In early April, as part of a comprehensive response to the COVID-19 pandemic, Boston Medical Center launched a mobile pediatric unit to provide modern-day house calls for vaccinations and well-visits as an alternative to the hospital. Now, as the nation braces for a convergence of flu season and increasing cases of COVID, BMC is finding another pressing reason to continue its home visits: to administer flu vaccinations to pediatric patients with asthma or sickle cell disease. Patients with asthma and sickle cell disease are at increased risk of serious complications from the flu as well as COVID-19—their respiratory systems can be easily compromised by respiratory viruses like the flu and COVID-19.
Melissa Nass, MD, MPH pediatrician and Medical Director for Mobile Programming, shares how the mobile unit is making strides in protecting high-risk patients from the flu and COVID-19.
BOSTON MEDICAL CENTER: What drove the decision to evolve mobile health programming into this newest phase where flu vaccines are being administered to patients with asthma and sickle cell disease?
MELISSA NASS, MD: When COVID rates in our community fell and patients started coming back to clinic for routine care, we started to think about what was the most pressing public health need in the context of this pandemic. And flu prevention is a top priority—it’s a very important public health intervention right now. We worry about the effects of a double diagnosis—flu AND COVID –in our medically vulnerable patients and we want to prevent that possibility. Additionally, we really want to reserve our inpatient resources for patients with COVID. Preventing influenza—and hospitalizations associated with influenza– protects our resources for the anticipated need during this pandemic.
We thought about which of our patients are most vulnerable to respiratory illnesses and which of our patients we should try to protect and our asthmatic patients immediately emerged as a group. Then, I was discussing the programming with one of our patient navigators, explaining how we were going to start bringing flu shots to our patients with asthma who have no other reason to come to the hospital. He turned to me and said, “What about patients with sickle cell disease?” I thought that was brilliant and immediately said, “Let’s do it!” Growing the program has been a huge team effort all around.
BMC: What is the objective of bringing flu vaccines to patients with asthma and sickle cell disease? What are the implications of the flu on someone with either of these conditions?
MN: This is a two-part intervention. First, although our hospital is very safe right now—it’s a low-risk environment for contracting COVID—we don’t want medically vulnerable patients taking public transportation and coming to the hospital if it’s not necessary, in order to mitigate any risk of coming into contact with COVID. The second part is flu prevention. That’s why we’re delivering flu vaccinations to patients’ doorsteps. Someone with poorly controlled asthma could become quite ill with the flu and that could require hospitalization and even intensive care. This is the population we want to protect.
BMC: How is the intervention being rolled out?
MN: We’re doing a couple of things. Registered nurses recently received approval to go out in the mobile unit without physicians so they’re administering flu vaccines and other needed vaccinations to our high-risk asthmatics and patients with sickle cell disease. They’re offering vaccines to patients’ siblings as well. Then, they do an asthma screening to see if the patient’s asthma is well-controlled. If it’s not, we have a system in place where a primary care provider will conduct a telehealth visit within 24-48 hours. At that time, the provider will do a more thorough assessment and provide further intervention or education. It’s not simply delivering a flu vaccine—it’s really part of comprehensive asthma management.
Mobile programming offers many possible interventions. Recently, we started doing active outreach to patients under five who had not come to our clinic in over 18 months. We figure they’re not coming in for a reason—maybe access is a problem, maybe transportation is a problem—these are families that could likely benefit from mobile services. We schedule these patients on days when a physician is on the ambulance so they can receive comprehensive services on the mobile unit. Along the way we’ll discover things like their insurance has lapsed so we developed a system to connect patients back to insurance. We’re out here assessing what the greatest needs are for community health. We are also focused on the health of families, which comes in the form of the packages prepared by the Project REACH [an outreach program which assesses patients’ needs and connects them to necessary resources] team because families are telling us they have many unmet material needs right now.
BMC: Why is mobile health so important for high-risk patients?
MN: Our general patient population and the communities we serve have been disproportionately burdened by COVID. You might have a very healthy baby that you’re going to see, but grandma’s there and grandma is medically complicated and at high-risk for complications from COVID. Even in taking care of that typical, healthy baby you’re protecting the grandmother [by doing the visit in the mobile unit instead of at the hospital.] In a way, you’re taking care of the whole family. So while I do think there’s an obvious role for reaching medically high risk patients with mobile health, because our patients come from families at high-risk for COVID complications, reaching out to even our healthiest patients is keeping families and the community safe.
BMC: What’s on the horizon for mobile programming?
MN: We hope to create a high-quality comprehensive program for dyadic care where mom and baby are seen multiple times during the first six weeks of life—a critical time where health disparities exist that could impact moms and babies long-term. There are several barriers to such care and mobile health programming helps eliminate them. For one, in order to come to the hospital for an appointment, a new mother must take her baby in a carrier on a couple of buses. She usually has to come in a few times, too. On top of that, the mother is supposed to be going back for her postpartum visits. However, 40 percent of our patients don’t come in for those postpartum visits. Moms are really good at taking care of their babies, but not always taking care of themselves.
We would staff the mobile unit with a pediatric provider and a postpartum provider who would do lactation consultations, address mom’s chronic health conditions and screen for postpartum depression. We could look at the impact of this program on health outcomes by evaluating the difference in ER visits, impact on breastfeeding and a variety of other things.
BMC: It’s quite evident that no idea is ever too extreme when it comes to doing what’s best for our patients. What is it about BMC that nurtures this kind of innovation?
MN: That speaks to the history of BMC. We have always been a group of innovators and people who say “yes” when somebody has an idea. Our leadership supports us. [We create solutions] because we are really great listeners. We listen to our patients and our families and really try to understand what they need the most. And then we meet them where they’re at. In this case, it’s at their doorstep. I know this programming is innovative and exciting, but the reality is this is consistent with what BMC Pediatrics is all about—we just happen to be rolling out this programming in particular in response to the worst pandemic ever.
We are surrounded by a group of people who always rise to the occasion and share a commitment to our patients and the mission. Everyone involved—from the people who are assembling the bags of goods to the people who are making the phone calls and scheduling patients for mobile visits—are doing this incredible work on top of the responsibilities of their full-time jobs. Everyone wants to make this really great thing a success.
BMC: Mobile programming at BMC rose as a response to the COVID-19 pandemic. How does this speak to the current health care landscape and where we are headed?
MN: COVID has shown us that overnight we can completely overcome obstacles. In the context of a pandemic, there are new reimbursement models. There are new clinical platforms. We stood up telehealth overnight. People started getting on mobile units and taking health care into the community. This is a time of enormous change. We have an opportunity to build a more equitable system and quite literally get out of the ivory tower. We really partner with families and their communities. Holding onto that idea has been really important in what is an otherwise extraordinarily challenging period of time. It’s amazing how, when people are on the same page, things can change and change quickly for the better.