We report on a man seeking care at the UCLA mobile clinic, illustrating and then discussing the challenges of caring for people who are homeless (especially mental illness and potential distrust of providers). Student-run free clinics can be beneficial but further research must examine how well such clinics meet homeless patients' needs.
A survey of clients seeking homeless services at agencies in the SF Peninsula, indicates that a disproportionate percentage are minority group members (African American and Hispanic) and veterans, and points to the need for integrated housing, social services, and health care for this vulnerable population.
In a participatory action research program called Photovoice, Hispanic immigrants in a Midwestern community took photographs to provide researchers with insight regarding family planning. This report describes the Photovoice approach, why the researchers chose it, how they implemented it, what they learned, and the benefits derived for a larger service project.
The objective of this study was to evaluate a clinic-centered oral cancer screening initiative in one of the poorest communities in Canada, assessing the need for screening and the acceptance of screening and identifying hindrances to both screening and follow-up. The study group included 204 people in the Vancouver Downtown Eastside (DTES). This was shown to be a high-risk community based on risk factors, lack of access to care, and the high frequency of oral mucosal anomalies. Acceptance of screening was high (98%); however, acceptance of biopsy for abnormal findings and follow-up was low. Among the 12 patients with clinical leukoplakia who were biopsied, 10 showed cancer or precancer. In summary, these data show a need for screening in this population and an ability to recruit patients to screening. They support a future expansion of this initiative to create a more comprehensive strategy for outreach to this underserved community that extends to screening, diagnostic work-up, and treatment.
Deaths of children due to neglected dental diseases have put the issue of access to care by minorities at the forefront of dental public health discussions. We evaluated the trends in dental service utilization in relation to racial disparities and other factors using Medicaid enrollment and claims data from 1990 to 1997 for Alabama children 19 years of age and younger (n=512,049). Alabama Medicaid children visited the dentist at a low and declining rate. The number of participating providers gradually declined over time and the racial disparities in service utilization were related to the availability of a local provider. Lower service utilization, however, was not a simple function of race, but a complex interaction of race with age and gender. Identification of these complex interactions and removal of barriers to service utilization in race, age, and gender sub-groups will help the U.S. meet the year 2010 oral health objectives.
For mothers of Medicaid children aged 3 to 6 years, we examined whether mothers' characteristics and local supply of dentists and public dental clinics are associated with having a regular source of dental care. Disproportionate stratified sampling by racial/ethnic group selected 11,305 children aged 3 to 6 in Medicaid in Washington State. Mothers (n=4,373) completed a mixed-mode survey that was combined with dental supply measures. Results reveal 38% of mothers had a regular dental place and 27% had a regular dentist. Dental insurance, greater education, income, length of residence, and better mental health were associated with having a regular place or dentist for Black, Hispanic, and White mothers, along with increased supply of private dentists and safety net clinics for White and Hispanic mothers. Mothers lacking a regular source of dental care may increase oral health disparities disfavoring their children.
Objectives. This study was designed to describe the oral health status of adolescents residing in northern Manhattan. Methods. Clinical, demographic, and behavioral data were collected from 3,282 youths who ranged in age from 12 to 16 years. Clinical examinations were performed by two trained examiners. Demographic and behavioral data were self-reported. Results. The adolescents were predominantly Hispanic/Latino and Black/African American (94%), with 6% falling into other racial categories. Caries were discovered in a significant proportion of these youths (52% of Hispanics, 54% of Blacks and 54% of others). Despite similar caries experiences, the oral health disease burden was not evenly distributed across groups. In many cases, Hispanic youths demonstrated less disease and more frequent engagement in oral health promoting behaviors than their non-Hispanic peers. Gender differences were less consistent. Conclusions. Economically disadvantaged and minority youths, such as those residing in northern Manhattan, continue to be unduly burdened by untreated dental disease. Further, our data suggest that certain subpopulations may be particularly vulnerable to dental disease. This vulnerability underscores the need for accessible services addressing the oral health needs of these segments of the population. Finally, effective community-based oral disease prevention and health promotion programs are sorely needed to improve these youths' oral health.
