The Strategic Advantage of FQHCs in Implementing Mobile Health Units: Lessons Learned from a Pilot Initiative

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

In this manuscript, Bifulco et al. present a descriptive observational study detailing the implementation of mobile health units (MHUs) within the FQHC network in Connecticut. The authors report initial outcomes following the implementation of MHUs, including the number of patients served, demographics, and the most common clinical assessments. The authors also describe the recommendations for the initial implementation of MHUs and discuss potential challenges and limitations of the program.

 

The manuscript is well-written, and the observations provide a valuable framework for the critical initiative to increase access to healthcare for historically underserved populations. I believe that this report will be interesting to a broad audience of medical professionals and officials who work with underserved communities and within FQHC. I have several suggestions for the authors as listed below:

 

1. In the presented framework, there is only limited information on how MHUs may facilitate continuity of care by connecting patients to needed subspecialty services (e.g., OB/Gyn, addiction medicine, or surgical care) when such needs arise, which would likely require coordination and cooperation with larger health systems. I believe that clarifying these referral pathways and partnerships would help better define the scope, capabilities, and long-term impact of the MHU initiative.
2. The authors nicely summarize challenges and practical considerations associated with MHUs' implementation, such as staffing, costs, and sustainability. It will be important to discuss more broadly potential strategies to overcome those challenges, for example: workforce recruitment efforts, financial sustainability, and funding sources.

Author Response

MDPI Review #1 Comments and Suggestions for Authors

Please see below for our response to each comment. Reviewer comments are shown in bold and our responses are in plain text.

In this manuscript, Bifulco et al. present a descriptive observational study detailing the implementation of mobile health units (MHUs) within the FQHC network in Connecticut. The authors report initial outcomes following the implementation of MHUs, including the number of patients served, demographics, and the most common clinical assessments. The authors also describe the recommendations for the initial implementation of MHUs and discuss potential challenges and limitations of the program.

The manuscript is well-written, and the observations provide a valuable framework for the critical initiative to increase access to healthcare for historically underserved populations. I believe that this report will be interesting to a broad audience of medical professionals and officials who work with underserved communities and within FQHC. I have several suggestions for the authors as listed below:

1. In the presented framework, there is only limited information on how MHUs may facilitate continuity of care by connecting patients to needed subspecialty services (e.g., OB/Gyn, addiction medicine, or surgical care) when such needs arise, which would likely require coordination and cooperation with larger health systems. I believe that clarifying these referral pathways and partnerships would help better define the scope, capabilities, and long-term impact of the MHU initiative.

 

Response: Thank you for your assessment of the contribution of our work to the literature on increasing access to healthcare for historically underserved populations. We’ve added text to the Discussion section as follows:

Our mobile health unit program connects patients back to the primary care system, which can also serve as a conduit to connecting patients to specialty and subspecialty services when needed – for example, through asynchronous electronic specialty consultation [17] or direct referral – both of which are available to help primary care providers on our MHUs obtain consultation, feedback, and treatment recommendations for the patients they treat.

 

2. The authors nicely summarize challenges and practical considerations associated with MHUs' implementation, such as staffing, costs, and sustainability. It will be important to discuss more broadly potential strategies to overcome those challenges, for example: workforce recruitment efforts, financial sustainability, and funding sources.

Response: We agree that workforce recruitment and retention, financial sustainability, and funding sources are among the most important constraints on FQHC-led MHU programs. We’ve added language to the Discussion to acknowledge these challenges.

 

Reviewer 2 Report

Comments and Suggestions for Authors

The authors analyze the operational experiences of mobile health units (MHUs) established within Federally Qualified Health Centers in the US state of Connecticut for those who do not even reach the basic level of health care because of various reasons. These organizations provide care without a doctor, led by nurse practitioners, primarily for the underprivileged and uninsured, among others in terms of determining the need for care and the degree of urgency. The draft is a descriptive, observation-based review, the value of which is that it also contains appropriate recommendations for setting such services.

