Service Learning in Health Care for Underserved Communities: University of Iowa Mobile Clinic, 2019

Abstract

The University of Iowa Mobile Clinic (UIMC) is an interdisciplinary student-run free medical clinic founded in 2002. UIMC provides free health screenings, education, and basic services to underserved populations in Iowa: immigrants, refugees, migrant farmworkers, individuals experiencing homelessness, low-income individuals, and people who live in rural communities. Forty-four percent of patients surveyed use UIMC as their only source of care. Ninety-seven percent of patients surveyed rate care as excellent or good. UIMC is a crucial safety net health care resource in Iowa to improve health equity.

The University of Iowa Mobile Clinic (UIMC) is an interdisciplinary initiative of health sciences students from the schools of medicine, nursing, pharmacy, dentistry, physician assistant, physical therapy, public health, and social work. Founded in 2002, for nearly two decades, UIMC has provided free health screenings, education, and basic services to underserved populations in Iowa: immigrants, refugees, migrant farmworkers, individuals experiencing homelessness, and those who are justice involved, are low income, or live in rural communities.¹

INTERVENTION

A student-run free medical clinic, UIMC service learning is grounded by the five core values of health equity, service, diversity, community, and integrity.¹ Because Iowa is a predominantly agricultural state, there remain large disparities between urban and rural areas.² UIMC fills a need to provide health screenings, education, and community referrals for uninsured and underinsured patients in Iowa.

PLACE AND TIME

Unlike most student-run free medical clinics operating from a single, permanent location, UIMC operates nine traveling clinics within a 50-mile radius of Iowa City, Iowa. Although the original mobile clinic in 2002 was a retrofitted school bus in migrant farmworker camps, continual growth has led to direct partnerships with local religious, civic, and educational institutions. In 2019 UIMC coordinated, on average, monthly clinics at nine sites, each catering to a specific underserved population in Iowa (Table 1).

TABLE 1—

Community Demographics and Clinical Services: Iowa, 2002–2019

Clinic/Citya	City Population, No.	Community Partner	Patient Population	Year Clinic Founded	No. of Clinics, 2016–2019	Special Services
Pheasant Ridge/Iowa City, IAb	76 200	Low-income housing	Low income	2002	21	Spanish/Arabic interpreters
			Sudanese refugees			HIV/HCV testing
Columbus Junction/Columbus Junction, IAb	1 900	Local church	Hispanic/Latino	2003	32	Spanish interpreters
			Burmese/Lao refugees			Sports physicals
			Migrant farmworkers
St. Patrick’s Church/Iowa City, IAc	76 200	Local church	Hispanic/Latino	2009	11	Spanish interpreters
Street Medicine/Iowa City, IA	76 200	Shelter House Community Shelter	Individuals experiencing homelessness	2008	47	HIV/HCV testing
West Liberty/West Liberty, IAb	3 700	Local school district	Hispanic/Latino	2011	44	Spanish interpreters
			Migrant farmworkers			Sports physicals
						Behavioral health
Ecumenical Towers/Iowa City, IA	76 200	Assisted living facility	Elderly, fixed income	2019	11	. . .
InsideOut Reentry/Iowa City, IA	76 200	Community resource center	Justice involved	2019	10	Social work
						HIV/HCV testing
Center for Worker Justice/Iowa City, IA	76 200	Workers’ center	Migrant farmworkers, day laborers	2019	7	Spanish interpreters
						HIV/HCV testing

Note. HCV = hepatitis C; HPV = human papillomavirus.

^aAll clinics offer screening for blood pressure, diabetes, and cholesterol; physician visits; health education; and seasonal influenza vaccines.

^bPhysical therapy, dentistry, and special health education sessions are offered each semester.

^cAll clinics offer HPV vaccinations with the exception of Saint Patrick’s Church.

POPULATION

Filling a need, UIMC serves a largely uninsured population (Table A, available as a supplement to the online version of this article at http://www.ajph.org). Although Iowa was a Medicaid expansion state following the Affordable Care Act, recent legislation significantly reduced eligibility and enrollment.³ Safety net health centers exist in larger metropolitan areas like Des Moines, Iowa, or Iowa City but are inaccessible for rural Iowa and those who lack transportation.

