’s electronic medical record. Awareness of the mobile clinic pilot soon spread through the neighborhoods and was followed by requests for visits. The program responded by setting up tents for outdoor screening at large senior residential complexes in especially distressed areas of the community. This tent format proved more efficient, allowing the team to see more patients and connect them to virtual hospital televisits, thus eliminating a barrier of individuals fearful of inviting strangers into their homes.

Methods

Study design

A qualitative research study using inductive thematic analysis was conducted to better understand perceptions of how a CMHC fits into the healthcare delivery landscape. We employed qualitative semi-structured, in-depth interviews as our primary data source. Such interviews are a commonly used data collection method within health services qualitative research¹⁴ and typically involve the use of flexible interviewing protocols supplemented by follow-up questions and probes to maximize data quality.¹⁴ For our study, we conducted eleven 30–40 min semi-structured interviews between November 2020 and May 2021 with individuals who staffed LifeBridge Health’s CMHC. The study team worked with LifeBridge Health administrative leads to identify the providers, CHWs, and RNs who supported implementation of the COVID-19 initiatives of the health system’s CMHC. The study team recruited N = 11 participants by email. Three members from the pilot project were lost to follow-up after departing from the LifeBridge Health organization. Interview responses were consistent with each role within the mobile clinic team. The method and reporting follow the Consolidated Criteria for Reporting Qualitative Research.¹⁵

Sample and recruitment

This qualitative study used purposive sampling to select individuals who worked as health-care providers on the LifeBridge CMHC initiative. All data collection occurred remotely using the Zoom video conferencing software. According to Archbald et al.¹⁶ there is sufficient evidence to suggest that the Zoom video conferencing software would be a feasible method for qualitative interview data collection. Participants were eligible for the study if they were aged 18 or older; participated in the CMHC outreach initiative; and provided verbal consent to participate in the study. Individuals were excluded if they participated in the CMHC outreach initiative but could not to be reached because they left the LifeBridge Health organization or lost to follow-up; or declined to provide verbal consent. Prior to the interview we provided detailed information regarding the purpose of the qualitative study and procedures. Participants were asked to provide a verbal consent prior to starting the interview due to the virtual format of the qualitative interviews. Ethical approval for this study was waived by the LifeBridge Health Institutional Review Board based on applicable federal regulations 45 CFR 46.104(d)(2 and 4).

Data collection

To accommodate social distancing and provider availability, interviews were carried out and recorded using Zoom remote conferencing software. We gained consent for participation and audio recording from participants prior to each interview. We created interview guides to elicit provider/staff perspectives on experiences with the CMHC pilot initiative, and on the potential use of mobile clinic models in other settings. After the initial list of questions was designed, the questions were not piloted on a subset of the target population; however, they were reviewed by departmental colleagues to check for length, language suitability, and potential sources of bias (e.g., leading questions). The semi-structured questionnaire asked participants about their workflow experience, to compare working in traditional healthcare settings with mobile clinics, to describe their willingness to promote working in mobile clinics, and to share their thoughts on the impact that mobile clinic models can have on the community. CHWs and RNs were asked specifically about their experience traveling to patient homes and resources that could enhance the model. The Grace Medical Center outreach specialists and the physician assistants were asked to share their perspectives working under virtual conditions. Emerging concepts that were not anticipated in the initial interview structure were incorporated into subsequent interviews. The interviews lasted from 30 to 45 min. Semi-structured interviews were conducted by KC and AB, and field notes were made during each interview. All interviews were audio-recorded and transcribed verbatim by the Otter.ai technology and subsequently reviewed alongside the original audio recording to verify precision. Transcripts were then imported into Dedoose (http://www.dedoose.com), an online platform for qualitative and mixed data analysis.¹⁷ A member of the study team added descriptors, such as demographic and occupation information, to each transcript. The researchers conducted interviews until no new data appeared and all concepts were well developed due to saturation.

