Characteristics of MOCUs in Philadelphia (Table 1)Table 1 Characteristics of MOCUs in PhiladelphiaPhysical space

Two MOCUs operate out of custom-made medical vehicles (RV) holding two exam rooms, and a bathroom. Another MOCU operates out of a retrofitted RV with lab testing equipment (e.g., centrifuge), one clinical space, and a bathroom. Two MOCUs operate out of vans–one a converted shuttle bus and the other a converted camper van–that include a clinical space but not a laboratory space. The remaining two MOCUs operate out of SUVs; these units also do outreach and travel around the city to a variety of locations to deliver harm reduction supplies.

Location

Most MOCUs operate in Kensington, Philadelphia, an epicenter of injection drug use and the area of the city with the highest overdose death rate in Philadelphia. Half of the MOCUs operate in other neighborhoods in the city, including South or North Philadelphia. Operating hours of the MOCUs ranged from 7 to 35 h per week, Monday through Friday. Four units stay in the same location each day of operation, and two units vary between key locations (e.g. Kensington, West Philadelphia, Southwest Philadelphia).

Six of seven MOCUs return to a specific location within a neighborhood for at least six months before choosing a new area. Among these six, two MOCUs reported serving a location for six to twelve months then using city overdose data to guide a new location to service. The two SUV MOCUs do not park but instead drive around a neighborhood to meet and transport clients as needed.

Staffing

MOCUs are typically staffed by three to six people. Six of the seven MOCU’s have a clinician (e.g. physician, registered nurse, nurse practitioner) on the MOCU at all times. Three of seven MOCUs employ peer recovery specialists, and three of seven MOCUs have community outreach specialists. Four MOCUs employ case managers who help clients address barriers that make traditional clinical settings difficult to access such as insurance enrollment or obtaining photo identification. One staff member, typically an outreach specialist, drives the vehicle.

Affiliation and funding sources

Each MOCU was supported by a larger organization. Three MOCUs are affiliated with universities located in Philadelphia and four MOCUs are part of non-profit service organizations. MOCUs are funded through federal research grants, their parent organization, city partnerships, and Medicaid reimbursement.

Caseload and capacity

Current caseloads ranged from 20 to over 100 individuals. MOCUs reported having anywhere from one touchpoint a week per patient for an indefinite period—to up to five times a week for the first month. Descriptions of capacity varied due to different definitions of length of stay and client status. Three units were unable to approximate a maximum capacity. One unit was unable to estimate capacity due to clients being seen at both their mobile unit and brick-and-mortar sites. One unit is a part of a randomized controlled trial study with a pre-specified capacity (52 people at maximum for a 6 month period).

Services provided by MOCUs in Philadelphia (Table 2)Table 2 Services Offered on MOCUsMedical services

Most MOCUs provide wound care, pregnancy testing, and sexually transmitted infection testing. Four of seven MOCUs provide screening for HIV and hepatitis C virus. Every unit reported providing a form of primary care services depending on their capacity to do so, referring to higher care when necessary.

Medications

All MOCUs provide the overdose reversal, naloxone. Six MOCUs have a buprenorphine prescriber on the unit. Two MOCUs dispense MOUD on-site; one dispenses buprenorphine films; one provides injectable extended-release buprenorphine (i.e. Sublocade) and injectable naltrexone (i.e. Vivitrol). No MOCU provides methadone but four units clients to methadone clinics. Only one unit directly dispenses MOUD refills, but others provide a short-term “bridge” prescription. Six MOCUs prescribe PrEP for HIV.

Harm reduction services

Five MOCUs refer clients to other organizations to obtain fentanyl test strips and two units dispense fentanyl test strips on site. All MOCUs (and other treatment facilities) refer their clients to only local SSP to receive clean syringes.

Other supports

All MOCUs provide case management (e.g., procuring identification, housing, insurance), and basic supplies (e.g., food, water, toiletries, clothing). Six MOCUs offer transportation assistance through the local transportation authority or ride share services. Six MOCUs help individuals obtain housing and insurance, including providing education about co-pays. Three MOCUs provide peer support through certified peer recovery specialists employed on the unit.

Approach to service delivery

MOCU leaders described a treatment philosophy centered around providing access and engaging underserved populations. Some leaders described their MOCU as a bridge from which they could work towards empowering their clients and building their trust in the health care system. MOCU leaders responded to several factors that disconnect individuals from the health care system, such as being unhoused, having a substance use disorder, being poorly treated in the treatment system and “falling through the cracks.” As one leader described,

“I think we’re what I call…gap fillers. Anyone that’s worked in the [health] system knows, you have to accept that it’s broke before you even start working in it…there are gaps in the system, where people could get assessed, but then they never make it to the program.”

