Mobile clinic is the safety net’s safety net

A dozen people sat in the church basement, now serving as a makeshift waiting room. Their clinic was parked outside.

The Malta House of Care, a medical clinic aboard a 36-foot Winnebago, provides free health care to uninsured residents. Four afternoons a week, it parks outside a different Hartford church and takes patients on a first-come, first-served basis. Prospective patients often show up several hours early.

While many clinics for the uninsured focus on episodic care, Malta House of Care treats most of its patients on an ongoing basis, providing primary care and managing chronic diseases. Some 2,000 patients receive regular care aboard the van.

Clinic officials call it “the provider of last resort,” the safety net’s safety net.

In theory, demand for the mobile clinic should dwindle in the coming years. Federal health reform is expected to expand health care coverage to 32 million Americans by 2019, making a lack of insurance far rarer than it is today.

But those working at the Malta House of Care don’t expect their clinic to be obsolete anytime soon.

“There will always be a need for our services,” said Dr. Laurel Baldwin-Ragaven, the clinic’s medical and executive director. She said she gets questions about whether the clinic will be needed in the future “all the time.”

The clinic was the brainchild of Jean-Pierre van Rooy, former CEO of Otis Elevator Company and a knight of the Order of Malta, a Catholic lay organization whose mission is to serve the sick and the poor.

It opened in 2006 in a 12-year-old van secured from St. Francis Hospital and Medical Center, where van Rooy and another founder, attorney Peter Kelly, also a knight of Malta, served on the board.

The founders envisioned the clinic as a way to care for people who would otherwise fill emergency rooms at city hospitals because they had nowhere else to go. But the volunteer physicians who staffed it soon found that many of their patients had conditions that required ongoing care. It’s not enough, they determined, to treat severe symptoms caused by conditions like high blood pressure or diabetes. They needed to manage the underlying conditions.

So the clinic evolved. Now about 80 percent of the patients are regulars.

“We have become their medical home,” said Bobbie Bartucca, director of philanthropy and organizational advancement at the Malta House of Care Foundation.

The clinic is funded through private donations, and the clinic and foundation are staffed by 70 to 100 volunteers, depending on the time of year. It has an operating budget of just over $2 million, about half of which represents in-kind services that medical professionals provide free.

The original van was recently replaced by a custom-built van. Information is stored on electronic medical records, something many private practices do not yet have.

As patients registered with medical assistants inside the church on a recent afternoon, Dr. Brad Wilkinson prepared for his afternoon of patients in the exam room built just behind the Winnebago’s driver’s seat.

The Durham family doctor began volunteering a week after Hurricane Katrina, flying to the Gulf Coast to help out. It reminded him why he became a doctor. “I remember this now,” he recalled thinking. Now he spends Wednesday afternoons volunteering on the Malta House van.

Wilkinson is the sort of doctor who prefers to spend 10 minutes of any visit chatting with patients about their families. He likes that about Malta House, the chance to care for his walk-in patients on a regular basis, just as he would with his patients in private practice. He calls the care sustainable, making it possible to manage chronic conditions.

“It’s very satisfying,” he said.

Most of the Malta House patients he sees are the working poor. Many who come for the first time have been prescribed medication for diabetes, high blood pressure or cholesterol in the past, but can no longer afford them.

“A lot of people do without,” he said. “We’re filling a gap.”

When she arrived at Malta House last year, Baldwin-Ragaven, who previously worked in Canada, Britain and South Africa, was struck by what some patients did when they could not afford to manage their conditions.

One woman with diabetes should have been testing her blood glucose level three times a day, but could only afford about three test strips a week. She told Baldwin-Ragaven that she “feels” her blood sugar level.

Other people cope by sharing medications, or stretching a 30-day dose of drugs to last 90.

Getting patients the medications they need is a patchwork job. There are pharmacies that offer some drugs free, $4 generics available at Walmart and Target, and programs run by pharmaceutical companies that provide free medication to needy patients.

The clinic used to provide medications at no cost, but it became financially unfeasible; last December’s drug bill was $30,000. Now patients who can afford it are charged a small co-payment.

They can get basic lab work and X-rays free. Getting a patient to a specialist is harder. There are some specialty clinics run through the UConn School of Medicine and at St. Francis and Hartford Hospital. The Malta House doctors can lean on their specialist friends to help get a patient an appointment. But sometimes, it’s just a struggle.

Wilkinson is pleased there is a universal health care law, but skeptical that it will produce much change very fast.

Others who staff the clinic have similar expectations.

Giving people insurance coverage does not mean they will be able to find a doctor to treat them, a problem likely to become more acute as 32 million newly insured people try to get medical care.

Baldwin-Ragaven expects that even after health reform rolls out, there will still be people underinsured, covered by plans that are inappropriate for them. High-deductible health plans, for example, require consumers to pay a set amount of money – often thousands of dollars – before the insurance coverage kicks in, which can lead some people to put off care.

There will be others, she believes, who skirt the requirement to buy insurance. Undocumented immigrants are left out of the health reform law. While 92 percent of non-elderly U.S. residents are projected to have health care coverage by 2019, 23 million won’t.

Officials at Malta House of Care, meanwhile, see the Hartford clinic as a template for others to use. A second mobile clinic opened one day a week in Waterbury this fall, and Bartucca said the organization has fielded requests from other cities, including San Francisco, Atlanta and Baltimore, on how to create a similar program.

“This is a replicable model,” she said.