Data analysis

Two members of the study team (KC and AB) participated in an inductive, emergent thematic analysis, through which each member individually read transcripts and coded the meanings in an emic way using Dedoose.^17,18 To enhance the rigor of the study, KC (doctoral candidate who is experienced in qualitative research) and AB (master’s level researcher) coded the data independently prior to collaboratively synthesizing code meaning and names. They evaluated the data in a line-by-line fashion and provided codes that identified key concepts and notable phrases. After coding each transcript, the code tree was evaluated and revised, if necessary. The different codes were sorted into themes, which were defined and refined.¹⁹ The authors applied multiple coding sessions to adjust for discrepancies by consensus throughout the analysis and ensure that emerging themes were reported concisely. To ensure validity and transparency of the results, the researchers documented the methodological choices and substantive concepts that were made during the analysis and interpretation of the data. Coding continued until theoretical saturation was reached (e.g., no new concepts emerged). This study also triangulated the findings across investigators and source data to ensure the trustworthiness of the data.

Results

In total, we interviewed n = 11 health-care providers, of which n = 8 (72.7%) identified as African American and n = 3 (27.3%) were White. Participant occupations included CHWs (n = 4), RNs (n = 2), Grace Medical Center outreach specialists (n = 2), and physician assistants staffing LifeBridge’s virtual hospital (n = 3). Furthermore, 10 (90.9%) were females and 1 (9.1%) was male. For participant characteristics, see Table 1. Additionally, thematic provider perspective and salient quotes are presented in Table 2.

Table 1.

Demographics of interviewed CMHC healthcare team (n = 11).

	n (%)
Race
White	3 (27.3)
African American/Black	8 (72.7)
Gender
Male	1 (9.1)
Female	10 (90.9)
Occupation
Community health worker	4 (36.3)
Grace Community Outreach Coordinator	2 (18.2)
Physician assistant/health provider	3 (27.3)
Registered nurse	2 (18.2)

Table 2.

Illustrative quotes on provider satisfaction and experiences with COVID-19 CMHC outreach model.

