Mobile Health Adherence and Barriers to Care: A Community Partnership Between University of Arizona College of Medicine-Tucson Aequitas Health Honor Society and COPE Wellness on Wheels

As fellows from the University of Arizona College of Medicine - Tucson Chapter of the Aequitas Health Honor Society, we strongly believe in the importance of continuity with community partners in sustainable community-based work. As such, we have compiled a reflection paper about our partnership and project with the Community Outreach and Patient Empowerment (COPE) Wellness on Wheels (WoW) program over the past year, with the hopes of inspiring future cohorts at the University of Arizona to continue the relationship with COPE and to emphasize continuity in their future partnerships.

Background

A complex interplay among socioeconomic status, geography, insurance coverage, and structural inequities shapes access to healthcare in the United States. While these barriers are well-documented, they remain inadequately addressed for many marginalized populations. Our literature review found that financial barriers to care, physician shortages, transportation barriers, insurance coverage, and medical debt are all significant barriers to accessing care in underserved communities. Community-based programs such as COPE help address these challenges by serving a large and diverse patient population in Tucson, including individuals experiencing mental health disorders, substance use disorders, and psychiatric crises requiring intervention. Community members served by COPE often experience overlapping barriers to care, including behavioral health needs, housing instability, limited insurance coverage, transportation barriers, and financial insecurity, which may further restrict access to consistent healthcare. We partnered with COPE’s mobile health clinic, Wellness on Wheels to review these healthcare access barriers and describe how strong community partnerships can positively impact both partner organizations and the community. To better understand the population served by COPE, we started our project with a brief review of healthcare disparities in the United States, with a specific focus on Arizona.

Financial Barriers to Care

Cost remains one of the most significant deterrents to seeking medical care in the United States. Between 10-22% of adults report forgoing needed medical care due to cost, with rates higher among low-income patients, exceeding 50% in some populations.^1,2 A report from the Centers for Disease Control and Prevention (CDC) showed that among the 57.9% of adults aged 18-64 who took prescription drugs during 2021, 8.2% (9.2 million adults) reported not taking prescribed medications as indicated due to cost, including skipping doses, taking less than prescribed, or delaying prescription fills. These cost-driven behaviors carry downstream consequences, as unmanaged conditions progress to more serious illness, and patients may need further expensive treatments.³ An analysis of 2018 survey data from 8,073 Arizona adults found that 28.7% lacked a personal physician and 14.1% reported cost as a barrier to seeking medical care, highlighting persistent access barriers in the state. These values demonstrate how financial barriers translate into access deficits for Arizona residents, particularly among elderly individuals, those with chronic conditions, and those living in rural communities.⁴

Physician Shortages

Workforce shortages further compound access barriers in Arizona. The state has 722 federally designated Health Professional Shortage Areas (HPSAs), 36 medically underserved area designations, and 11 medically underserved population designations. In 2019, Arizona had 243 physicians per 100,000 residents, compared to the U.S. median of 263.8 per 100,000.⁵ Although the physician workforce has grown, providers remain heavily concentrated in urban centers. Brady et al. found that among physicians who relocated between 2014 and 2019, only 2% moved to more rural areas, reflecting a more persistent pattern of geographic maldistribution that leaves rural and frontier communities chronically underserved.⁵ These gaps highlight the need for workforce strategies, including expanded telehealth services, incentives for rural practice such as loan repayment, and dedicated recruitment pathways, to strengthen healthcare access across the state.

Transportation Barriers

Transportation barriers represent a significant and underrecognized determinant of healthcare access. Nationally, an estimated 5.8 million individuals report delaying medical care due to transportation-related challenges. In Arizona, these barriers are amplified by the state’s geographic landscape, characterized by dispersed populations across rural and frontier communities where healthcare facilities are often substantial distances from residential areas. Underserved populations in these communities often have lower socioeconomic status, are historically marginalized, and are geographically isolated, resulting in a greater reliance on public transportation. While Tucson has made meaningful strides in reducing transportation barriers, most notably by making public transportation free since March 2020, significant gaps remain.⁶ Those residing in rural or outlying areas continue to face limited or no access to public transit infrastructure. Furthermore, 7% of Pima County households lack access to a personal vehicle, compounding reliance on a transit system that does not yet serve all communities equitably. Transportation barriers frequently lead to missed or rescheduled appointments, delayed care, and poor medication adherence, all of which contribute to worsening health outcomes. Disruptions in care continuity are associated with poorer clinical outcomes, increased emergency department utilization, and higher overall healthcare costs. Addressing these barriers requires targeted investments in transit connectivity, mobile health services, and community-based delivery models to mitigate preventable gaps in care.

