Health services utilization, satisfaction, and attachment to a regular source of care among participants in an urban health provider alliance.
Tataw, David B. ; Bazargan-Hejazi, S. ; James, F.W. 等
BACKGROUND
Introduction
The difficulty in navigating a fragmented United States health
system is exacerbated in vulnerable urban communities where resources
are limited, barriers to health services access are numerous, knowledge
of preventive techniques is lacking, awareness of existing services is
limited and primary and specialty health services are often not
coordinated. Enabling community access sometimes requires community
efforts and community partnerships that will provide seamless access and
empower vulnerable consumers in urban communities to utilize existing
health resources.
Collaborative relationships have become a common phenomenon in
medical and public health for social change (Greenberg et al. 2003;
Rousos & Fawcett, 2000; Sullivan & Kelly, 2001). The South
Central Los Angeles Health Care Alliance (SCHCA) was a strategic
initiative between The Charles R. Drew University Department of
Pediatrics at King /Drew Medical Center, an academic medical
institution, and St. John's Well Child Center, a community primary
care provider. This strategic initiative was designed to facilitate the
delivery of a coordinated continuum of health services for children and
families living in South Los Angeles. The South Central Los Angeles
Health Care Alliance was a partnership created to improve health care
access, knowledge of preventive health practices and maximum utilization
of available health resources by residents of South Los Angeles. This
improvement was facilitated through the creation of a medical home for
each child in conformity with the six recommended services of the
American Academy of Pediatrics encompassing preventive care, acute care,
continuity of care, specialty referrals, interaction with school and
community, and maintenance of a database with a child's pertinent
medical information (AAP,1992). The South Central Los Angeles Health
Care Alliance also used mid-level providers (Physician Assistants and
Nurse Practitioners) at both the primary care and sub specialty
pediatric settings. Though many studies have demonstrated the successful
use of mid level providers such as Physician Assistants and Nurse
Practitioners in primary care (Lemley & Marks, 2009, Hunter et al.,
2009); emergency care settings (Ducharme et al., 2009); and for special
procedures such as abortion (Berer, 2009); the authors are not aware of
studies which have reported or evaluated the use of midlevel providers
to provide pediatric sub-specialty services.
The purpose of this study is to examine and report on the effect of
the South Central LosAngeles Health Care Alliance (SCHCA) on service
utilization, satisfaction , self efficacy, and attachment to a regular
source of care for participating children and their families.
Self-efficacy refers to the state of competence to perform certain
desired tasks or behavior. Satisfaction with health services refers to
the extent to which the patient is comfortable with, or accepts the
services of a health provider. Though entrance into the health care
system does not guarantee the quality of health services or the
elimination of unmet needs, a child who is not attached to a source of
care can not have any of their needs met. Satisfaction , self efficacy,
and social support/service coordination are important constructs for
health services scholars and practitioners because they have been linked
to one another as well as to health and clinical outcomes. Satisfaction
with health care is an important quality measure because satisfaction
has been linked to health status and clinical process outcomes including
compliance to medical treatment, prevention interventions, and
improvements in health conditions (Cameron, 1996; Hall et al., 1998;
Deyo & Diehl, 1986; Winefield et al., 1995; Redekop et al., 2002;
Alazri & Neal, 2003). Studies also tie self efficacy to compliance
with therapy regimens and positive coping styles. SoEderlund &
Lindberg (2001) showed that self efficacy is related to patients'
use of different coping styles. Patients with high self efficacy
reported less use of "maladaptive" and passive coping styles
than patients with low self efficacy.Non-adherence has also been
associated with personal factors such as self-efficacy and interpersonal
factors such as provider-patient relationship (Remien et al., 2007).
Adherence is associated with patients' self-efficacy regarding
their medical regimen (Atkinson et al., 2008), which in turn is
associated with their social support (Atkinson et al., 2008; Knoll et
al., 2009). Self efficacy has been shown to be a predictor of
satisfaction (Tataw, Bazargan-Hejazi, Patel, 2009). Also, coordination
across settings has been shown to affect patients' clinical
outcomes and satisfaction with their care (Weinberg et al., 2007).
The empowerment of vulnerable individuals entails the matching of
"multiple determinants of health with multiple interventions or
sources of support (Green & Kreuter, 1999), such as education and
ecological factors (social, political, economic, organizational, policy,
and regulation). Penchansky and Thomas (1981), conceive access as the
fit in the characteristics and expectations of providers and clients.
