Expanding the safety net of specialty care for the uninsured: a case study.
Care for the uninsured and underinsured un·der·in·sure
tr.v. un·der·in·sured, un·der·in·sur·ing, un·der·in·sures
To insure under a policy that provides inadequate benefits: Be certain that you are not underinsured against catastrophic illness. is largely provided by our nation's health care safety-net system comprised of providers who care for patients regardless of their ability to pay (Institute of Medicine 2000). Nevertheless, uninsured and underinsured adults have inadequate access to care, receiving fewer health screening, preventive, and specialty care services than privately insured patients (Ayanian et al. 2000; DeVoe et al. 2003; Wilper et al. 2008; Ayanian 2009). The demonstrated need for improved access and care delivery in the safety-net system has prompted increased federal funding (Hoadley, Felland, and Staiti 2004; Shi and Stevens 2007; Sack 2008), including 11 billion dollars to expand the capacity of federally qualified community health centers (CHCs) through the Patient Protection and Affordable Care Act (PPACA) (HealthCare.gov 2010).
Increased federal support to CHCs may help improve the quality of primary care in the safety-net system (Shi and Stevens 2007); however, access to specialty care remains a challenge. One quarter of patient visits to CHCs result in a referral to a specialist (Cook et al. 2007); yet fewer specialists are participating in the care of vulnerable populations, and there is no clear system for patients or primary care physicians to access those who do provide care (Dunham et al. 1991; Reed, Cunningham, and Stoddard 2001; Hartwig 2002; Cunningham and May 2006). Continued reliance on a limited pool of specialty physicians results in long wait-times for appointments, and, subsequently, fragmented care plans, disease advancement, and overutilization of emergency departments and hospitals (Ayanian et al. 2002).
Models of engaging specialty physicians in the care of the uninsured and underinsured are emerging (Isaacs and Jellinek 2007; Blewett, Ziegenfuss, and Davern 2008; Darnell 2010). Prior studies suggest, however, that these models need to extend beyond improving reimbursement to address other reasons many providers have opted out of caring for the uninsured; these include feeling overwhelmed by administrative hassles; lack of provider autonomy within the program; and patient complexity, including psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects.
Involving aspects of both social and psychological behavior. needs (Shortell and Hull 1996; Chaudry et al. 2003; Cunningham and O'Malley 2009).
One program, Project Access, is responding to these concerns by creating a network of specialists and hospitals willing to provide donated care for uninsured and underinsured patients and integrating this care through patient navigation (Cofer 2008). The model has been replicated in communities throughout the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. (Ablah, Wetta-Hall, and Burdsal 2004; Baker, McKenzie, and Harrison 2005). Core principles and processes of implementing Project Access may be relevant for policy makers seeking to increase the capacity of the safety-net system to accommodate the specialty care needs of the uninsured (Lavis et al. 2002) and of the growing number of Medicaid beneficiaries expected to enter the safety-net system in 2014, when legislation from PPACA takes effect.
Accordingly, we aimed to describe the 2-year process of developing and implementing Project Access in New Haven New Haven, city (1990 pop. 130,474), New Haven co., S Conn., a port of entry where the Quinnipiac and other small rivers enter Long Island Sound; inc. 1784. Firearms and ammunition, clocks and watches, tools, rubber and paper products, and textiles are among the many , Connecticut. Using a case-study approach, we report how the core principles of community-based participatory research Community-based participatory research (CBPR) is research that is conducted as an equal partnership between traditionally trained "experts" and members of a community. In CBPR projects, the community participates fully in all aspects of the research process. (CBPR CBPR Community-Based Participatory Research ) were applied to address barriers to participating in an expanded safety net for the uninsured, and ultimately, to engage community stakeholders in all phases of implementation of Project Access-New Haven (PA-NH), including (1) assessing the scope of the problem of access to specialty care for the uninsured; (2) defining the goals of the project; (3) engaging new providers in the safety net, including specialists in private practice; (4) establishing the evaluation and research agenda, including the review of early findings from the first 46 patients enrolled; and (5) disseminating and translating research findings (Israel et al. 2010). Deliberate attention to these key stages of implementation may facilitate the expansion of the safety-net system for vulnerable populations in communities nationwide.
Conceptual Framework For the concept in aesthetics and art criticism, see .
A conceptual framework is used in research to outline possible courses of action or to present a preferred approach to a system analysis project. : Core Principles Guiding Implementation
We were guided by a conceptual framework informed by principles from the field of CBPR (Israel et al. 2005). CBPR is an effective method for engaging stakeholders in capacity-building efforts aimed at improving health outcomes for vulnerable populations (Israel et al. 2010; Schmittdiel, Grumbach, and Selby 2010). CBPR is built on the principle that when consumers of the research are involved in all steps of the project, outcomes are more relevant to the community needs and, therefore, the community members are more likely to sustain the outcomes long after the research project is finished. Another hallmark of CBPR is its commitment to action or translating research into practice.
Our team hypothesized that the successful implementation of Project Access would depend on our identifying and building collaborative relationships with each of the groups within our community with a vested interest Vested Interest
A financial or personal stake one entity has in an asset, security, or transaction.
For example, if you have a mortgage, your bank has a vested interest on the sale of your house.