Themes	Subthemes	Quotes
Discussion of social determinants of health	Neighborhood and built environment	“So, I remember getting up, on Thursday mornings, going to the food banks and picking up food and delivering to patients that didn’t have enough food to last them throughout the month”—Community health worker
	Education access and quality	“So, I would say health literacy was definitely—something that’s needed.”—Registered nurse
	Economic stability	“You don’t know that this person—it’s not that they’re non-compliant, or they don’t care about their health, they’re living in a world where I’ve got to make a decision on whether I’m going to pay for this prescription this week, or I’m going to pay my gas and electric, or I’m going to buy food, or I’m going to buy shoes for my kid who has to go to school, you know, those kinds of. . . I think being in the community, you get a whole different picture.”—Community health worker
	Healthcare access and quality	“[. . .]if I’m in a position where I don’t have, you know, I don’t have the income, like many folks in this community are. I’m not coming to a hospital, because I don’t want to have to pay out of pocket. So, we’re bringing the. . .if we’re bringing the service to them, I think it can really cut down on the amount of inappropriate visits to the ER, and then for people again, who can’t afford it.”—Grace Community Outreach Coordinator
Perceived impact of CMHC	Improved relationships with health-care providers	“People were just so grateful to be able to get tested. And to know that someone cared enough to actually come out and do the testing for them.”—Grace Community Outreach Coordinator
		“I saw them encouraging our community where we were very skeptical about new vaccines, and we don’t trust the health care system so much. I saw the trust build there.”—Community health worker
		“They were impacted greatly, because like I said, they had someone in person, they had a personal connection with you”—Community health worker
	Ability to bring services to patients	“I think it’s. . .it was very rewarding. Just because you were actually reaching out to people who don’t get regular care. And getting those people that sometimes could have fallen through the cracks, and really being able to help them.”—Physician assistant
		“Visiting a person in their own private space, one thing is we can get a better picture a clearer picture of what—the whole person, of what the barriers are, and look at them other than just a physical problem”—Community health worker
		“They were very grateful. And again, some felt that they were truly blessed because they really had no way of actually getting out of their homes. So, coming in or going to a patient it was very beneficial.”—Community health worker
Staff satisfaction with the pilot project	Providing care in patient’s environment	“When we’re working with patients, we like to be able to observe them in their own environments. And it did really help a lot seeing them in their environment.”—Community health worker
		“You have more time, I feel in my personal experience, patients are more open when they’re in their own environment, and they’re more comfortable, they’re willing to talk and be more honest about their situation.”—Community health worker
		“But once you’re able to see them in their environment, you see that they can adapt to you a little quicker other than being in the clinical field.”—Community health worker
	Connect patients to follow-up services	“We connected with them in a way that would not have been possible were it not for the mobile clinic.”—Community health worker
		“We were able to connect them back to their primary care doctors via telehealth.”—Community health worker
		“I think the best experiences is when the [patients] was asking us when were we coming back. . .”—Registered nurse
		“She was so elated. That someone showed her how to use her insurance card to get connected to her PCP, or a dentist, or even how to reach out and make an appointment. You will be amazed of the gratitude that they show, just from those simple things like that. And I just remember the smile and the gratitude that she showed as we were leaving.”—Community health worker
	Current satisfaction with CMHC	“I was very satisfied. I was actually sad to see it end. . .because I really enjoyed being a part of the mobile clinic.”—Registered nurse
		“I guess I’m hopeful that this will continue. Services, the scope of services will expand. . . I am hopeful that we can focus on preventive services.”—Grace Community Outreach Coordinator
Limitations of CMHC	Barriers of telehealth services	“There was a lot of growing—growing pains. One, one of the issues that we kind of had problems with is just, you know, a lot of these people are older individuals, they don’t use technology very well. So, they might not have the greatest internet connection. And/or know how to use the iPad.”—Physician assistant
		“Some of the visits, I mean, instead of looking at the patient, I was looking at the ceiling.”—Physician assistant
		“I couldn’t hear the patient, and I couldn’t read the patient’s mouth, because they were wearing a mask and/orinternet would cut out. And so then, you know, just basic communication was. . .was the downfall.”—Physician assistant
	Extreme weather	“Mobile clinic experience could have been a lot easier knowing that it wasn’t 102 degrees outside.”—Community health worker
		“Huh, I don’t know. . .another barrier that I just kind of thought of is that HIPAA is probably, kind of a difficult thing to do, I don’t know how I would really word it. It makes HIPAA difficult being at home because not everyone was at home alone, my husband was also sometimes doing mobile clinic work, not for LifeBridge. . .for a different medical facility. And I kind of, you know had to try to distance myself from him and put headphones in and face away . . .”—Physician assistant
Future implications	Less hospital visitations	“I think having a service like that in the community could actually cut down on unnecessary trips to the emergency room. And perhaps people would even rely upon a mobile clinic coming to their area and be more involved with their healthcare because they don’t have to worry about paying for it.”—Grace Community Outreach Coordinator
		“It can really cut down on the [number] of inappropriate visits to the ER, and then for people again, who can’t afford it. Getting care when they do need it without the fear of, you know, a bill or coming to a hospital.”—Grace Community Outreach Coordinator
	Promote preventive care	“But I think if we can provide health care services and preventive [care] and I think that’s probably something I haven’t said before, but for this community, and I’m sure many communities of color, preventative services are so desperately needed. It could keep many people from getting to the point where they’re suffering these chronic conditions, and all that comes with them.”—Grace Community Outreach Coordinator
		“I think with primary care I honestly feel that we would be able to reach more people and do more preventive medicine if we had more mobile clinics. . .if we were able to bring the services to the patient.”—Community health worker
	Meet patients where they are	“If we can bring the care that you need to where you are, we can meet people where they are at their point of need, I think that makes the difference.”—Community health worker

Discussion of SDOH

In an effort to build a comprehensive picture of the barriers and needs that the members of the community often face, CHWs assisted with administering health-related need questionnaires. Mobile clinic team members commented on factors relating to SDOH that were made apparent or frequently discussed by patients during the mobile clinic visits. Four out of the five categories of SDOH as defined by US Department of Health and Human Services were identified and discussed by the CHWs: neighborhood and built environment; education access and quality; economic stability; healthcare access and quality; and social and community context.¹ Participant quotations are presented to illustrate the themes and study findings.