Their discussion of the A's of access to care: affordability,
availability, accessibility, accommodation, and acceptability covers
cost of care, provider resources to meet consumer's needs, ease of
physical contact between consumers and providers, and the extent to
which the consumer is satisfied or comfortable with provider services.
Improving the provider-patient fit is at the center of the SCHCA
program.
Needs Assessment
Just as it is widely documented in the literature, the needs
assessment for the South Central Los Angeles Health Care Alliance
(SCHCA) project reflected low utilization patterns among low income
children. Regardless of insurance coverage, low-income children and
children with special needs have been found to have high levels of unmet
needs (Janicke, Finney & Riley, 2001, Newacheck, Hughes &
Stoddard, 1996, Melnick et al., 2002, Newacheck, Hung & Wright,
2002); and experience poorer quality of primary care (Stevens &
Shi,2002a,b, 2003). Parents' self-confidence to voice concerns
(Janicke & Finney, 2003, McCarthy et al., 2003); language barriers
(Seid, Stevens &Varni, 2003, Weech-Maldonado et al.,2001; 2003);
parents' perception of having a regular provider (Weech-Maldonado,
2001); and satisfaction with care (Stevens & Shi 2002a, Christakis
et al.,2002, Baltutis & Morgan, 2002); allimpact parents'
primary care utilization behavior.
Two needs assessments implemented via the Los Angeles County Survey
of 2000, and three focus groups organized by the Department of
Pediatrics at Charles Drew University in 1997, involving groups drawn
from 10,915 students, parents, school officials and other community
members within South Los Angeles ; identified the following top critical
health and health care needs : low levels of health services
utilization, limited knowledge of identification and prevention of
common diseases, lack of patients' voice, lack of specialty care,
lack of knowledge of available services to children and adults, lack of
health education, substance use problems in families, lack of positive
parental involvement in child development, domestic violence, fear of
being turned in if services are accessed due to immigration status, lack
of access to vision dental care, mental health care and immunizations,
lack of knowledge regarding identification and treatment of
Tuberculosis, lice, ringworm, scabies, need for strong school based
health education and resource program for the parent, and lack of
referral to pediatric acute care and subspecialty care.
THE SOUTH CENTRAL HEALTH CARE ALLIANCE (SCHCA)
The South Central Los Angeles Health Care Alliance was an
initiative between an academic medical institution and a community
primary care provider for the delivery of a coordinated continuum of
health services to children and families living in South Central Los
Angeles implemented from January 2002 to December 2004. The project was
implemented through the creation of a medical home for each child in
conformity with the six recommended services of the American Academy of
Pediatrics as mentioned above (AAP, 1992).The Alliance created a
"one-stop" medical home which enrolled children and families
in health programs for which they qualified , attached families to
medical homes, provided primary care to children, referred families to
specialty services as needed, provided clinic-based health education to
families, provided case management support in order to empower families
to navigate the health care system, and utilized mid-level providers in
pediatric primary care and subspecialty settings.
Expected Outcomes of SCHCA
The specific aim of this study is to examine and report the effect
of the South Central Los Angeles Health Care Alliance (SCHCA) on service
utilization, satisfaction, self efficacy, and attachment to a regular
source of care for participating children and their families. Parents
and/or children who participated in the South Central Health Care
Alliance project would demonstrate improved knowledge of existing health
services, improved knowledge of preventive health practices, improved
self-efficacy in preventive practices and utilization of health
services, and improved utilization of existing health services including
successful completion of specialty care referrals. Participants would
also exhibit improved skills in the identification and self-management
of health conditions.
Conceptual Framework
The South Central Health Care Alliance is a variation of the
Preventive Health Education and Medical Home Project (PHEMHP) which is a
contextual and predictive health services utilization improvement
approach designed by faculty in the Department of Pediatrics at Charles
R. Drew University (Tataw, James, Bazargan, 2009). A key focus of the
Preventive Health Education and Medical Home Project is the
strengthening of the fit between provider and client characteristics.
This is done by coordinating and maximally utilizing existing health and
medical services within the community for improving the health of a
child. This task is accomplished by being an information resource,
providing health education, engaging a network of providers and
community volunteers, and focusing on establishing a medical home for
the child and family (Tataw, James, Bazargan, 2009). The alliance
provided a one stop medical home consisting of primary care and
specialty pediatric services centered on consumer advocacy and
empowerment; and implemented within a network of community
collaborators.
