Reviving Health Care in Rural Pennsylvania Community

Snow Shoe Township, Pennsylvania, is a small, rural community of around 1,700 people that lies approximately 30 miles north of State College, Pennsylvania. A former coal mining town, Snow Shoe has seen an economic decline over the years.

Then, in the span of one year starting in 2020, Snow Shoe lost its only grocery store, hardware store, bank, pharmacy and federally qualified health center. The only businesses left in town were a dollar store, pizza shop, post office, laundromat, and an outdoor and sporting goods store.

With the closure of the town's health care facility and pharmacy, many of Snow Shoe's aging residents, and others with health needs, were no longer able to access health care.

This led clinicians from the Penn State College of Medicine (PSCOM) to initiate conversations with local, state, federal, University and health system leaders to see what they could do to help area residents access basic health care needs. Through these conversations, they learned that the primary barriers to receiving health care were transportation and time constraints.

Without the ability to access basic health care services, clinicians from PSCOM and faculty members across academic colleges at Penn State collaborated to support the health and wellness of the residents in Snow Shoe and the surrounding community.

Combining service and education to make an impact

Discussions began exploring the potential of providing a mobile health clinic that would bring health care services and resources to Snow Shoe. In May 2022, PSCOM launched the LION Mobile Clinic. The LION Clinic increased health care access for the Snow Shoe community while also serving as a hands-on training opportunity for medical students enrolled in the PSCOM regional campus at Penn State's University Park campus.

According to Michael McShane, assistant professor of medicine with the Penn State College of Medicine regional campus at Penn State University Park and internal medicine physician at Penn State Health, the team at PSCOM felt this was a great opportunity to combine service and education. Medical students were given an opportunity to provide health care services to a community in need while learning how the social determinants of health - health care access and quality, education access and quality, community context, economic stability and neighborhood environment - affect people's health and well-being.

"One of the primary focuses of this project has been identifying ways we can include students in parts of the research, service or education mission," McShane said. "It's a great opportunity for them to not only help a local community, but also gain experience that will help differentiate them as they enter the next phase of their careers."

The role of research in a mobile health clinic

McShane connected with Kristina Brant, assistant professor of rural sociology in Penn State's College of Agricultural Sciences, to begin a broader conversation about doing something with Penn State resources and medical students that would give back to the Snow Shoe community and also explore the larger role research could play in the development of mobile health clinics in general.

"One of the most important aspects of doing work with communities is hearing from community members to integrate their perspectives into the model of how to work there," Brant said. "We wanted to ensure that what we were creating would be adaptable and responsive to the needs of the community the clinic is serving, but also provide valuable experience for our students."

Researchers from the Penn State colleges of Health and Human Development, Agricultural Sciences and Nursing joined the LION Mobile Clinic to collect and analyze data as part of the project. Brant was joined by Joel Segel, associate professor of health policy and administration; Danielle Rhubart, assistant professor of biobehavioral health and demography; Jennifer Kowalkowski, assistant professor in the College of Nursing; and Hazel Velasco Palacios and Jorden Jackson, doctoral candidates in the Department of Agricultural Economics, Sociology, and Education.

"We wanted to be intentional about embedding researchers in this mission as we went out into the community," McShane said. "This helped us better understand what the needs of the community were so we could make adjustments and provide the best possible care."

Overcoming challenges

While the mobile health clinic provided great experiences and opportunities to the students, there were significant challenges to starting the service in a rural community. Getting the word out about the clinic proved to be more difficult than the clinic team anticipated.

Through interviews with community members, the researchers on the LION Mobile Clinic team learned that their marketing strategies - making an announcement on a local radio station and asking the township council to post a flyer on their official Facebook page - did not align with how community members typically learned about events. These interviews served as a great tool to facilitate more effective ways to spread information.

"Our research team was out in the community in real time interpreting and understanding their needs and passing that information back to us in the clinic to make adjustments," McShane said. "This allowed the community to see the results of their input. This was extremely powerful in letting community members know that they were being heard, and we wanted to help."

From there, several community members shared information about the clinic in a private Facebook group. As more patients started showing up to the clinic, they were given a flyer to share with other area residents.

Snow Shoe resident Mary Anne Raymond was part of the push to get the word out more broadly. Raymond posted in multiple community Facebook pages, made announcements at churches and helped post flyers around town, at the post office and at a local sandwich shop in order to try and reach as many community members as possible.

The research team also learned of skepticism or hesitation among residents regarding the new mobile clinic initiative. Other outside organizations had previously tried to bring programs to Snow Shoe but did not stay long term. Even as more people were learning about the clinic and its services, the clinic team still needed to build trust within the tight-knit community and prove that they were there to serve and to stay.

To build relationships with the community, the clinic team launched a "Coffee Talks with Future Docs" initiative. They asked residents who visited the clinic to identify health-related topics they would like to learn more about. From that feedback, medical students prepared short presentations to be delivered at a local senior center. The presentations also were paired with an activity where the seniors and students could engage together, such as preparing a healthy soup or dessert.

"It has been a great example of what does not typically occur in a health-care setting," Segel said. "A typical health-care setting is 15-minute appointments, in and out, where you don't always get to know the patient and delve into what larger, underlying issues they might be dealing with. In the health care field, we don't tend to address these other social determinants of health, like food and making healthy food palatable, but those things can have a real impact."

According to Segel, this research plays an important role in identifying many of the larger scale issues plaguing rural communities like Snow Shoe.

"There's a real opportunity having made this connection to expand on this research and do more than health care," Segel said. "If we can identify other needs in the community, we have the ability to tap into the wealth of knowledge at Penn State to include other researchers and bring additional resources to Snow Shoe. In return, researchers are learning more about how to ask the right questions when we go into a rural town. We are learning how to make the connections that need to be made so a community can get the most from the LION Mobile Clinic and from Penn State."

According to Kristen Houser Rapp, who graduated from Penn State with a degree in human development and family studies in 1993 and is currently the executive director of the Pennsylvania Charitable Healthcare Coalition, there are many families whose household income exceeds the limits to qualify for public assistance benefits such as SNAP, Medicaid or rent assistance, but is not enough to cover basic necessities like the cost of housing, food, utilities, transportation and child care.

"When you are focused on covering your family's basic needs and there aren't any known health issues, health insurance can seem like an unaffordable luxury expense," Houser Rapp said. "The reality is, making sure you stay healthy is the best way to avoid medical crises, which can put a family into debilitating debt. Mobile clinics like the LION Mobile Clinic can bring basic services to communities that are geographically isolated or have a shortage of health care professionals and can provide linkages to other free or charitable clinics for patients needing regular care to treat, medicate and monitor chronic conditions."

Looking forward

In the future, the clinic team would like to see the mobile clinic - which McShane refers to as a 'mobile resource hub' - serve as a mobile classroom. The LION Mobile Clinic team seeks to identify educational opportunities spanning across academic colleges that can embed students in local communities to achieve course objectives and goals for students, giving them valuable real-world experience while also giving back to the community.

"There is so much great work being done University-wide at Penn State by combining education, service and research to solve real problems for Pennsylvanians," McShane said. "We hope the mobile clinic can serve as a platform to broaden the reach and impact of the work already being done to address other needs in these communities."