See also: Right in the uninsured. Figure 1 outlines our model of an expanded safety net of providers for the uninsured, which includes the CHCs, individual physicians and practices, hospitals, and nonprofit service organizations intimately familiar with the needs of the uninsured, as well as local foundations and policy makers, who were driving local health care reform efforts. As the figure illustrates, we hypothesized several potential barriers that potentially would impact their willingness to participate in and/or support Project Access (Chaudry et al. 2003; Cunningham and O'Malley 2009). Importantly, these barriers were identified during the 2-year development phase and targeted as opportunities to apply core principles from CBPR to engage providers in the process of developing a program responsive to the challenges of caring for the uninsured.
[FIGURE 1 OMITTED]
Program Intervention: Project Access
Project Access is an organized system of specialty care for the uninsured. The model first emerged in Asheville, North Carolina Not to be confused with Ashville.
Asheville is a city in Buncombe County, North Carolina, and is its county seat. As of the 2000 census, the city had a total population of 68,889. It is the largest city in western North Carolina, and continues to grow. , in 1996, and has since been replicated with substantial variation in program goals and capacity, in over 50 cities nationwide (Baker, McKenzie, and Harrison 2005). When optimally implemented, Project Access expands the safety net of providers caring for the uninsured to include the majority of community specialty physicians, most of whom are in private practice, along with all local hospitals, to provide donated care for the uninsured. At the core of the program are patient navigators who, using a patient-centered approach, help patients to (1) schedule medical appointments and tests; (2) access free or discounted prescription medication; (3) negotiate language and literacy barriers; and (4) connect with health-related resources. Additionally, patient navigators empower patients to be more proactive, facilitate communication among participating primary care and specialty physicians, and help execute the care plan. Several Project Access sites have demonstrated timely access to specialty care, patient and physician satisfaction, and a reduction in visits to the emergency department among enrollees.
Following a community assessment of the unmet health care needs of the residents of New Haven (described in detail below), we recognized that access to specialty care for the uninsured was a significant problem in our community. As we were in the midst Adv. 1. in the midst - the middle or central part or point; "in the midst of the forest"; "could he walk out in the midst of his piece?"
midmost of a recession and a vitriolic national health care debate, the Project Access model emerged as a potential intervention to address access to care in New Haven. The model appeared feasible as it involved coordinating volunteer health care; thus, all funding would be invested in patient navigation. Other Project Access sites had demonstrated that for every $1 invested in patient navigation, $4-$5 of donated care was rendered. Furthermore, patient navigation was increasingly being recognized as a potential method of improving quality and appropriate care utilization (Peikes et al. 2009).
To guide the process of implementing PA-NH, we applied a triangulation triangulation: see geodesy.
The use of two known coordinates to determine the location of a third. Used by ship captains for centuries to navigate on the high seas, triangulation is employed in GPS receivers to pinpoint their current location on earth. approach to understand the principles, tasks, and data needed to accomplish each implementation step (Yin 1999). We considered multiple data sources to inform these steps, including CHC CHC Chicago Cubs
CHC Community Health Center
CHC Chestnut Hill College (Philadelphia, Pennsylvania)
CHC Congressional Hispanic Caucus
CHC Community Health Council (UK National Health Service) and hospital administrative records; in-depth interviews with both early supporters and skeptics of the model; site visits to other Project Access programs; and policy briefs and health services health services Managed care The benefits covered under a health contract literature related to access to care for the uninsured. In addition, to affirm program fidelity in reaching the targeted population, we performed a preliminary review of data collected from patient surveys. In the results below, we describe how these data sources were used to inform each implementation step. The Institutional Review Board of Yale University Yale University, at New Haven, Conn.; coeducational. Chartered as a collegiate school for men in 1701 largely as a result of the efforts of James Pierpont, it opened at Killingworth (now Clinton) in 1702, moved (1707) to Saybrook (now Old Saybrook), and in 1716 was approved this study.
From August 2008 through August 2010, a team comprised of academic researchers, primary care physicians, specialty physicians in private practice, and advocates for the underserved partnered to form PA-NH, a 501[c]3 organization aimed at improving access to specialty care among the uninsured. Table 1 describes the core components of this process, which are elaborated in turn.
Assess the Scope of the Problem
CBPR Builds on Strengths and Resources within the Community. We conducted a comprehensive, systematic baseline needs assessment of the community, including insurance trends, problems associated with lack of insurance, the quality of access to primary and specialty care, and reliance on safety-net providers (e.g., emergency departments and hospitals) in New Haven. We used multiple sources of data, including: (1) systematic review of the literature; (2) key informant informant Historian Medtalk A person who provides a medical history interviews with eleven members of the medical community of New Haven; (3) review of administrative data systems from one CHC to define wait-times for primary care and specialty care appointments; and (4) reports from other community assessments and from local policy organizations(Hartwig 2002; Connecticut Health Policy Brief 2009).
From this community needs assessment, it emerged that primary care in New Haven was robust; despite the growing number of uninsured, the CHCs were able to accommodate the primary care needs of the uninsured. However, there was frustration with long wait-times for specialty appointments and broken communication systems among primary care providers and specialists. From key informant interviews, we learned that the rising number of uninsured was disproportionately affecting Latino and African American African American Multiculture A person having origins in any of the black racial groups of Africa. See Race. adults, and that this further contributed to health care disparities. They highlighted several common barriers experienced by these groups to accessing care for both acute and chronic medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis. , including transportation and language interpretation, along with mistrust of the medical system and fear of excessive medical bills.