METHODS AND PROCEDURES
Target Population and Setting
The Department of Pediatrics was an academic department at Charles
R. Drew University and a clinical service of the Los Angeles County
King/Drew Medical Center. At the time of SCHCA implementation (January,
2002- December, 2004), the Department of Pediatrics operated a
comprehensive secondary and tertiary pediatric service at the King/Drew
Medical Center including a 24-hour pediatric service for acute care.
Sub-specialty services included adolescent Health and Medicine, Allergy
Immunology, Child Development, Critical Care Medicine, Cardiovascular
Health and Medicine, Endocrinology, Gastroenterology, General
Pediatrics, Infectious Disease, Neonatology, Nephrology, Hematology, and
Emergency Medicine. Inpatient services included Neonatal Intensive Care
Unit, Medical Unit, Pediatric Intensive Care Unit and Acute Care Nursery
Unit. Outpatient services included Pediatric Ambulatory Care, Pediatric
Emergency Care and Sub Specialty Clinics covering all the Physician
Services mentioned above. Special Programs included Multidisciplinary
screening services and OASIS Clinics which targeted AIDS related
complications.
St. John's Well Child Center provided a full range of
pediatric primary care services at two clinics. These services included:
complete physical examinations, including hearing, vision and
tuberculosis tests; immunizations for such common childhood diseases as
diphtheria, pertussis, tetanus (DPT), measles, mumps, rubella (MMR),
polio, H-influenza and hepatitis; pharmaceutical services; expanded care
and treatment; primary dental services and dental hygiene and health
education which had as its primary focus nutrition, oral care, and
detection of lead exposure.
Both St. John's Well Child Center and the Department of
Pediatrics at Charles R. Drew University served the South Los Angeles
region, covering the communities of Compton, Crenshaw, Lynwood,
Paramount, South Central Los Angeles and University area. This is the
service area of Charles R. Drew University and King/Drew Medical Center.
The service community covers 124.2 square miles of the County of Los
Angeles with an estimated population of 1.7 million. The population of
children in the service area is estimated at approximately 727,000 in a
total population of approximately 1.7 million. The demographics are as
follows: 30% African American, 67% Hispanic and 3% Asian/Other (U.S
Census Bureau, 2002. Forty percent are at poverty rate, 95% of the
children receive subsidized school lunch, 71% rent their primary
residence, less than 10% have a college education or degree, and 50%
have not completed high school (LACDHS, 2000). The children have the
lowest scores in Los Angeles County on the Stanford test, and Scholastic
Aptitude Test (SAT) scores are below the district average. Prevalence
and intensity of disease is the highest in the county of Los Angeles.
Health problems of concern to children in these areas include diabetes,
obesity, asthma, childhood lead poisoning and low immunization rates
(United Way, LA, 2000).
Program Design
The South Central Los Angeles Health Care Alliance was implemented
using a prospective quasi experimental design with three intervention
sites (St. John clinic located at down town Los Angeles; St. John clinic
located in Compton, and King/Drew Medical Center pediatric sub-specialty
site. The project also included many community-wide outreach activities.
The project was implemented from January 2002 to December 2004.
The Alliance (i.e. SCHCA) created a "one-stop" medical
home which enrolled children and families in health programs they were
qualified for, attached families to medical homes, provided primary care
to children, referred families to specialty services as needed, provided
clinic- based health education to families, provided case management
support to families as they learned to navigate the health care system,
and utilized mid-level providers in pediatric primary care and
sub-specialty settings.
During a primary care clinic intake, written or verbal consent from
the parents were obtained and children were screened using California
and American Academy of Pediatrics well-child care standards. Based on
the outcome of the initial screening, enrollees were provided with
treatment, and clinic based education, as well as referral to any needed
sub-specialty services. They were also mentored through non-clinical
case management while navigating subspecialty services.
From December 1 to 31, 2003 we conducted telephone interviews with
the parents of children who received both primary care services at St.
John's Well Child Center and pediatric sub-specialty care at
King/Drew Medical Center Department of Pediatrics from January 2002 to
November 2003. The survey instrument included 30 items using 5-point
Likert scale response categories to assess parent's perceptions of
their children's difficulties in accessing primary and pediatric
services as well as satisfaction with medical services. It also included
items to assess parents' satisfaction with services provided by
their child's sub-specialty health provider. Other data on
community outreach, source of referral to primary care services,
enrollment to payer sources, attachment to medical homes, wait time in
completing appointments, and sub-specialty appointment completion rates
were collected and stored in the program database.
