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PubMed2001

A comparison of unmet needs for dental and medical care among persons with HIV infection receiving care in the United States.

OBJECTIVE: Oral health conditions associated with HIV disease are frequently more severe than those of the general population, making access to both dental and medical care important. Using the domains specified in the Behavioral Model of Health Services Use, this paper examines the correlates of unmet needs for dental and medical care in a nationally representative sample of patients with HIV. METHODS: This investigation is a cross-sectional study using baseline data from the HIV Cost and Services Utilization Study (HCSUS), the first nationally representative study of persons in care for HIV. Using probability-based techniques, 4,042 people were randomly selected in January 1996, and 2,864 (71%) completed a structured interview that included questions on unmet needs for dental and medical care. Regression analysis was used to identify variables associated with having unmet needs for dental care only, medical care only, and both medical and dental care. RESULTS: Of the estimated 230,900 people in treatment for HIV in the United States, approximately 58,000 had unmet medical or dental needs based on self-reported data. Unmet dental needs were more than twice as prevalent as unmet medical needs (32,900 vs 14,300), and 11,600 people were estimated to have both types of unmet needs. Multinomial logit regression showed that persons with low income had increased odds of reporting unmet needs for both dental and medical care. The uninsured and those insured by Medicaid without dental benefits had more than three times the odds of having unmet needs for both types of care than did the privately insured. CONCLUSIONS: To serve both the dental and medical needs of diverse populations affected by HIV disease, greater coordination of services is needed. In addition, state insurance programs for people with HIV should consider the feasibility of expanding their benefit structure to include dental care benefits.

Adult↗
PubMedDate not supplied

Columbia University's Informatics for Diabetes Education and Telemedicine (IDEATel) Project: rationale and design.

The Columbia University Informatics for Diabetes Education and Telemedicine (IDEATel) Project is a four-year demonstration project funded by the Centers for Medicare and Medicaid Services with the overall goals of evaluating the feasibility, acceptability, effectiveness, and cost-effectiveness of telemedicine in the management of older patients with diabetes. The study is designed as a randomized controlled trial and is being conducted by a state-wide consortium in New York. Eligibility requires that participants have diabetes, are Medicare beneficiaries, and reside in federally designated medically underserved areas. A total of 1,500 participants will be randomized, half in New York City and half in other areas of the state. Intervention participants receive a home telemedicine unit that provides synchronous videoconferencing with a project-based nurse, electronic transmission of home fingerstick glucose and blood pressure data, and Web access to a project Web site. End points include glycosylated hemoglobin, blood pressure, and lipid levels; patient satisfaction; health care service utilization; and costs. The project is intended to provide data to help inform regulatory and reimbursement policies for electronically delivered health care services.

Case Management↗
PubMed2006

Who serves the underserved? Predictors of physician care to medically indigent patients.

Using a national sample of 466 doctors, this work is the first to determine how sociodemographic characteristics, family lives, educational experiences and work environments combine over the life course to shape physician attitudes and behaviors toward serving the medically indigent. Survey data reveal that most physicians have positive experiences with indigent patients, and feel responsible for providing care for the needy. On average, one-quarter of doctors' patients are medically indigent, and physicians provide six hours of charity care per week. Multivariate regression and path analyses indicate that disparate social forces predict humanitarian attitudes and behaviors of physicians. Physician attitudes toward the indigent are shaped largely by socializing forces, including medical education and relationships with mentors. In contrast, care of indigent patients is driven by physician attitudes and by characteristics of medical practice such as specialty and practice setting. Implications for scholarship and for medical education, practice and health policy are discussed.

Adult↗
PubMed2003

Health concerns and learning styles of underserved and uninsured clients at a nurse managed center.

The medically underserved and uninsured often seek care for immediate health concerns rather than use health promotion activities. To facilitate health promotion activities, it is important to understand the health concerns and learning styles of these underserved clients. The purpose of this descriptive study was to assess specific health concerns and identify learning styles of clients seeking care at a nurse managed center. Eighty-two participants completed the Hilltop Health Questionnaire, a self-report instrument developed by the research team. Top reasons for seeking care included upper respiratory infections (17%), routine physical (17%), medication refill (12%), and low back pain (11%). Preference for learning style included hands-on instruction (82%), reading (63%), and listening (59%). These data were used to obtain or customize teaching modules based on the clients' health concerns and preferred style of learning. Continued emphasis should be placed on health education that engages the underserved and uninsured in their care and health promotion activities.

Adult↗
PubMed2006

A dose of reality: assessing the Federal Trade Commission/Department of Justice report in an uninsured, underserved, and vulnerable population context.

Despite the size of their report, the Federal Trade Commission and Department of Justice pay virtually no attention to tens of millions of uninsured and underinsured persons. By focusing on an increasingly rarified group of health care customers--healthy, affluent, and highly insured--the report takes on an untethered quality, with only the slightest tip of the hat to its own limitations. Furthermore, the report overstates the extent of legal constraints on the market, in particular, the degree to which the market is free to select its customers and tailor its goods and services to the best risks. By miscasting the legal context of the American health care system, the report ultimately undermines much of its potential value.