Insurance Coverage and Medical Debt

In the 2022 National Health Interview Survey, 12.6% (CI: 7.4-19.8) of Arizona adults aged 18-64 were uninsured, compared with 12.4% nationally, making it the 8th highest uninsured rate amongst 28 states.⁷ Although Arizona expanded Medicaid eligibility in 2014, gaps in eligibility, administrative barriers, and coverage gaps continue to disproportionately affect lower-income populations. Insurance inequities in Arizona are further shaped by its restrictive immigration policies and demographic composition. Evidence suggests that in mixed immigration status households, the fear of discrimination, detainment, and deportation leads to avoidance of public health services and programs even if members in the household are eligible.⁸ While health insurance has historically functioned as a protective factor for healthcare access, medical debt may more accurately predict health outcomes because it captures persistent financial barriers to care, including delayed treatment and reduced medication adherence, even among insured individuals.⁹ Findings highlight that insurance coverage rates alone may underestimate structural barriers to care in Arizona, where immigration policy context, socioeconomic vulnerability, and medical debt interact to shape access and health outcomes.

Housing Instability

Housing instability is another critical and compounding determinant of both healthcare access and medication adherence. The number of unhoused individuals in Arizona increased by over 29% from 2020 to 2023.¹⁰ A needs assessment of unhoused youth and young adults conducted by the Tucson Pima Collaboration to End Homelessness identified that lack of transportation was a key barrier to accessing medical care (46%), surpassing lack of income (40%) in this specific population.¹¹ For adults (aged 19-86) in Tucson experiencing homelessness, lack of transportation was also a significant barrier (25%), but not as significant as lack of money (42%), according to the 2023 City of Tucson Needs Assessment of Adults Experiencing Homelessness.¹² These findings highlight housing instability and lack of transportation as central barriers to care in Tucson and across Arizona.

Our Initiative

Community-based interventions are essential to addressing these gaps in care that conventional healthcare systems have failed to close. COPE is a community-based non-profit healthcare organization that aims to create pathways to better health by offering innovative solutions for behavioral and physical healthcare and wellness. COPE serves over 16,000 patients annually and has been providing care in Tucson for over 50 years. One of its innovative solutions is the Wellness on Wheels (WoW) program, a fully licensed mobile integrated health services clinic designed to provide mobile, no-cost, community-based care to marginalized populations.

A partnership between the University of Arizona College of Medicine - Tucson (UACOMT) Aequitas fellows and COPE was established during the 2024-2025 year through a quality improvement (QI) project examining patient encounters, follow-up, and barriers to care plan adherence. The UACOMT Aequitas Honors Society Chapter emphasizes community partnerships as instrumental to successful and sustainable health equity projects.¹³ As the 2025-2026 cohort, we built upon the prior partnership with COPE and the WoW program. This continuity allowed fellows to leverage existing knowledge, systems, and shared goals to implement a project with greater potential for long-term impact. Given the one-year duration of the fellowship, continued engagement across successive cohorts strengthened the partnership with COPE, enhanced project effectiveness and accountability, and ultimately yielded a more sustainable impact for the community as well as the fellows.

Approach – Collaborating with COPE in Identifying Needs and Data Collection

We continued the QI work initiated by the previous cohort to support a more sustainable impact and build on COPE’s established efforts. To assess healthcare engagement and medical adherence within the COPE Wellness on Wheels program, we conducted a retrospective program data review as part of a QI initiative at the COPE WoW integrated health services clinic. Results of our study were used internally by COPE Community Services to inform efforts and to improve access to care. Here, we report our approach to partnership building and evaluation, which we hope will be useful for other cohorts across the country.

Clinical visits were reviewed using surveys completed by the primary physician operating the COPE WoW clinic, which documented key features of each patient encounter. Subsequently, follow-up forms were completed by members of the Aequitas fellowship group to review encounter diagnoses and assess whether continuity of care was pursued.

Collected responses were compiled into a spreadsheet and analyzed for trends in qualitative and descriptive data, including visit type, primary reasons for visits on WoW, and patient demographics (with particular attention to housing status), as well as adherence to recommended care plans, including prescription pick-up, laboratory completion, and completion of follow-up or referred care.

Descriptive statistics were used to characterize patient demographics, visit types, reasons for visit, diagnoses, medications prescribed, laboratory orders and completion, and referral outcomes. For adherence outcomes, prescription pick-up was assessed among patients prescribed medication, and laboratory completion was assessed among those with laboratory orders. ICD-10 codes were reviewed and tabulated to identify the most frequently documented diagnoses during the study period.

Results were shared with COPE Community Services to help guide the development of targeted resources to better address barriers faced by patients who utilize the WoW mobile clinic.

Discussion

The findings from this QI review of the COPE WoW program emphasize both the utility of WoW as a mobile, integrated health service and the structural barriers that continue to challenge care engagement among marginalized populations in Tucson, Arizona. As a QI initiative, these findings are intended to inform program-level improvements specific to WoW and are not intended to be generalized beyond this program or setting. The data reflect patterns consistent with the broader literature on healthcare access among underserved and unhoused populations but also highlight potential areas for targeted improvement.