Recruitment and Selection
Community outreach. Trained Community Health Workers conducted
outreach activities involving community education which consisted of an
awareness/notification campaign. These workers were equipped with a
resource manual to inform the community about the benefits of receiving
healthcare, the availability of health services at St John's Well
Child Centers, and sponsoring/insurance programs for children's
health services. The Community Health Workers attended parents and
teachers meetings, participated in health fairs, collaborated with
other community agencies and churches, and distributed printed health
materials at shopping malls.
SCHCA participation eligibility..To be able to enroll in the
program, parents/guardians had to meet the following criteria: (1) have
a child between the ages of 0-18 or are adolescents; (2) reside within
the geographic area of South Los Angeles; (3) provide consent signature
or verbal consent indicating that they were aware of the objectives of
the program and were willing to be a part of it; (4) had no definite
plans to leave the area in the next year.
Intervention Components
The program was made up of four intervention components: health
assessment and medical treatment; clinic-based education; sub-specialty
fast-track referral and non-clinical case management.
health assessment and medical treatment. This was conducted in the
Medical Home, which was the central site of coordination of all aspects
of the patient's medical care. The Medical Home for the patients in
SCHCA was St John's Well Child Center. The SCHCA utilized Physician
Assistants at both Primary and Sub-specialty sites
clinic-based education. Clinic-based education was provided by the
primary care provider when the patient's health assessment and
condition deemed it necessary. Decisions on the type and topics of
health education were made after the patient's initial health
screening at the intake.
A "fast-track" referral system between primary and
sub-specialty sites. This system was created to shorten the waiting time
between the child's first encounter with a primary care source or
the emergency room to when he/she would receive sub-specialty care at
the King/Drew Medical Center. The St. John's Well Child clinic(s)
would refer patients in need of specialty care to the Pediatric
subspecialties at the King/Drew Medical Center where St. John's
clinic(s) were listed as the preferred community providers. The Alliance
staff stationed at the Department of Pediatrics, from that point on,
facilitated smooth transition and communication between the
Department's subspecialty services, primary care providers and the
patients.
non-clinical Case management. Non-clinical case management for
parents was implemented by the community health workers. Community
health workers were drawn from the same community as the participants
and had an average educational level of an associate degree. They had no
formal clinical training but received training on specific disease
conditions and in case-management techniques. SCHCA case management was
made up of assessment/screenings, referrals, service coordination,
individualized planning, coaching, monitoring, and third party advocacy
for the purpose of maintaining a continuum and a regular source of care.
This approach is distinct from clinical case- management which includes
treatment plans and implementation and is usually physician driven and
nurse implemented (Huber 2000, Birmingham & Colon, 2005).
EVALUATION MEASURES
Data were collected to assess the impact of the program on
participants' attachment to a regular source of care and existing
payer source; utilization of primary and specialty care; and
satisfaction with pediatric sub- specialty care provided by a Physician
Assistant versus a physician (MD). A 30 item parent survey instrument
was administered in the second year of the program. Items in the survey
assessed parent's perceived difficulty in accessing primary and
subspecialty pediatric services. Parents were asked to respond on a
5-point Likert scale (extremely difficult.... not difficult at all)
stating how difficult it was for them to get: medical care; routine
checkup; referral for subspecialty care; and an appointment with a
pediatric sub-specialist. Using a 5-point likert scale, participating
parents were also asked to respond how satisfied they were with the
services received. (Extremely satisfied.... not satisfied). The survey
instrument also assessed consumer satisfaction with specialty services
provided by the Physician Assistant in comparison to the Physician (MD).
In this section of the survey, parents were asked to rate their
satisfaction with subspecialty providers in terms of the overall
services received, friendliness of the provider, helpfulness of provider
, time spent with provider, provider's explanation of health
condition, provider's explanation of treatment, and provider's
respect for parents. In the years 2002, 2003, and 2004, a patient
database was used to collect service utilization and financial data
including number of children attached to medical homes, number of
outreach activities to children and families, number of children
enrolled in existing payer sources, number of patients receiving clinic
based education, number of sub-specialty referrals, number of completed
sub-specialty referrals and the interval between the time a
sub-specialty appointment was made and the visit was completed. Data
entered into the data base was retrieved from numerous operational and
administrative tracking instruments and reports at both the primary and
specialty care sites.
RESULTS
Table one below presents the number of children attached to medical
homes, number of children reached through outreach activities,
sub-specialty services completion rate, average length of time it takes
to complete sub-specialty appointments and number of children attached
to existing payer sources. After two years of community outreach
services, 404 outreach events were completed reaching 11,533 children.
