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Results for “Medically Underserved Area”

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PubMed2003

The role of low-bandwidth telemedicine in surgical prescreening.

PURPOSE: Low-bandwidth, Internet-based telemedicine is an inexpensive technology that could help deliver heath care in medically underserved areas. The purpose of this study was to evaluate the usefulness of low-bandwidth telemedicine in remote surgical evaluation. METHODS: A group of surgeons and nurses traveled to Mombasa, Kenya to provide surgical assistance at the Coast Province General Hospital (CPGH). Before the visit of the surgical team, surgeons evaluated patients via low-bandwidth telemedicine. Prescreening was performed through use of an Internet-based desktop computer system that was supported technically by the Virginia Commonwealth University (VCU) Medical Informatics and Technology Applications Consortium (MITAC) telemedicine laboratory. Surgical patients were evaluated remotely regarding appropriateness of surgical intervention by reviewing e-mails that included the patient's age, history, physical examination, digital images of the patient, and digital images of pertinent radiographs. RESULTS: Fifty-one patients, including 7 pediatric patients, were prescreened. Thirty-three of the 51 patients (65%) were deemed inappropriate for surgery before this trip because of advanced disease or absence of necessary local medical resources. Of the 18 patients determined to be appropriate candidates for surgery by remote prescreening, 18 (100%) were operated on successfully during the relief effort. Sixty patients including 9 (15%) pediatric patients underwent surgery over the course of 5 days in CPGH. Pediatric cases included various laparoscopic, oncologic, and soft tissue reconstruction. CONCLUSIONS: Low-bandwidth, Internet-based telemedicine is a cost-effective technology that can efficiently and effectively prescreen surgical patients in remote areas.

Adult↗

PubMed2001

Barriers to healthcare access in a non-elderly urban poor American population.

An understanding of perceived barriers to health-care is critical to improving healthcare access for all Americans. To determine perceived barriers to health-care in an urban poor population in Dayton, Ohio, a face-to-face door-to-door survey of individuals identified through targeted, stratified, area probability sampling was done. A sample of 413 non-elderly poor adults, including 19% without telephones, reported personal relevance of various barriers to healthcare access. Most frequently endorsed barriers were lack of information about free or reduced-cost health-care, anticipated cost, and difficulty accessing child-care. Seventy-four per cent of respondents reported more than one barrier. Individuals without telephones and those without health insurance reported more barriers to health-care. Reported barriers were similar for working and non-working poor, except for transportation problems, more frequently reported by non-working respondents. This study provides important data on what poor people in a medically underserved community perceive to be barriers to accessing health-care and underscores the importance of including people without telephones in the study design. Respondents who did not have telephones were more likely to report multiple barriers, particularly problems with lack of information about free or discounted medical care, child-care, and transportation. These findings suggest the importance of door-to-door surveys rather than telephone surveys for getting accurate data on the poor.

Adolescent↗

PubMed2002

Logic modeling: a tool for improving educational programs.

PURPOSE: Palliative care education programs must be systematically designed and accurately evaluated in order to account for their impact on learners and learning communities. Logic modeling is a framework for designing educational programs and monitoring their influence. METHODS: We applied a logic modeling process to a Palliative Care Educational Program (PCEP), embedded within a required month-long geriatrics rotation for third-year general internal medicine residents at the VA Medical Center in Milwaukee, Wisconsin. Each of four main categories of a logic model and the process for applying the steps to the PCEP are described. The four logic model categories that form the basis of the analysis are: (1) inputs, the raw resources consumed by the program (human resources, money, and space); (2) outputs, program activities and the number and types of actual participants; (3) outcomes, what the program will achieve in the short term (knowledge, attitudes and behavior change); and (4) impact, the results that are of ultimate interest to program stakeholders, such as placement in medically underserved areas, improved health or more efficient care. RESULTS: The application of logic modeling to the PCEP exposed achievements (e.g., resident knowledge gains) and gaps (no evidence of long-term impact) in each of the model categories and has resulted in the design team's reassessment of each program component. DISCUSSION: Palliative care educators can improve their programs by using the logic model categories and process steps to explicitly define and assess the links between key program components.

Education, Medical↗

PubMed2006

New Mexico community voices: policy reform to reduce oral health disparities.