An assessment of the baseline characteristics of the first 46 patients enrolled in PA-NH, from September 2010 to December 2010, supported the data from the key informant interviews (Table 2). The mean age of this early group of enrollees in PA-NH was 42.8 years. Most were either Latino (76.1 percent) or African American (13 percent); half were unemployed. Chronic illness was prevalent (52.2 percent), and over one quarter had an emergency department visit in the past year. Nearly 70 percent avoided care due to cost, and most (56.6 percent) experienced difficulty accessing care. In addition, patients faced challenges in adhering to the care plan, as evidenced by 43.5 percent not filling a prescription because of cost. The most common self-reported barriers to access in the year prior to enrollment were cost (52.2 percent), language barriers (26.1 percent), transportation (26.1 percent), work-schedule conflicts (13.0 percent), and child care issues (6.5 percent).
To address these barriers, PA-NH has hired all bilingual patient navigators, who can culturally identify with the challenges faced by the local community. Patient navigators do not have a clinical background, but they have excellent interpersonal skills "Interpersonal skills" refers to mental and communicative algorithms applied during social communications and interactions in order to reach certain effects or results. The term "interpersonal skills" is used often in business contexts to refer to the measure of a person's ability , are organized and proactive, and have a passion for advocacy. All patient navigators receive education about local health-related resources and attend a 3-day training workshop given by the Harold P. Freeman Patient Navigation Institute in New York City New York City: see New York, city.
New York City
City (pop., 2000: 8,008,278), southeastern New York, at the mouth of the Hudson River. The largest city in the U.S. . In addition, to address language barriers, hospitals are providing free telephone interpretation services for all PA-NH physician visits, and all materials are produced in both English and Spanish--the two most common languages spoken by the uninsured in New Haven.
Engage Key Stakeholders
Invest in Long-Term and Robust Relationships with Partners. Our process for engaging key stakeholders in the implementation of Project Access was threefold. First, we interviewed leadership of the two New Haven CHCs and three nonprofit organizations providing social services social services
welfare services provided by local authorities or a state agency for people with particular social needs
social services npl → servicios mpl sociales to many African American and Latino residents in New Haven, groups who were disproportionately affected by lack of insurance. We also met with the deputy mayor, and two senior administrators from the New Haven Department of Health, along with the philanthropy arms of two local businesses who were committed to helping vulnerable populations. We conducted in-depth interviews with these community leaders to (1) understand their perspective of the health care needs of the uninsured; (2) inform them about Project Access--as it exists in other communities; and (3) reconcile barriers to participation.
Second, we engaged local health care leadership and potential volunteer providers. We met with senior administration of both local hospitals (Yale New Haven Hospital and the Hospital of Saint Raphael The Hospital of Saint Raphael or Saint Raphael Hospital, located in New Haven, Connecticut, USA, is a 511-bed hospital and an academic health center affiliated with Yale University School of Medicine. It was founded by the Sisters of Charity of Saint Elizabeth in 1907. ), including the chief executive and operating officers, chairs of medicine and surgery, and chiefs of specialty departments, including radiology, pathology, and anesthesiology anesthesiology (ăn'ĭsthē'zēŏl`əjē), branch of medicine concerned primarily with procedures for rendering patients insensitive to pain, and for supporting life systems under the strains of anesthesia and surgery. . We gave formal presentations about the uninsured and Project Access at medical grand rounds and section meetings. We used email to engage individual specialty providers, and we published articles in medical newsletters and in the lay press. Finally, the members of our team who were also members of the New Haven County Medical Association reached out, individually, to their constituency.
Third, we engaged funders. While other Project Access programs were started with large federal or foundation grants, such funds were not available to us. We focused on local foundations, hospitals, and the medical community to support Project Access. These groups were most informed about the downstream effects of limited access to care for the uninsured. Several local foundations have missions to fund projects that reduce health care disparities and/or focus on improving social determinants of health Social determinants of health are the economic and social conditions under which people live which determine their health. Virtually all major diseases are primarily determined by specific exposures to these conditions. . Hospitals were potential funders as well, as implementation of Project Access had the potential to reduce emergency department visits and hospitalizations. Finally, we recognized that substantive financial support from the medical staffs of both hospitals would serve the dual goals of educating our physician pool about the program and its projected merits, while simultaneously building investment in the outcomes of the project.
In engaging funders early on in the development process, we learned about state-wide goals for health care reform and about the priorities of some private foundations. This exchange was critical to informing the program's goals and outcomes of interest. During a meeting with the executive directors of seven local and state foundations, in which we presented Project Access and elicited feedback, we learned that funders were concerned with how this program might unintentionally worsen access to care for Medicaid beneficiaries, whereby preference for caring for PA-NH patients might lead physicians to drop out of caring for Medicaid beneficiaries. We appreciated this concern, and since then, a main goal of PA-NH is to reach out to providers who are not currently accepting Medicaid patients but also to ultimately expand the program to include the Medicaid population. This latter commitment has resulted in PA-NH engaging in a demonstration project with both local hospitals to study the impact of the program on the uninsured and its potential expansion to Medicaid beneficiaries. Ultimately, input from local foundations, hospitals, and physicians helped us to develop a model that was responsive to the health and health-related needs of the uninsured in New Haven, and that considered the potential unintended consequences of the model. Since that meeting, we have continued to coordinate PA-NH with other local health care reform efforts with the aim of optimizing outcomes for all vulnerable populations.
Define the Goals of Project Access
CBPR Fosters Co-learning and Capacity Building among All Partners. To define the goals of the program, we aggregated the local and external experiences with access to care for the uninsured. For example, from our discussions with two community organizations, we learned that communication among primary care and specialty physicians was poor. In bringing together physicians from primary care and specialty practices, each learned of the others' frustrations. Primary care providers often did not receive standard consultation letters from specialists. Specialists complained that little patient information was sent to them, and that it was difficult to reach the provider on the phone. These discussions challenged PA-NH to develop new systems to improve communication among providers. We developed new referral forms, requested emails and direct phone numbers of all participating providers, and developed a system whereby correspondence among providers goes through the patient navigators, ensuring the transfer and receipt of referral and consultation letters.