Two years of community outreach efforts led to 80,000 children (10% of
the children in the service area) ,who previously did not have a regular
source of care being attached to a medical home and 8,545 children being
enrolled in available payer sources. The growth in new patients for the
down town Los Angeles primary care location averaged 50 % in the first
two years before leveling off in the third year. In the Compton primary
care location, the growth was about 200% annually. A bonus to the
program was the linkage of 20,000 adults to medical homes in the last
two years of the program. Sub-specialty referral completion rate
increased from 25% in 2001 to 78% in 2002, and 80% in 2003 then fell to
20% in 2004. The difference between the time a pediatric sub-specialty
appointment was made and the time the patient was seen reduced from four
months in 2001 to two and a half months in 2002, and one month in 2003,
before rising to nine months in 2004.
Table 2 shows patterns of distribution among measures that were
used for program evaluation. Though some questions could have multiple
responses, participants had to select only the single response which
best represented their experience. Nearly 39% of the sample reported
having a child that required continuous medical care and the majority of
the sample used St. John's community clinic as a regular source of
care for their children (74.2%). Also, the overwhelming majority
reported that they prefer to have the same doctor for their child (84%).
In general, Table 2 reveals a positive trend in the responses of
participants. In reference to the perceived difficulty reported, the
majority of the respondents reported less difficulty to obtain medical
care (48.4%), less difficulty to obtain routine checkups for their
children (58%), and less difficulty to obtain referral (48%). Also, the
majority of the respondents reported being more satisfied with the
services received for their children including general medical care
(52%), routine checkup (48%), and were holding the same level of
satisfaction with subspecialty care in comparison to the past 12 months
(44%).
In addition, whereas the majority of the respondents reported that
making an appointment for the child to receive sub-specialty care was
less difficult compared to the previous 12 months (48%), a slightly
higher number of participants reported that wait time to receive a visit
from a sub-specialty care has been longer in comparison to the previous
12 months.
Table 3(column 1), presents participants' mean level of
satisfaction and difficulties with services received and needed across
participants who reported having a child who needed continuous medical
care with those who reported their child didn't have any health
condition that would require such care. It appears from Table 3 that,
overall, participants who reported having a child who needed continuous
medical care (column 1) compared to those who reported their child did
not need such services, reported higher levels of satisfaction with the
services received and less difficulty accessing needed services.
Furthermore, Table 3 (column 2) reveals mean differences between
the responses of those who had received medical care for their child
from a community clinic compared with those who reported receiving
medical care from other places (i.e. private doctors' office,
private medical group, hospital clinic, urgent care, and emergency
room). We detected that that those who received care from places other
than the community clinic were more likely to report difficulty with
making an appointment for their children to receive sub-specialty care
(-.14), and more likely to report that the time between receiving a
referral and seeing a sub-specialty care for their child was much longer
in comparison to the previous 12 month (-.43).
In addition, column 3 in Table 3 presents the overall mean score of
the participants regarding their perception of satisfaction with care
received and difficulties receiving services needed. The total mean
scores shows an overall positive trend in the responses of the
participants, with the exception of the item related to differences in
the time period between receiving a referral and seeing a subspecialty
care, where no change was indicated.
Lastly, we detected a positive trend in the mean score of the
parents who reported having a child who needed continuous medical care
in comparison to those who didn't report such need (2.32 vs. 2.75),
as well as a positive trend between those who use community clinic
versus those who reported using other medical care places (1.14 vs.
2.87).
Tables 4 and 5 present satisfaction with subspecialty services by
the provider types (N=71). Table 4 shows high levels of satisfaction
with both the Cardiology and Nephrology clinics. Table 5, shows the
results of the sample t-test comparing clients' satisfaction across
the services received from the Physicians and the Physician Assistants.
We were not able to detect any statistically significant differences
between the two groups. However, satisfaction based on the summated
scores for the seven items revealed that parents who receive services
from a Physician Assistant were more likely to report a slightly higher
level of satisfaction in comparison to the their counterpart who
received services from the Physician.
DISCUSSION
The South Central Los Angeles Health Care Alliance successfully
attached thousands of South Los Angeles children and their families to a
regular source of primary and sub-specialty care within a three year
period. Thousands more were enrolled in existing payment programs.
Participants in the program reported high levels of satisfaction with
the primary and sub-specialty care they received. Patients' level
of satisfaction with care did not change when sub-specialty services
were provided by a Physician Assistant. Rather, parents as a whole
reported greater levels of satisfaction with the care provided by a
Physician Assistant in comparison to a Physician.