Using a socio-ecological framework to guide the initiative, New Mexico Community Voices developed, with state and local stakeholders, responsive oral health policies to address oral health disparities. Several policy objectives were achieved: increasing awareness of the public health importance of oral health; improving access to dental services for uninsured or underserved populations; enhancing dental services specialty care; and increasing sustainable oral health infrastructure through pipeline development of oral health providers to relieve service shortages and diversify the oral health workforce. Improving access to oral health and augmenting numbers of dental providers in rural areas were also successful. The governor has appointed the New Mexico Oral Health Advisory Council to address state oral health issues. The New Mexico partnerships have demonstrated how effective policy change can generate important incremental shifts in oral health care delivery and provide best practice models that diminish the oral health crisis faced by underserved populations.

Community Dentistry↗

PubMedDate not supplied

An educational needs assessment of rural family physicians.

BACKGROUND: A shortage of family physicians persists in rural and medically underserved areas of the United States. We explore the hypothesis that a definable set of educational needs should be addressed for rural family physicians, both during their formal education and as part of continuing education while in practice. METHODS: An educational needs assessment questionnaire was sent to 1096 family physicians who had finished residency and entered rural practice within the last 3 years. Six hundred twenty-seven (57.2 percent) of the questionnaires were returned. The demographic characteristics of the respondent physicians and their assessment of the appropriateness and adequacy of their educational process in preparing them for rural practice were analyzed by looking at individual items and groups of items or subject areas. RESULTS: We were able to define successfully a group of items that were important components of rural practice but were not adequately addressed in training programs. Theses groups included counseling, pediatrics, obstetrics and gynecology, geriatrics, surgery and trauma, medical specialties, surgical specialties, community medicine and management, and a mixed factor that included rehabilitation, behavioral sciences, learning disabilities (in children), chronic childhood problems, and human growth. CONCLUSIONS: It is possible to define a group of educational areas not covered adequately by standard family practice curriculum that should be included in preparation for rural practice. If these areas were included in the education of rurally oriented family practice medical students and residents, these physicians would be more adequately prepared to meet the demands of rural practice. If preparation for rural practice is improved, rural communities might be more successful in recruiting and retaining well-trained family physicians.

Curriculum↗

PubMed1999

Retention of family medicine faculty development fellows in academic medicine.

OBJECTIVE: This study measured the retention of family medicine faculty development fellows in academic medicine. METHODS: Surveys were sent, in two stages, to 1) fellowship program directors and 2) fellows. These surveys were about full-time faculty development fellowships with new or continued Title VII funding during the interval of 1993-1996. Retention as faculty was the primary outcome. Likelihood of leaving academics and service in a federally designated medically underserved area were secondary outcomes. RESULTS: The fellowship program directors survey produced an 88% response rate and identified 105 alumni. The survey of fellows yielded a response rate of 73% (n = 77). The retention rate of these newly graduated family medicine fellows in academic positions was 75% (n = 58). A total of 37% (n = 21) of alumni in full- and part-time teaching positions reported being likely to leave their current position within the next 2 years. CONCLUSIONS: Retention rates of newly graduated family medicine fellows in academic positions are similar to rates reported in the 1980s. This group anticipates a high job turnover within the next 2 years.

Adult↗

PubMed1994

Does subsidizing rural community health centers hurt private practice physicians?

One reason for the shortage of primary care physicians in rural areas may be these physicians' reluctance to compete for patients with federally subsidized Community Health Centers (CHCs). Yet little is known about the relationship between private practice physicians and physicians in federally subsidized practices who share service areas. We used surveys from a two-state subset of a nationally representative sample to compare practice characteristics of three types of physicians: those who work in CHCs; those in private practice within CHC service areas; and private practice physicians in other rural areas. We found that rural physicians who compete with CHCs earn incomes comparable to physicians in rural areas who do not compete with CHCs, and that the percentage of Medicaid and uninsured patients seen in private physician practices does not increase when a CHC is not in the county. We conclude that CHCs do not provide competitive barriers to physicians in private practice, although we do not know if the presence of a CHC inhibits new private physicians from entering practices in these communities.

Adult↗

PubMed2006

Nonurgent use of a pediatric emergency department: a preliminary qualitative study.

