healthcare week 6

profileroger fal
Chapter111.pptx

Chapter 11

Health Services for Special Populations

Learning Objectives

Learn about population groups facing greater challenges and barriers in health care access

Understand racial and ethnic disparities in health status

Be acquainted with the health concerns of America’s children and women

Learning Objectives

Appreciate the challenges faced by rural health, the homeless, and the migrants

Understand the nation’s mental health challenges

Understand the AIDS epidemic in America

Discuss the impact of the ACA on vulnerable populations

Introduction

Certain population group at greater risk of poor:

physical

psychological

social health

Terms used:

underserved

medically underserved

medically disadvantaged

underprivileged

American underclasses

Population Groups

Uninsured children

Women

Rural area residents

Homeless

Mentally ill

Chronically ill

Disabled

HIV/AIDS

Conceptual Framework of Vulnerability

The convergence of vulnerable risks

Predisposing, enabling, and need

Individual and ecological

Policy and intervention focus need to target multiple risks

Racial Ethnic Minorities

Over 34% of U.S. population is minority

Black Americans – 12.2%

Hispanic Americans – 15.4%

Asian Americans – 4.4%

American Indians and Alaska Natives – 0.8%

Racial Ethnic Minorities Stats

Low birth weight is most common among Black Americans

White adults drink more alcohol compared to other racial/ethnic groups

Mammography use of women 40+ years old is:

greatest among white females,

lowest in Hispanics

The Uninsured

Tend to be:

less educated, poor

working in part-time jobs and/or employed by small firms

younger 25-40 year olds

Medically uninsured are employed but not covered due to:

employer does not offer health

employee does not qualify, too few hours worked

can’t afford

Uncompensated care costs covered by Medicaid, federal grants to nonprofit hospitals and charitable organizations

Children

38% covered under Medicaid, 54% covered under private insurance

5-20% of children have disabilities (see Table 11-5)

Developmental Vulnerability: the rapid and cumulative physical and emotional changes that characterize childhood, and the potential impact that illness, injury, or disruptive family and social circumstances can have on a child’s life course trajectory.

Children

Dependency: children’s circumstances that require adults to take responsibility for recognizing and responding to their health needs.

New morbidities, e.g. drug, alcohol abuse, violence, emotional disorders, learning problems

Children and the US Health Care System

Health care for children is patchwork, disconnected programs

US characterizes children’s into three sectors:

personal medical and preventive services sector (primary and specialty care)

population-based community health services sector (e.g. immunization, abuse prevention, rehab, case management, referrals)

health related support services sector (e.g. nutrition, rehab, family support)

Women

The leading providers of care in the nursing profession

Also in allopathic and osteopathic medicine, dentistry, podiatry, and optometry (see Figure 11-9)

Women in the US live eight years longer than men, but they suffer greater morbidity and have poorer health outcomes.

Women

Heart disease and stroke account for a higher percentage of deaths among women than men at all stages of life: 42% of women with heart attacks die within the year, but only 24% of men do

Women account for approximately half of the HIV/AIDS cases worldwide

Women are more likely to be depressed than men

Women are at substantially greater risk for Alzheimer’s than men

Women

Substance Abuse and Mental Health Services Administration are targeting six areas for attention:

physical and sexual abuse of women

women as caregivers

women with mental and addictive disorders

women with HIV/AIDS

sexually transmitted disease or tuberculosis

older women

women detained in the criminal justice system

Women and the US Health Care System

Women are the principal users of the health care system, both for themselves and as the family care coordinator

Until the age groups 65 and older, women have higher physician utilization rates than men

However, hospitalization rates are comparable for men and women

Women and the US Health Care System

Women work more part-time jobs than men, receiving lower wages, and with more interruptions in their work histories; thus they are at a higher risk to be uninsured, and are more likely to be covered as dependents under their husbands’ plans

Women are twice as likely to be covered under Medicaid because the program is linked to Aid to Families with Dependent Children (AFDC)

Office on Women’s Health (OWH)

Dedicated to disease and disability

Coordinates and implements a comprehensive women’s health agenda on research, service delivery, and education across the agencies on Public Health Service

Responsible for implementing the National Action Plan on Breast Cancer (NAPBC), a major public-private partnership dedicated to improving the diagnosis, treatment, and prevention of breast cancer through research, service delivery, and education.

Office on Women’s Health (OWH)

Working to prevent physical and sexual abuse, as stated in the Violence Against Women Act of 1994.

The Women’s Health Initiative, supported by the NIH, is occurring in more than 50 centers across the country. It is the largest clinical trial conducted in US history.

The trial focuses on major causes of death and disability among women

Rural Health

Poor access due to:

poverty, long distances, topography, weather, availability of health care and transportation

Measures to improve rural health care:

1) The National Health Service Corps

2) Health Manpower Shortage Areas

3) Medically Underserved Areas

4) Community and Migrant Health Centers

5) The Rural Health Clinics Act

6) Rural Managed Care

The National Health Service Corps

Created in 1970

To recruit and retain physicians in shortage areas

A scholarship and loan repayment program

Targeted doctors, dentists, nurse practitioners, midwives, and mental health professionals who serve a minimum of two years in underserved areas.

Since 1972 over 27,000 have been placed in medically underserved communities.