A majority of WoW patients are unhoused or unsheltered (60/81, 74.1%), underscoring the crucial role of WoW’s mobile health services as a safety net in our community. Two-thirds of encounters were first visits (54/81, 66.7%), suggesting that WoW often serves as an initial point of contact with the healthcare system for this population. This is consistent with the broader context described in which Arizona has seen a greater than 29% increase in unhoused individuals between 2020 and 2023, and Tucson’s unhoused population faces numerous barriers, including transportation insecurity, safety and theft concerns, and financial difficulties.

The clinical profiles of patients seen at WoW reflect the acute and chronic needs within the community. Primary care needs were addressed in 54 encounters (66.7%), STI screening or treatment in 20 (24.7%), and substance use-related concerns in 9 (11.1%), with additional visits addressing wound care, acute issues, and mental health care. The four most frequently documented ICD-10 codes were sexually transmitted infections, opioid use disorder, essential hypertension, and COPD, which are conditions that disproportionately impact populations experiencing homelessness and socioeconomic barriers to healthcare. These are also diseases that carry significant consequences when inadequately managed, leading to further complications.

WoW also served an important care coordination role, with referrals for additional services made in 26 encounters (32.1%). The rate of referrals to COPE’s own primary care, behavioral health, and SUD treatment services reflects an important function of WoW, which allows this mobile clinic to serve as an entry point into a broader continuum of care.

Collectively, these findings affirm the value of COPE’s Wellness on Wheels program as a strategy for reaching populations that are underserved and underreached by the conventional healthcare system in Tucson, Arizona. Laboratory studies were ordered in 24 encounters (29.6%), and 21 of these 24 studies were completed (87.5%). This high completion rate suggests that lab collection services on WoW are effective at reducing structural barriers such as cost and transportation, as well as improving engagement of WoW’s patient population. This observation has important implications for program development and ongoing QI efforts within COPE. It suggests that reducing structural barriers may be more impactful in improving care engagement than focusing solely on individual-level behavioral change within this population.

At the same time, medication access remained an important area for improvement. Medications were prescribed in 38 encounters (46.9%) but confirmed prescription pick-up occurred in only 21 of these 38 encounters (55.3%). COPE provided transportation to the pharmacy in only 5 encounters (6.2%). The contrast between high laboratory completion and lower prescription pick-up highlights the limits of what a single mobile health encounter can accomplish when downstream barriers remain difficult to address. Closing this gap will likely require extending the WoW model’s goal of barrier reduction into the post-visit phase of care, potentially through strategies such as on-site medication dispensing, stronger pharmacy partnerships, longer-term transportation solutions, or medication storage support.

Finally, these findings also reinforce the importance of continued partnership in community-affiliated projects, as the continuity between the prior cohort and our cohort has allowed a more nuanced understanding of WoW’s patient population and adherence patterns, laying the groundwork for future QI efforts.

Future Directions

After identifying trends in service utilization and treatment adherence, we met with COPE Community Services leadership to share our findings and discuss program-level implications. This QI-focused discussion identified opportunities to use Aequitas grant funding to address gaps in prescription pickup, wound care, and follow-up adherence. Community partner-identified priorities included patient education materials on medication adherence and follow-up, wound care supplies, and expanded transportation and pharmacy access.

Patient education brochures represented a feasible, high-impact use of grant funding and were ultimately the intervention we pursued. Designed for the WoW population, these materials emphasized treatment adherence and provided community resources relevant to common WoW visits. Future brochures could be tailored to condition-specific guidance such as hypertension, COPD, and substance use disorder and include local Tucson resources. Materials should be written at an accessible reading level, available in English and Spanish, and easily distributed during clinic encounters. This initiative would directly address the gap between the care provided at the point of contact and the follow-through needed to sustain its benefits.

Grant funding could also support wound care supplies, including dressings, bandages, antiseptic supplies, and irrigation equipment, for patients with limited access to dressing changes and follow-up care. Stocking these materials on the mobile unit would allow more care to be provided during the initial encounter. Other useful supplies could include blood pressure cuffs, glucometers, and testing strips for chronic disease monitoring.

Finally, transportation and pharmacy access remain important areas for improvement. Although WoW offers transportation to pharmacies during clinic visits, only approximately 6.2% of patients used this service during the review period. Future cohorts could investigate barriers to its use and determine whether clearer patient education improves uptake. Additional strategies could include expanded transportation options or subsidized ride-share and pharmacy-delivery costs. Continued collaboration with COPE leadership will be essential to evaluating these interventions and ensuring that future QI efforts remain responsive to the WoW population. Together, these efforts may strengthen continuity of care and further reduce barriers for patients served by the WoW program.

Funding: The patient education materials described in this article were supported by an Aequitas Health Chapter Project Grant.

Conflicts of Interest: The authors declare no conflicts of interest.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the views of COPE Community Services.