OBJECTIVES: To understand patterns of decision making among families presenting to a pediatric emergency department (ED) for nonacute care and to understand pediatric ED staff responses. METHODS: Cross-sectional qualitative study using in-depth interviews, direct observations, and nonidentifying demographic data. RESULTS: Eleven percent of visits made during the study period were identified as nonacute. All were made by families from low-income areas. Three main themes emerged: (1) most families had been referred by their primary care providers; (2) the complexity of living in low-income areas makes the ED a choice of convenience for these stressed families; and (3) mistrust of primary health services was not identified by our respondents as a motivator for ED utilization, in contrast with other published data. Two themes emerged from ED staff: (1) actual nonurgent visit rates were lower than staff estimates; and (2) these visits produced frustration among staff members, although their degrees of insight and understanding of factors motivating these visits were variable. CONCLUSIONS: In this setting, nonacute visits occurred with lower than perceived frequency and caused disproportionate frustration among staff and families. These visits appear to be driven more by consequences of system design and structure than by family members' decision making. Mistrust of primary care services was not a strong family decision-making factor; the study's setting may have limited its ability to capture such data. Recommended system changes to lower barriers to primary care include expanded office hours, subsidized staffing for offices in medically underserved areas, and lowering barriers to sick care.

Adolescent↗

PubMed2005

Educational and health services innovation to improve care for rural Hispanic communities in the USA.

BACKGROUND: Access to comprehensive and quality healthcare services is difficult for socioeonomically disadvantaged groups in rural regions. Barriers to health care for rural Latinos include lack of insurance, language barriers and cultural differences. For the Latino immigrant population in rural areas, barriers to access are compounded. HEALTH NEEDS OF RURAL AREAS: THE CASE OF WALHALLA, SC: The town of Walhalla, South Carolina, USA, is a rural community located in Oconee County, the northwest corner of the state. Disparities exist between rural and urban residents in several health categories, and these disparities illustrate the need to provide competent, appropriate and affordable healthcare to rural populations. The Hispanic population of Oconee has dramatically increased in the past decade, and the majority of these immigrants have no health insurance and have limited access to health services. DESIGNING A PROGRAM TO FIT THE COMMUNITY--THE "WALHALLA EXPERIENCE": The purpose of the Accessible and Culturally Competent Health Care Project (ACCHCP) is to provide care for underserved populations, in Oconee County, South Carolina while providing rural educational opportunities for health services students. Funded by the Health Resources and Services Administration of DHHS, the program is designed to offer culturally appropriate, sensitive, accessible, affordable and compassionate care in a mobile clinic setting. In this interdisplinary program, nurse practitioners, health educators, bilingual interpreters, medical residents and Clemson University students and professors all played key roles. Women in the community also serve as promotoras or lay health advisors. The program is unique in using educational initiatives and innovative strategies for bringing health care to this underserved community and offers important information for rural healthcare initiatives targeting minority groups. This article reports on the challenges and successes in the development and implementation of the ACCHCP program in Walhalla, South Carolina.

Adolescent↗

PubMed2000

The effectiveness of a rural nursing center in improving health care access in a three-county area.

The purpose of this article is to describe an innovative nurse-managed health center that has been effective in improving access to primary health care for residents of a Midwestern three-county rural area. Penchansky and Thomas's (1981) framework for evaluating health care access was used to analyze client satisfaction and utilization data. Findings clearly indicate success in improving access. Client satisfaction surveys consistently show a high level of satisfaction across all framework dimensions, including overall satisfaction with the health care received. Utilization data indicate a steady increase in the number of clients served, especially those who are uninsured or underinsured. This article demonstrates that key dimensions of access can be effectively measured using the Penchansky and Thomas framework and concludes with recommendations for enhancing the model.

Community Health Centers↗

PubMed2004

Connecting rural African American and Hispanic women to cancer education and screening: the Avon Health Connector project.

BACKGROUND: Many barriers prevent minority women in rural areas from being screened for breast and cervical cancer. METHODS: A partnership was formed to screen low-income women in a Southern Appalachian area, with particular focus on African American and Hispanic populations. A lay health advisor model was utilized, and 45 LHAs were trained to participate in the program. RESULTS: In this program, 456 women were screened for breast and cervical cancer, 1943 received health education, and 59 health professions students participated. CONCLUSION: A successful partnership model builds on the strengths and assets of partners, provides culturally competent services, and benefits from continual project evaluation.

