Taking Veteran Care on the Road

They travel roughly 400 times a year, to sites as far-flung as Sonora, King City, and the edge of the Yosemite Valley, serving eight counties and parts of two others. They visit Santa Cruz once a week, working with homeless veterans and supplying medical needs for countless veterans each year. And they just got a new van.

They are the VA Palo Alto’s Mobile Medical Outreach team. Led by Jean Lighthall, MD, clinical assistant professor of primary care and population health, the team of eight has traveled to various sites around their catchment area, helping provide veterans with medical care for the past 12 years.

As Lighthall explains, the group—two part-time physicians, two registered nurse practitioners, two health techs, a business outreach specialist, and an outreach coordinator—has two goals. The first is simple: Get health care to veterans who need it. Some veterans don’t even know they’re eligible. “It’s a great thing to offer someone,” she says. Team members often see patients for an initial visit, which includes taking their history, giving a basic physical exam, and offering appropriate medication and referrals. With very few exceptions, the patients are walk-ins. As Lighthall puts it, “You can just stop in and get the services.”

The other goal is to improve access for veterans already enrolled in the system who have difficulty seeing doctors for various reasons including distance, homelessness, lack of transportation, and substance abuse. By coming directly to them, the Mobile Medical Outreach team can address these problems.

Lighthall says it may be more than physical access problems that stop veterans from getting the care they need. “One thing that we see a lot is that there are veterans, particularly of the Vietnam era, who weren’t treated as well as they could have been when they first came back and went to the VA,” she says. “Or just because their whole homecoming was so bad, many didn’t want to have anything to do with the VA or any type of veteran’s benefits.” But the Mobile Medical Outreach is addressing this problem, too. As Lighthall puts it, “We may be a little more welcoming than the big huge concrete structures like the Palo Alto VA. We’re just out there with our van.”

To that end, the Mobile Medical Outreach team travels—a lot. They split up and go everywhere: to colleges to see younger veterans, halls for veterans of foreign wars and American Legions, libraries, senior centers, veteran resource centers, and Native American pow-wows, including the Stanford and Stockton pow-wows. They make 30 to 40 site visits a month, often covering several events a day, with two vans and help from host sites when exam rooms are available. At each site, they see patients, sometimes up to 10 or more. In 2018 they served 870 veterans, and 149 of them were homeless, almost 20% of the total.

Their work is often more focused on same-day and urgent care, but they also provide stopgaps for struggling communities.  Stockton and Modesto are working on providing additional medical providers; therefore the Mobile Medical Unit is a great asset to support veterans in the area.   Their services include referrals to specialists, mental health care, physical therapy, ordering labs, prescriptions, and giving vaccines for diseases including influenza and hepatitis A (especially important considering the recent hepatitis A outbreak among the homeless).

The team, which is the only VA medical mobile outreach program of its kind in the Bay Area, is small for such a large project. But it’s clearly a labor of love for Lighthall and her colleagues. Lighthall, who got involved with the VA in what she calls the “second half” of her career, worked for the VA while in medical school and “loved the veterans.” When she wanted a change from “the traditional internal medicine practice,” she turned to the VA. She’d been interested in working with the homeless population for a long time, and she’s been with the outreach team in one form or another since 2008. She was named section chief for outreach in 2013.

We’ve been able to bring in veterans who have been very reluctant to receive care.

The program has grown in its 12 years, and the team has adjusted, traveling to new sites and discontinuing visits to old ones when they seemed unnecessary. Still, the number of sites and the area they cover has grown exponentially. “We’re always looking to find areas of need,” Lighthall says.

As for the future? Lighthall isn’t opposed to further expansion, but she also has high hopes for telehealth. Their new van is now equipped with telehealth capabilities, which could mean a further expansion into specialty care. “We could go out there with a nurse practitioner or with a health tech and then a patient could come to the van and we could loop them into dermatology or cardiology without having them drive all the way into Palo Alto,” Lighthall explains.

It’s clear that the team works incredibly hard, but they see their rewards in the community. They work tirelessly to get veterans care on their own terms. Lighthall’s pride in the program is as apparent as it is earned. As she adds, “I think we’ve been able to bring in veterans who have been very reluctant to receive care and they’re happy that they’re now able to get that care.”

Doral Gonzales, a nurse practitioner who works with the team, is a veteran herself. She retired from the army in 2012 at the rank of lieutenant colonel after a 22-year career that included deployments to Afghanistan and Iraq. She’s worked with VAPAHCS since 2008 since 2008 (with gaps for her deployments) and earned a midwifery degree at UC–San Francisco as well as a master’s in family nurse practice and a doctor of nursing practice in 2010. During her time in Iraq she served as a trauma nurse in combat support hospitals as part of a triage unit, and in Afghanistan she worked in a Department of Defense detainee facility treating enemy combatants and prisoners of war. She also worked with a clinic with multinational medical providers to provide for women and children who had injuries from exploding mines.

At one point in Iraq a rocket-propelled grenade exploded 20 feet from her, causing a traumatic brain injury as well as post-traumatic stress disorder. Gonzales explains that this background has made her both dedicated to veterans and able to speak their language. “I went through a lot with the VA,” she explains, “so I figured I might as well work there. And then I wanted to do outreach because I couldn’t stand being inside a clinic with four walls, so I knew I was going to be out and about, helping veterans who had the same issues with PTSD that I did. Most of us, my health techs and I, are veterans, so the veterans trust us. And we have rapport with them; we connect.

 During her time in the program she’s taught others how to interact with their veteran patients. “When we started adding more providers, we trained them on how military speak works and how to relate to the way veterans speak so it was easier for them to connect with the veterans,” she says. “This made the veterans more open, trusting us with their issues. It’s really important to me that we continue with the outreach.