Parents who reported taking their children to St. John Well Child
Clinics also reported reduced difficulty in obtaining a sub-specialty
appointment and a reduction in the difference between the time a
sub-specialty appointment was made and a specialist was seen, at a
statistically significant level. The survey results correspond to the
operational data patterns that showed a dramatic drop in the difference
between the time a sub-specialty appointment was made and the time the
patient saw a specialists in the first two years of the program.
Operational data also showed a dramatic increase in the sub-specialty
appointment completion rates in the first two years of the program. The
findings presented above are strengthened by the similarity of patterns
across data sources.
The data also shows a dramatic change in subspecialty outcomes in
the third year of the program. Appointment completion rates dropped to
levels lower than pre intervention years. The difference between the
times an appointment is made and when a sub-specialty is completed also
increased to pre intervention levels. This reversal of positive trends
in the third year of the program was due to the significant
institutional instability at King/Medical Center which was the only site
in the program that offered sub-specialty care. Therefore, new
sub-specialty providers were added to the sub-specialty panel even
though receiving medical services from these new sites involved greater
travel and greater wait time for the patients. This changed the
implementation design from a one subspecialty provider and one primary
care source to a multiple sub-specialty providers and one primary care
source design. This change created challenges to the program since new
sub-specialty providers were not part of the original plan, did not
follow the same protocols as the sub-specialty providers at Charles R.
Drew University and were not necessarily amenable to advocacy on behalf
of consumers in their organizations.
CONCLUSION AND IMPLICATIONS FOR COMMUNITY BASED RESEARCH AND
PRACTICE
The findings in this study add to the existing evidence in support
of the positive effects of community outreach, service coordination, and
the use of midlevel providers on health services utilization,
satisfaction with health services and self efficacy among vulnerable
populations. It introduces the successful use of Physician Assistants to
expand pediatric cardiology and pediatric nephrology services and
underscores the limitations of innovative service delivery practices in
the face of unstable and limited provider capacity in vulnerable
communities. The ability to adapt the implementation of the program to
the realities of unanticipated pediatric sub-specialty resource shortage
in South Los Angeles, speaks to the strengths of a contextual and
adaptive model- based program such as the South Central Los Angeles
Health Care Alliance. On the other hand, the delayed access to
sub-specialty care that followed the resource shortage, illuminated the
fact that even the smartest delivery system cannot overcome some of the
effects of inadequate and unstable health resources in vulnerable
communities.
The evaluation results of the South Central Health Care Alliance
above demonstrate that community outreach and coordination of services
within and between care settings can increase health services
utilization, satisfaction with health services, parent self efficacy in
navigating the health care system for their children, and service
convenience for at-risk populations. Other studies have linked
self-efficacy to social support (Atkinson et al. 2008, Knoll et al.
2009); and coordination across settings has been shown to affect
patients' clinical outcomes and satisfaction with their care
(Weinberg et al., 2007).
The results of this study also point to the potential for expanding
pediatric sub-specialty resources through the use of Physician
Assistants without undermining patient satisfaction. Other studies have
shown the successful use of mid-level providers (Physician Assistants
and Nurse Practitioners) with high levels of satisfaction and other
positive outcomes such as safety in a variety of care contexts:
including primary care settings (Lemley & Marks, 2009, Hunter et
al., 2009); emergency care settings (Ducharme et al., 2009); and in
performing special procedures such as abortion (Berer, 2009). The
authors are not aware any studies that have focused on Physician
Assistants as pediatric sub-specialty providers. If replicated with a
bigger sample, these findings could offer important practice and policy
implications for the expansion of pediatric sub-specialty resources in
low income urban communities through the use of Physician Assistants .
Expansion of sub-specialty pediatric provider resources through the use
of Physician Assistants will be more cost effective and can be achieved
in a timelier manner than policy efforts to increase the number of
physicians because it takes less time and it cost less to train a
Physician Assistant compared to a Physician.
The fact that sub-specialty care from King/Drew Medical Center
became threatened and unreliable, therefore, creating a negative trend
in the outcomes for the program during the third year of implementation,
underscores the limits to the benefits of coordination, community
outreach and other interventions in the face of scarce and fragile
provider resources in low income urban communities such as South Los
Angeles. Stable and adequate provider resources in low income urban
communities are a critical precondition if utilization-enabling
interventions are to work well. The crisis at King/Drew Medical Center
in the third year of the program revealed the risks to vulnerable
consumers when a community relies almost exclusively on a single
provider for critical services such as pediatric sub-specialty care. For
the alliance patients, trouble at the King/Drew Medical Center meant
waiting longer to access health services, higher probability of missing
appointments, or not completing specialty referrals.