Neighborhood and built environment

The mobile clinic team discussed the relationship between neighborhood environment and resident’s health in two contexts: food security and housing quality. Within the scope of their capabilities, the health professionals and CHWs described the actions they took to assist with food disparities faced by residents of the community:

So, I remember getting up. . .on Thursday mornings, going to the food banks and picking up food and delivering [it] to patients that didn’t have enough. . .to last them [through] the month—CHW

Education access and quality

Team members identified health literacy as a barrier that frequently impacted health outcomes of residents. The COVID-19 pandemic created additional limitations on individuals’ ability to access their primary care physicians. Consequently, team members stated that additional time was often required to provide comprehensive healthcare explanations to the community members they assisted.

So, I would say health literacy was definitely something that is needed.—RN

Economic stability

The mobile clinic team noted that one of the model’s many benefits includes its ability to address financial burdens community members may face when attempting to access traditional forms of health services. Several health care and CHWs acknowledged resident fears when trying to obtain health care and the ways in which those concerns impacted self-management and outcomes. Team participants were sensitive to how the various barriers that residents encountered affected their physical health. One CHW noted:

It’s not that [the patient is] non-compliant, or [that] they don’t care about their health. They’re living in a world where, ‘I’ve got to make a decision on whether I’m going to pay for this prescription this week, or I’m going to pay my gas and electric, or I’m going to buy food, or I’m going to buy shoes for my kid who has to go to school.’ You know, those kinds of [concerns]. I think being in the community, you get a whole different picture.—CHW

Healthcare access and quality

Several team members mentioned community worries about high costs of hospital services and/or emergency room visits. Resident’s concerns with poor or nonexistent health-care coverage were discussed in conjunction with the potential benefits of the mobile clinic model. The ability to bring health services to community members and reduce out-of-pocket costs was identified as a key advantage of the mobile clinic model.

[. . .] if I’m in a position where I don’t have, you know, I don’t have the income, like many folks in this community are, I’m not coming to a hospital. Because I don’t want to have to pay out of pocket. So. . .if we’re bringing the service to them, I think it can really cut down on the amount of inappropriate visits to the ER, and. . . for people. . .who can’t afford it.—Grace Community Outreach Coordinator

Social and community context

Team members who worked on the mobile health clinic discussed how pre-existing community relationships were a vital advantage to the model design. As a result of introducing the mobile health clinic to residents in West Baltimore zip codes (21223, 21225, 21226), the positive civic engagement was highlighted by many of the members during their interviews.

I think the best experience was when the [patient] was asking us when we were coming back.—RN

Perceived impact of CMHC

Members of the mobile clinic team identified several advantages that this model of care had, not just for the community, but also within a greater public health context. Team member observations and commentaries have been summarized into two key themes related to the apparent influence of the mobile clinic model.

Improved relationships with health-care providers

Although there are many vulnerable populations that have developed a skepticism toward public health initiatives and health services over the years, many team members observed that the mobile clinic model provided ample opportunity to improve the relationships between health-care providers and the surrounding community. Community gratitude for the services the mobile clinic provided was emphasized and described as an influential factor in some of the best experiences reported by CMHC team members. They highlighted that establishing a connection with the residents who participated in the mobile clinic and building trust within the community were crucial aspects of their ability to effectively provide services as health workers.

People were just so grateful to be able to get tested. And to know that someone cared enough to actually come out and do the testing for them.—Grace Community Outreach Coordinator

I saw them [engaging] in our community where we were very skeptical about new vaccines, and we don’t trust the health care system so much. I saw the trust build there.—CHW

They were impacted greatly, because like I said, they had someone in person, they had a personal connection with you—CHW

Ability to bring services to patients

Team members frequently mentioned that having the ability to meet community members in their own environment positively impacted both residents and members of the mobile clinic team. Many providers described the benefit that the mobile clinic model had on their ability to provide services to residents during an unforeseen pandemic that abruptly limited patient and clinician contact. The social need assessments captured by CHWs at each mobile clinic visit were essential in providing the team with the necessary information to connect community members to follow-up services and resources to address underlying contributors to poor health. The ability to meet residents where they were was consistently regarded as a key strength and described as one of the best characteristics of the mobile clinic model.

