If you are in the Metro Atlanta area, you might catch a glimpse of a beautiful tiny house on wheels parked outside your children’s school or local church. That tiny house was born out of an idea to make mental health care approachable and accessible to women and children.

“I was a former OB nurse so I know what the obstetrics wing is like: It’s home-centered, comfy, and cozy,” said Joanne Patterson, DNP, MSN, PMHNP-BC, an Atlanta -based, board-certified psychiatric nurse practitioner (NP). “I wanted to extend that sensibility to maternal and pediatric mental health and fill the gaps in care. When I started benchmarking to see if someone had done mobile mental health in a tiny house, I couldn’t find anything. So I just started doing it on my own,” she said.

Today, Nurse Practitioners on Wheels, Georgia’s first mobile mental health clinic, is thriving.

Dancing on Two Sides

One positive thing to come out of the COVID pandemic was the explosion in telehealth services. For Patterson, a mobile health unit represented a natural extension of online sessions, especially for patients whose conditions required management with controlled substances.

“There were rules around DEA (Drug Enforcement Administration) licensing where we would first have to see patients in person. This was my creative, innovative way of saying ‘I don’t want to go back to the office; women and children need something different, less scary. And I wanted to be free,” said Patterson.

“The beauty is an in-person visit covers whatever the DEA requires. After that, we can always do a virtual visit because it’s a follow-up. That’s the beauty of being able to dance on both sides of how I’m administering care and the place of service,” she said.

Mobile health services like Patterson’s also address long-standing inequities in rural communities.

“I’ve seen things change in very positive ways due to telehealth but it doesn’t always meet the needs of all of the people. For example, though its expanded access in rural communities, it doesn’t address some of the inequities, like lack of broadband or access to devices,” said Kathleen Schachman, PhD, FNP-BC, PMHNP-BC, professor of nursing at Saginaw Valley State University in Saginaw, Michigan. “There’s also a small number of people with severe mental health issues, schizophrenia for example, who don’t do well with telehealth,” she said.

The same rings true for older or homebound patients.

Jessica Vaughan, ACNP, a primary care NP at Ochsner Health Center in Livingston, Alabama, drives roughly 250 miles once a month to visit the 22 patients she sees outside the clinic. She alternates patients every other month, usually seeing 10 or so in a day. She uses her own car and makes her own schedule.

“Most of my patients are geriatric patients,” said Vaughn, who, in the middle of the pandemic returned home to rural, west central Alabama where she grew up.

“When I started here, I had a rule that I would only send in 30 day refills until people came to the clinic. I called one patient to learn why she was not coming in and she told me she was homebound and hadn’t been evaluated in person for 3 or 4 years.” Vaughn said.

With her office manager’s permission, Vaughn started to visit patients directly to either conduct regular clinic activities, coordinate with home health, or ensure they were connected to social services.

“Every other month I have one group and go to their homes. If they need labs, they get labs; if they need a flu shot, they get a flu shot. For me, telehealth is tricky. I want to put my hands on patients. And, in rural care settings, reimbursement for telehealth can be minimal,” said Vaughn.

These services “put us in contact with people earlier in the disease spectrum so we can focus on early intervention,” said Schachman. “It enables us to touch these hard to reach populations and helps build trust and continuity over time," she said.

Serving Rural Communities

Given the scarcity of psychologists, long wait times, geography, and travel challenges (not to mention stigma and a lack of anonymity), it’s not surprising that the mental health needs of rural communities are often unfilled.

Brooke A. Finley, PhD, DNP, RN, PMHNP-BC, CARN-AP, APHN-BC, is one of only a few NP psychotherapists in her field who is also trained in psychoanalysis, a clinical area historically reserved for wealthy clients. She practices in Canandaigua, New York, a rural area in the Finger Lakes Region.

“Telehealth visits are like house calls, but hybrid care is really optimal,” said Finley, “the reason being that we actually get to see a patient’s living situation and see what’s happening.”

That hybrid care model can look like telehealth/in-office visits, or mobile health.

“I had a mentor in rural Mississippi who basically did home health; she had a little hospital in her car and would drive to the sickest patients in rural MS and deliver care. I think they’re quite a few nurses and NPs doing that,” she said.

Although stigma often runs through mental health care, Finlay pointed out that in rural communities, embarrassment and privacy commonly have a flip side.

“People want their communities to do well, especially rural communities where everyone looks out for one another,” she said, sharing that she “was driving one day and a man almost ran me off the road. I asked my neighbor, ‘what’s going on with him?’ He’s addicted to drugs and driving everyone around town crazy. We really want to get him help,” she said.

Rules of the Road

Starting a mobile health practice involves more than simply purchasing a tiny house office on wheels.

Both Patterson and Vaughn emphasized the need to be very flexible, acknowledging that what one might think a community wants is not what they need, or vice versa.

Vaughn noted her background was hospital medicine.

“Clinic medicine is still very new to me. And I was recently joking with a colleague that when I was in the hospital and working with a hospitalist, I would advise patients to follow-up with their primary care provider. That’s me now, but I like the ‘wellness’ part of this; I get to see patients when they’re well and when they’re sick,” she said.

“In rural America, you might be seeing someone for anxiety but there’s also something medical going on at the same time; you have to be able to pivot,” said Patterson.

Financial backing is also key.

Though NPs are known for banding together and figuring things out, Patterson said she has been exclusively partnered with CareSource Medicaid Georgia to provide services.

“I fall under an umbrella of mobile services called Wellness on Wheels,” said Patterson. “They’ve also partnered with a pediatrician who provides pediatric services with their mobile clinic.”

When Nurse Practitioners on Wheels was first launched, it became viral on social media twice, and Patterson herself appeared on The Kelly Clarkson Show, which helped increase visibility and connect with interested partners. But aside from a driver who transports the tiny house clinic from event to event, it’s a solo gig, and a fulfilling one, at that.

“I’m passionate about women’s and children’s mental health. I’ve stayed true to myself and being true to myself has really paid off,” Patterson said.

Patterson reported working exclusively with CareSource Medicaid. Vaughn reported working for Ochsner Health System. Schachman and Finlay reported having no relevant financial relationships.

Liz Scherer is an independent health and medical journalist. She frequently writes about health equity issues.