The Family Van Makes Boston a Healthier City

Outside the Dudley Square Station passengers ebb and flow. No city bus idles for long under the metal awning—except for one, with wrap-around blue trim. A woman steps off board.

“Take it easy, Aunty Rai!” she calls. She pockets a small piece of paper, a note of her blood pressure and cholesterol.

She had just paid a visit to The Family Van.

Founded in 1992 by current Medical School Dean for Students Nancy E. Oriol, The Family Van hits the streets of Boston six days a week.

The HMS-affiliated mobile health clinic provides free health screenings for blood pressure, glucose, cholesterol, glaucoma, pregnancy, and HIV counseling for Boston’s most impoverished residents.

From its inception, The Family Van has provided an alternative to the traditional model of health care delivery. Rethinking the doctor-patient relationship by bringing service providers to local communities, The Family Van staff consider their method an important innovation in medicine.

“Aunty Rai”—Manager of Direct Service Rainelle Walker-White—has ridden the van for the past 18 years, providing care in Dorchester, Hyde Park, Mattapan, Roxbury, and East Boston.

“Mobile is beneficial, mobile is keeping people alive,” she says. “What better way to serve your people than where they are?”

Oriol says she was first spurred “to meet people where they are” during her work as an anesthesiologist in 1989.

She says an experience treating a poor, pregnant woman—who ignored headaches for weeks until having a seizure—spurred her to think about barriers to medical care.

“[The woman] told me after her surgery that she ‘hadn’t felt that her headaches were important enough to bother her doctor.’ She did not want to appear stupid,” says Oriol.

Searching for a solution, Oriol ventured into Boston’s forgotten neighborhoods and asked residents about their challenges in accessing a doctor.

Through these conversations, she conceived of a “user-friendly” model of mobile care.

“There is a reticence in every person’s soul when they begin to feel sick—it is human nature,” Oriol says. “Mobile clinics overcome geography, but they also overcome this reticence.”

Oriol adds that communities view The Family Van as a “one of their own—a ‘knowledgeable neighbor.’”

CRUNCHING THE NUMBERS

Many say Oriol’s model of preventive care was ahead of its time. According to Professor of Health Care Policy Richard G. Frank, preventive services were emphasized less as health insurance came to dominate the American health care system.

Frank says that, in his own work for the Department of Health and Human Services from 2009 to 2011, he worked to reinstate the value of preventive care through the Affordable Care Act.

“Now that we have a better understanding about the course of illness and biological mechanisms, we can take a more sophisticated view of prevention,” Frank says. “As the science has evolved, the policy and the insurance are trying to catch up.”

In this vein, The Family Van has turned a critical eye toward the role of mobile medicine in a reformed health care system.

“We are trying to bring evidence of what we know to be true on the street,” Oriol says. “After 20 years of seeing thousands annually, we need to take our stories and turn them into data.”

The barriers to health care for The Family Van’s clients are substantial. In the last fiscal year, 87 percent of the Van’s 4,000 clients were minorities. Thirty-seven percent did not speak English. Thirty-one percent were unemployed.

Over the past six years, Research Program Director Caterina Hill has analyzed data to understand how the Family Van empowers clients to manage their health while controlling costs. The results, she says, “were shockingly good.”­

One in three of the van’s clients discovered for the first time through screening that they had glaucoma or elevated blood pressure, glucose, or cholesterol. More than one in two regular clients who had high blood pressure during their first visit had it under control during their most recent visit.

Accounting for the value of emergency department visits avoided and quality life years saved for clients, Hill says the Family Van is worth over $11,000,000. She adds that the return on investment for the American health care system is $23 saved for every dollar spent on the Van.

The Family Van Executive Director Jennifer L. Bennet says the initiative provides a promising model at a time when controlling health care costs has become increasingly urgent.

“As an organization that relies on community health workers, the van is a cost-effective partner with neighborhood health centers to deliver heath education and monitor chronic disease,” she says.

FILLING IN THE GAPS

After attending the Mobile Health Clinics Annual Forum in 2006, Bennet discovered that The Family Van’s success had been shared by nearly 2,000 mobile clinics nationally and around the world.

She says mobile clinics have been implemented from China to Africa to Central America. In the Amazon, boats are even being used to deliver mobile health services.

The value of mobile clinics, as Oriol adds, is their versatility.

“Mobile fills in the gaps. When you look across the country, mobile clinics are extremely different because we were all designed to fill different gaps,” she says.

The advantages of mobile health delivery have also caught the attention of the U.S. Department of Health and Human Services. The HHS Office of Minority Health announced on October 24 that it would sponsor an initiative to develop a website allowing mobile health clinics to share data online in real-time.

The site is called the Mobile Health Map and will enable researchers to quantify the efficacy of the mobile health model. Oriol and Bennet—alongside leaders of the Mobile Health Clinics Network—are leading this initiative.

With these colleagues, Oriol and Bennet plan to carry out a “return on investment” analysis using the Mobile Health Map—this time for America’s entire mobile health sector.

Many mobile clinics are collecting data on some level “but lack the funding or academic resources to publish papers,” Oriol says.

TRACKING A MOVEMENT

The Mobile Health Map website was built with the guidance of John S. Brownstein, a professor of pediatrics at Harvard Medical School.

Brownstein—an expert on public health surveillance—is also the creator of HealthMap.org, an internet-based global infectious-disease intelligence system.

“Instead of using John’s internet maps to track infectious disease, we use them to track mobile clinics around the country. We can capture how many vans have shared data and the demographics of their clients in real time on our home page,” Bennet says.

Within two weeks after the Mobile Health Map’s unveiling, 400 mobile clinics began to contribute data.

“It is very exciting to research mobile health clinics right now because it a sector that has only just begun to document itself,” Hill says. “[This] is our opportunity come together and demonstrate our value.”

THE PRE-OP VISIT

From conducting a single health screening to collecting a nation’s data on Mobile Health Map, The Family Van staff and volunteers place their clients at the heart of their learning.

Oriol says that her patients have showed her the complexity of accessing basic care—the “antecedents” to surgery.

“I felt I had to go to the community and learn how to do the ‘pre-pre-op’ visit,” she says.

The “pre-pre-op” visit—and the creative thinking it represents—is also what keeps Frank drawn to the field.

“Everything that can go wrong with markets goes wrong with markets in health care—which makes it fascinating,” Frank says.

“BETTER THAN THEY COME ON”

It is 4:30 p.m. and “Aunty Rai” packs up the van. Pamphlets, boxes of free condoms, and cords of blood pressure monitors spill over her arms as she shouts farewell to the last clients. “They always leave better than they come on,” she says.

She walks under the Dudley Station awning and boards the Number 47 back to her Longwood office as the van driver takes the blue-trimmed bus back to the garage.

They’ll be in Hyde Park Tuesday morning.

—Staff writer Alyssa A. Botelho can be reached at abotelho@college.harvard.edu.

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