Establish Evaluation and Research Agenda
CBPR Integrates and Achieves a Balance between Knowledge Generation and Intervention for Mutual Benefit of All Partners. The research goals of Project Access are aligned with evaluating and improving the quality of the program, and supporting the sustainability and generalizability of the model. The research agenda consists of four parts: (1) identification of the sociodemographic characteristics, health and health-related needs, and perceived barriers to access among the uninsured; (2) comparison of wait-times and show-rates to specialty appointments before and after program implementation; (3) assessment of utilization and cost of health services rendered through the program; and (4) study of physician satisfaction with the program.
There are several challenges to collecting data in this population. First, there is no integrated health information technology (IT) system, making it difficult to track utilization across hospitals and CHCs. Second, there is substantial variation among the CHC administrative record systems, and they are not easily queried; much of the data are collected by hand. As a result, it is difficult to compare and to trend referral wait-times and show-rates to appointments. Third, primary data collection must be balanced with time and space constraints, as often this adds responsibility to direct service providers. We are working to overcome these barriers. For example, to track utilization, we collect claims (cost set to zero) generated by specialty physicians, clinics, hospitals, and other volunteer providers. We have invested in an IT system, recommended by other Project Access sites, to house demographic information about patients, and to track process measures and outcomes, such as wait-times. We developed patient questionnaires, piloted in both English and Spanish, that are administered by a patient navigator; as requested by the patient navigators, responses to surveys are documented on paper and then entered into the database by a research assistant. For the demonstration project, we have budgeted for a full-time researcher, which will allow us to collect follow-up data on patient outcomes, measure physician satisfaction, and assess whether the program is effective in reducing hospital expenditures of uncompensated care uncompensated care,
n health care services provided by a hospital, physician, dental professional, or other health care professional for which no charge is made and for which no payment is expected. .
Disseminate and Translate Research Findings
CBPR Disseminates Results to All Partners and Involves Them in the Dissemination Process. We have developed ongoing dissemination processes for sharing our findings with the local community, the professional community, and among policy makers, and past and future funders. These dissemination strategies were informed by the literature and other Project Access sites. In the local community, we are sharing key results and anecdotal patient stories with our partners in the form of newsletters, briefs, and frequent in-person meetings. We developed a website with information for patients and providers (http:// www.pa-nh.org). For the medical community, we have presented Project Access at medical conferences and workshops on urban planning urban planning: see city planning.
Programs pursued as a means of improving the urban environment and achieving certain social and economic objectives. initiatives, and we are finalizing a systematic review of the literature on physician attitudes toward caring for the uninsured and publicly insured. For policy makers, we have developed relationships with state and U.S. representatives of Congress, have created policy briefs, served on health care reform panels, and regularly updated both officials and their staff about Project Access. For funders, we report program activity and efforts toward expanding to the Medicaid population. In addition, we report the cumulative dollar value of the care and services that are rendered to PA-NH patients, demonstrating similar leveraging of funding dollars to donated care ($1/$4-$5) as other Project Access sites.
Under the PPACA, dozens of demonstration projects will be implemented to test new models of providing health care, such as accountable care organizations and patient-centered medical homes. These demonstration projects provide important opportunities to study the impact of the project on the health care system (Rittenhouse, Shortell, and Fisher 2009). Yet how these projects will be implemented is not clear. Experience with managed care plans in the 1990s suggests that physicians, hospitals, and consumers may not embrace efforts to coordinate care (Shortell and Hull 1996; Feldman, Novack, and Gracely 1998). One hypothesis is that these groups were never included in the design, conduct, or evaluation of the care plan. Our experience in using CBPR to implement PA-NH suggests that early inclusion and partnership are key for generating support and commitment to the model.
In applying principles from CBPR, we were able to develop and implement a coordinated care model to improve access to specialty care for the uninsured. We built partnerships with an expanded safety-net of providers by engaging them in the process of designing, funding, evaluating, and disseminating results about the program. We believe that inclusion in all phases of the implementation process will have important implications for the programs' effectiveness and sustainability.
We involved policy makers at the front end of our work. We believe that linking grassroots efforts with local and state health policy agendas can help increase visibility, investment in outcomes, and ultimately, if effective, expansion and translation for other populations. Thus, from the beginning, PA-NH has been poised to deliver results on outcomes relevant to policy makers, including a sustained commitment from volunteer physicians, a positive impact on health disparities
Health disparities (also called health inequalities in some countries) refer to gaps in the quality of health and health care across racial, ethnic, and socioeconomic groups. , improved patient outcomes, and a reduction in avoidable emergency department visits, hospitalizations, and readmissions. These data will help inform whether PA-NH is truly having an impact on the health care system; if so, then we may be better able to convince local legislators to support models that include patient navigation. One example may be to consider including patient navigators as part of the patient-centered medical home.