New York City (NYC) has one of the highest incidence and mortality rates of oral and pharyngeal cancer (OPC) for Hispanics of any major U.S. city. This qualitative assessment explores OPC awareness, attitudes, and screening practices among at-risk Hispanics, health care providers, and community leaders in a Hispanic neighborhood of NYC. Four focus groups (n=39) were conducted with at-risk Hispanics. Structured interviews were conducted with ten health care providers (four physicians, four dentists, two dental hygienists) and three key community leaders. Results showed major gaps in OPC awareness across all key stakeholders. Focus group participants expressed difficulty in accessing appropriate health care. Health care providers were not familiar with OPC prevention and early detection practices. Community leaders lacked the knowledge and resources necessary for advocating prevention and early detection for their constituencies. All participants reported cultural, social, and structural barriers to prevention. There is a need for developing a comprehensive, culturally competent health communication program that targets all key stakeholders in the at-risk Hispanic community of NYC.
We recently demonstrated with the Florida Dental Care Study (FDCS) that the racial mix of the dental practice attended was significantly associated with patient-specific service receipt and health outcome. Therefore, our objective here was to determine if African Americans and lower-income people attended dental practices with characteristics systematically different from the practices attended by their counterparts. The FDCS was a prospective cohort study of 873 people at baseline who were followed for 48 months. Participants' dentists were asked to complete questionnaires about their practices. Significant racial and income differences were evident in dentists' reports of payment mix, characteristics of typical patients, types of procedures typically done, typical fees, practice busyness, waiting room times, and delays to get an appointment. Systematic differences in the dental practices attended were evident, as a function of the person's race and income, differences that are associated with social disparities in oral health.
Abstract: Oral diseases disproportionately affect older Americans from minority populations. Approaches to reducing such disparities include increasing community-based interventions that target vulnerable older adults. To help in developing and implementing such programs, the U.S. Department of Health and Human Services suggests using the MAP-IT technique, from a strategic planning guide to address public health issues in the community. This approach served as the method of investigation for the Take Charge of Your Oral Health educational program, a health promotion initiative targeting older African Americans. This paper describes the development and evaluation of the program. A total of 111 African American elders from 7 senior sites in Philadelphia participated in the program. A 6-item pre-test and post-test indicated a significant improvement in mean test scores from baseline (p,.001). The program demonstrated merit in improving oral health knowledge among community-residing, inner city, older African Americans.
Disability care coordination organizations (DCCOs) arrange comprehensive, disability-competent social and medical services for people with disabilities. This study used consumer ratings of access and quality to measure outcomes in one of the first operational DCCOs over a three-year period. Working-age Medicaid adults with physical disabilities reported statistically significant improvements in service coordination, patient education, system-wide disability competency, comprehensive assessment, health visit support, and self-direction of care. Global quality ratings showed statistically significant and sustained improvement over two years, with the percentage of people rating the health system as excellent rising from 7% before enrollment to 44% in the DCCO. The percentage of people rating primary care physicians as excellent rose from 18% before enrollment to 38% in the DCCO. Over time, enrollees became more knowledgeable about the need for preventive health care services, were more likely to receive needed care and medical equipment, and reduced their need for rehabilitation therapies. Disability care coordination organizations can reduce disparities and improve access to care for this vulnerable population.
The purpose of this study was to understand the impact of living environment on the health and access to health care of low-income working-age adults with physical disabilities. We conducted focus groups of participants with physical disabilities in the District of Columbia living in each of three housing situations (a homeless shelter, a nursing home, and an inaccessible house or apartment). Twenty-eight people participated in the focus groups. Most were male (79%) and African American (93%). Participants from a homeless shelter expressed concerns about accessibility and sanitation at the shelter. Nursing home participants expressed a need for privacy and autonomy that would foster consumer-directed care. Participants living in inaccessible apartments or houses worried about their ability to maintain daily living and social activities. Participants perceived barrier-free housing conditions to be a prerequisite for independent living and for ensuring their basic health and well-being.
