It was the asthma death of a young man who had run out of medication, and lacked funds and transportation to get more, that set Dr. Paul Sharkey on the road to developing the Breath of Life Mobile Asthma Clinic, a custom-built Airstream bus that takes asthma care to schools and other sites throughout Northeast Texas.
“It was a needless tragedy,” said Sharkey, an asthma and allergy specialist at UT Health Northeast in Tyler. He was inspired to look for a solution, and with the help of funding from a variety of sources, and financial and organization support from UT Health Northeast, he and his colleagues were able to build the bus, hire staff, and create a program that now serves 27 school districts in the northeast Texas area.
Texas Health Journal spoke with Sharkey about Breath of Life Mobile, treating kids with asthma, and the challenges of rural medicine.
John Flynn: How did this program come about?
Paul Sharkey: This program was started after the asthma death of a young man in my clinic in 1998. He was a young, healthy African American male with moderate persistent asthma. He had a single mother with no transportation, and could only get asthma medications when his mother was able to get a ride to Barksdale Air Force Base in Shreveport.
They could not afford to get medications locally. During a time period when he was without asthma medications, he had a fatal asthma attack at home. It was a needless tragedy.
Later that same fall, I was at my national allergy meeting and I was walking across the convention center parking lot to get lunch. I saw a bus pulled over that appeared to be running a clinic. I walked over to see what was going on, and saw one of the physicians who trained me in Kansas City during my allergy fellowship. He was the physician caregiver on the bus. He explained that he was part of a mobile asthma team (the original Breathmobile program) that treated underserved children with asthma, primarily in the Los Angeles area. We arranged to have dinner that night, and it was from our conversations that night that I became driven to get a similar program established here.
After many years of writing grants and being turned down, we were awarded a federal HRSA grant to purchase the bus. The bus was designed after many conversations with other Breathmobile sites and was built in Jasper, Texas.
When we received the bus, we still did not have funding to pay for staffing to run the bus at a full-time level. We received enough funding to go out locally to five area schools during the school year once-weekly. Then several years ago, through the Texas 1115 Waiver, we received funding for staffing for several years. At that time, we were able to greatly expand our services.
Currently, we are serving 27 school districts in the northeast Texas area and have evaluated and treated more than 1,600 individual children. At least one parent must accompany each student less than 18 years of age on each clinic visit. Our focus remains on serving underserved school age children with asthma. We serve to bridge several main impediments to care, including financial barriers, language barriers, and transportation barriers. We do this by providing free care at every visit, treating children at school or health fairs or apartment complexes, and always trying to have at least one bilingual staff to help with language concerns.
We are the first program serving a predominantly rural medically under-served area.
Could you explain the setup of this program?
The bus is divided into three different areas. Entrance to the bus occurs in the middle of the bus, and this area is for intake and for obtaining information about insurance, asthma outcomes, and personal, family history.
The front of the bus is the nursing area where spirometry, skin testing and asthma education (inhaler, peak flow meter use) takes place. The back of the bus is where the caregiver works.
The caregiver looks at all the history, spirometry, and skin tests (when performed) results, and obtains additional history if needed and makes a treatment plan specific for the patient. If the patient has insurance, prescriptions will be written. If the patient is self-pay or cannot obtain prescriptions, we will provide free medication samples though in-kind pharmaceutical donations so there is no cost to the patient.
All three areas of the bus can be closed off from each other so at least two patients can be seen simultaneously if needed.
How do you arrange meetings with schools?
Before attending a school, we have to get permission through the school system to hold clinic at their school. We do this primarily by attending SHAC (School Health Advisory Council) meetings for the various school districts.
Once approved, we have a program coordinator who works with schools and school nurses to set up a clinic schedule. School nurses are encouraged to identify high morbidity patients who have recurrent or severe exacerbations that need emergency care, cause frequent missed school days, or limit full participation in schools.
Is there cooperation between Breath of Life and school nurses?
Yes. We are hopeful that school nurses will help identify high morbidity patients not receiving specialty asthma care. We also take physician referrals and self-referrals. When a school is identified as a participating school, they are given flyers for every student that list our services and the times we will be at their school, and we will accept appointments directly or from the school nurse.
What does a typical day look like?
We offer our services to any patient but are targeting students with the aforementioned issues who are not receiving specialty care. Our program arranges a clinic schedule through the school nurse with slots for new and follow-up patients. A typical clinic day is run from 9 a.m. until 2 or 2:30 p.m. to avoid trying to leave during school pick up. Some schools are now having us park at non-student pick up areas so we can run longer schedules. We typically are scheduled for 10-14 visits per school day, but will see more students if needed. We try to see students at their school 3 times yearly (baseline, 6 months, 12 months) if they’re doing well and more frequently if needed. Students that need our services sooner than our return visit may be seen at another area school (with advance permission) or at a central site such as St. Paul's Children's clinic in Tyler. Identified caregivers are given a clinic visit report from each visit.
Who are the staff?
Our current staff is the following:
I'm the physician supervisor. I'm not typically on the bus.
Our Program Specialist is the scheduler who helps set up community events and all non-school sites and helps with getting approval for future schools/districts.
Our nurse practitioner is the caregiver on the bus. She makes all medical treatment plans, provides a lot of medical education, and identifies high risk patients who need additional follow-up or care. She treats any co-morbid illnesses that negatively impacts asthma (e.g. allergic rhinitis, sinusitis, GERD, obstructive sleep apnea, etc.).
The nurse helps with spirometry, skin testing, and asthma education.
Our driver drives the asthma van and helps with Intake.
How often does the bus go out?
Four to five times weekly. Usually four times weekly so we can get all charting done on the fifth day, but many weeks the bus is out five days a week. Currently, we are going out Monday through Friday.
What are some drawbacks/limitations of mobile medicine and how are they being addressed?
We have run into several limitations:
1. Funding is always a major issue, since this program provides free care and does not generate revenue. Currently, our funding is provided through DSRIP funding. We are always seeking additional avenues of funding. UT Health Northeast has also provided additional financial help for the program.
2. We have a very large no-show rate for return visits. We are trying to identify reasons for this currently. Some thoughts are that parents cannot/will not travel to attend the follow-up visit, and patients are improved and don't see the need for a follow-up visit. Some sites incentivize their patients to return for visits, but we do not do this. We are continually evaluating our program to make sure we are providing optimal and efficient care.
3. The asthma van is a specially designed 37-foot Airstream bus. It is difficult to maneuver in close quarters, has intermittent mechanical breakdowns, and is not gas efficient. We are considering having the asthma bus just serve in the Tyler area and health fairs/apartment complexes. We are evaluating having the team travel by van or SUV to more distant sites with all necessary equipment/medications, but it may be difficult to continually take donated asthma medications out in this situation. We would expect the school or visiting site to provide us with the needed space to run our clinic.
What are the benefits of mobile medicine? What can this do that other facilities cannot?
Mobile medicine takes the medical care/expertise to the patients rather than relying on them to make it to medical care. This can overcome transportation issues common in many underserved areas both urban and rural. We perform the same services on the asthma van that would be given in a state-run or private practice allergy clinic.
Do you see a possible expansion of this program in the future?
We are hopeful that this program will expand in the future. We have excellent documented outcomes demonstrating significant improvements in reducing asthma related hospitalizations, emergency room visits, oral steroid bursts, and missed school days, and in improving National Asthma Education and Prevention Program (NAEPP) guidelines levels of control. Our hope is that this is a program that can be extended statewide.