Date of Award

January 2016

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Marjorie Rosenthal

Abstract

Healthcare access is a complex concept that involves more than insurance coverage and resource utilization. Influenced by milieu, an understanding of the local dimensions of access is essential to develop community strengths as well as create appropriate solutions to access gaps. Accordingly, the objectives of the study were to identify, enumerate, and characterize medical practices delivering primary care to children within greater New Haven.

In partnership with community leaders, a community-based participatory approach was used to design a 57-question and 21-observation item, practice-based survey. The survey was administered in-person to 17 pediatric practices and 19 school-based health centers (SBHCs) in greater New Haven. Summary statistics and workforce data were calculated using Excel. The Mann-Whitney U test for non-normal distributions (M test) was used to observe associations between practice characteristics and percent Medicaid panel. Interactive maps were created using ArcGIS.

Participation included 89% of practices and 100% of SBHCs. Seventy-seven percent of practices accepted new Medicaid patients, and 47.0% had a Medicaid panel over 50%. Regarding accessibility at practices, all offered same day visits, most offered in-hospital care (88.2%), many had extended hours (82.4%), and the vast majority were located less than a 5-minute walk from a bus stop (82.4%). Regarding on-site services, few practices offered specialty mental healthcare (41.2%), dental (29.4%), social work (29.4%), or nutritionist (41.2%) resources. SBHCs provided more specialty mental healthcare (100%), social work (94.7%), and care management services (68.4%) but fewer dental (31.6%) and nutritionist (0%) services on site. At practices, 52.9% had Spanish-speaking providers, and 47.1% had Spanish-speaking staff. At SBHCs, no providers and 68.4% of staff spoke Spanish. The practices that offered adult primary care, mental health services, dental services, social services, and a Spanish-speaking provider had a statistically significant higher Medicaid panel than those practices that did not offer such services (M< 0.05). Regarding required trainings at practices, although mandated customer service was high for staff, mandatory cultural competency and trauma-informed care training for providers and staff was limited. Mandatory customer service, cultural competency, and trauma-informed care trainings at SBHCs was higher, although trauma-informed care training for staff was inadequate. Triage privacy was achieved at 23.5% of practices and 10.5% of SBHCs. Forty-seven percent of practices had an automatic door to the main entrance, and 17.6% had a check-in counter at a handicap-accessible height. Most practices (76.5%) and all SBHCs used an EMR. Forty percent of practices were patient centered medical homes and another half were seeking designation. Few practices used an online patient portal (35.3%). Regarding workforce, there were 124 pediatric primary care providers (MD, DO, physician associate, advance practice registered nurse) with only 1 in West Haven. The Health Professional Shortage Area (HPSA) pediatric population: provider full time equivalent (FTE) ratio was 3,548:1 in East Haven and 29,778:1 in West Haven, both of which meet the HPSA geographic designation threshold. When calculated for the Medicaid population, the ratio of high needs children to provider FTE in West Haven was 8,425:1 and increased to 11,233:1 when adjusted for the practice panel percent Medicaid. Providers at SBHCs constituted 14.8% of the workforce yet delivered 20.0% of primary care and 22.1% of primary care to Medicaid patients. State licensing data grossly overestimates the primary care workforce.

In addition to numerous community strengths, PCare4NHVv2 has clearly identified four local needs: increased access to nutritionists, improved mandatory trainings for providers at practices, enhanced patient privacy, and improved handicap accessibility at practices. Subsequent policy priorities include communication of the East Haven and West Haven HPSA geographic findings to the appropriate agencies and dissemination of the improved workforce calculation methods. Additional research is needed on the state of local dental care access well as the impact of SBHCs.

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This is an Open Access Thesis.

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