Man on a Mobile Mission

 

Childrens Hospital of Orange County Breathmobile Program 

It’s not quite a house call, but a visit from the 38-foot “Breath Mobile” represents an old school devotion to bringing care directly to patients. The idea has roots in Los Angeles, but Stanley P. Galant, MD, made it a reality in nearby Orange
County, California.

As medical director of the Children’s Hospital of Orange County (dubbed CHOC Children’s) Breathmobile, the 75-year-old Galant has used his considerable experience to bring expert medical care to children who have little or no attachment to physicians or even clinics. “Our target is the underserved child with asthma,” says Galant, a board certified allergist/asthma specialist. “These kids may have Medicaid insurance, called Cal Optima, or they are simply uninsured. Whatever the case, we do not turn anybody away if there is a need.”

In pitching the idea to CHOC Children’s more than a decade ago, Galant sought to address the familiar problem of access to preventive care—a scenario that routinely leads to costly emergency room visits and hospitalizations. Hospital officials readily embraced the concept and schools, community clinics, and community centers soon benefited from the mobile model.

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These days, two “Winnebago-like” vehicles each have a staff of three composed of a driver/administrative person, a nurse, and a health care provider. The vans visit 24 sites every 4 to 6 weeks to all points north and south.

Each patient receives a detailed history and physical, skin test, and breath test (spirometry). “We save a lot of money for payors because the kids don’t end up in the hospital,” says Galant, who also serves as a clinical professor of Pediatrics at
the University of California, Irvine. “Most importantly, the quality of life improves for patients and parents alike.”

Interacting with a minority group of mostly Mexican Americans means that most Breathmobile workers speak both Spanish and English. According to Galant, this “culturally compatible” bilingual approach ensures that nothing is missed in the vital communication process.

Consistent communication through continuity of care is attained by going to the same site every 4 to 6 weeks to follow-up with patients. “It takes three visits to reach asthma control,” explains Galant. “Patients see the same health care provider,
nurse, and driver, so there is bonding and trust.”

Galant estimates his Breathmobile has helped close to 10,000 patients over the last 11 years. All interactions are tracked, and results thus far have been worth the cost. “Everything we do is recorded into a computer program called Asma Trax, and we
have been able to produce metrics or outcomes that are impressive,” he says. “Among these patients, we have helped cut down ER visits and hospitalizations by approximately 60%. We have decreased school absenteeism by over 70%.”

Galant has been keen to systematically collect the data and present the results at local and national conferences. In terms of education, he set up an allergy/immunology/asthma elective. Pediatric residents,pharmacy residents,and nursing have spent
time in the “floating classroom”—a symbiotic relationship that provides in-the-trenches experience and expert care for patients.

Fight for Funding

Despite the mobile unit’s undeniable success, funding has been the biggest challenge. A small percentage comes from Medicaid, but the rest is cobbled together through a variety of 1- to 2-year grants. Galant spends many hours with staff pouring
over grant paperwork—tedious work to be sure—but necessary for the program’s continued success.

Actual home visits are occasionally done by the Breathmobile, a special concession for children who are an especially high risk of hospitalization. “Education is the critical piece here,” says Galant. “We’ll go wherever the need is. That is the beauty of mobility. The good side is mobility and accessibility. The bad side is it is extremely expensive. There are no economies of size. We are it when we go out there, and we must have a full complement of staff. It is a sizable financial burden.”

Galant has more of a managerial role these days, but he still goes out on the “van” under certain circumstances. “I am training some allergy fellows, and I am going with them to go over the cases,” he says. “I have gone out three times in April 2013, and I fill in when my docs are ill or on vacation.

“In spirit, I am working on the Breath Mobile 24/7,” continues Galant, who retired from clinical practice 6 years ago. “I work a lot from home, so I’m in constant contact with my staff. I help write grant proposals, papers, and work on curricula for CHOC/UC Irvine Pediatric residents. I come to the office about two days a week, and I’m on the phone quite a bit. I also play the violin and I’ve been married for 53 years. I would work more, but my wife would like to see me occasionally.”
Fight for Funding Past, Present, and Future: Q&A with a Trailblazer

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What Breath Mobile cases stand out in your memory?

SG: MD, medical director of the Children’s Hospital of Orange County Breath Mobile, a 38-foot “Winnebago-style” medical van that visits schools, CHOC community clinics and community centers to administer preventative asthma care: I was on the van
about a month or two ago, and this 17-year-old kid came in with his mother. He is a star football player at one of the high schools. His problem was he couldn’t exercise adequately, even though he’s playing football. He had a lot of trouble on and off the field. He and his mother came aboard the Breath Mobile. His mother looked at me and asked, “Are you Dr. Galant? Do you remember me?” It turns out I took care of her son when he was two years old. She explained that he was well for a number of years and she had always remembered me. She gave me a big hug and took my picture with her son. He also gave me a big hug.