Population growth in much of Iowa is driven by immigration, particularly in agriculture and manufacturing (9% and 10% of industry workers, respectively).⁴ Approximately 5% of Iowa residents are immigrants (148 700 people), an estimated 26% of whom (38 700) are undocumented and thus ineligible for health care coverage.⁴

PURPOSE

The purpose of UIMC is to provide holistic, culturally appropriate care intersecting the diversity of our patients. UIMC aims to sustainably provide free health education and services to communities. We deliver needed services such as immunizations, medical management of acute and chronic conditions, health education, and referrals to higher levels of care.

UIMC brings interdisciplinary teams of health sciences students and faculty to underserved populations of undocumented migrant farmworkers, Sudanese and Burmese refugees, individuals experiencing homelessness, justice-involved individuals, and low-income populations (Table 1). Participating in student-run free medical clinics introduces team-based care and a health equity lens to address social determinants of health.⁵ Working alongside and for our patients, health sciences students gain exposure to lessons of cultural humility in the heartland.

IMPLEMENTATION

Across nine core UIMC sites, our mobile services are tailored to each population’s health needs (Table 1). Core services offered at every clinic include chronic disease screening and management, acute condition medical evaluations, and healthy lifestyle education. Additionally, specialty services are available, such as physical therapy, dental care, social work, HIV and hepatitis C screening, human papillomavirus vaccinations, and seasonal influenza vaccinations.

UIMC partners with university and community organizations to promote health care access in Iowa through several grant-funded initiatives. Programs include musculoskeletal evaluations for agricultural-related occupational injuries, behavioral health counseling for depression and anxiety, and a no-cost eyeglass program.

For services UIMC is unable to provide onsite, we have a network of referrals. Pediatric patients are referred to local health departments for school-entry vaccinations. Iowa City Free Medical Clinic and Iowa City Free Mental Health Clinic allow additional laboratory testing and continuity chronic disease management.

Two of our largest initiatives include interpreter services and electronic health record integration. Our corps of volunteer interpreters and electronic health record experts undergo training by student-led clinic operations. Interpreters function as cultural brokers to provide culturally tailored care, including nutrition counseling for the patients they follow. Preclinical students are trained to take vital signs for clinical medical students who serve as patient examiners responsible for the clinical encounter. These students all work under the supervision of practicing physicians, nurse practitioners, physician assistants, pharmacists, or other appropriate clinical faculty.

EVALUATION

Drawing on data since the implementation of electronic health records at UIMC from 2012 to 2019, we found that more than 2275 patients were served by UIMC and that an estimated 6800 students have volunteered since 2002. Table 2 demonstrates that through 2018 to 2020 UIMC cared for roughly an equal number of adult and pediatric patients. Spanish (24.8%) and Arabic (24.0%) were the two most common languages of interpretation. Additionally, UIMC served patients geographically distant from traditional medical centers (Table A).

TABLE 2—

University of Iowa Mobile Clinic, Clinic Services and Patient Satisfaction Surveys: Iowa, 2014–2020

	No. (%)
Clinical services reports, 2018–2020a
Patient demographics, age, y
< 18	594 (45.5)
≥ 18	711 (54.4)
Total	1305 (100.0)
Interpretation services documented
English	363 (50.7)
Spanish	178 (24.8)
Arabic	172 (24.0)
French	2 (0.2)
Total	715 (100.0)
Health services providedb
Patients seen by MD/ARNP/PA	712 (54.5)
Health education	377 (28.8)
Flu shots	240 (18.3)
Dentistry	134 (10.2)
ReSpectacle (free eyeglasses program)	123 (9.4)
Sports physicals	76 (5.8)
Physical therapy	30 (2.2)
HPV shots	14 (1.0)
Laboratory tests performedb
Hemoglobin A1c	667 (51.1)
Lipid/cholesterol panel	645 (49.4)
Fasting glucose	127 (9.7)
HIV/HCV tests	37 (2.8)
Coordination services performedb
Prescriptions written	152 (11.6)
Referrals to ICFMC	102 (7.8)
Referral follow-up visit	16 (1.2)
Patient satisfaction survey, 2014–2018
How often do you come to UIMC?
First time	36 (52.1)
Monthly	4 (5.7)
A few times a year	26 (37.6)
Every few years	3 (4.3)
Total	69 (100.0)
Do you receive health care outside UIMC?c
No, mobile clinic only	12 (44.4)
Yes, primary care/family physician	9 (33.3)
Yes, Iowa City Free Medical Clinic	3 (11.1)
Yes, emergency department	5 (18.5)
Total	27 (100.0)
How are we doing? Rate satisfaction.
Excellent	47 (69.1)
Good	19 (27.9)
Fair	2 (2.9)
Poor	0 (0.0)
Total	68 (100.0)
Were we able to answer your questions/meet your needs today?
Completely	62 (89.8)
Somewhat	5 (7.2)
Not at all	2 (2.8)
Total	69 (100.0)