Lessons learned from the implementation of PA-NH may be particularly useful for other communities seeking to expand access to specialty care for their uninsured population (Grol and Jones 2000; Foy, Eccles, and Grimshaw 2001). First, the expanded infrastructure of physicians and providers assuming responsibility for the care of the uninsured ensures that no one physician, practice, or hospital is overwhelmed. We have found that allowing physicians to dictate the terms of their involvement (i.e., number of PA-NH patients they see per month) has helped recruitment. Second, putting patient navigators at the center of the care plan has been well accepted by patients and providers. As two-thirds of PA-NH patients are Latino, and 26 percent cite language as a barrier to accessing care, patient navigators must be bilingual but also bicultural bi·cul·tur·al
Of or relating to two distinct cultures in one nation or geographic region: bicultural education.
bi·cul . Data suggest that for vulnerable populations, having a patient navigator who can identify with them helps build trust and adherence to the care plan (Jandorf et al. 2006; Petereit et al. 2008). Moreover, physicians are more inclined to participate in PA-NH, as they can focus on addressing the medical needs of the patient, while patient navigators address the health-related needs of patients--which tend to be higher among patients with limited resources (Ablah, Wetta-Hall, and Burdsal 2004).
Our description of the process of implementing Project Access has limitations. As with any single-location study, lessons learned may be considered too idiosyncratic id·i·o·syn·cra·sy
n. pl. id·i·o·syn·cra·sies
1. A structural or behavioral characteristic peculiar to an individual or group.
2. A physiological or temperamental peculiarity.
3. to the specific circumstances in which the case took place. However, because one of our earliest goals was to potentially expand Project Access for Medicaid beneficiaries, we used established principles and overarching o·ver·arch·ing
1. Forming an arch overhead or above: overarching branches.
2. Extending over or throughout: "I am not sure whether the missing ingredient . . . concepts to guide our process of engagement. In so doing, we believe that this process has wider applicability for other communities. Another limitation is that it is too early to determine whether Project Access will meet its stated goals. However, preliminary results demonstrate that we are reaching our targeted population; rigorous evaluation methods are established to study the programs' impact.
In summary, there is increasing interest in coordinated models to improve care delivery for vulnerable populations. Yet it is unclear who will be the drivers of these health system changes and what steps will be required for their successful implementation. Important lessons may be derived from our experience applying principles from CBPR to implement PA-NH that should be considered by communities and policy makers seeking new methods for increasing access to specialty care for vulnerable populations.
Joint Acknowledgment/Disclosure Statement. Authors ESS (1) (Electronic Switching System) A large-scale computer from Lucent used to route telephone calls in a telephone company office. The 5ESS is a Class 5 central office switch, and the 4ESS is a Class 4 tandem office switch. , MSP (1) (Management Service Provider or Managed Service Provider) An organization that manages a customer's computer systems and networks which are either located on the customer's premises or at a third-party datacenter. , and OJW OJW Orthodontic Jaw Wiring
OJW On-The-Job Web (training) are funded through the Robert Wood Johnson Foundation Robert Wood Johnson Foundation, charitable organization devoted exclusively to health care issues. It was established in 1936 by Robert Wood Johnson (1893–1968), board chairman of the Johnson & Johnson medical products company. Clinical Scholars Program. Research for this community project was supported by the Yale Center for Clinical Investigation.
Ablah, E., R. Wetta-Hall, and C. A. Burdsal. 2004. "Assessment of Patient and Provider Satisfaction Scales for Project Access." Quality Management in Health Care 13 (4): 228-42.
Ayanian, J. Z. 2009. "America's Uninsured Crisis: Consequences for Health and Health Care." Statement before the Committee on Ways and Means WAYS AND MEANS. In legislative assemblies there is usually appointed a committee whose duties are to inquire into, and propose to the house, the ways and means to be adopted to raise funds for the use of the government. This body is called the committee of ways and means. , United States House of Representatives Public Hearing on Health Reform in the 21st Century: Expanding Coverage, Improving Quality and Controlling Costs. March 11.
Ayanian, J. Z., J. S. Weissman, E. C. Schneider, J. A. Ginsburg, and A. M. Zaslavsky. 2000. "Unmet Health Needs of Uninsured Adults in the United States." Journal of the American Medical Association JAMA: The Journal of the American Medical Association is an international peer-reviewed general medical journal, published 48 times per year by the American Medical Association. JAMA is the most widely circulated medical journal in the world. 284 (16): 2061-9.
Ayanian, J. Z., M. B. Landrum, E. Guadagnoli, and P. Gaccione. 2002. "Specialty of Ambulatory Care ambulatory care
Medical care provided to outpatients.
n the health services provided on an outpatient basis to those who can visit a health care facility and return home the same day. Physicians and Mortality among Elderly Patients after Myocardial Infarction myocardial infarction: see under infarction. ." New England Journal of Medicine The New England Journal of Medicine (New Engl J Med or NEJM) is an English-language peer-reviewed medical journal published by the Massachusetts Medical Society. It is one of the most popular and widely-read peer-reviewed general medical journals in the world. 34 7 (21): 1678 86.
Baker, G. K., A. T. McKenzie, and P. B. Harrison. 2005. "Local Physicians Caring for their Communities: An Innovative Model to Meeting the Needs of the Uninsured." North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures
Area, 52,586 sq mi (136,198 sq km). Pop. Medical Journal 66 (2): 130-3.
Blewett, L. A.,J. Ziegenfuss, and M. E. Davern. 2008. "Local Access to Care Programs (LACPs): New Developments in the Access to Care for the Uninsured." Milbank Quarterly 86 (3): 459-79.
Chaudry, R. V., W. P. Brandon, C. R. Thompson, R. S. Clayton, and N. B. Schoeps. 2003. "Caring for Patients under Medicaid Mandatory Managed Care: Perspectives of Primary Care Physicians." Qualitative Health Research 13 (1): 37-56.