Health Professional Shortage Areas (HPSA)

The Health Professions Educational Assistance Act of 1976 provided for HPSAs

Three different types of HPSAs:

geographic areas

population groups

medical facilities

Medically Underserved Areas (MUA)

Developed to support the

federal health maintenance organization grant program

community health center and rural health clinic programs

Factors in designing MUAs:

available health resources related to area size and population, health indices, care and demographics

Medically Underserved Areas (MUA)

The Index of Medical Underservice was developed comprising four variables:

Percent of population below poverty income levels

Percent of population 65 + years old

Infant mortality rate

Primary care physicians / 1,000 population

Community and Migrant Health Centers

Service to low income populations on a sliding-fee scale

Serve over 18 million patients per year:

Offers primary and prevention care

Hard to attract physicians here

The Rural Health Clinics Act

Created due to concerns that isolated rural communities could not generate revenue to support physician services

A reimbursement mechanism to create financial viability and ability to receive Medicare and Medicaid reimbursement

Midwives, Physician Assistants, Nurse Practitioners do not need physician oversight

There are over 3000 currently operating

Rural Managed Care

Gives physicians :

consultation opportunities

continuing education units

coverage for time off

Faces demographic, geographic, and infrastructure challenges

Health care needs in rural areas are as great or greater than in urban areas

Physicians, hospitals, leadership, and governance usually in short supply

contributes to lack of access

The Homeless

An estimated 3.5 million people are without a home

Single men – 43%

Single women – 17%

Children under 18 – 39%

Families with children – 33%

The Homeless

A multifaceted problem related to personal, social, and economic factors

Homeless adults and children have a high prevalence of untreated acute and chronic medical, mental health, and substance abuse problems

At a greater risk of assault and victimization

Exposure to harsh weather

The Homeless

Barriers to Health Care

Barriers to ambulatory services

High hospitalization rates

Reasons for barriers:

1) Individual factors (e.g., competing needs, substance dependence, mental illness)

2) System factors (e.g. availability, cost, convenience)

The Homeless

Outreach to shelters, hotels, soup lines, parks, bus stations

Health Care for the Homeless

A federal effort for medical service

Robert Wood Johnson supported

Salvation Army provides:

Social, rehab, support, food, housing

Mental Health

1 in 4 Americans have a mental disorder in any given year

Industry plagued with disparities in availability and access

Hinges on financial status

Tear down the stigma, fear and the hopelessness

Medicaid is the single largest payer

States had strong emphasis on inpatient care

Mental Health

The plan:

Build science base

Overcome stigma

Improve public awareness

Ensure supply of mental health

Ensure state-of-the-are treatment

Tailor treatment to demographics

Facilitate treatment

Reduce financial barriers

Mental Disorders

Managed care

Managed care is also expanding into mental health

State and local government want to contract with managed care organizations to handle the mental health and substance abuse services covered by Medicaid.

Mental Health Professionals

Psychiatrists

physicians

postgraduate training in mental health

have power to prescribe prescriptions, and admit patients

Psychologists

usually have doctoral degree, some masters

interpret and change people’s behavior

cannot issue prescriptions

use psychotherapy and counseling

Mental Health

Depression is the most common illness among primary care patients; it affects approximately 14.8 million adults in the US.

Risk Factors

History of depression

Family history

Stressful life events

Lack of social support

History of anxiety

Postpartum period

Substance abuse

Medical comorbidity

Being single

Old age

Low socioeconomic status

Female gender

The Chronically Ill and Disabled

This demographic presents challenges to our health system that is oriented toward acute care

Chronic disease accounts for 75% of the total medical expenditure

Chronic illness is a disease or injury with long-term symptoms, three or more months

Disability is a person’s short-term or long term limitation or inability to perform tasks that were previously done unaided

HIV/AIDS

July 1982, a disease was officially named:

Acquired immuno-deficiency syndrome (AIDS)

AIDS caused by human immunodeficiency virus (HIV)

Sixth leading cause of death among people aged 25-44 years old

In 2006, 446,098 people were living with AIDS

HIV/AIDS

Risk factors:

male-to-male sexual encounters

male to female sexual contact

injection drug use

blood product exposure

perinatal transmission from mother to infant

during pregnancy, delivery or possible breastfeeding

See Tables 11-8, 11-9, and 11-10

HIV/AIDS

HIV testing is anonymous or confidential

Most states offer anonymous HIV testing

All states offer confidential testing

Have rapid HIV tests

Treatment tries to slow the progression of

HIV and opportunistic infections (i.e., tuberculosis)

Includes cocktails of highly active antroviral therapy

Cost of HIV/AIDS

The course of AIDS:

a gradual decline in a patient’s physical, cognitive, and emotional function and well-being.

Medical care is very expensive

$385,200 per person on average lifetime cost (see Figure 11-12)

Cost of HIV/AIDS

Medicaid is primary payer

Medicaid waiver programs

packages of services

an alternative to institutional care

Ryan White CARE Act, 1990

federal monies to develop treatment and care options

purpose was to give emergency assistance to cities affected (ie testing, counseling, case management)

ACA Takeaway

The problem of the uninsured will continue to haunt the US health care system even after the ACA.

The ACA requires private insurance plans to cover, with no cost-sharing, a wide variety of preventive services and additional services for women.

Many HIV/AIDS patients are expected to gain health insurance under the ACA.