Many MOCU leaders described their “one stop shop” approach of providing point-of-care services for imminent health needs such as wound care and “bridge scripts,” (i.e., short term prescriptions), for buprenorphine regardless of insurance status. Most of the MOCUs tried to refer individuals in community-based care. One leader clarified:

“We’re a linkage program. We aim not to keep people; our goal is to link people to a more permanent place…we view ourselves as we're sort of a bridge.”

BarriersTreatment system deficits

Even as MOCUs leaders sought to connect individuals to the treatment system, they identified many deficiencies in the traditional treatment system as a primary barrier to patient success. Many cited that there are too many agency requirements for care. One leader described them as, “regimented, old-school programs.” Leaders pointed out that treatment facilities that require intensive outpatient attendance to receive medication are problematic. One leader noted:

“While that works for some people, for others, it can be a really big commitment, it prevents them from working, it prevents them from doing what they need to do to be ok.”

Leaders zeroed in on processes such as waiting on-site for assessments and induction:

“Right now, you increase all the services, buprenorphine access, more spots available, you can throw a lot of harm reduction supplies, and expand access to MOUD…but we’re still having an increase in overdose deaths and HIV [transmission] with drug users. The old model [the structured process: go to clinic, you need to be abstinent for 24/48 hours, then start induction]…isn’t benefitting people. People want to avoid the withdrawal, especially if they are living on the street.”

Other treatment system barriers included the variability in whether recovery houses accepted patients on MOUD, waitlists for outpatient substance use treatment, lack of accessible mental health services, and lack of inpatient treatment beds. As one leader described:

“We actually do have easy access to medical treatment that people need but psychiatric services are a major problem.”

An additional difficulty was lack of access to data on the people the MOCUs served, as well as little data sharing infrastructure within the treatment system, which limits coordination and patient care:

“When we finally do get people to go into the hospital, which is rare, were encountering where [the hospital] won’t give us information. You know, naming things about like HIPAA even though our folks are saying they can talk to us, or just not taking the time to involve us in the care. So it ends up being a lost opportunity that sort of further stigmatizes our folks from engaging in the healthcare system.”

Another leader commented:

“I’m hoping that we can all get on the same page with data… I wish there was one central place. I've done a lot of research with like other jurisdictions, in California, if you're in a hospital Monday, and you go to a different hospital Wednesday, that hospital that you go to on Wednesday, they would already know that you were in the hospital.”

Patient-facing barriers

Leaders mentioned important patient-level barriers to treatment. Being unhoused and lacking a phone or other means to communicate were the most commonly mentioned. One leader described:

“I used to think we could treat our way out of this epidemic, [however] given the co-occurring crisis in these folks lives, which I think the most important is housing, but there are lots of other issues…having reliable communications with people, [and] psychiatric services that can be delivered quickly”.

Due to these factors, patients have difficulty attending appointments on the MOCU or for other services. Leaders also noted that their patients often feel uncomfortable in traditional facility waiting rooms:

“You might be concerned about how you look when you present in a traditional waiting room, as well as sometimes, if you don’t have a safe place to live, leaving your stuff somewhere to come.”

Community-related barriers

Several unit leaders spoke of community resistance toward PWID and the MOCU. One leader noted:

“We've been asked to leave on many occasions, interestingly, by residents of the Southwest and by the police in Kensington and residents in Kensington.”

Leaders described community resistance to the MOCU and a belief that the unit was attracting “undesirable” individuals to the area. One leader reported that a local pharmacist refused to stock buprenorphine, making it difficult for MOCU patients to fill their prescriptions. Another leader described the tension between the community and the OUD population:

“This is a travesty. [People with OUD] need help. It's also a travesty for the people that live in the community. And how can [we help] both at the same time, knowing that it's not going to be perfect for either one, right? It's not going to be perfect for the community. It's not going to be perfect for the people we're trying to help. You hear it from the community, you guys seem like all you care about is these people, nobody cares about us.”

Lastly, unit leaders described how increases in gun violence in the communities being serviced has led to challenges in maintaining safety and care for patients and staff. One leader likened it to delivering care, “in a war zone.”

Physical space and practical challenges

The MOCUs face many practical challenges. A lack of space (and lack of private space) limits MOCUs from providing the full range of services that patients would normally receive at a brick-and-mortar health center. The space also limits patient accessibility and volume:

“[Our unit is] essentially just one room. There’s only one clinical space. We can only see one patient at a time.”