I convinced him that if he wanted to be the star athlete he was capable of being, he should take his medication regularly. I had seen him 15 years ago, and fate had it that I was on the van the day he came aboard. I’ve been doing this since 1970 when I was board certified, and those kinds of things are known to happen. This was a very emotional moment for me.

How far can this mobile concept go?

SG: I think it can and will be part of programs to reach disenfranchised populations. I think the van is an entree into the community. If you do it right, you can successfully provide access to specialty care, and you need specialty care particularly for chronic diseases.

How viable is the 38-foot Breath Mobile from a financial standpoint?

SG: The van can give a good return on investment, because it’s the only way of consistently reaching the disenfranchised population—which is enormous. It can prevent many people from going to emergency rooms for costly visits. It’s money now for money later. It is the future.

Why is the Breath Mobile so important in tough economic times?

SG: Well, even if the economy turns around, there’s always going to be a large cadre of disenfranchised people. If you go to where they live, which the van can do, you’re going to have much better results. And if they see the same personnel each time, that engenders a lot of trust. You don’t get that now in medicine. You don’t know who the doctor is going to be for that day. It could be anybody. They don’t know you, and you don’t know them. That’s a problem.

What is your opinion of modern health care?

SG: Well, we talk about disparities in health care, and I think medicine is as much social as it is medical. At Children’s Hospital of Orange County we do things very well, so I’m just talking philosophically about what I see with different plans and the way medicine has been going for the last 30 to 40 years.

What is your opinion of modern health care?

SG: Well, we talk about disparities in health care, and I think medicine is as much social as it is medical. At Children’s Hospital of Orange County we do things very well, so I’m just talking philosophically about what I see with different plans and the way medicine has been going for the last 30 to 40 years.

What is the state of the doctor-patient relationship these days?

SG: There has been a real disconnect between the patient and the doctor with all kinds of intermediaries. There is little trust and bonding. That’s as much a part of medicine as is giving the medication. It’s particularly important for chronic disease like diabetes, asthma, and arthritis where you need a bond between patient and doctor.

What are the limitations of this kind of care?

SG: You’re asking a biased person, because I love the program. I think it’s a great idea, but it does have limitations. We only see 8 to 10 patients a day, because part of the 8 hours is drive time, and some of the distances are pretty long, and then the school shuts down at about 2:00 or 3:00, so you can’t stay later. We’ve initiated some Saturday morning clinics and some later afternoon clinics, but it is limited. You can’t see 30 patients. When I was in private practice as a specialist, I
might have seen that many in a day.

Can the mobile concept apply to medical problems besides asthma and/or respiratory concerns?

SG: Fifty to sixty percent of the kids we see on the van are either overweight or obese. It’s a major problem. This is primarily a Mexican-American population, which is known to have a high prevalence of obesity. We have a perfect model for looking at obesity because we do all the things you need to do for obesity management. We go where they live. We go to the same site every 4 to 6 weeks. We do home visits, and we spend a lot of time on education. I think I may be able to expand the van from just asthma to asthma/obesity. I am optimistic.

How big is the mobile concept nationwide?

SG: There are over 2,000mobile medical vans in the United States. Harvard did a study with their van where they did a lot of preventative care that dealt with blood pressure, blood sugar, and cholesterol. They figure there is a big return on investment, and their data shows it was very effective. If you don’t catch diabetes or high blood pressure, morbidities are enormous.

This is a nationwide movement, not just with the Breath Mobile, but for other outreach programs that go into the community to reach a population that ordinarily does not get medical care. Ultimately, it is a very attractive model.

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References

  1. The relationship of the bronchodilator response phenotype to poor asthma control in children with normal spirometry. Galant SP, Morphew T, Newcomb RL, Hioe K, Guijon O, Lian O. J. Pediatr. 2011 Jun;158(6):953-949.e1
  2. Lung function measurement in the assessment of childhood asthma: recent important developments. Galant SP, Nickerson B.
    Curr Opin Allergy Clin Immunol. 2010 Apr; 10(2): 149-54 doi: 10.1097/ACI.0b013e328335cd48
  3. The Breathmobile: a novel comprehensive school-based mobile asthma care clinic for urban underprivileged children. Liao O, Morphew T, Amaro S, Galant SP. J Sch Health 2006 Aug; 76(6):313-9

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