Purpose. The purpose of the current study is to evaluate the effectiveness of a pilot project providing a medical home to children with special health care needs (CSHCN). This study differs from previous work in that it monitors a cohort of CSHCN one year prior to and two years after participation in a medical home intervention utilizing a quasi-experimental design. Results. The groups being compared demonstrated descriptive differences in emergency room (ER) and preventive visits. Statistically significant differences in ER visits were achieved by the second intervention year. Conclusions. The current research demonstrates that a medical home can have demonstrable effect on utilization of preventive and emergency care by CSHCN. Limitations of the current research include small sample size and lack of information on acuity and quality of life.
We examined racial/ethnic disparities in unmet specialty, dental, mental, and allied health care needs among children with special health care needs (CSHCN) using data on 38,866 children in the National Survey of CSHCN. Compared with White CSHCN, Black CSHCN had significantly greater unmet specialty (9.6% vs. 6.7%), dental (16% vs. 8.7%), and mental (27% vs. 17%) health care needs. Hispanic CSHCN had greater unmet dental care needs (15.8% vs. 8.7%). Black females had greater unmet mental health care needs than other groups (41% vs. 13–20%). Most disparities disappeared after multivariate adjustment. Significant risk factors for unmet health care needs included uninsurance, having no personal doctor/nurse, poverty, and condition stability and severity. Eliminating unmet specialty, dental, and mental health care needs for all CSHCN, and especially minority CSHCN, may require greater efforts to reduce poverty and increase insurance coverage among CSHCN, better mental health care assessment of Black female CSHCN, and ensuring all CSHCN have a medical home.
Abstract: This study compares the expenditure patterns and characteristics of high-cost dual eligibles to normative-cost dual eligibles within institutional and community settings. Using claims records for people dually eligible for both Medicare and Medicaid in 18 California counties (n=349,433) in 2000, high-cost users in the long-stay institutional care setting spent a much higher amount and a much greater proportion of total costs in Medi-Cal (61%) but spent less proportionally in Medicare (39%) than high-cost users in the long-term community care (66% of total costs from Medicare) or episodic care (79% of total costs from Medicare) setting. Although individuals who are long-stay nursing facility residents are high-cost in the overall sample, multinomial logistic regressions revealed that the impact of diseases/conditions on high-cost status varied within each setting. These findings suggest that policymakers and providers should consider care setting as an important component when designing disease management strategies.
Pay-for-performance programs are being developed to improve quality of care despite limited empirical evidence demonstrating their effectiveness, especially in underserved communities. Using data on 1,166 patients treated by 46 primary care physicians, this paper examines the effect of an innovative pay-for-performance program implemented in 2004 at the nation's largest federally qualified health center on hemoglobin A1c (HbA1c) testing and HbA1c scores. Univariate analysis and logistic regression results show that the pay-for-performance program significantly increased the likelihood that patients received two HbA1c tests per year as recommended by the American Diabetes Association. Ordinary least squares (OLS) regression results reveal that physicians' baseline performance was positively related to performance after program implementation. Finally, OLS regression results suggest that the program did not contribute to improved blood sugar control. The pay-for-performance program appeared to improve compliance with HbA1c testing recommendations, but a more comprehensive strategy, including increased patient support, may be necessary to improve health outcomes in disadvantaged populations.
Physician supply in the U.S. is again on the national health policy agenda. A central issue in this debate is the availability of physicians willing to work in underserved and disadvantaged communities—an issue closely linked to the number of minority and international medical graduate (IMG) physicians working in the U.S. In California, South Asian IMGs, but not South Asian U.S. medical graduates, are more likely to work in underserved communities. Incorporation of strong policy levers aimed at an equitable geographic distribution of physicians will be critical as the U.S. moves toward greater self-sufficiency of physician supply. More specifically, the authors note the continuing central importance to addressing the needs of medically underserved populations of training physicians from under-represented minority groups (African Americans, American Indians, and Hispanic Americans) in U.S. medical schools.