I think. . .it was very rewarding. Just because you were actually. . .reaching out to people who don’t get regular care. And getting those people that sometimes could have fallen through the cracks, and really being able to help them.—Physician assistant

Visiting a person in their own private space, one thing is we can get a better picture, a clearer picture of. . .the whole person, of what. . .the barriers are, and look at them other than just [as] a physical problem—CHW

They were very grateful. And again, some felt that they were truly blessed because they really had no way of actually getting out of their homes. So, going to a patient — it was very beneficial.—CHW

Staff satisfaction with the pilot project

Providing care in patient’s environment

Participants highlighted their satisfaction with working in the CMHC and noted how satisfying it was to physically go to patients’ homes for outreach purposes and to provide care in the patient’s environment. This enabled them to more quickly adapt to care compared to when patients come to clinics, hospitals, or other clinical locations.

When we’re working with patients, we like to be able to observe them in their own environments. And it did really help a lot seeing them in their environment.—CHW

You have more time, I feel in my personal experience, patients are more open when they’re in their own environment, and they’re more comfortable. They’re willing to talk and be more honest about their situation.—CHW

Once you’re able to see them in their environment, you see that they can adapt to you a little quicker than [when they are] . . .in the clinical [setting].—CHW

Connect patients to follow-up services

The individuals staffing the mobile clinic noted that the CMHC model enabled them to uniquely connect with members of vulnerable communities who are traditionally underserved by the healthcare system. The RNs and CHWs discussed their satisfaction with being able to link residents with primary care physicians or specialists, walking patients through the process of making appointments, as well as the gratitude expressed by patients after visits were completed. Many patients asked our healthcare team when they would return, which further underlines the acceptability, appropriateness, and adoption of this model within marginalized communities.

We connected with them in a way that would not have been possible were it not for the mobile clinic.—CHW

We were able to connect them back to their primary care doctors via telehealth.—CHW

She was so elated that someone showed her how to use her insurance card to get connected to her PCP, or a dentist, or even how to reach out and make an appointment. You [would be amazed by] the gratitude that they show, just from. . .simple things like that. And I just remember the smile and the gratitude that she showed as we were leaving.—CHW

Current satisfaction with CMHC

Finally, the team noted their personal satisfaction with working in the CMHC and their hopes that this model would expand and contribute to improved delivery of preventive services and an overall positive change in healthcare access.

I was very satisfied. I was actually sad to see it end. . .because I really enjoyed being a part of the mobile clinic—RN

I guess I’m hopeful that this will continue. Services, the scope of services will expand.. . . I am hopeful that we can focus on preventive services.—Grace Community Outreach Coordinator

Limitations of CMHC

The healthcare team noted a few obstacles with implementing the CMHC model, including patients unaccustomed to using telehealth services, unstable Internet connections, weather challenges, and working-from-home barriers.

Barriers of telehealth services

Frequently cited obstacles concerned challenges with the technology required for visits with providers who joined virtually. Health-care providers noted that:

There [were] a lot of growing—growing pains. One of the issues that we. . .had problems with is just, you know, a lot of these people are older individuals. They don’t use technology very well. So, they might not have the greatest Internet connection. . .or know how to use the iPad.—Physician assistant

Some of the [virtual] visits, I mean, instead of looking at the patient, I was looking at the ceiling. –Physician assistant

I couldn’t hear the patient, and I couldn’t read the patient’s mouth, because they were wearing a mask. . .or [the] Internet would cut out. And so then, you know, just basic communication. . .was the downfall.—Physician assistant

Extreme weather and work-from-home limitations

RNs and CHWs commented on the weather being a limitation, especially at the extreme ends of the spectrum.

Mobile clinic experience could have been a lot easier [if] it wasn’t 102 degrees outside.—CHW

Additionally, security of patient health information was noted as a concern by a physician assistant who supported the initiative virtually from home. She described how she would distance herself from family members and use a headset to protect patient health information.

It makes [privacy of patient health information potentially] difficult being at home because not everyone was at home alone. My husband was also sometimes doing mobile clinic work, not for LifeBridge; for a different medical facility. And I kind of, you know, had to try to distance myself from him and put headphones in and face away.. . .—Physician Assistant

Future implications

Fewer hospital visits

The healthcare team commented on how the CMHC model’s health screening and intervention efforts can help improve the overall quality of life of community residents. In the process, it can reduce expensive and potentially avoidable emergency room and hospital visits.