Delivery of Health Care↗
PubMed1996

Community health clinics under managed competition: navigating uncharted waters.

In this article, we consider how major changes in the health care system, both real and proposed, may affect the future of community health clinics (CHCs) in the United States and their ability to continue to provide comprehensive care to underserved populations. We discuss the constraints and opportunities that CHCs face in a health care system that is rapidly moving away from fee-for-service medical care toward a model of managed competition. We describe the role that the National Association of Community Health Centers has played in advocating for CHCs in Congress and the role state primary care associations are playing in spear-heading the development of statewide CHC-sponsored health maintenance organizations. We also analyze CHC reactions to the changes in federal policies that were proposed in the major health care reform bills of the 103d Congress, as well as the prospects for CHCs under Medicaid managed care as it sweeps rapidly across the nation. As a case study, we examine California's policies that mandate that Medicaid recipients enroll in either a private managed care plan or a newly created public plan, which compete against each other within each county. CHCs are vulnerable during the transition to managed care and managed competition, and they have neither the resources nor the ability to integrate or compete successfully with private health maintenance organizations without safeguards, new sources of funding, technical assistance, improved infrastructure, and vigorous monitoring and oversight from federal and state governments, as well as the continued education, training, and policy advocacy provided by the National Association of Community Health Centers and state primary care associations.

California↗
PubMed2006

Mandating education of dental graduates to provide care to individuals with intellectual and developmental disabilities.

In 2004, The Commission on Dental Accreditation adopted new standards for dental and dental hygiene education programs to ensure the preparation of practitioners to provide oral health services for persons with special health care needs. The course of action leading to the adoption of the new standards, together with the continuing obstacles of limited government support for dental services and the availability of faculty members to provide the needed dental educational experiences is reviewed. Expanding Health Resources and Services Administration definition of medically underserved areas is presented as one approach to improving the delivery of dental services.

Accreditation↗
PubMed2006

Community health center integration: experience in the State of Ohio.

In the face of severe financial challenges and demands to improve quality and service to patients, many community health centers (CHCs) have aligned or integrated with other CHCs, physician groups, or hospitals. Yet the nature of and rationale for these organizational decisions are not well understood. Our research applied an organizational theoretical framework to test whether strategic adaptation theory or institutional theory best describes the integration activity of CHCs in Ohio. We collected primary data from case studies of seven CHCs selected for geographic representation and studied December 2000-January 2001. Semi-structured interviews and a case study database supported our chain of evidence. We found that CHC integration activity was substantial (five of seven CHCs integrated) and extremely varied. Consistent with strategic adaptation theory, we determined that CHC integration actions were predominantly center-specific, rational responses to environmental challenges and were initiated to improve operations or financial performance. Rarely did CHCs initiate major organizational change merely to mimic other CHC actions, as might have been expected of highly institutionalized organizations. Understanding the basis for CHCs' strategic decisions while monitoring financial health will remain critical as lawmakers and administrators work to develop policies that both maintain progress made and improve primary care access for the poor, the uninsured, and those with special health care needs served by these important safety net providers.

Community Health Centers↗
PubMed2006

Colorectal cancer screening among the medically underserved.

Prevalence of physician recommendation and patient completion of colorectal cancer screening was investigated among Federally Qualified Health Centers (FQHC) serving low-income neighborhoods in Chicago. Medical records of 3,416 patients receiving primary care services at 1 of 31 FQHCs were randomly chosen for review. In all, 642 patients were identified by age and family history as eligible for colorectal cancer screening and included in this study. Patient demographic information and colorectal cancer screening history were collected. The physician screening recommendation rate was 9.2% (n=59); 7.0% (n=45) of patients were determined to have been appropriately screened for colorectal cancer, primarily by Fecal Occult Blood Test (94.1%, n=43). Among patients who received a recommendation from their physician, 76.2% had completed a screening test. Older patients were more likely than their younger counterparts to have received a recommendation from their physician (p<.05) and to have been screened (p<.01). Organizational interventions are needed to support physicians in medically underserved areas and to promote recommended screening practices.

Aged↗
PubMed2006

The medically underserved: who is likely to exercise and why?

Adults who exercise regularly have better health, but only 15% of U.S. adults engage in regular exercise, with some social groups, such as people with lower incomes and women, having even lower rates. This study investigates the rate at which medically underserved patients receive exercise counseling from health care providers, characteristics of those who exercise, and barriers and motivations to exercise. The convenience sample was predominantly female and White and exclusively low-income and uninsured or underinsured. On average, participants were obese, by Federal Obesity Guidelines; 43% smoked. Although 60% of 126 patients reported that providers discussed exercise with them, the discussions had no relationship with patients' engagement in exercise. Women and those with lung problems, diabetes, or children in the home were less likely than others surveyed to exercise. The highest rated motivations included body image and health issues. The most important barriers were time, cost, and access to exercise facilities and equipment. In order for exercise counseling to be more effective, health care providers' interventions must consider patients' personal characteristics, health status, readiness to engage in an exercise program, and motivations and barriers to exercise.