MOCUs that lack bathrooms are unable to conduct pregnancy tests and urine screenings. Two MOCUs lack air conditioning, which makes them uncomfortable in the summer. Multiple MOCUs reported closing operations for an extended period due to vehicle servicing and repair. In addition, MOCUs lack the security benefits of buildings: several leaders reported that they are unable to keep medication on their MOCU due to concerns about theft. One leader enumerated the limits of their unit:

“[We] can’t dispense methadone, can’t leave Narc[an] on bus, no AC, no restroom, no urine screens.”

Financing and funding model

All MOCUs leaders listed lack of funding as an immediate barrier to MOCU operation and sustainability. Most MOCUs were partly or fully grant funded. Four MOCUs billed for medical services, and leaders noted that the reimbursement was inadequate to fully cover the costs for mobile services. Leaders reported that their parent organizations are small and operate on small budgets. Due to limited funding, there is a constant fear of service shutdown and an inability to hire, retain, or sufficiently compensate staff:

“There’s always the funding issue and paying salaries for better retention: I'm a huge believer in peers and people that do that frontline work should be compensated better than they are.”

Several leaders also report that the data collection and reporting mandated by funders is difficult to complete in addition with their daily operations. As one leader reflected: “We struggle with the data management needed to comply with our funding. We are too busy answering phones, providing care to improve our process.”

Facilitators

We inquired about facilitators to MOCU operations. Participants responded about facilitators broadly, describing facilitators to unit operations and patient success. We report on these facilitators below.

Patient and community-facing presence and engagement

MOCU leaders describe their placement in the community and their ability to bring services to individuals in need as the main reason for their success. Leaders described significant efforts in reaching out and engaging potential patients. Leaders described how their mobility as a van-based service helps reach people who otherwise wouldn’t have access to care, even in the hardest to reach areas. One leader described:

“We can go down alleys, we can go under bridges, we can go into different encampments… with our huge [emergency medical treatment] bags.”

Several of the MOCU leaders described travelling locally to find and provide services to individuals within the neighborhood. Leaders also described significant engagement and education efforts towards community members:

“We then go out on foot into those neighborhoods, and we talk to local business owners. We want to know if they see a lot of overdoses, do they have Narcan? Do they have ‘Stop-The-Bleed Kits’? Do they have First Aid Kits? Are they comfortable responding to those things? If they aren't, can we train them?”

About half of the MOCUs described working with community advisory boards to inform their location and services. As one leader described:

“When it comes to making decisions for the program, we like to have their input also, because they are a part of the community where we provide service.”

Interagency collaboration

MOCU leaders relied on interagency collaborations to improve care. In addition to connecting people to substance use and mental health treatment services, MOCU leaders reported connecting individuals to SSP, employment services, housing services, and medical services. Many of the MOCU leaders reported working with other MOCUs. MOCUs refer to each other to coordinate care, to refer patients in other geographic locations, and to ensure that services are not redundant. As one leader described:

“We reach out to say, “Hey we’re going to be doing this …’ just so that we’re not duplicating services.”

Several MOCUs collaborate with local police; at least one MOCU reported that the police refer individuals to their unit for care. Finally, many leaders stated that their collaboration with the city is critically important both for funding and because the city provides access to data about overdose hotspots.

Clinical teams

Unit leaders extol the value of their clinical staff. Leaders describe having staff familiar with the neighborhood greatly facilitates the unit’s operations:

“We have a mobile research coordinator that’s been around, working here since we started, he is really familiar with the neighborhoods in Philadelphia and the gatekeepers in the community.”

Outreach workers with experience in the neighborhood help choose the MOCU’s location and leverage social connections in the neighborhood for community acceptance and messaging the MOCU’s services to the population in need. Leaders also describe the importance of case managers on staff to address multiple social determinants of health. Case managers, outreach workers, and peers also provide warm handoffs to higher levels of care, give reminder calls for follow-up appointments, and empower clients about their patient rights. On some MOCUs, case managers accompany clients to their initial referral appointment to other substance use treatment services (e.g., IOP, OP or primary care-based treatment) to advocate and support them. As leaders describe all these functions “jumpstart” an individual’s capacity to engage in treatment on the MOCU and in the community. The staff are also skilled at adapting and “meeting people where they are.” Leaders described how staff conduct informal check-ins; some go on walks with clients or locate clients within the community to reduce stigma associated with being seen on the MOCU:

“[Some clients] can be a little bit more private. For example, someone doesn't want to be seen necessarily at the Suboxone bus. I have seen in the past case managers and providers essentially walk the park with the participants. So it looks like a casual stroll, which has been really great.”