However, the paper does not ask the legitimate question of why the number of people living without insurance is increasing in the country that spends the most on health care in the world, and why the current Trump administration is dismantling the system created by President Obama's Affordable Care Act. In fact - in my opinion - MHUs can be considered a kind of replacement measure and it would be interesting to know whether and under what conditions the patient has access to medical treatment in the event of an immediate need for care. The draft does not contain any related data in the observes community (hospital demand, mortality, intervention outcomes, etc.), and the factual statements in the introduction do not provoke systemic criticism. As a health policy expert, I believe that the manuscript could form the basis for a poverty certificate for American healthcare. 

Author Response

MDPI Review #2 Comments and Suggestions for Authors

Please see below for our response to each comment. Reviewer comments are shown in bold and our responses are in plain text.

The authors analyze the operational experiences of mobile health units (MHUs) established within Federally Qualified Health Centers in the US state of Connecticut for those who do not even reach the basic level of health care because of various reasons. These organizations provide care without a doctor, led by nurse practitioners, primarily for the underprivileged and uninsured, among others in terms of determining the need for care and the degree of urgency. The draft is a descriptive, observation-based review, the value of which is that it also contains appropriate recommendations for setting such services.

However, the paper does not ask the legitimate question of why the number of people living without insurance is increasing in the country that spends the most on health care in the world, and why the current Trump administration is dismantling the system created by President Obama's Affordable Care Act. In fact - in my opinion - MHUs can be considered a kind of replacement measure and it would be interesting to know whether and under what conditions the patient has access to medical treatment in the event of an immediate need for care. The draft does not contain any related data in the observes community (hospital demand, mortality, intervention outcomes, etc.), and the factual statements in the introduction do not provoke systemic criticism. As a health policy expert, I believe that the manuscript could form the basis for a poverty certificate for American healthcare.

Response: Thank you for reviewing our work with attention towards the number of uninsured people in the United States, many of whom are served in federally qualified health centers like ours. Our desire to further improve access to healthcare for populations in the areas we serve who are unable or unwilling to receive care at our fixed locations fueled our desire to implement an MHU program.

While a detailed analysis of the current health policy context in the United States is out of scope of our descriptive, observational study of the mobile health unit program at our federally qualified health center, we’ve updated the text in the Introduction section (pg. 3) to place greater emphasis on the number of patients served by federally qualified health centers in Connecticut, which care for patients regardless of insurance status or ability to pay for care.  We’ve also noted that communities that are disengaged from the health system tend to seek care at retail clinics, urgent care centers, and emergency departments, which fill a temporary need but are not intended to promote long-term well-being and engagement in care. (pg. 3).

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors

Please, see few comments you might consider or clarify

The manuscript makes effectiveness-oriented and strategic claims that are not supported by the stated descriptive, observational study design.

Reframe the manuscript explicitly as a descriptive implementation or operational case study

Remove or substantially qualify all causal, comparative, or success-oriented language

Revise the Abstract, Highlights, Discussion, and Conclusions to ensure alignment with descriptive findings only

No primary research question, evaluative objective, or hypothesis is explicitly stated

Clearly articulate one primary research objective (e.g., feasibility, reach, implementation process)

Align all analyses and results explicitly with the stated objective

Avoid introducing new aims in the Discussion that are not addressed in the Methods

The manuscript reports inconsistent figures for patient numbers, visit counts, and study periods across section

Define a single analytic cohort and observation period

Explain any expansion or changes in the dataset explicitly

Revise all tables, figures, and text to ensure numerical consistency throughout

 

The Methods section lacks sufficient detail regarding data sources, qualitative analysis procedures, and analytic rigor.

Specify data collection procedures for stakeholder input (sampling, instruments, timing)

Describe qualitative analysis steps (coding process, reviewers, theme development)

Clarify the rationale for limiting analysis to descriptive statistics

Distinguish clearly between operational data and research data

The manuscript contains promotional or normative statements regarding FQHCs and MHUs that are not empirically demonstrated within the study.

Replace normative language with neutral, conditional phrasing

Separate empirical findings from policy or practice recommendations

Ensure conclusions are directly supported by reported data

 

Despite extensive discussion of staffing, infrastructure, and logistics, no cost, sustainability, or resource-use analysis is presented.