Academic Medical Centers↗

PubMed2004

Unequal access to breast-conserving surgery in Western Australia 1982-2000.

BACKGROUND: The purpose of the present study was to examine the effects of demographic, locational and social disadvantage and the possession of private health insurance in Western Australia on the likelihood of women with breast cancer receiving breast-conserving surgery rather than mastectomy. METHODS: The WA Record Linkage Project was used to extract all hospital morbidity, cancer and death records of women with breast cancer in Western Australia from 1982 to 2000 inclusive. Comparisons between those receiving breast-conserving surgery and mastectomy were made after adjustment for covariates in logistic regression. RESULTS: Younger women, especially those aged less than 60 years, and those with less comorbidity were more likely to receive breast-conserving surgery (BCS). In lower socio-economic groups, women were less likely to receive BCS (OR 0.73; 95% CI 0.60-0.90). Women resident in rural areas tended to receive less BCS than those from metropolitan areas (OR 0.84; 95% CI 0.55-1.29). Women treated in a rural hospital had a reduced likelihood of BCS (OR 0.74; 95% CI 0.61-0.89). Treatment in a private hospital reduced the likelihood of BCS (OR 0.70; 95% CI 0.54-0.90), while women with private health insurance were much more likely to receive BCS (OR 1.39; 95% CI 1.08-1.79). CONCLUSION: Several factors were found to affect the likelihood of women with breast cancer receiving breast-conserving surgery, in particular, women from disadvantaged backgrounds were significantly less likely to receive breast-conserving surgery than those from more privileged groups.

Female↗

PubMed2004

Information-seeking behavior changes in community-based teaching practices.

A National Library of Medicine information access grant allowed for a collaborative project to provide computer resources in fourteen clinical practice sites that enabled health care professionals to access medical information via PubMed and the Internet. Health care professionals were taught how to access quality, cost-effective information that was user friendly and would result in improved patient care. Selected sites were located in medically underserved areas and received a computer, a printer, and, during year one, a fax machine. Participants were provided dial-up Internet service or were connected to the affiliated hospital's network. Clinicians were trained in how to search PubMed as a tool for practicing evidence-based medicine and to support clinical decision making. Health care providers were also taught how to find patient-education materials and continuing education programs and how to network with other professionals. Prior to the training, participants completed a questionnaire to assess their computer skills and familiarity with searching the Internet, MEDLINE, and other health-related databases. Responses indicated favorable changes in information-seeking behavior, including an increased frequency in conducting MEDLINE searches and Internet searches for work-related information.

Adult↗

PubMed2000

Medical training debt and service commitments: the rural consequences.

This study assesses how student loan debt and scholarships, loan repayment and related programs with service requirements influence the incomes young physicians seek and attain, influence whether they choose to work in rural practice settings and affect the number of Medicaid-covered and uninsured patients they see. Data are from a 1999 mail survey of a national probability sample of 468 practicing family physicians, general internists and pediatricians who graduated from U.S. medical schools in 1988 and 1992. A majority of these generalist physicians recalled "moderate" or "great" concern for their financial situations before, during and after their training. Eighty percent financed all or part of their training with loans, and one-quarter received support from federal, state or community-sponsored scholarship, loan repayment and similar programs with service obligations. In their first job after residency, family physicians and pediatricians with greater debt reported caring for more patients insured under Medicaid and uninsured than did those with less debt. For no specialty was debt associated with physicians' income or likelihood of working in a rural area. Physicians serving commitments in exchange for training cost support, compared to those without obligations, were more likely to work in rural areas (33 vs. 7 percent, respectively, p < 0.001) and provided care to more Medicaid-covered and uninsured patients (53 vs. 29 percent, p < 0.001), but did not differ in their incomes ($99,600 vs. $93,800, p = 0.11). Thus, among physicians who train as generalists, the high costs of medical education appear to promote, not harm, national physician work force goals by prompting participation in service-requiring financial support programs and perhaps through increasing student borrowing. These positive outcomes for generalists should be weighed against other known and suspected negative consequences of the high costs of training, such as discouraging some poor students from medical careers altogether and perhaps influencing some medical students with high debt not to pursue primary care careers.

Career Choice↗

PubMed2006

Sustaining a safety net breast and cervical cancer detection program.