Cofer, J. B. 2008. "Project Access: Giving Back at Home." Bulletin of the American College of Surgeons 93 (1): 13-7.
Connecticut Health Policy Brief. 2009. Danbury and Windham County Windham County is the name of two counties in the United States:
Cook, N. L., L. S. Hicks Hicks , Edward 1780-1849.
American painter of primitive works, notably The Peaceable Kingdom, of which nearly 100 versions exist. , A.J. O'Malley, T. Keegan, E. Guadagnoli, and B. E. Landon. 2007. "Access to Specialty Care and Medical Services in Community Health Centers." Health Affairs (Millwood)26 (5): 1459-68.
Cunningham, E, and J. May. 2006. "Medicaid Patients Increasingly Concentrated among Physicians." Tracking Report 16: 1-5.
Cunningham, EJ., and A. S. O'Malley. 2009. "Do Reimbursement Delays Discourage Medicaid Participation by Physicians ?" Health Affairs 28 (1): w17-28.
Darnell, J. S. 2010. "Free Clinics in the United States: A Nationwide Survey." Archives of Internal Medicine The Archives of Internal Medicine is a bi-monthly international peer-reviewed professional medical journal published by the American Medical Association. Archives of Internal Medicine 170 (11): 946-53.
DeVoe, J. E., G. E. Fryer, R. Phillips, and L. Green. 2003. "Receipt of Preventive Care Preventive care is a set of measures taken in advance of symptoms to prevent illness or injury. This type of care is best exemplified by routine physical examinations and immunizations. The emphasis is on preventing illnesses before they occur. See also
Dunham, N. C., D. A. Kindig, S. Lastiri-Quiros, M. T. Barham, and P. Ramsay. 1991. "Uncompensated uncompensated (n·kômˑ·p and Discounted Medicaid Care Provided by Physician Group Practices in Wisconsin." Journal of the American Medical Association 265 (22): 2982-6.
Feldman, D. S., D. H. Novack, and E. Gracely. 1998. "Effects of Managed Care on Physician-Patient Relationships, Quality of Care, and the Ethical Practice of Medicine: A Physician Survey." Archives of Internal Medicine 158 (15): 1626-32.
Foy, R., M. Eccles, and J. Grimshaw. 2001. "Why Does Primary Care Need More Implementation Research?" Family Practice 18 (4): 353-5.
Grol, R., and R.Jones. 2000. "Twenty Years TWENTY YEARS. The lapse of twenty years raises a presumption of certain facts, and after such a time, the party against whom the presumption has been raised, will be required to prove a negative to establish his rights.
2. of Implementation Research." Family Practice 17 (suppl 1): S32-5.
Hartwig, K., and M. Harris. 2002. "The Uninsured and Publicly Insured's Access to Specialty Care in New Haven, Connecticut" [accessed December 1, 2010]. Available at: http://www.cga.ct.gov/ph/medicaid/mmcc/minutes/Care-NewHaven. doc
HealthCare.gov. 2010. "Community Health Centers and the Affordable Care Act: Increasing Access to Affordable, Cost Effective, High Quality Care" [accessed on December 1, 2010]. Available at http://www.healthcare.gov/news/factsheets/increasing_access_.html.
Hoadley, J. F., L. E. Felland, and A. Staiti. 2004. "Federal Aid Strengthens Health Care Safety Net: The Strong Get Stronger." Center for Studying Health Systems Change, Issue Brief 80 [accessed December 1, 2010]. Available at: http:// hschange.org/CONTENT/669/.
Institute of Medicine. 2000. America's Health Care Safety Net: Intact but Endangered Washington, D C: National Academy Press.
Isaacs, S. L., and P. Jellinek. 2007. "Is There a (Volunteer) Doctor in the House? Free Clinics and Volunteer Physician Referral physician referral A physician's recommendation to a Pt to consult another physician for a 2nd opinion. Cf Self-referral. Networks in the United States." Health Affairs (Millwood)26 (3): 871-6.
Israel, B. A., C. M. Coombe A coombe is a short, deep, generally bowl-shaped valley or hollow, see cirque.
Coombe may refer to one of these places in England:
Israel, B. A., E. Eng, A.J. Schulz, and E. A. Parker. 2005. Methods in Community Based Participatory Research for Health. San Francisco San Francisco (săn frănsĭs`kō), city (1990 pop. 723,959), coextensive with San Francisco co., W Calif., on the tip of a peninsula between the Pacific Ocean and San Francisco Bay, which are connected by the strait known as the Golden , CA:Jossey-Bass.
Jandorf, L., A. Fatone, P. V. Borker, M. Levin, W. A. Esmond, B. Brenner, G. Butts, and W. H. Redd. 2006. "Creating Alliances to Improve Cancer Prevention and Detection among Urban Medically Underserved Minority Groups. The East Harlem Partnership for Cancer Awareness." Cancer 107 (8 suppl): 2043-51.
Lavis, J. N., S. E. Ross, J. E. Hurley,J. M. Hohenadel, G. L. Stoddart, C. A. Woodward, and J. Abelson. 2002. "Examining the Role of Health Services Research Health services research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, in Public Policymaking pol·i·cy·mak·ing or pol·i·cy-mak·ing
High-level development of policy, especially official government policy.
Of, relating to, or involving the making of high-level policy: ." Milbank Quarterly 80 (1): 125-54.
Peikes, D., A. Chen, J. Schore, and R. Brown. 2009. "Effects of Care Coordination on Hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun)
1. the placing of a patient in a hospital for treatment.
