Delivering free healthcare to rural Central Appalachia population : the case of the Health Wagon

Central Appalachia residents present unique healthcare challenges. This vulnerable population faces poor health status and low access to health care. ‘The Health Wagon’ was established to innovatively enhance access to health care for the poor and marginalized rural population of Central Appalachia. This article describes the operations of the Health Wagon, a full mobile medical clinic, in delivering free health care to those in rural Southwest Virginia in Central Appalachia. The Health Wagon provides a wide range of comprehensive healthcare services, such as acute and chronic disease management, laboratory and diagnostic services, medication assistance, dental and eye care and specialty clinics for marginalized, poor and disenfranchised patients living in the mountains of that region. In 2009, a total of 157 clinics were provided and 2900 patients were seen (3165 patient encounters) in addition to 268 telemedicine specialty consultations at no cost to the patients. The work of the Health Wagon has broken down a financial barrier to healthcare access and offers unique and profound opportunities to improve health and expand health care in rural Central Appalachia.


Introduction
Access to health care is a significant issue in American society 1 .Health outcomes are directly related to access to healthcare 2,3 ; however, different US population groups have differential healthcare access, according to minority versus non-minority status, severity of illness/disease, race, ethnicity, socioeconomic status, and geographic (rural vs urban) location 3 .A large and growing section of society is unable to obtain quality healthcare services 1,4 .This is especially so in Southwest Virginia in Central Appalachia, where many people lack access to medical care due to a number of factors.
This article describes the access to care issues of the population living in Southwest Virginia in Central Appalachia, and the innovative approach of the Health Wagon designed to address the problem of access to health care.

Background and health disparities in Southwest Virginia in Central Appalachia
The Appalachian Region stretches from southern New York to northeastern Mississippi, a distance of more than 1609 km (1000 miles), covering 329 916 km 2 (205 000 miles 2 ) across 420 counties 5 .The region includes parts of Virginia, Kentucky, Tennessee, South Caroline, Alabama, Georgia, Maryland, Ohio, Pennsylvania, North Carolina, New York, Mississippi and all of West Virginia -a total of 13 states.The Appalachian Regional Commission divides the region into five sub-regions: Northern Appalachia, North Central Appalachia, Central Appalachia, South Central Appalachia, and Southern Appalachia, based on economic and demographic characteristics.This report concerns Southwest Virginia in Central Appalachia where the Health Wagon operates.
The Southwest Virginia population is poorer than the rest of the nation and the poverty rate is higher than state (Virginia) average.In 2008, 24% of the Central Appalachian residents were poor 5 .Most people are unemployed, and unemployment rates are higher than state and national averages 5 .The Appalachian residents have lower educational attainment than the rest of the state 6 , and relatively more people over the age of 25 years do not have a high school diploma compared with the state average.Southwest Virginia residents have poorer health outcomes compared with the rest of the state and nation 5 .Many people in Southwest Virginia smoke tobacco and are obese than the rest of the state 7 .Data from the Virginia Behavioral Risk Factor Surveillance System show that from 32.4% to 34.7% of the adults in Buchanan, Dickenson, and Wise counties are obese.Appalachian residents have higher rates of heart disease, diabetes, and cancer than the state and national averages 5,8 .The Centers for Disease Control found that cancer (lung, cervical and colorectal) death rates in rural Appalachia (176.3 per 100 000 population) and all of Appalachia (173.1 per 100 000 population) in the period 1994-1998 were much higher than the national average in the same time period 9 .
Many Central Appalachia residents lack access to health care owing to factors such as lack of specialist services, long distances to travel in order to access services, limited public transportation, lack of health insurance, cost, and shortages of healthcare professionals 10 .The Central Appalachia region has a shortage of healthcare professionals and specialist services such as dentistry, mental health services and obstetrics services.

The Health Wagon
The Health Wagon (www.thehealthwagon.org)was founded in 1980 to provide free health care to medically under-served people in the mountains of Southwest Virginia in Central Appalachia.The Health Wagon operates a mobile health clinic and a walk-in clinic from a fixed location to deliver care to residents of Buchanan, Dickenson and Wise counties.The Health Wagon provides comprehensive primary healthcare services that emphasize education and prevention free of charge to patients (although donations are encouraged and accepted).The Health Wagon also provides diabetic supplies and prescription medications through the state sponsored Pharmacy Connect Program at no cost to patients.The Health Wagon coordinates Wise Remote Area Medical which is the largest free outreach of its kind in America.

Patients
Most of the patients (61%) seen at the Health Wagon do not have health insurance and report that they afford health care (Table 1).Some patients who have insurance also come to the Health Wagon because they cannot afford the copayment charged at other institutions (Table 1).
In 2009, a total of 157 clinics were provided and 2900 patients were seen (3165 patient encounters) in addition to 268 telemedicine specialty consults.In 2009, there was a 20% increase in patient volume compared with 2008 (3165 patients received comprehensive healthcare services).The average age of patients in 2009 was 43 years and 16% of these were disabled (Table 2).

Human and financial resources
The work of the Health Wagon is possible due to the efforts of its board, staff, volunteers, organizational partners and funders.It is the recipient of Federal funding and receives financial support from a pharmaceutical company (Astra Zeneca Foundation) and private foundations and corporations.