I think having a service like that in the community could actually cut down on unnecessary trips to the emergency room. And perhaps people would even rely upon a mobile clinic coming to their area and be more involved with their health care because they don’t have to worry about paying for it.—Grace Community Outreach Coordinator

It can really cut down on the [number] of inappropriate visits to the ER, and then for people again, who can’t afford it. Getting care when they do need it without the fear of, you know, a bill or coming to a hospital.—Grace Community Outreach Coordinator

Promote preventive care

Health-care providers discussed the innovative role that CMHCs can play in promoting preventive care, especially within under-resourced communities to help alleviate health disparities. By leveraging this model as a community asset, affordable health care can be brought directly to neighborhoods to prevent community residents from suffering from chronic diseases and their associated negative health outcomes.

If we can provide health care services and preventive [care]–and I think that’s . . .something I haven’t said before–but for this community, and I’m sure many communities of color, preventative services are so desperately needed. It could keep many people from getting to the point where they’re suffering these chronic conditions and all that comes with them.—Grace Community Outreach Coordinator

I think with primary care I honestly feel that we would be able to reach more people and do more preventive medicine if we had more mobile clinics. If we were able to bring the services to the patient.—CHW

Meet patients where they are

Finally, meeting patients where they are was a focal point of discussions with the healthcare team. The necessity of delivering quality health care to marginalized communities where they are was viewed as important to make a significant impact in health outcomes.

If we can bring the care that you need to where you are, we can meet people where they are at their point of need. I think that makes the difference.—CHW

Discussion

This study set out to explore healthcare workers’ experiences and satisfaction with a COVID-19 CMHC outreach model within disadvantaged Baltimore neighborhoods. This study further examined how implementation of this model fits into overall healthcare delivery. Our results synthesize provider perspectives into five broad themes: discussion of SDOH; perceived impact of CMHC; satisfaction for the pilot project; limitations of the CMHC; and finally, future implications of the CMHC model. First, the results show that the CMHC model helped healthcare workers better understand how factors relating to SDOH such as housing, finances, healthcare access, and educational factors directly influenced a patient’s decision or ability to access healthcare services. Second, healthcare workers felt that the CMHC had a positive impact on the Baltimore community for the ways that it brought services directly to patients and improved relationships with health-care providers.

Assessing healthcare worker satisfaction is particularly useful in understanding the feasibility of the CMHC, as well as which elements contribute to the model’s successful adoption and implementation. Health-care providers (physician assistants) identified the ability to assess patients in their respective environment as a significant factor that influenced their overall satisfaction with the model. Opinions from CHWs and outreach coordinators not only coincided with those of the health-care providers but also highlighted that the positive community response to the services extended by the mobile clinic also contributed to their satisfaction. Limitations of the mobile clinic pilot project centered mainly on aspects associated with implementation of the telehealth format and with concerns about data security when working from home. Telehealth frustrations were related to difficulties with stable audio and Internet connectivity, both of which are important to ensure that a visit runs smoothly. In addressing the limitations of the pilot project, we were able to identify which barriers the healthcare workers experienced and how those can be addressed in future implementations of the model. Lastly, the care team considered future implications of how the mobile health clinic model can improve healthcare delivery and solve important gaps in our existing system of care. Ultimately, the mobile clinic’s work was noteworthy for the ways in which it helped to promote efficiency in the delivery of care and establish preventative healthcare services in otherwise underserved communities.

While prior studies have focused on client experiences seeking healthcare services aboard CMHCs, this study aligned with emergent themes regarding innovative aspects of CMHC models for patient care, especially within medically underserved communities. Our findings are supported by previous qualitative research highlighting the vast array of SDOH that effectively limit healthcare access, particularly among underserved communities.⁶ Yu et al. noted that CMHC can help overcome structural and social barriers to equitable health care by delivering health services directly to residents’ doorsteps, thereby eliminating logistical barriers such as transportation, long waiting times and administrative processes, and difficulty making appointments to occur at clinical care settings during business hours.⁶ Furthermore, qualitative research has found that familiar settings and convenient geographical locations promote an environment that makes it easier for patients to discuss health concerns with the healthcare team.^6,20–22 Previous literature has also described the important role that CMHC outreach models can play in improving health outcomes at the population-level through increased screenings and initiation of preventive care for various conditions that are disproportionately observed within economically disadvantaged populations and communities of color.²³ Moreover, there is ample evidence to support the strength of the CMHC model in becoming an equitable setting for chronic disease management.^6,24 Such findings suggest that the CMHC model offers a valuable way to reach underserved neighborhoods and begin to identify and address the SDOH that increase the risk of virus transmission and poor health outcomes for these communities.

