Program Foundations

Established in 2012, the Mobile Health and Wellness Program (MHWP) delivers weekly wellness visits to medically vulnerable and underserved communities at nine sites across the central Virginia region.

The program brings person-centered care in three areas:

  • assessment and access to care
  • health promotion and prevention services
  • addressing social risk factors to reduce inequities

MHWP participants receive access to key services to help them independently manage their healthcare needs, including assistance with care coordination, transitions from the emergency room to an inpatient hospital stay, and health education and coaching. 

The aim is to proactively manage health and wellness needs. The program is led by the VCU School of Nursing and faculty partnerships  with the VCU schools of Pharmacy, Medicine, Social Work, and the Occupational Therapy, Physical Therapy, Kinesiology, Health Sciences, and Psychology departments.

Program Features

Participant Example

The following case exemplifies the MHWP process.

MHWP participant Mr. AV reported falls on two occasions over a 20-month period. In addition, AV frequently indicated fear of falling, occasional dizziness and feeling unsteady and weak.

Using the Mobility workflow, a more complete assessment was initiated with medication review, home assessment and evaluation of mobility using the Timed Up and Go (TUG), all indicating positive factors for fall risk. 

Education was provided over time about hypoglycemia symptoms and the timing of eating and insulin to reduce hypoglycemia as a risk for falls. After a home visit, the MHWP also offered education to address insulin administration and storage, diabetes self-monitoring and use of a shower chair and rollator to reduce fall risk.

In this case, no intervention plan for referrals was documented, demonstrating a need to continue to work towards improved follow-up from week to week. Student teams working with AV also explored how he was using his rollator in the community, including making the half-mile walk to a grocery store, taking rest breaks as needed.

A year into the COVID pandemic lockdown, AV reported difficulty getting in/out of bed. Through the relationship built over time with AV, MHWP uncovered a number of issues interfering with his ability to achieve his health and wellness goals, including a deep mistrust of the health care system, low health literacy, lack of self-efficacy in managing medications and self-monitoring of diabetes and hypertension, and episodes of feeling depressed or helpless in facing health challenges.

Through education, MHWP helped AV learn how to more effectively communicate with his health care providers, established frequent check-ins and encouragement to build AV's skills in self-monitoring. As a result, AV is has improved self-management of these aspects of his care, exhibited better control of his chronic health conditions and maintained independent living.