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Health care van rides a road less traveled

Yale Medicine Magazine, 2004 - Spring


For city residents with limited access to medical services, Yale’s mobile clinic fills a critical void.

The Community Health Care Van parks in front of an apartment house with plywood nailed over the windows. Orange spray paint on the Congress Avenue tenement demands, “Whose Livable City Is This?”—a reference to New Haven’s anti-blight initiative. It is cold and rainy, the kind of weather that discourages patients from venturing out to the mobile clinic. But enough people show up to make for tight quarters.

Joel stoops to walk inside.

“It’s a good day because we’re alive to see it,” the lanky man says with a grin as he brushes raindrops from his jacket.

This is an optimistic time in Joel’s life; with the assistance of the van staff, he has just signed up for substance abuse treatment. But first he needs a physical and a tuberculosis test, and the van takes walk-ins. Waiting weeks or even days for an appointment at a clinic would be difficult and risky for a man who says he is “just trying to find the strength one day at a time.”

Entering its 10th year of service to New Haven, the van has always emphasized free, immediate and dignified care, says Frederick L. Altice, M.D., HS ’89, associate professor of medicine (AIDS Program) and director of the Community Health Care Van initiative. Altice got the idea for a mobile clinic a decade ago while working with New Haven’s needle exchange program. He saw people come in with abscesses that went untreated until they were acute enough to land the client in the emergency room.

With a small van borrowed from Yale-New Haven Hospital’s Primary Care Center, Altice began following the needle exchange van once a week. Along with a social worker and HIV counselor, Altice provided primary care, mostly to injecting drug users. Today, a newer, 36-foot van serves patients 11 hours a day, five days a week throughout the city. The rotating staff includes senior physicians, residents, HIV specialists, a nurse practitioner, a physician associate, an HIV counselor, a drug treatment coordinator, a case manager, outreach workers and a number of volunteers. Usually four staff members ride on most trips. Many others are immediately available by cellular telephone.

The van’s impact on the community is well-documented: a 41 percent reduction in emergency department visits for clients who are injecting drug users, a 66 percent success rate in getting drug users to complete all three shots in the hepatitis B series, and promising results using buprenorphine to reduce heroin cravings. For clients who do not qualify for entitlements, the van may be their only treatment option. Where possible, the aim is to move the patient toward a community health center or some other fixed source of primary care. In 41 percent of the cases, that transition is successfully made. The van has done promising work on TB screening with undocumented residents, says Altice, which he expects to publish soon. Similar work is going on with the homeless.

About half of the 500 to 600 patients who visit the van each month arrive with issues unrelated to drugs. On the same morning that Joel needs a physical to get into treatment, a teenage girl with seashells braided into her hair, powder-blue tennis shoes and a handbag that says “Princess” takes a seat in the van. “I’m here for two reasons,” she announces with studied nonchalance, “a pregnancy test and an HIV test.”

Within minutes, she has seen a mental health counselor, a physician and an HIV counselor. She is relieved to get test results quickly and without a lecture. As she leaves with condoms she smiles and says, “I’ll be seeing you.”

“Everybody I meet on the van is always nice,” says Michael, 28, who takes his daily HIV medications here. “This gets my morning going.”

Much of the ongoing care the van provides also is the basis for research that might help patients far beyond New Haven. Some clients take their HIV medications in the van as part of an effort to increase adherence. Data collected so far show that the directly observed medication program works, according to Robert Douglas Bruce, M.D., clinical instructor of medicine. Some patients, he says, have seen their viral loads fall and their T cells rise substantially. The research project is funded by the National Institute on Drug Abuse.

Research funding has largely sustained the van, says Altice. The mobile clinic is an ideal setting for many other investigations. For example, he is eager to monitor HIV therapy for inmates released from prison. HIV tends to be well-managed in prison, but viral loads often rise after release.

Aside from research grants, fund-raising efforts have been difficult, Altice says, in part because the clientele arouses little public sympathy. It is precisely that lack of sympathy that the van staff is determined to combat. For example, many patients say they have been treated terribly by other health care providers, which makes them reluctant to seek treatment. Charly began coming to the van for primary care after her release from prison. Though she found work immediately after returning to New Haven, her job provides no health benefits. Charly says that on the van she gets a measure of respect she rarely finds elsewhere: “You don’t have to be afraid to tell them about nothing,” she says. Perhaps that’s the secret of the van’s success.

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