These findings suggest that the overarching benefit of the CMHC model lies in its ability to bring services directly to individuals and thereby minimize or eliminate barriers to accessing healthcare services. In doing so—and with enhanced community trust—this model can improve health inequities. The results from our study indicate that there are clear benefits to be gained from adding mobile preventive care and disease management services to the traditional scope of healthcare delivery. While the CMHC is not a solution to all the obstacles experienced by marginalized communities, the findings from this study suggest that the CMHC model has the capability to bridge long-standing gaps within the healthcare delivery framework by better delivering preventative healthcare services in a way that results in improved health outcomes for patients. Furthermore, the costly utilization of emergency departments for nonurgent care by underinsured and underserved populations is well documented in the literature.^1,25 However, mobile health clinics provide an equitable and cost-effective portal to the healthcare system for those who are disenfranchised. According to Attipoe-Dorcoo, implementing CHMCs provide an annual cost savings of $3,125,668 from emergency department room visits.¹ Additionally, the total annual value of running the CMHC is approximately $17,780,000 while the cost to run CMHC programs is only $567,700. This results in a 36:1 return on investment in addition to the value of life years saved.

This study is one of the first to focus on healthcare worker perspectives on using a mobile health clinic model to identify and address SDOH across marginalized communities. While the study is able to document health worker perspectives regarding model implementation, it is unable to speak to this initiative’s feasibility in the context of providing specialized medical treatment. Many of the perspectives from respondents addressed the CMHC model’s potentiality for improving visit efficacy and reducing health complications and emergency department visits. Nevertheless, evaluation of the effectiveness of these tenets was outside the scope of this study. Furthermore, this study did not consider patient viewpoints on the usefulness of the CMHC, which in turn limits the ability to discuss the effectiveness of this model as a whole. However, there is ample quantitative and qualitative literature that assesses the usefulness of this model through the lens of the client.⁶ Although there are limited studies within the healthcare delivery field, this one bolsters the need for future research to explore qualitatively as well as quantitatively. As variants of the COVID-19 virus continue to emerge, it remains important to address the ways in which care delivery models such as this one can be used to improve health equity in topics including who is receiving testing, vaccinations, and other preventive health services.

Overall, our healthcare team found value in their experiences with the CMHC outreach model because they were able to understand the roots of the barriers that often keep people from accessing health care, such as logistical and transportation issues. They were able to observe firsthand some of the relevant SDOH that impact health outcomes for community residents and impede their ability to adequately manage their health. This initiative identified many of the unseen barriers to health in the United States that disproportionately impact the health of medically underserved and under-resourced communities. This model combined an in-person visit format with telehealth communication by clinical providers who conducted virtual health assessments with the support of CHWs and RNs on site. Through this qualitative study, the healthcare team discussed the benefits of deeper relationships that were formed in the patient’s home setting in contrast to the sometimes stressful and impersonal clinical office setting. This is particularly relevant for work within under-resourced communities that have disproportionately high levels of health illiteracy and mistrust of the healthcare system. Structural barriers of traditional healthcare delivery can negatively impact its efficacy. For example, the power differential sometimes experienced between provider and patients in traditional clinical settings can manifest itself in higher blood pressure readings compared to home readings (i.e., “white coat syndrome”). The CMHC model relaxes this power dynamic as individuals can receive care within their home and neighborhood setting. Altogether, the CMHC model offers a promising strategy in the efforts to eliminate health inequities and optimally meet the needs of underserved communities.