Note. ARNP = advanced registered nurse practitioner; HCV = hepatitis C; HPV = human papillomavirus; ICFMC = Iowa City Free Medical Clinic; MD = physician; PA = physician’s assistant; UIMC = University of Iowa Mobile Clinic.

^aPartial year, data calculated January–April 2020.

^bDenominator 1305 patient encounters. Services not exclusive, cumulative % may sum > 100%.

^c2014–2015, no data for question “Do you receive health care outside UIMC?”

The most common health care services accessed by patients (Table 2) included clinician visits (54.5%), health education (28.8%), flu shots (18.3%), and dentistry (10.2%). The most common laboratory tests performed were hemoglobin A1c (51.1%) and cholesterol (49.4%). Prescription medications and referrals to Iowa City Free Medical Clinic for chronic disease management were a minority of UIMC visits (11.6% and 7.8%, respectively).

According to patient satisfaction surveys administered from 2014 to 2018, 44.4% of patients used UIMC as their only source of health care, and approximately half (54.6%) of patients were return visits (Table 2). Despite limited resources as a student-run free medical clinic staffed by multitudes of learners, patient satisfaction was high (69.1% excellent, 27.9% good) and trainees were able to answer questions and patient needs “completely” 89.8.% of the time.

ADVERSE EFFECTS

Unintended consequences of UIMC included fragmentation of health care, that only 1.2% participated in a new postreferral follow-up initiative (Table 2), and the inability to provide comprehensive preventive and diagnostic health care such as diabetic urine microalbumin or x-ray services. Additionally, ethical issues remain regarding whether student-run free medical clinics provide sufficient continuity with a rotating cast of health care trainees to serve as medical homes for patients requiring chronic disease management.⁵ However, in our small sample, approximately 44% of patients surveyed used UIMC as their only source of care and 6% returned monthly (Table 2).

SUSTAINABILITY

Despite limitations, UIMC has been a sustainable intervention to address health care services for underserved populations in Iowa. Two physician faculty advisors, a pharmacy faculty advisor, and a finance advisor provide institutional resources. These resources support the student-led executive board, which coordinates more than 800 student volunteers across eight health professional schools and the undergraduate campus to carry out UIMC’s mission.

As seen in previous studies, the benefits of clinical exposure at student-run free medical clinics during preclinical years at UIMC are evidenced by high levels of engagement.⁶ Day-to-day decisions are made by approximately 70 student board members who implement operational protocols, train student volunteers, facilitate provider recruitment, and provide clinical services under supervision. Additionally, UIMC student clinic coordinators maintain ongoing partnerships with local public-school systems, faith-based organizations, and community-based nonprofits. UIMC is continually improving service learning processes through reflection, feedback, and fielding requests for new clinical sites to better serve the community.⁷

PUBLIC HEALTH SIGNIFICANCE

Providing culturally appropriate health education and services is difficult in large urban areas, and these challenges are exacerbated in rural areas.² In states such as Iowa with no coverage for undocumented individuals and increasingly stringent requirements for Medicaid eligibility for natural-born citizens and immigrants alike, community-based solutions to policy deficiencies are urgently needed. This evaluation of services provided by the UIMC demonstrates the impact of a sustainable student-led, community-based public health intervention for the underserved.^5,6 UIMC is a crucial safety net health care resource in Iowa, whose student leaders will strive to improve health equity among our patients for years to come.