Healthcare services provided
The Health Wagon provides mainly primary healthcare services, and health education that emphasizes disease prevention.The main healthcare services provided are: • acute disease management (eg upper respiratory tract infections, sore throats) • chronic disease management (eg hypertension, diabetes, high cholesterol) • lab and diagnostic services Fixed clinics: The Health Wagon also operates a walk-in clinic at a fixed location (Clintwood, Virginia) that provides all the services described.An additional stationary clinic was opened in Wise, Virginia in January, 2012.

Operational challenges
The Health Wagon faces a number of challenges in providing health care.First, available staff and resources are small compared with the need/demand for services.Second, given the operational location (a predominantly rural area), it is difficult for the organization to attract staff with specialized skills (eg healthcare professionals, information technology support and grant writers).Third, there are significant difficulties in obtaining electronic medical records in the mobile clinic.Finally, only a small proportion of patients make donations/contributions towards their care.Obtaining finances to sustain clinic operations has always been challenging.

Conclusion
The Health Wagon provides a wide range of comprehensive health services to marginalized, poor and disenfranchised patients living in the mountains of Southwest Virginia in Central Appalachia.The Health Wagon has established positive and working collaborations with other organizations and has been able to attract resources to carry out its work, which has broken a financial barrier to healthcare access for many and offers unique and profound opportunities to improve health and expand health care in Central Appalachia, USA.
The work of the Health Wagon has been covered by several national and international media organizations such as AARP Magazine, Time Magazine Online, BBC, National Public Radio, Paris Match, Zuma Press, Associated Press, Reuters, and CNN.In addition, the Health Wagon and its executive director have been recognized by several awards: 2009 AANP Nurse Practitioner State Award for Excellence, 2008 Kid's Central Community Service award, 2007 Virginia Governor's Nonprofit Outstanding Nonprofit Award, 2004 Virginia Rural Health Association's Best Practices Award, 2004 Virginia Governor's community Service and Volunteerism Administrative Award.

Table 1 :
Staff and board of directors:The Health Wagon is directed by a 13 member board of directors.The Health Wagon is headed by an executive director who is a doctoral trained certified family nurse practitioner.The Health Wagon employs two full-time certified family nurse practitioners, four nurses, two office staff, a social worker, data systems coordinator, program developer and a part-time clerk.Reasons (%) given by patients for visiting the Health Wagon in 2009 Volunteers: Volunteers include several community members (through the Experience Works Program), healthcare professionals (mostly nurses) and students (most are from University of Virginia at Charlotesville, Appalachian College of Pharmacy and East Tennessee State University on clinical rotation or practicum).Other volunteers help with mailing (newsletters, reports etc), filing, faxing, receptionist duties, and calling patients about specialty clinics.No recent data exist on volunteer hours but it is estimated that 2500 hours are donated by volunteers annually.

Table 2 :
The Health Wagon patients' demographics, 2009 In 2010, the Health Wagon's annual income was US$779,985 excluding the value of volunteer time.While the Health Wagon conducts activities and special events to raise funds, regular funding comes from the following main sources: In 2010, 76% ($594,257) of total income came from federal and state support through the Health Resources and Services Administration (HRSA) and Bureau of Primary Health Care grants.Although only $1,306 (in cash) was raised from patient donations in 2010, many patients also donate canned foods, fruit and vegetables in exchange for services.
11e Health Wagon provides patients in need with walkers, canes, crutches, adult diapers and nutritional supplements through its Loan Closet for Medical Supplies program.Over 1700 volunteers, most of whom are medical professionals, have contributed more than 20 000 hours of donated time to the event from 2000 to 2009.The RAM health expedition has provided $10.5 million in free care to 51 535 patient encounters over 10 years (2000-2009)11.Mobile clinics and health fairs:The mobile clinic is the primary means of the Health Wagon health care delivery.The (mobile) Health Wagon visits eight sites in Southwest Virginia's Buchanan, Dickenson, and Wise counties on weekly, biweekly and monthly bases.The Health Wagon also offers specialized mobile clinics, including mobile mammography clinic and lung cancer early detection.In addition, there is a cardiovascular and chronic obstructive pulmonary disease outreach program.Lung Cancer Early Detection Program:The Health Wagon in conjunction with a pulmonologist (Dr Joe Smiddy) offers the Lung Cancer Early Detection Program using a mobile unit.Services provided to patients include free chest X-rays, arterial blood gas tests, pulmonary function testing, medical examinations, and respiratory medications.The mobile unit has provided more than 1500 chest X-rays which contribute greatly to treating lung cancer.Education about smoking cessation is also routinely provided through this program.
• medication assistance and Pharmacy Connect Program • immunization programs • wellness classes and health education • dental and eye clinics • diabetes outreach program • cancer screenings • specialty clinics (eg cardiac, diabetology, nephrology with renal ultrasound), pulmonology • lung cancer early detection (chest X-ray) • women's health.•Cariovascular Outreach In addition, • Remote Area Medical (RAM) Health Expedition • mobile clinic and health fairs • linking patients with specialists at University of Virginia Health System via telemedicine • Fixed clinics.•138 ear, nose and throat examinations, 364 audiotests, 126 hearing aids • 20 colposcopies, 10 colposcopies with biopsy, 9 endometrial biopsies and 4 loop electrosurgical excision procedures (LEEP)• 50 sigmoidoscopies.