“Telemedicine Can’t Weigh The Baby”

Marlena Santos brought her newborn son to a 40-foot converted school bus occupying two spaces in the Sherman-Tyler Parking Lot near Ella T. Grasso Blvd. There, an advanced practice registered nurse weighed and measured him, checked his heart rate, and listened to his lungs.

“There’s only so much doctors can do looking at babies through MyChart video, and it doesn’t feel safe going to the hospital right now, so this was something nice,” Santos said during the in-person visit Monday evening.

The converted school bus is a mobile medical clinic known as the Community Health Care Van. Created by Dr. Rick Altice, an infectious disease specialist and professor of medicine at Yale School of Medicine, the van has been traveling directly to New Haven’s poorest neighborhoods since 1993, offering free care and community outreach to people impacted by HIV/AIDS, substance use disorders, homelessness, and mental illness.

Now, in the face of the Covid-19 pandemic, the van has a repurposed mission: In addition to its overall objective of using community outreach to distribute facial coverings and educational materials, it is providing crucial postpartum visits for mothers and their infants, according to Altice.

It’s the first such mobile clinic in the state focused on the care of mothers and newborns.

Altice said that Leslie Sude, a Yale pediatrician, contacted him in the third week of March.

“She’d been working tirelessly to figure out how mothers and babies could safely get medical care while practicing physical distancing in the postpartum time period,” he said.

The issue of delivering maternal-infant care amid a pandemic had been weighing on Sude’s mind from the time the virus bore down on New Haven.

“A third of our patients rely on public transportation or ride sharing services to bring them back and forth, and I was concerned what that might look like in terms of trying to prevent continued viral contact exposures and viral transmission throughout the community,” Sude said.

Soon she and her colleagues, she said, ​“were hearing from some patients that they were anxious about coming to the hospital and were willing to forgo or skip these clinic visits out of their concerns for Covid.”

Telemedicine was available, but ​“telemedicine can’t weigh the baby,” Sude said. ​“These early visits are important because we sometimes see issues post-natally with weight gain or poor weight gain or jaundice that need to be identified early to prevent complications.”

For mothers, ​“blood pressure checks might show hypertension as a complication of pregnancy which can have adverse effects on long-term cardiovascular health and mood screens can detect postpartum depression,” she said. 

At the same time, Marietta Vazquez, a pediatrician and infectious disease specialist who also runs the Yale Clinic for Hispanic Children, was having the same concerns.

“We needed to think about contagion, about transportation, and about the reality which is that many of these mothers were very scared to leave their homes,” she said.

Together with Sude, she convened a virtual meeting that included, she said, ​“the well-newborn nursery, OB-GYN, leadership in the primary care center, our core team in pediatrics, and” the Visiting Nurse Association (VNA).

Home visits by visiting nurses agencies seemed a possible course, but some nurses were being barred access to their patients’ homes due to concerns about coronavirus, they learned.

Then someone from the VNA suggested a mobile clinic.

“They said if we could have a van that would provide a neutral, easily sanitized, and safe place outside the home, perhaps we would be more effective,” Sude said.

Enter Altice. With the services provided by his Community Health Care Van sidelined as a result of the pandemic, he’d already been approached by colleagues at Yale Medical School’s Department of Internal Medicine to spearhead a community outreach program to give out masks and sanitizer as well as educational materials on the disease.

A zip code analysis showed Covid-19 hot spots in New Haven overlapping with the neighborhoods of the mothers facing challenges getting back to the clinic. The Department of Internal Medicine and the Yale New Haven Hospital Fund were amenable to combining the community outreach with the mother-infant care.

“It seemed to be the perfect storm to make things work,” Altice said.

He previously had a van equipped with examination and counseling rooms, and engineered to communicate with YNHH’s medical record system, Epic, and a ​“very experienced, bilingual, bicultural staff,” as Altice put it.

The staff includes advanced practice registered nurse Sharon Joslin (who directs the program) and three community outreach workers: Angel Ojeda, also a phlebotomist and certified nutritionist; Rolo Lopez, an outreach case manager; and Rolo Lopez, Jr., a licensed commercial driver. Migdalia Williams, who does scheduling and community harm reduction, works off-site.

“People know us as a trusted place to get services,” Altice said. ​“We don’t require insurance and don’t report people if they’re undocumented, we just take care of them.”

Still, there were administrative and bureaucratic snafus about billing and insurance. There was no financial support from either Yale University or the City of New Haven. Funding ultimately came from the YNHH Physician Fund and the March of Dimes, and would only be enough to maintain services for a month. 

Altice wasn’t about to wait. ​“This is an epidemic,” he said. ​“That’s why we’re doing this without sustained funding. It’s absolutely critical to get out there and get people services.”

While his hope, he said, ​“is to keep this going, for now I just wanted enough money to get us through the epidemic hump and if we get started maybe people will become invigorated and maybe even expand it further as the community needs grow.”

The protocols, reviewed by an infection prevention specialist, are strict. Visits are by appointment only and are limited to collecting physical data to coordinate with telehealth visits, as well as assessing breastfeeding and formula-feeding practices, and other issues that need attention, according to Sude.

The driver is separated from the main exam areas, with providers wearing PPE, and cleaning, sanitizing, and disinfecting procedures performed in between each visit. A ​“bouncer” stationed outside the van ensures passersby maintain safe distancing.

“By shining a light on all of our vulnerabilities, Covid is showing that we need to be much more open to rethinking traditional models of health care services,” said Vazquez.

As with mobile clinics affiliated with Boston Medical Center and Dell Children’s Hospital in Austin, Texas, that bring care to underserved communities, ​“this program flips around the traditional model of the patient going to where the health care is,” she said.

“It’s showing us how we can overcome traditional medical care barriers and decrease inequities in access to health care by bridging the gap to link patients to medical services in their own communities.”

The set-up seemed to work well for Marlena Santos and her infant son on Monday.

“I felt very safe there,” she said. ​“It was nice to have something like the van for first-time parents at a time like this.”

For more information, visit this website.

To designate the Community Health Care Van as the recipient of a tax-free donation to Yale School of Medicine, visit this website and include ​“Community Health Care Van” in the comments of your donation.