Thank you so much for being here with me today, Dr Gupta. Can you tell me a little bit about your interests and your work?
“I’m a primary care physician and also medical director for clinical community-based programs for Mass General Brigham, which is a healthcare system in the Boston area. My interests are in addressing health disparities in medicine through my practice and practicing medicine at the interface between medicine and public health. So thinking about all of the social risk factors that go into an individual’s health in addressing health conditions that are preventable and treatable.”
Could you give some examples of projects you’ve worked on?
“When the COVID-19 pandemic first surged, our hospital system set up a few pop-up clinics to help provide COVID care to individuals that needed it at that time, initially COVID testing. Many primary care physicians who started staffing those clinics, started noticing that COVID-19 was highlighting many of the social determinants of health that we had often ignored in healthcare and medicine,” continued Dr Gupta. “We were seeing that, while some patients were accessing care, there were many other patients that weren’t accessing care.
“For example, one of my patients, an Uber driver at the time, couldn’t afford to be out sick. He didn’t want to know whether he had COVID or not, because if he was given the positive diagnosis of COVID, he would have to quarantine in his house for ten days and he would not be able to make enough money to put food on the table for his family. Similarly, I remember taking care of an elderly patient who was living in Chelsea, one of our communities that was hardest hit in Massachusetts. She didn’t want to know whether she had COVID either, because her multi-generational family lived in a two-bedroom house and if she knew she had COVID, where would she go and quarantine?” added Dr Gupta.
“So, as those stories emerged, I and others were inspired to think about how we could do some social risk mitigation and that, coupled with engaging with community partners in these communities where COVID was highest, guided the formation of what was initially a clinic on wheels through the Massachusetts General Hospital Kraft Center for Community Health. The focus was on bringing care to the communities but also on providing social risk mitigation and, as COVID stabilised, we realised that this mobile platform was a way to reimagine our hospital’s front door to not only provide sick care but healthcare.”
“Initially, on this mobile service line that I oversee from Mass General Brigham, we were providing COVID testing, and then COVID test and treat, and COVID vaccinations. Then we began to think about other conditions that contribute to vulnerable patient populations having increased morbidity and mortality, and we’ve had this data-driven approach all along. What we realised was that conditions like hypertension and diabetes could benefit from some of these services out in the communities as well. As well as substance use disorder care. And so our vans first helped close the gap around COVID-19 care, but now we’re trying to also tackle these chronic diseases in a more effective way.”
So you are not just perpetuating the same care using the mobile units, but you are actually extending it now?
“Exactly,” answered Dr Gupta. “Our goal is to expand high-quality healthcare to vulnerable patient populations but in a targeted way to meet them out in the community and meeting the needs that they have at this time.”
How do you generate those additional resources it requires?
“In its early stages, our work was funded by the NIH, and that funding allowed us to do a lot of community engagement and needs assessment,” Dr Gupta explains. “But our system has been incredibly supportive of this work as they’ve seen the effectiveness and now the Mass General Brigham community care events, which is the name of our mobile service line, is funded by the United Against Racism initiative through Mass General Brigham.”
How do you see this going forward and how can you make this standard-of-care for communities that are lacking resources?
“Essentially, we’ve shown through our proof of concept that these clinics on wheels have been effective in reaching people who have historically been disengaged with care or marginalised, or just not been able to access care for many reasons. To take this forward, we can build on what we’ve learnt. Our work has been an example of ‘system-ness’, where we’ve partnered with community organisations, as well as other local health systems in the communities that we reached with our vans. So, instead of all of us working in silos, we worked closely together to produce a greater collective impact. Our path forward thus includes building upon that to provide both clinical care and risk reduction with our clinics on wheels.”
“We’re present in the communities with 3 vans for 20 hours per week, each with 4-hour walk-in clinic sessions. Our clinic sessions are held in the early evening hours or on Saturdays, and we also co-locate our vans at bigger community gatherings and fairs,” Dr Gupta continued. “For instance, to reach adult men with hypertension and diabetes, we’ve co-located at food distribution lines, or we’ve co-located at soccer fields on Sundays when there are large gatherings of our targeted population. Thinking outside the box and coming up with creative ways to find the people we need to reach is an important effort, guided by the direction that our community partners give us.”
I would like to twist the conversation a bit and ask about the drug dependency programmes that you have been working on. Could you tell us about that?
“One of our newer services includes providing substance use disorder care, which we are doing in close collaboration with our substance use disorder programme at Mass General Brigham led by Dr Sarah Wakeman. Essentially, addiction medicine-trained providers co-locate with our core team of clinicians on the vans to provide this care. As mentioned before, with every service we provide, we provide risk mitigation in addition to clinical care. When it comes to substance use disorders, we provide education around substance use but also other harm reduction interventions, like the distribution of Narcan. We recently received approval from the state to distribute Narcan from our vans to those who will benefit from this.”
That’s great to hear. It’s been big news in the USA that Narcan has been approved for over-the-counter distribution. How do you expect it will affect the situation of people with substance abuse?
“Over-the-counter distribution of Narcan may be a life-saving method for any individual who has overdosed on opioids. It may also help to destigmatise and normalise the need for it. But I think one of the issues that will remain is the cost. The drug manufacturer of Narcan hasn’t published the costs for over-the-counter distribution yet. However, the out-of-pocket cost for one box of Narcan, which is about two sprays, is between $50–100, and this makes it too costly and inaccessible for many of the individuals that need it most. Therefore, I think that there is a strong need for community distribution sites that can provide this medication free of charge, and that we still need the state and federal government to continue supporting these community distribution sites so that we can keep Narcan more accessible. And, hopefully, the stigma around its use changes so that we will see the impact that we hope to see with the number of lives saved.”
Probably with a little bit of health economics, it will prove it’s worth way and above what they’re charging for it. Is there anything else you’d like to share with your colleagues about the mobile health programmes that you are working with?
“One of the core elements of our mobile healthcare programme that makes it very effective is that we’ve put together a staff on each of our vans consisting of a physician lead, a full-time nurse practitioner, a community health worker, a medical assistant, and an operations manager. We’ve tried to build our team with individuals that live in and are from the communities that we’re trying to serve. This way we can bring medical care to these communities in the language and with the cultural humility that’s needed to be effective.
Finally, the addition of a community health worker to our mobile teams has been especially helpful because we are realising more and more the impact and importance of social risk mitigation in bringing healthcare that is effective and brings equity to the care that we provide in everything and everywhere.“
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