Add a section discussing resource requirements and funding dependence

Include a preliminary or qualitative assessment of sustainability

Clearly distinguish grant-supported components from core operational elements

 

The manuscript implies broad applicability of findings despite a single-system, single-state context.

Explicitly limit generalizability claims

 

Add a subsection addressing contextual specificity

 

Clarify which elements may not be transferable to other settings

Best wishes

Author Response

MDPI Review #3 Comments and Suggestions for Authors

Please see below for our response to each comment. Reviewer comments are shown in bold and our responses are in plain text.

Dear authors

Please, see few comments you might consider or clarify
Our thanks and appreciation for your detailed feedback and fresh eye on our work, which has helped us reframe our study. We’ve addressed each of your comments below.

• The manuscript makes effectiveness-oriented and strategic claims that are not supported by the stated descriptive, observational study design.
  
  We’ve clarified throughout the highlights, abstract, and text that our findings are descriptive and observational, and have softened or removed language to better align with the descriptive, observational nature of the study.

• Reframe the manuscript explicitly as a descriptive implementation or operational case study
  
  We have explicitly reframed the manuscript as a descriptive implementation study.

• Remove or substantially qualify all causal, comparative, or success-oriented language
  
  We’ve removed or qualified language that implies cause or comparison, and have softened the language describing what we see as the successes of our ongoing health service delivery program.

• Revise the Abstract, Highlights, Discussion, and Conclusions to ensure alignment with descriptive findings only
  
  We’ve updated these sections to better reflect our descriptive findings. As this journal has an international focus, we’ve retained elements of the Highlights, Background, and Discussion explaining the United States (U.S.) health care and health policy context under which federally qualified health centers (FQHCs) and mobile health units (MHUs) operate, to ensure that readers outside of the U.S. understand them.

• No primary research question, evaluative objective, or hypothesis is explicitly stated.
  
  We’ve updated the Introduction section to more clearly describe the objective of our study: “The objective of this observational study is to describe the reach of a MHU program serving populations located in and near the catchment area of a statewide multisite FQHC system in Connecticut which is the primary care medical home for approximately 110,000 people.”

• Clearly articulate one primary research objective (e.g., feasibility, reach, implementation process)
  
  We’ve clarified in the Introduction section on pg. 3 that the objective of this observational study is to describe the reach of a MHU program serving populations located in and near the catchment area of a statewide multisite FQHC system in Connecticut which is the primary care medical home for approximately 110,000 people.

• Align all analyses and results explicitly with the stated objective
  
  We’ve aligned all analyses and results with the stated objective of the study, to assess the reach of our MHU program.
  
  

• Avoid introducing new aims in the Discussion that are not addressed in the Methods
  
  We’ve removed the statement about time and capital required to establish a new MHU program, which we hadn’t discussed as part of our Results.

• The manuscript reports inconsistent figures for patient numbers, visit counts, and study periods across section
  
  To help reduce potential confusion, we’ve simplified the description in section 2.1 Participants and Setting of where and when our MHU program began offering services throughout the state.
  
  
• Define a single analytic cohort and observation period
  
  We describe the cohort of patients served by our MHU program between March 2023 and October 2025.
  
  
• Explain any expansion or changes in the dataset explicitly
  
  We haven’t expanded or changed the dataset.
  
  
• Revise all tables, figures, and text to ensure numerical consistency throughout.
  We’ve updated the tables, figures, and text to clarify the cohort of patients included in our analysis.
  
  
• The Methods section lacks sufficient detail regarding data sources, qualitative analysis procedures, and analytic rigor.
  
  We’ve added more detail to Section 2.2 Data Collection and Analysis to clarify that a group of MHU team members completed a secondary qualitative analysis of existing data from two types of sources – records of “key stakeholder analysis” activities and qualitative “operational data” like program planning documents, reports and meeting summaries, and to address your questions and comments about the methods used. 

• Specify data collection procedures for stakeholder input (sampling, instruments, timing).
  