2. the term of confinement in a hospital. , Quality of Care, and Health Care Expenditures among Medicare Beneficiaries: 15 Randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. Trials." Journal of the American Medical Association 301 (6): 603-18.
Petereit, D. G., K. Molloy, M. L. Reiner, P. Helbig, K. Cina, R. Miner, C. Spotted Tail Spotted Tail (b. Sinte Gleska) (?1833–81) Brûlé Sioux leader; born along the White River in present-day South Dakota or near present-day Laramie, Wyo. A signer of the Fort Laramie Treaty of 1868—in which the U.S. , C. Rost, P. Conroy, and C. R. Roberts. 2008. "Establishing a Patient Navigator Program The Navigator Program is a long term NASA project charged with over-seeing all missions related to the detection and characterization of Earth-like planets. It also seeks to further understand how galaxies, stars and planets form. to Reduce Cancer Disparities in the American Indian Communities of Western South Dakota South Dakota (dəkō`tə), state in the N central United States. It is bordered by North Dakota (N), Minnesota and Iowa (E), Nebraska (S), and Wyoming and Montana (W). : Initial Observations and Results." Cancer Control 15 (3): 254-9.
Reed, M. C., P. Cunningham, and J. Stoddard. 2001. "Physicians Pulling Back from Charity Care." Issue Brief Center for Studying Health Systems Change, Issue Brief 42 [accessed December 1, 2010]. Available at: http://www.hschange.com/ CONTENT/356/356.pdf.
Rittenhouse, D. R., S. M. Shortell, and E. S. Fisher. 2009. "Primary Care and Accountable Care--Two Essential Elements of Delivery-System Reform." New England Journal of Medicine 361 (24): 2301-3.
Sack, K. 2008. "Community Health Clinics Increased during Bush Years." New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of Times.
Schmittdiel, J. A., K. Grumbach, and J. V. Selby. 2010. "System-Based Participatory Research in Health Care: An Approach for Sustainable Translational Research and Quality Improvement." Annals of Family Medicine 8 (3): 256-9.
Shi, L., and G. D. Stevens. 2007. "The Role of Community Health Centers in Delivering Primary Care to the Underserved: Experiences of the Uninsured and Medicaid Insured." Journal of Ambulatory Care Management 30 (2): 159-70.
Shortell, S. M., and K. E. Hull. 1996. "The New Organization of the Health Care Delivery System." Baxter Health Policy Review 2: 101-48.
Wilper, A. P., S. Woolhandler, K. E. Lasser, D. McCormick, D. H. Bor, and D. U. Himmelstein. 2008. "A National Study of Chronic Disease Prevalence and Access to Care in Uninsured U.S. Adults." Annals of Internal Medicine Annals of Internal Medicine (Ann Intern Med) is an academic medical journal published by the American College of Physicians (ACP). It publishes research articles and reviews in the area of internal medicine. Its current editor is Harold C. Sox. 149 (3): 170-6.
Yin, R. K. 1999. "Enhancing the Quality of Case Studies in Health Services Research." Health Services Research 34 (5 Pt2): 1209-24.
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Appendix SA1: Author Matrix.
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Address correspondence to Erica S. Spatz, M.D., M.H.S., Robert Wood Johnson Foundation Clinical Scholars Program, Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, 330 Cedar Street, FMP FMP FileMaker Pro
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FMP Federación de Mujeres Progresistas (Spanish: Federation of Progressive Women) 310, New Haven, CT 06520-8017; e-mail: email@example.com. Michael S. Phipps, M.D., M.H.S., is with the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Neurology neurology (nrŏl`əjē, ny–), study of the morphology, physiology, and pathology of the human nervous system. , Yale University School of Medicine, New Haven, CT; Veterans Affairs Veterans Affairs is a term of the business that deals with the relation between a government and its veteran communities, usually administered by the designated government agency. , West Haven West Haven, town (1990 pop. 54,021), New Haven co., S Conn., a suburb across the West River from New Haven; settled 1638, inc. as a separate borough 1873. Although mainly residential, there are diversified manufacturing industries. , CT. Oliver J. Wang, M.D., M.B.A., is with the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Division of Cardiology cardiology
Medical specialty dealing with heart diseases and disorders. It began with the 1749 publication by Jean Baptiste de Sénac of contemporary knowledge of the heart. Diagnostic methods improved in the 19th century, and in 1905 the electrocardiograph was invented. , Yale University School of Medicine, New Haven, CT, Kaiser Permanente Kaiser Permanente is an integrated managed care organization, based in Oakland, California, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney R. Garfield. , Los Angeles Los Angeles (lôs ăn`jələs, lŏs, ăn`jəlēz'), city (1990 pop. 3,485,398), seat of Los Angeles co., S Calif.; inc. 1850. , CA. Suzanne Lagarde, M.D., EA.C.E, is with the Yale University School of Medicine, New Haven, CT. Georgina I. Lucas, M.S.W., is with the Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, New Haven, CT. Leslie A. Curry, Ph. D., M.EH., is with the Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Public Health The Yale School of Public Health was founded in 1915 by Charles-Edward Amory Winslow.
The School of Public Health offers programs in biostatistics, chronic disease epidemiology, environmental health sciences, epidemiology of microbial diseases, global health, health , New Haven, CT. Marjorie S. Rosenthal, M.D., M.P.H., is with the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Pediatrics, Yale University School of Medicine, New Haven, CT.
