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Health on Wheels

Uninsured adolescents use a clinic that comes to them.

Photo: Rod Searcey

THE TO-GO DOCTOR: Seth Ammerman, Health Van director, estimates that the mobile clinic saves $4 in health care costs for every $1 it spends.

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By Sheila Himmel

Under the pine trees shading Peninsula High School’s parking lot, a couple of students mill around a gleaming white 38-foot motor home. This Tuesday in April, two others wait for their appointments inside, on a bench with seat belts.

Sydney DeAngelis, 17, checks out the waiting-room literature: “Dating Violence: Talks with Teens,” “Overweight and Yet Malnourished,” ”Care for Your Teeth” and “VIH: Piénselo (“HIV: Think About It”). She picks up a six-inch plastic ruler printed with stop-smoking help numbers on one side, and vivid photographs of smoker’s (black) and nonsmoker’s (pink) lungs on the flip side. “I think I’ll keep this with me,” Sydney says. “So every time I want a cigarette—there it is, just look at it.”

Sydney is among the uninsured adolescents at the continuation high school in San Bruno, Calif., who regularly get health care from the Lucile Packard Children’s Hospital Adolescent Outreach Program, better known as the Health Van. This mobile clinic regularly visits six sites from San Francisco to San Jose, including homeless shelters and continuation schools. It spends five hours at a site, the same time each month. In these patients’ lives, there hasn’t been a lot of consistency or follow-up, and the Health Van aims to provide both.

The clinic turns 10 in September, having provided comprehensive primary health-care services to about 1,800 teens and young adults, many of whom otherwise would have gone untreated or been seen only at emergency rooms. Its staff includes a doctor who specializes in adolescent medicine, a pediatric nurse practitioner, a pediatric registered nurse, two job-sharing social workers, a dietician, a driver and an administrative assistant. The Health Van rides out two days a week, providing one-stop medical care, including medications. (A homeless teenager can catch the bus to school, but getting to a pharmacy—not to mention paying for prescriptions—can be daunting.) “We focus on prevention and early intervention,” says medical director Seth Ammerman, the pediatrician who founded the mobile clinic for teens.

The hospital owns the van, and the Lucile Packard Foundation for Children’s Health raises money to support it. Individual gifts and corporate grants keep it going, with an annual budget of around $450,000. In 2005, there were 908 visits to the van—772 visits by returning patients and 136 by new clients.

The motor home has been refitted to hold two private exam rooms, a pantry of medications (cough medicine to antibiotics to nicotine patches) and a restroom as tiny as an airplane’s. A TV set in the waiting area sometimes plays DVDs about health issues, sometimes entertainment. “We don’t want to overload the kids with education,” says Ammerman.

Nor do they want to scare kids off. Ammerman dresses casually—no white coat in sight. “All the people who work in this program like young adults,” he says. “Right up front every kid meets every staffer. Rather than, ‘Oh, we think you’ve got psychosocial issues. Go see the social worker.’”

Each patient is asked to fill out a carefully worded questionnaire at the initial visit, and again at most subsequent visits, so staff can track their changing health-care needs. The questionnaire works to give the kids a feel for the broad scope of primary care. Its 20 questions (Are you in a gang? Do you use alcohol? Have you ever been physically, sexually or emotionally abused, or beaten?) are answered yes or no, or with numbers, no elaboration. Answers are voluntary and confidential, with this important caveat: “If you report that you are in any danger (past, present or future) we are required by law to contact the authorities. If you are under 14 and are having sex with someone over the age of 14, we are required to report that too.”

Patients are treated as adults would be, in confidence and without judgment. For minors who are not homeless, the staff requests parental consent, but it is not always necessary: California law allows minors to consent for their own care in “sensitive services,” including reproductive health care, substance abuse counseling and treatment, and mental health counseling. “Most parents want what we’re providing—comprehensive care,” Ammerman says. “Not just immunizations. Not just birth control. Not just headaches. We treat the whole patient.”

High-risk, at-risk, marginalized and vulnerable are adjectives often applied to the population of uninsured and homeless adolescents. (In the course of a year, about 1,500 adolescents in Santa Clara County experience homelessness.) Teens who come to the van typically have the same problems as any adolescent, but they typically have more of them at once. A new patient often has eight to 10 health concerns right up front. A teenage girl may have irregular periods, headaches, back pain, depression and high blood pressure, besides using tobacco and alcohol, lacking immunizations and being overweight. Obesity and asthma are the two fastest-growing problems.

The issues also vary by site. Nurse practitioner Lisa Lestishock sums up, “At homeless sites, more mental health. At continuation schools, drugs.’’ Social worker Heather Sorensen rides the van and does individual counseling in East Palo Alto. Many of her referrals are victims of gang violence. Then, too, “a lot of kids are trying to quit using [drugs and alcohol], but there aren’t a lot of options for healthy activity, and everybody’s using, and they can get it for free.”

The lack of options for healthy activity struck dietician Kim Knight. She recently got a grant from one of the Lucile Packard auxiliaries to set up fitness equipment at three of the Health Van’s schools. A homeless shelter in San Jose has no room for the bikes and weights, so Knight arranged to buy memberships at local fitness clubs for the teens there.

The economics of health care are such that Ammerman estimates the van saves at least $4 in health costs for every $1 spent on it. As an example, he mentions a young woman who came in complaining of headaches. It turned out she was pregnant, and a smoker. Health Van staff arranged for prenatal care and helped her stop smoking. She delivered a healthy baby. “Had the van not been there, she would’ve likely had a premature baby and complications. It could’ve easily cost $75,000 just for the birth,” Ammerman said. Similarly, one case of hepatitis B prevented by immunization saves tens of thousands of dollars.

Dealing with insurance is a constant challenge. At the Bill Wilson Center, which shelters homeless and runaway youths in Santa Clara, registrar Jennifer Jackson and van driver Esther Aguirre set a table to help fill out forms. “There are clinics with sliding scales that people aren’t aware of,” Aguirre says. She and Jackson help kids get set up with insurance programs like Healthy Families, the state-run program for the working poor, or for MediCal.

Ammerman gets calls every week from agencies that would like to have the van visit. “We could easily be full-time,’’ Ammerman says, if the money were available. “Our goal is to raise an endowment.” Packard’s was the first mobile health program to target teens, and its success has prompted similar programs in Phoenix, Orlando and New York City.

Up in the San Bruno hills, Sydney DeAngelis has been coming to the Health Van since October and now anticipates its arrival every month. Nurse practitioner Lestishock sits casually on the exam table with Sydney, in a tiny but private exam room. School records don’t show that Sydney received her second hepatitis A shot, but Sydney thinks she did. She’s worried about getting the same shot twice. “So you guys want to give that to me? Am I going to die?” No, she is assured. Maybe the school just hasn’t recorded the shot yet. It can wait till next month.

Sydney proudly tells Lestishock she hasn’t smoked today. It is noon. “How are you planning on quitting? Did we talk about methods?” Lestishock asks. Sydney isn’t keen on the nicotine patch or gum, but she agrees to talk about them at the next visit. She is having problems with Depo-Provera, the hormone injections for long-term birth control. Lestishock agrees that Depo-Provera can have unpleasant side effects, especially at first. But she adds, “I think it’ll get better. Don’t be discouraged.” At the appointment’s end, Sydney leaves with condoms and a box of acne gel (which Lestishock has warned her not to wear in bright sunlight and to apply carefully lest it bleach her clothing.) She is clutching her ugly-lung ruler, too.


SHEILA HIMMEL, a former reporter for the San Jose Mercury News, is working on a book about eating disorders.

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