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By Liora Engel-Smith
As coronavirus abruptly overturns nearly every facet of life in North Carolina, agencies whose providers care for people in the community are adjusting or stopping their services.
Health care has transcended brick-and-mortar clinics or even hospitals in many communities. Medical services, including dental care, screenings, syringe exchanges, and even primary care, now take place at community events, schools and homes. But the extent of health care service in the community doesn’t stop there. For instance, in North Carolina, crisis response teams respond to mental health emergencies at people’s homes.
It’s hard to gauge the number of workers who fit into the category of mobile care providers in North Carolina, but the website Mobile Health Map estimates that more than 40 mobile clinics operate in the state, including dental vans, organizations that screen for STDs, health care providers who make home visits, and more. The site does not track syringe exchange programs, but as of December 2019, 31 programs covered 45 North Carolina counties with mobile and stationary syringe exchanges.
The coronavirus pandemic poses a unique challenge for these providers. Some mobile clinics see patients in specially outfitted vans or trailers, where social distancing can be difficult to achieve. A patient with flu-like symptoms would be difficult to isolate in a limited space.
Community health workers who provide at-home services may unknowingly venture into the home of a patient with COVID-19, especially if that person is still not showing symptoms. With face masks and hand sanitizers in short supply, workers may find themselves without much protection.
As social distancing efforts have already extended to schools, bars, restaurants and workplaces, providers at mobile clinics and other outreach services are considering their options. Several, such as the New Hanover County mobile dental clinic and UNC’s mobile clinic, have already suspended their services. Others have modified their offerings for now but said they may reconsider down the line.
Shutdowns, cancellations and revamped care
School closures prompted providers who normally visit schools to temporarily suspend their mobile services. This is the case with the mobile dental clinic at New Hanover County, said spokeswoman Jessica Loeper.
“We will continue services as soon as possible, and will certainly refer any patients as best we can if there are pressing care needs in the meantime,” she said in an email.
Other outreach workers are revamping their approaches but said services will continue for now. At the North Carolina Harm Reduction Coalition, an organization that operates several syringe exchanges across the state, staff members decided to continue providing services for as long as possible.
“We don’t want to disrupt services, that’s going to cause additional harm,” said Loftin Wilson, rural program coordinator at the North Carolina Harm Reduction Coalition. “We’re seeing very vulnerable people.”
Older people and those with underlying conditions are at greater risk for complications from a COVID-19 infection, according to the CDC, and Wilson said many syringe exchange participants fall into one of these groups.
But the prospect of completely discontinuing syringe exchange services, Wilson added, could also cause harm since using dirty needles is associated with transmitting HIV and hepatitis B infections.
To stem large gatherings, Wilson said the coalition suspended needle exchanges in fixed sites and ended events and support groups, instead opting for mobile outreach. Syringe exchange workers have been instructed to exchange syringes with participants in the open air, rather than go in people’s homes, he added, and to wear gloves as they pack syringes and wound care supplies.
The coalition may be compelled to discontinue its syringe exchange services altogether at some point, Wilson said this week. In the meantime, staff members are preparing participants for that possibility by giving them more supplies than usual.
Staff members haven’t yet encountered anyone who they suspect has COVID-19, but Wilson said workers will help participants get help if that happens.
“We’d be doing our normal sort of linkage of trying to make sure people are connected to the appropriate resource,” he added.
From care to COVID-19 testing
CommWell Health, a community center that normally offers primary and dental care in mobile vans, has converted their three mobile clinics to support outdoor testing sites for COVID-19, said CEO Pamela Tripp.
Patients aren’t allowed in the van, said Tamara Dunn, chief operating officer and chief nursing officer at the organization, and testing is done outside. The test itself, a nasal or throat swab, can induce coughing and sneezing.
“If we take them [patients] in the mobile unit then you’d have to shut that down for a certain amount of time,” she said.
The CDC recommends that contaminated areas be shut down for a period of time before cleaning to allow the virus to settle on surfaces, Dunn said.
Shifting to phone when possible
At Doctors Making Housecalls, a 125-doctor primary care mobile clinic for seniors with complex medical needs across the state, clinicians have also made adjustments, said CEO and co-founder Alan Kronhaus.
Kronhaus, who is also a primary care physician, said doctors in the practice have shifted to phone consultations and virtual visits when possible and they wear protective masks when visiting homes of patients with respiratory illnesses. Ideally, Kronhaus said, physicians would wear masks when they visit every patient, but shortages worldwide have prompted clinicians to conserve their supplies.
Even with these measures, the practice averages roughly 200,000 visits annually, Kronhaus said.
He isn’t sure how long the masks will last.
For now, he said, clinicians will continue to make visits to patient homes when necessary and will offer support via phone and email when visits aren’t possible. His practice is also working on purchasing more masks, he added, but if masks aren’t available and a patient is very sick, clinicians would likely instruct them to go to an emergency department.
“We just keep on keeping on,” he said. “That’s mainly what we’re doing.”