Study strengths/limitations

This study has some strengths and limitations. A key strength of this study is that it is the first study of its kind to evaluate provider satisfaction and experience with a CMHC outreach model that specifically targets underserved neighborhoods. Health-care providers who worked on the team were predominantly African American, which additionally served as a key strength because it mirrored the racial and ethnic composition for the target population where the CMHC outreach initiative was implemented. Nevertheless, there are limitations to the study that are important to address. The team did not conduct a series of pretest interviews to assess the rigor or threats to bias before carrying out the formal phase of the qualitative research. Furthermore, although we did reach saturation for the overall concepts provided by the healthcare professional perspectives, we may be underpowered across the specific occupations. As an example, we only had two RNs in the sample, and it is unclear if we fully captured the salient perspectives and satisfaction of this occupation to make generalized interpretations. Future research studies using qualitative designs may bring insightful results on themes that are targeted toward specific roles within the CMHC outreach framework. Another observed limitation to the study is that sex differences were not captured due to the limited sample size of males in the study. Future studies may want to explore any emergent differences across male health-care providers compared to females regarding satisfaction and experiences of working in CMHC models.

Policy implications

The evidence gleaned from our study demonstrates the effectiveness of the mobile clinic—as described by health-care providers implementing the model—in filling a crucial gap in our country’s healthcare delivery system, one that has limited the access to health-promoting services for disadvantaged communities. The high level of satisfaction with the CMHC model by our healthcare team indicates the likelihood for its successful implementation as a needed extension within our current system of care. Based on these findings, we call on national and local leaders and policy makers to commit to the following three actions: (1) create budgetary allotments to support and sustain primary healthcare services delivered through CMHC models and focus on disadvantaged communities; (2) develop and monitor local plans to measure the impact of CMHC in expansion of access to preventive services and reduction of potentially avoidable ED and hospital utilization; and (3) create mechanisms within disadvantaged communities to create or enhance collaboration among community-based organizations, mobile health clinics, outpatient clinics, and hospitals.¹

Conclusion

The LifeBridge CMHC initiative provides one example of the ways in which mobile clinics can successfully reach populations whose experience with systemic racism has impacted their ability to access care and maintain their health. Many of the healthcare workers addressed the CMHC model’s potentiality for improving visit efficacy and reducing health complications and emergency department visits. The mobile clinic model can help alleviate these challenges and address the unique and often ignored medical and social service coordination needs of traditionally underserved populations. The model’s unique ability to quite literally “meet people where they are” and, in doing so, obviate a number of social and structural barriers that impede health, shows the promise of this approach toward mitigating racial disparities.

Supplemental Material

sj-docx-1-smo-10.1177_20503121231152090 – Supplemental material for A qualitative assessment of provider satisfaction and experiences with a COVID-19 community mobile health clinic outreach model in underserved Baltimore neighborhoods

Supplemental material, sj-docx-1-smo-10.1177_20503121231152090 for A qualitative assessment of provider satisfaction and experiences with a COVID-19 community mobile health clinic outreach model in underserved Baltimore neighborhoods by Kechna Cadet, David R Baker and Annice Brown in SAGE Open Medicine

Footnotes

Acknowledgements

AcknowledgmentsThe authors wish to acknowledge the clinical and administrative professionals at LifeBridge Health who rapidly organized, tested, and adapted the elements of this program to understand and address the needs of our community’s residents.

Author contributions

KC and AB led the data collection and data analysis. KC, DRB, and AB conceptualized the article, contributed to the writing, and provided critical review to the article during its draft and final stages. All authors contributed substantially to the authorship of this article and approved the version to be published.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics approval

Ethical approval for this study was waived by the LifeBridge Health Institutional Review Board based on applicable federal regulations 45 CFR 46.104(d)(2 and 4).

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was partly supported by grants from the National Institute on Drug Abuse (T32DA007292, KC supported).

Informed consent

The qualitative study was conducted during the COVID-19 pandemic, therefore, the verbal consent procedure occurred remotely via Zoom between the consent designee (e.g., interviewer) and the participant to reduce risk to study personnel and research participants. All participants were asked to provide verbal consent prior to starting the interview. Under waived ethical approval by the LifeBridge Health Institutional Review Board for this study based on the federal regulations 45 CFR 46.104(d)(2 and 4), verbal and written informed consent were permissible.

ORCID iD

Kechna Cadet

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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