DOI (Digital Object Identifier) A method of applying a persistent name to documents, publications and other resources on the Internet rather than using a URL, which can change over time. : 10.1111/i.1475-6773.2011.01330.x
Table 1: Process Used to Guide Implementation of a Navigated Care Model to Expand Access to Specialty Care for the Uninsured Steps CBPR Principle Tasks 1. Assess the scope Build on strengths and * Identify and of the problem resources within the describe target community population * Understand community perceptions about access * Define wait-times for specialty care 2. Engage key Invest in long-term * Engage leaders stakeholders and robust representing the relationships with uninsured communities partners in New Haven * Engage a volunteer core of private and hospital-based physicians 3. Define project Foster co-learning and * Learn community's goals capacity building prior experience with among all partners efforts to improve access * Learn from similar models 4. Establish Integrate and achieve * Align research goals evaluation and a balance between with program research agenda knowledge generation evaluation and quality and intervention for improvement goals mutual benefit of all * Establish database partners * Early assessment of enrolled patients' health and healthrelated needs 5. Disseminate Disseminate results to * Consider research findings all partners and professional and lay involve them in the media for dissemination process disseminating results * Ensure that findings are in plain language * Develop website * Develop policy briefs * Reports to funders and other stakeholders Steps Data Source 1. Assess the scope * Policy briefs; community needs of the problem assessments * Administrative books and databases * In-depth interviews 2. Engage key * In-depth interviews stakeholders * Debriefing of meetings and community presentations * Literature review 3. Define project * In-depth interviews goals * Surveys 4. Establish * In-depth interviews evaluation and * Site visit research agenda * Literature review * Surveys 5. Disseminate * Input from stakeholders on type research findings and presentation of data Table 2: Baseline Characteristics of First 46 Patients Enrolled in PA-NH Number (%) Demographics Age (mean [+ or -] SD) 42.8 [+ or -] 13.1 years Gender (%female) 23 (50.0%) Race White 5 (10.9%) Black 6 (13.0%) Asian 1 (2.2%) Ethnicity Latino/Hispanic 35 (76.1%) Education No or some high school 23 (50.0%) High school 16 (34.8%) Any college 7 (15.2%) Employment/assistance Current employment Not working 23 (50.0%) Part time 18 (39.1%) Full time 5 (10.9%) Among working patients, employer offers insurance (n = 23) 4 (17.4%) Public assistance received in the past 12 months * None 24 (52.2%) Food stamps 9 (19.6%) Cash assistance (Welfare) 1 (2.2%) Women infants and children (WIC) 9 (19.6%) Unemployment 7 (15.2%) Disability 2 (4.31%) Health insurance Ever had health insurance 16 (34.8%) Among those with prior health insurance, period without insurance (n = 16) <3 months 0 (0%) 3-6 months 2 (12.5%) 6-12 months 1 (6.3%) 1-3 years 7 (43.8%) >3 years 6 (37.5%) Reason for being uninsured * Not working 18 (39.1%) Cannot afford premiums 22 (47.8%) Company does not offer 10 (21.7%) Have not had health problems/need 0 (0%) Preexisting condition 1 (2.2%) Do not know how to get insurance 0 (0%) Works part time 1 (2.2%) Other 9 (l9.6%) Current health needs Type of specialty service needed 1. Gastroenterology 2. Urology 3. Cardiology 4. Orthopedics 5. ENT Amount of time with current complaint <1 month 10 (21.7%) 1-3 months 10 (21.7%) 3-6 months 6 (13.0%) 6-12 months 2 (4.3%) >1 year 18 (39.1%) Health status Number of days missed from work/activities in past 30 days due to illness 0 10 (21.7%) 1-6 14 (30.4%) >7 21 (45.6%) Comorbid medical conditions * Hypertension 13 (28.3%) Diabetes 7 (15.2%) Hypercholesterolemia 11 (23.9%) Asthma 3 (6.5%) Depression 2 (4.3%) Arthritis 0 (0%) Coronary heart disease 2 (4.3%) Chronic lung disease (COPD) 1 (2.2%) Cancer 2 (4.3%) Stroke 1 (2.2%) Autoimmune/inflammatory disease 2 (4.3%) None of the above 22 (47.8%) Health care utilization Usual source of care * Clinic/health center 39 (84.8%) Private office 2 (4.3%) Emergency department 2 (4.3%) None 3 (6.5%) Is there one doctor or health professional you usually see? Yes 29 (63.0%) No 17 (37.0%) In past 12 months, number of emergency department visits ([double dagger]) 0 31 (67.4%) 1-3 10 (21.7%) >4 3 (6.5%) In past 12 months, number of hospitalizations 0 40 (87.0%) 1-3 6 (13.0%) >4 0 (0%) In past 12 months, number of times desired to see a doctor but did not ([double dagger]) 0 21 (45.7%) 1-5 20 (43.5%) >6 4 (8.6%) In past 12 months, ease of getting desired care Easy 11 (23.9%) Somewhat easy 9 (19.6%) Somewhat difficult 17 (37.0%) Difficulty 9 (19.6%) Ever avoided health services due to cost Yes 32 (69.6%) No 14 (30.4%) Ever not taken a prescription medication because of cost Yes 20 (43.5%) No 26 (56.51%) Barriers to seeing physician Transportation 12 (26.1%) Work schedule conflicts 6 (13.0%) Cost 24 (52.2%) Language barrier 12 (26.1%) Child care 3 (6.5%) Do not know how to get appt 1 (2.2%) None 12 (26.1%) Notes. * Categories not mutually exclusive; percentages may not sum to 100%. ([double dagger]) Due to missing data, percentages may not sum to 100%.