Our findings are also important for institutional health providers
in low-income urban communities. Incorporating community outreach and
service coordination as a routine component of operations can improve
health services outcomes such as utilization and satisfaction. This can
be done using non-clinical case management implemented by community
health workers at lower cost than clinical staff.
LIMITATIONS
The South Central Los Angeles Health Care Alliance as a variation
of the Preventive Health Education and Medical Home Project (PHEMHP) had
a number of limitations in its intervention components and evaluation
strategies. First, the content and delivery of patient education was not
standardized so it was not clear how and what doses of patient education
were delivered to patients. Second, providers were not given any kind of
orientation as to the special needs of the population and the
expectation of the program. Third, there was no process evaluation and
the primary care settings did not receive any orientation for data
collection. These limitations were taken into consideration during the
future implementations of the Preventive Health Education and Medical
Home Project (PHEMHP) (Tataw et al. 2007; Tataw & Bazargan-Hejazi,
2010). The above limitations should also be considered by researchers
implementing interventions in collaboration with community health
providers.
Acknowledgements: This Project was supported by Unihealth
Foundation.
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DAVID B. TATAW
Indiana University, Kokomo
S. BAZARGAN-HEJAZI
F W. JAMES
Charles R. Drew University
Table 1
Four Year Summary of Program Services
2001 2002 2003 2004
Medical Homes for
Children
Down Town Location 13,753 17,983 21,665 16,099
New Patients
Compton Location New 1,869 5,898 12,740 13,224
Patients
Medical Homes for 0 2,226 17,711
Parents
Clinical-Based Health 100% 100% 100% 100%
Education
Number of Children and 0 4,855 6,678 None
Families Reached
through the Outreach
Activities
Number of Outreach 0 195 209 None
Activities
Specialty Services 25% 78% 80% 20%
Completion Rate
Average Wait Time to 4 2.1 1 9
Receive Specialty months months month months
Appointments
Healthy Family and 326 1689 2,422 4,434
MEDICAL Enrollment
Table 2
Patterns of Distributions among Measures Used to
Evaluate SCHCA (n = 71)
1. Does your child have a medical condition? %
[] Yes 38.7
[] No 61.3
2 In the past 12 months, which of the following
places did you receive most of the medical care
services for your child? 3.2
[] Private/group medical group 9.7
[] Hospital clinic 74.2
[] St John's Community clinic 6.5
[] Emergency room
3. Do you prefer to have the same doctor for your
child? 12.9
[] No 3.2
[] Doesn't make a difference 83.9
[] Yes
4. Compared to 12 months ago, how difficult is it for
you to get medical care for your child? 19.4
[] More difficult 32.3
[] Just as difficult 48.4
[] Less difficult
5. Compared to 12 months ago, how satisfied are you
with the medical care for your child?
[] More satisfied 51.6
[] Just as satisfied 35.5
[] Less satisfied 12.9
6. Compared to 12 months ago, how difficult is it for
you to get routine check up for your child?
[] More difficult 16.1
[] Just as difficult 25.8
[] Less difficult 58.1
7. Compared to 12 months ago, how satisfied are you
with your child's routine check up for preventive
care?
[] More satisfied 48.4
[] Just as satisfied 41.9
[] Less satisfied 9.7
8. Compared to 12 months ago, how difficult is it for
you to get a referral for subspecialty care for your
child?
[] More difficult 9.7
[] Just as difficult 22.6
[] Less difficult 48.4
9. Compared to 12 months ago, how difficult is it for
you to make an appointment for your child to receive
subspecialty care?
[] More difficult 12.9
[] Just as difficult 22.6
[] Less difficult 48.4
10. Compared to 12 months ago, would you say the
time period between receiving a referral and visiting
a subspecialist was:
[] Much longer 30.8
[] Just as long 38.5
[] Less longer 30.8
11. Compared to 12 months ago, how satisfied are
you with the subspecialty care for your child?
[] More satisfied 44.0
[] Just as satisfied 44.0
[] Less satisfied 12.0
12. Does your child have dental insurance now?
[] Yes 50.0
[] No 50.0
13. Did he/she have dental insurance 12 months ago?
[] Yes 43.3
[] No 56.7
14. Does your child have insurance for eye care now?
[] Yes 41.4
[] No 58.6
15. Did he/she have insurance for eye care 12 months
ago? 34.5
[] Yes 65.5
[] No
16. In the past 12 months, were you prevented from
seeking medical care because you didn't know where
to go or who to talk to?