  To be clearer about the feedback available from key stakeholders, we’ve noted that the question guides for the key stakeholder analysis activities were developed by MHU programmatic leadership and team members in order to obtain the perspectives of convenience samples of patients, potential patients, community partners, and the public on gaps in healthcare services and access in the communities served. We now use the terms “group and individual discussions” rather than “focus groups and interviews” to better reflect how MHU team members approached these conversations.
  
  
• Describe qualitative analysis steps (coding process, reviewers, theme development).
  
  We’ve clarified in the text of section 2.2 that we conducted an inductive (bottom-up) thematic analysis of barriers to care prior to MHU service delivery. We used a very simple process of iterative review and group discussion between MHU team members until consensus was reached.
  
  
• Clarify the rationale for limiting analysis to descriptive statistics.
  
  We’ve specified in Section 2.2. Data Collection and Analysis that analyses were limited to descriptive statistics to summarize the characteristics of patients who used the MHU and services provided.
  
  
• Distinguish clearly between operational data and research data.
  
  We’ve provided a more explicit separation of “key stakeholder analysis” versus “utilization” data in section 2.2 on Data Collection and Analysis.
  
  
• The manuscript contains promotional or normative statements regarding FQHCs and MHUs that are not empirically demonstrated within the study.
  
  We’ve updated language throughout the paper to clarify places where we’re referring to attributes of our own FQHC, and have removed normative statements about FQHCs in general.
  
  
• Replace normative language with neutral, conditional phrasing
  
  We’ve updated the language throughout the paper to replace normative language.
  
  
• Separate empirical findings from policy or practice recommendations
  
  We’ve ensured that all policy and practice recommendations (i.e. “We recommend that MHUs”/”MHUs should”) appear in Section 3.3 Recommendations for Policy and Practice and Lessons Learned and its subheadings (3.3.1-3.3.4) , including the Recommendations table in this section (Table 2).
  
  
• Ensure conclusions are directly supported by reported data
  
  We’ve limited the Conclusions of the article to statements referring to the work we’ve presented.
  
  
• Despite extensive discussion of staffing, infrastructure, and logistics, no cost, sustainability, or resource-use analysis is presented. AND
• Add a section discussing resource requirements and funding dependence
  
  We’ve acknowledged the lack of a detailed financial analysis as a limitation of our study and have noted economic analysis as a priority for further study. We’ve also clarified that this program currently operates as part of FQHC service delivery, and a detailed financial analysis was outside the scope of the present study, which may limit the generalizability of our recommendations and findings to programs implemented outside of FQHC service delivery.
  
  
• Add a section discussing resource requirements and funding dependence AND
• Include a preliminary or qualitative assessment of sustainability
  
  We’ve noted in the Discussion that, “…our program’s financial sustainability is reliant on maintaining and increasing patient volume or pursuing outside funding, a challenge shared by many MHU programs in the U.S.”, with reference to the Mobile Healthcare Association 2024 Impact Report, describing the state of its 531 member MHU programs in the United States.
  
  
• Clearly distinguish grant-supported components from core operational elements
  
  We’ve removed potentially confusing statements in section 2.1 about funding to purchase our first MHU and subsequent finding to purchase a second MHU. Both MHUs are owned by the FQHC and used for programmatic activities throughout the state.
  
  
• The manuscript implies broad applicability of findings despite a single-system, single-state context. AND
• Explicitly limit generalizability claims.
  
  We’ve applied the prior recommendations to more clearly discuss limitations on transferability and generalizability in order to further clarify the potential applicability of our findings and recommendations for policy and practice.

 

• Add a subsection addressing contextual specificity AND
• Clarify which elements may not be transferable to other settings
  
  We’ve acknowledged in the Discussion section that our program’s staffing (primary care providers who have received additional training in serving vulnerable key populations), setting in an FQHC that’s well-established with many locations statewide, and leadership commitment (based out of a dedicated center that focuses on improving access and quality of care for key populations, with direct involvement of the center’s clinical and administrative leadership) may limit transferability to other settings.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors cautiously followed advices of my previous review. The paper is still remaining on the ground of technical approach although it would have been more critical. 

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you so much for addressing the comments