Health on Wheels
Mobile clinic staff go the extra mile to bring well-child care to families in need

By Jessica M. Scully
March 20, 2003

With two asthmatic children and health problems of her own, life hasn't always been easy for Tammy Mayo. The Chula Vista, Calif., mother of three had health insurance through her husband's job, but it paid little of her or her children's medical expenses-only $2,000 of a recent $10,000 hospital bill.

After Mayo's now 13-year-old son Dionne had a series of asthma attacks that left him struggling for breath and suffering bouts of severe coughing, she found help through nurse practitioner Evy McNitt-Silk, a nurse at a mobile clinic.

"Evy got him on all the right medicines to control his asthma," Mayo said. "She even gave me a [nebulizer] machine for when he has attacks, so I wouldn't have to run to the emergency room. I can do it here at home."

Mayo is one of hundreds of parents in Chula Vista receiving help through a partnership between the school district and two local hospitals.

In 1999, Sharp Chula Vista Medical Center and Scripps Memorial Hospital along with the school district began operating a mobile clinic for the district's children in a 40-foot van. Staffed most days by nurse practitioner McNitt-Silk and Grace Rangel, RN, the van makes regular visits to several schools in the 20,000-student district.

Chula Vista is the largest elementary school district in California and faces many challenges. Roughly half of the children are on a subsidized lunch program. About 60 percent of the students are Hispanic, many recent immigrants from Mexico. Some families in the district are homeless, living in tents or shelters. Many families move frequently, some going back and forth across the Mexican border. Before the van clinic, the emergency rooms at the two local hospitals were the only source of medical treatment for many children in the district.

Caring for these children has presented more than a few challenges for McNitt-Silk, Rangel and others involved in the partnership. One of the first was gaining the trust of the children and their families.

The nurses can boast of many accomplishments in the three years since the mobile clinic began. They have managed to obtain free prescription medicine and breathing machines for asthmatic children like Dionne. By using their holistic nursing training to look beyond an illness and to understand all the problems patients are facing, they have helped families make their way through rough times.

Linking resources

Before the partnership, hospital administrators found their emergency rooms crowded with school-age children suffering from nonemergency problems. Usually, their uninsured parents had nowhere else to take them. Meanwhile, across the school district, school officials were concerned about student absentee rates. The high rates not only reduced the amount of money the district was awarded from the federal government, but also disrupted student learning.

School officials and hospital administrators eventually realized their problems were intertwined. When children with health insurance had an earache or other problems, they could get treatment quickly and would miss little school time, Assistant Superintendent Dennis Doyle said. Uninsured children often were not treated promptly and spent more days out of class, he said.

"A child without insurance will try over-the-counter and traditional remedies for several days, and pretty soon that child is septic and screaming in the night, and the emergency room becomes the care of last resort," he said.

With the joint goals of reducing absences, clearing out emergency rooms of nonemergency cases and helping more families obtain low-cost health insurance, the district and hospitals applied for a series of grants. The hospitals kicked in funds and the district provided money to operate the van. A year later, the van, which cost $250,000 just to purchase, began making trips to the schools. District officials said the mobile clinic costs about $25,000 per month to operate.

Sharp's emergency room reported a 12 percent reduction in the number of school-age children with nonemergency problems last year compared to the year before, and Scripps reported a 22 percent reduction. The number of uninsured families also dropped from 69 percent to 57 percent during the same period, and district officials think this is the fruit of the clinic staff's efforts to connect clinic patients with low-cost insurance programs.

"I think [the van] helps by providing identification of conditions that could be treated immediately, rather than allowing them to fester and get worse and need to be seen in the emergency department," said Sharon Rudnick, RN, manager of emergency and mobile clinic services at Sharp.

Doyle said attendance rates and test scores have improved since the van's arrival, although he credits both partly to improved educational policies at the school. Many of the children who make van visits suffer from common childhood problems like strep throat, ear infections and communicable skin diseases-problems common to people living in crowded or less-than-ideal conditions. But asthma, on the rise in many urban areas, is another major reason children visit the van.

Culturally sensitive

McNitt-Silk had another leg up in earning the trust of the community she now serves. She's spent most of her 26 years as a nurse caring for low-income patients, many of them new immigrants from all over the world.

"You have to know how to teach them and how to be culturally sensitive," she said. "It's a challenging group to work with, but it's a really wonderful group to work with."

Everyone who works on the van is bilingual in English and Spanish. But sometimes they need a little help from Rangel.

Born in Mexico, Rangel lived there until she was 15. She feels that her Hispanic patients trust her more because of her ethnicity and because she understands the culture of recent Mexican immigrants.

For example, Rangel said, sick Mexican children traditionally are not given anything cold to drink, even though, in the case of fever, a cold drink would help bring down a child's temperature. The theory is that one shouldn't mix hot and cold.

Sometimes, Rangel's knowledge can help her understand what to others might seem an inexplicable injury. In one case, a baby sitter damaged a boy's eardrum by rolling paper into a cone and putting it inside the child's ear.

The baby sitter did this, Rangel said, because in Mexican cultures some people believe an earache is caused by excess air in the ear. The air is removed, they believe, by lighting a piece of paper on fire near the ear.

"If you're not familiar with the culture, you might say, 'Oh my God, this woman is crazy,' " Rangel said.

It didn't take long for McNitt-Silk and Rangel to discover that health problems aren't the only challenges their patients and families face. Many of the families are poor and feeling the pressures of the economic downturn. Finding decent housing and clothing, let alone presents for their children at the holidays, is a struggle.

McNitt-Silk remembers one single mother-once a medical assistant-who lost everything after she was injured. The woman, who also has a daughter with asthma, was living in a shelter where it was difficult to provide her daughter with the medicine and care she needed. The woman wanted to move to Tijuana, Mexico, where her living expenses would be cheaper, but couldn't because she would lose her monthly disability payment.

"Many families we see, such as this single mother, have been working and haven't asked for help before," McNitt-Silk said. "They are kind of embarrassed to ask for help and many are unaware of what resources are available to them."

By working with families in need and asking for assistance from friends and acquaintances, McNitt-Silk was able to help this family and many others during the holiday season by providing presents for the children, clothing and basic necessities like toothpaste.

McNitt-Silk and Rangel aren't the only nurses doing their best to help the children and their families. School nurses like Frank DeLuca play an important role as well. DeLuca knows that many of his students walk to school because their parents don't have cars. When children are sick and their parents can't drive to the van's location, he takes over.

"I'll put them in my car and take them over to the van," he said. Although he is busy, he knows "it's more important the child gets seen."

According to McNitt-Silk, going the extra mile is all in a day's work for the school and clinic nurses.

"This is an important part of what we do," she said. "We know families well and the school nurses know them well. We get attached and can really find out what they need."

Contact Jessica M. Scully at Jessicam_scully@yahoo.com