[] Yes 6.5
[] No 93.3
17. State the place you get information about your
child's health
Word of mouth from friends or family 19.4
member 58.1
[] A health professional 3.2
[] St. John case manager -
[] Community Centers/seminar/classes 12.9
[] Newspaper/magazines/books/library 19.4
[] TV/Radio/Video -
[] Internet 6.5
[] Health fairs -
[] Church -6.5
[] Spiritual/traditional healer -
[] I don't know where to get them
18. Reported problems regarding current living
conditions
[] Having Problems with running water -
[] Having problems with sewers -
[] Having problems with heat and air-conditioning 10.0
-
[] Having problems with electricity 3.3
[] Having problems with lead paint -
[] Unsafe physical structure 33.3
[] Unsafe neighborhood
19. Reported problems in the family
[] Smoking 9.7
[] Alcoholism 6.5
[] Bad diet 32.3
[] Lack of exercise 41.9
[] Too much fighting between members of the family 12.9
21. Length of time living in the current address
[] Less than five year 77.4
[] Five or more 19.3
22.Number of adults living in the household
[] Less than five 80.6
[] Five or more 19.3
23. Number of children under the age of 18 living in
the household.
[] Two or less 36.7
[] Three or more 63.3
Table 3
Mean Changes in Perceived Satisfaction or Difficulties by
Medical Problems and Regular Visits.
Child having
medical
condition
requiring
continuing Receiving Care in
Medical care Community Clinic Overall
SURVEY ITEMS No Yes No Yes Mean
1.Difficulty to get .26 .33 .14 .33 .29
medical care
2. Satisfaction with .26 .58 .57 .33 .39
medical care
3. Difficulty to get .32 .58 .57 .38 .42
routine check up
4. Satisfaction with .37 .42 .14 .46 .39
getting routine check
up
5. Difficulty to get a .37 .42 .14 .46 .39
referral to receive
subspecialty care
6. Difficulty with .32 .42 -.14 ** .50 .35
making a subspecialty
appointment
7. Differences in the .16 -.25 -.43 ** .12 .00
time period between
receiving a referral
and seeing a
subspecialty care
8. Satisfaction with .26 .25 .14 .29 .26
specialty care
TOTAL SCORE * 2.32 2.75 1.14 2.87 2.48
-1 = Less satisfaction/more difficulty
0 = No change
1 = More satisfaction, or less difficulty
* Summated index of items (1-8) with Range score = -1, 0 +1
** Statistically significant at P= [less than or equal to].05
Table.4
Satisfaction with Provider of Sub-specialty Services
Received by Items (N-71)
SATISFACTION ITEMS %
Site Received Services -- Cardiology Clinic 69.0
Site Received Services -- Nephrology 31.0
Satisfaction With Services Received
[] Poor 31.3
[] Average 18.8
[] Excellent 50.0
Satisfaction With Provider Friendliness
[] Poor 18.8
[] Average 31.3
[] Excellent 50.0
Satisfaction With Provider Helpfulness
[] Poor 12.5
[] Average 25.0
[] Excellent 62.5
Satisfaction With Provider Time Spent
[] Not Appropriate 18.8
[] Somewhat Appropriate 62.6
[] Very Appropriate 18.8
Satisfaction With Explanation of Health
Condition
[] Poor 12.5
[] Average 50.0
[] Excellent 62.5
Satisfaction With Explanation of Treatment
[] Poor 18.8
[] Average 43.8
[] Excellent 37.5
Satisfaction With Respect Received
[] Poor 6.3
[] Average 25.0
[] Excellent 68.8
Table 5
Mean Satisfaction with Sub-Specialty Services Received by
Type of Providers.
TOTAL MD PA
SATISFACTION ITEMS MEAN MEAN MEAN
Services Received 3.19 3.0 3.0
Provider Friendliness 3.3 2.8 3.6
Provider Helpfulness 3.5 3.3 3.6
Provider Time Spent 2.5 2.3 2.6
Explanation of Health Condition 2.8 2.7 3.0
Explanation of Treatment 2.8 2.5 3.0
Respect 3.6 3.8 3.4
TOTAL SCORE * 21.7 15.00 27.00 **
* Summated index for seven satisfaction items with Range
= 7-27, and acceptable reliability alpha= .76
** Statistically significant at P= [less than or equal to].05