For the past six years, the Chicago-area faith-based Reach Out Consortium has mobilized low-income uninsured and underinsured African American women and Latinas to seek screening for breast and cervical cancer. The funding history for this program illustrates how funds for a small community-based program were leveraged into a broader program, and that grew to serve low-income women across the state. Further, as the program reached more and more uninsured women, community activism led to a further state investment in services for the uninsured. Program sustainability and expansion depended on a combination of public and private competitive grants and grassroots advocacy.

Adult↗

PubMed2004

The Milwaukee General Assistance Medical Program: patient perspectives on primary care in an urban safety net.

PURPOSE: The General Assistance Medical Program (GAMP) is a managed care model that provides a network of services through community-based clinics and area hospitals. An evaluation of the program included patient focus groups to determine the effectiveness of this safety net. METHODS: Focus groups were conducted with patients at various hospital and community-based clinics. Researchers identified patterns and themes that emerged from the data. RESULTS: The focus groups had the following themes: (1) eligibility and enrollment policies, (2) patient advocacy, (3) primary care access, and (4) patient recommendations for improving GAMP. DISCUSSION: Patient feedback allowed for several improvements in the GAMP system, including an overview seminar and health education materials for new enrollees. Future research could include studying similar safety nets and public insurance programs to compare to GAMP. GAMP still faces many challenges as the "safety net" providing care to these populations in Milwaukee.

Community Medicine↗

PubMed1995

Economic viability of a model rural family practice.

BACKGROUND AND OBJECTIVES: A model rural clinic was established by the Quincy Family Practice Residency Program with the financial support of sponsoring local hospitals. The purpose of the study was 1) to determine the financial viability of such a model practice and 2) to determine the practice's financial effect on the sponsoring hospitals. METHODS: The rural practice was established in a medically underserved area 30 miles from the sponsoring hospitals. A cost analysis of months 7-18 of operation was performed, including an analysis of charges generated at the sponsoring hospitals. Theoretical models of practice to enhance economic viability were explored. RESULTS: The 3,051 office visits fell short of expectations. These visits generated a net practice income of $18,596. Had the practice sought full payment for these visits instead of accepting Medicare assignments, the net income potential would have been $39,182. Growth of the practice until it reached the average size of a typical rural family practice (6,000 annual visits) would produce a net income of $67,113 with Medicare assignments and $103,578 if Medicare assignments were not accepted. Had the practice been a federally designated rural health clinic, a mid-level practitioner with physician supervision could have generated a net practice income of $53,640 for 3,051 visits or $138,863 for 6,000 visits. Referrals from the model clinic for laboratory work, radiology, and hospital admissions generated $9.17 in charges for the sponsoring hospitals for each dollar charged by the clinic. CONCLUSIONS: The financial viability of rural practices is adversely affected by the Medicare reimbursement system. Our model clinic had a positive economic effect on the sponsoring hospitals, suggesting that innovative collaborative sponsorship of such clinics may be mutually beneficial.

Costs and Cost Analysis↗

PubMed2003

The Arkansas River Valley Rural Health Cooperative: building a three-pronged approach to improved health and health care.

This paper describes the Arkansas River Valley Rural Health Cooperative (ARVRHC), one of the Arkansas networks jump-started with support from the Southern Rural Access Program (SRAP). The initial goal of the network was to develop a subsidized health insurance program to provide affordable medical services for the uninsured population (23%) in the 3-county service area. When planning efforts called for the network to address broader needs, the ARVRHC crafted a more comprehensive 3-pronged program model consisting of 3 interrelated programs: (1) the Health Care Access Program (HCAP), (2) the Health Education and Disease Management Program (HE&DMP), and 3) the Information and Assistance Program (I&AP). The HCAP is designed to address the financial barriers to access through a community-based health plan. The HE&DMP focuses on improving the health of individuals through education, counseling, and preventive care. The I&AP links low-income families to existing public assistance programs (e.g., Medicaid) and social support services. The Prescription Drug Assistance Program is one of the I&AP programs that helps individuals without prescription coverage obtain drugs at no cost. A key lesson learned is the importance of combining technical assistance with funding. The ARVRHC has been successful in leveraging funding, having received over $1.7 million in grant funds since 1999. A critical challenge facing the network today is the need for ongoing subsidy funding. Proposed legislation for a federal demonstration of the HCAP and similar programs would enable full implementation and evaluation of this model.

Arkansas↗