In Phoenix, AZ, like so many other urban areas, adolescents and teens hang around the streets unseen and unnoticed. These youth are homeless, runaways, throwaways-many with health problems, mental illness, and sometimes drug or alcohol abuse. Some have traumatic histories of parental physical or sexual abuse.

The youth of Phoenix are one of the demographics of the city's community lacking health insurance who use hospital emergency rooms as a stop-gap for care--mostly without an opportunity for follow-up to their initial health problems, and without a means to address the varied circumstances that have led to their current medical issues.

However, the Crews'n Healthmobile Homeless Youth Program (Crews'n) is making heroic efforts to change that situation. A recent "Innovation Profile" by the Department of Health and Human Services' Agency for Healthcare Research and Quality details how the Crews'n's freestanding clinic and mobile medical unit fill that gap of holistic care these troubled young people (the program serves those up to 24 years old) so desperately need.

Randal Christensen, MD, MPH, FAAP, Director of Crews'n, spoke to DOTmed News about the program's gratifying success and community support in helping these kids who are trying to survive despite, Dr. Christensen says, an "incredibly tough life" with violence and abuse as a regular occurrence. "The program that we run is kind of a newer model of health care. We see a number of kids that we think have higher levels of medical problems and certainly some other barriers to health care--they are in homeless shelters, they are living [on] the street, they are living with friends, they just have a number of difficulties. Because of this we think they need an enhanced medical home."

When people think about a medical home model, Dr. Christensen explains, they think of their doctor and an overall encompassing holistic approach to medical care. The staff of the Crews'n program believe that this model of health care works. Not only does this program work well for the youth in treating their medical problems and helping to solve some of the social issues and getting them access to health care, Dr. Christensen says, the program makes fiscal sense.

Showing the program is successful and leads to a reduction in emergency room visits demonstrates "...the patients win, the doctors in the emergency rooms win, the other patients waiting in the emergency rooms win, and the community itself wins because we are taking care of these kids in our clinic. They are spending less time in emergency rooms, they are incurring less costs and better treatment, more comprehensive treatment and we're saving money for the entire community."

Dr. Christensen also works for the local Phoenix Children's Hospital (who have been very excited over the program's results) and says that institution and many other hospitals in the community are supportive of the program because they see the success and fewer kids utilizing the emergency rooms; the doctors want the best for the patients and know the program is giving the kids the care they need.

The Crews'n Healthmobile treated 4,547 new patients and provided 13,165 health encounters between 2001 and 2008. The study shows that with this program, emergency room visits among those participants who accessed clinic services three or more times fell by 27 percent, from 1.5 visits to 1.1 visits over a 6-month period. In addition, 72 percent of program participants attended follow-up care appointments arranged by the clinic in 2007, up from 51 percent in 2006. Emergency room physicians also report high levels of satisfaction with the program in its ability to reduce ED visits.

Dr. Christensen describes how the program can work as holistically as an enhanced medical home through a hypothetical before/after example: A young man with painful feet impeding his ability to walk goes to the ER. The physician gives him prescriptions for antibiotics and other antifungal medication. Now that youth has a $500 bill from the emergency room and is worse off because he still has pain in his feet, owes the bill and can't afford the prescription. He also hasn't been able to address the circumstances that led to his medical condition. Now that young man hears about Dr. Christensen and the Crews'n Health Mobile and visits the clinic. The clinic sees the young man and actually gives him the antibiotics and antifungal medicine. The staff sees the reason he has this fungal infection is that is that he has been walking around in the Arizona monsoons in a pair of old combat boots with the same socks for the past month. Through the program, he gets new socks and shoes from the donation room. In this process, the staff also notices that his glasses are broken and him up with the Lion's Club to get him new glasses. He's also missing teeth so the staff puts him in one of their dental clinics the next. He is screened for mental health issues and is found to be suffering from depression from a long history of abuse. So he's then scheduled the clinic's nurse practitioner, trained in psychiatry, and can be started on medications. This young person hasn't finished school so the staff talks to him about getting in the GED program and to sign up with some of the adolescent shelters that are associated with the clinic.

"That overall comprehensive holistic approach is where we are going," Dr. Christensen says, "where our mission is."

Early in the program's mission Dr. Christensen realized that unless the other barriers to a productive life-- i.e. lack of mental health, dental health, mentorship, education levels, etc., were addressed, just treating the medical aspects conventionally wouldn't lead to significant success. "This [AHRQ] report was a little bit of scientific validation on the program and the fiscal success. While our program is expensive and supported through philanthropy, it is the first step to understanding and addressing these issues. We can see vast savings; we can be cost effective. I think that health care reform has three major tenets: increased access, improved quality of care, and most importantly cost reduction and savings. If a relatively expensive program such as mine can be shown to have cost savings, that makes it all worthwhile."

Dr. Christensen says he is seeing a growing number of kids involved in the program--not surprising in the current economic state; the 2008 numbers show an increase of 32% in clinical visits. The program's staff has grown from just a few in 2000 to a little over 10 at present, including two doctors, one family practice nurse practitioner, three nurses, two case managers, one office manager, one financial specialist and one part-time psychiatric nurse practitioner.

The feedback from the patients leads Dr. Christensen to feel he has the best job in the world. Regardless of the recognition and accolades the program has already received, the most important thing to him is the true appreciation of the patients. The community of the homeless children are very familiar and trusting with the staff and in essence part of their lives. The staff shares in the successes and tragedies of the patient community.

Dr. Christensen says that the program has collected a large amount of data that can possibly lead to four or five more papers being published in public health journals. He is grateful for the past funding from federal and state sources, private philanthropy--and the community support: "...the dollars that come from the community that really make us happy and are the lifeblood of our program. Moms and Dads, local churches and schools, are always there when we ask for help."

The AHRQ's Innovation Profile can be accessed at: http://www.innovations.ahrq.gov/content.aspx?id=2477

Watch for a report on mobile medical service providers in the November 2009 issue of DOTmed Business News.