healthcare week 6
roger fal
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.