Adolescent↗
PubMed2006

Emergency room use and access to primary care: evidence from Houston, Texas.

To cope with the rising number of uninsured, communities around the country are pursuing a variety of strategies to expand local health care safety nets. One measure that has been suggested to evaluate what is working is primary care-related emergency department (ED) visits. In this paper, we evaluate the applicability of this measure as an access indicator by examining its correlation with other indicators of medical under-service. We obtained ED visit data from safety net hospitals in Houston, Texas and applied the New York University ED Algorithm to estimate the rate of visits that were primary care-related. We then examined at the ZIP code level the correlation of primary care-related ED visits per 1,000 population with the federal government's Index of Medical Underservice (IMU), the poverty rate, and the uninsurance rate. Primary care-related ED visits were found to be weakly correlated with the IMU and strongly correlated with the rate of uninsurance and poverty. These findings suggest that the combination of this indicator with other measures of access could be used to monitor and evaluate local initiatives designed to expand care and coverage to the medically underserved.

Emergency Service, Hospital↗
PubMed2005

High prevalence of overweight among pediatric users of community health centers.

OBJECTIVE: With the increasing prevalence of pediatric obesity, it is important to identify high-risk populations of children to direct limited resources for prevention and treatment to those who are most vulnerable. The objectives of this study were to determine the prevalence of overweight in children who are clients of community health centers in medically underserved areas of the Health Resources and Service Administration regions II and III (Mid-Atlantic and Puerto Rico), compare this prevalence to nationally representative data, and contrast prevalence data between geographic areas and racial/ethnic groups. METHODS: The charts from a representative sample of 2474 children using 30 community health centers in 2001 were abstracted to collect clinically measured weight and height. Overweight was defined as a body mass index of > or =95th percentile of a reference population. To generate an unbiased estimate of overweight, multiple imputations were used for missing data. These data were compared with the 1999-2002 National Health and Nutrition Examination Survey. RESULTS: The prevalence of overweight was elevated in this sample of children aged 2 to 5 years (21.8%; 95% confidence interval [CI]: 19.1-24.8) and 6 to 11 years (23.8%; 95% CI: 16.9-27.7) compared with the 1999-2002 National Health and Nutrition Examination Survey (10.3% and 15.8%, respectively). No significant differences in prevalence were observed between Asian American (18.2%; 95% CI: 11.2-28.3), Hispanic (24.6%; 95% CI: 21.3-28.2), non-Hispanic black (25.6%; 95% CI: 20.8-30.9), and non-Hispanic white (22.8%; 95% CI: 19.0-27.0) children. Furthermore, no differences in prevalence were observed between children using community health centers in continental urban (23.7%; 95% CI: 20.6-27.2), suburban (24.0%; 95% CI: 20.0-28.5), or rural (22.9%; 95% CI: 19.3-26.9) areas. CONCLUSIONS: The present study identified a population of children at particularly high risk for obesity based on the type of health care delivery system they use regardless of race/ethnicity or geographic characteristics. Because community health centers are experienced in prevention and serve >4.7 million children in the United States, they may be a particularly promising point of access and setting for pediatric obesity prevention.

Child↗
PubMed1994

Commentary: Lessons from Medicaid--improving access to office-based physician care for the low-income population.

Medicaid offers important lessons about providing access to office-based physician services for the poor. First, differentials in physician fees between Medicaid and other payers compromise access to care and are difficult to reverse. Second, managed care alone is not enough to attain equity in access, especially if differentials in payment rates between Medicaid and private patients in managed care settings are allowed to grow. Finally, financing strategies alone are not sufficient to resolve the shortage of health care providers in medically underserved areas. In these areas, payment policy must be combined with resource development to ensure that vulnerable populations have access to care.

Health Policy↗
PubMed2002

A "health commons" approach to oral health for low-income populations in a rural state.

Oral health needs are urgent in rural states. Creative, broad-based, and collaborative solutions can alleviate these needs. "Health commons" sites are enhanced, community-based, primary care safety net practices that include medical, behavioral, social, public, and oral health services. Successful intervention requires a comprehensive approach, including attention to enhancing dental service capacity, broadening the scope of the dental skills of locally available providers, expanding the pool of dental providers, creating new interdisciplinary teams in enhanced community-based sites, and developing more comprehensive oral health policy. By incorporating oral health services into the health commons primary care model, access for uninsured and underserved populations is increased. A coalition of motivated stakeholders includes community leaders, safety net providers, legislators, insurers, and medical, dental, and public health providers.

Adult↗