Category Archives: Underserved Populations
Kelly Doran, MD, is an emergency physician and a Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Clinical Scholar at Yale University. This post is part of the "Health Care in 2013" series.
Around this time of year I think a lot about my friend Hank. He is one of only two people to whom I reliably send a Christmas card each year, and just as reliably I receive a holiday package from him containing thoughtfully chosen gifts.
When I first met Hank he was homeless, living out of a van he parked near Golden Gate Park in San Francisco. Hank had multiple serious chronic medical conditions, and the homelessness certainly did not help any. He was very sick and, sadly, though he was barely 50 years old I thought he had maybe five years left, tops. Well, 10 years have passed and Hank is still ringing in the New Year… in his own apartment. This is no Christmas miracle, but rather a predictable result of supportive housing.
Last week, NPR aired a story examining the prognosis for primary care providers in the United States. The country will have tens of thousands fewer health care providers than it needs to care for its the population by 2015, and the shortage is expected to hit rural and underserved areas especially hard.
Part of the problem, the story reports, is that medical students—often saddled with massive student loan debt—are choosing specialties over primary care and family medicine. In addition to higher salaries, specialties allow more schedule flexibility and predictability, and less stress. The nursing workforce, too, has a looming shortage. Many nurses are close to retirement, and a shortage of nurse faculty is making it difficult for nursing schools to educate the next generation.
Provisions of the Affordable Care Act may help alleviate the shortage in the areas most hard-hit, by providing loan forgiveness or other incentives for providers who practice primary care in underserved areas. “A lot of the money in the Affordable Care Act went to beef up programs that train primary care providers, not just doctors but nurse practitioners, physician assistants, what we call mid-level providers,” Julie Rovner, NPR health policy correspondent, said. Primary care “doesn’t necessarily have to be provided by someone with an MD after their name… [There are] lots of studies that say good primary care can be delivered by people like nurse practitioners, by physician assistants, by nurses.”
The show also took calls from listeners—a neurologist, a recent nursing school graduate, a surgical subspecialist, and a nurse practitioner, among them.
Listen to the NPR story or read the transcript here.
Roseanna H. Means, MD, is the founder of Women of Means, which provides free medical care to homeless women in the Boston area, a clinical associate professor at Harvard Medical School, and an internist on the attending staff at Brigham and Women’s Hospital in Boston. She is a 2010 Robert Wood Johnson Foundation Community Health Leader.
The prolonged recession of the last four years has hit many people hard. My work is taking care of homeless women, which I have done for the past 20 years. I lead a team of volunteer physicians and part-time paid nurses who provide free walk-in care to women and children in Boston’s shelters. We fill in the gaps left by larger, more bureaucratically rigid systems that put unrealistic and unattainable expectations on those who are disabled by extreme poverty, mental illness, trauma, and cognitive dysfunction.
I designed a program of “gap” care that brings health care to them. We act as the communication and advocacy bridge between the shelter/street world and the hospitals and health centers. Gap care is part of a continuum that I feel has an important role to play in health care access for vulnerable populations.
Here is a glimpse of our work.
Walking into one of the women’s shelters on a recent morning, I see a woman standing glumly in line for coffee, her hands chapped and shaky, her face pale and dry, a blanket heaped around her shoulder, pouring hot liquid into her body before staking out a cot where she can sleep for a few hours, let her guard down, away from the doorway where she was prey to drunk men who jumped her, raped her and stole her stuff.
She is hungover. She drank to escape the horror of having been attacked. She has been on and off the wagon so many times we have all lost count. She’s also been raped and stabbed more times than any of us can remember. She doesn’t go to the police any more. She’s just one more homeless woman who has been raped, a “nobody”; just more paperwork. I give her a hug and remind her that I love her no matter what. I know that she has a library of negative and self-loathing messages in her head. Mine is the one that can break through that chatter and give her a shred of self-respect.
The Affordable Care Act will allow more Americans to access dental health services, former Surgeon General and Robert Wood Johnson Foundation Clinical Scholars almnus David Satcher, MD, PhD, said recently at forum on unmet oral health needs, but there are concerns that the current dental workforce will not be able to meet the increase in demand. Satcher spoke at “Unmet Oral Health Needs, Underserved Populations, and New Workforce Models: An Urgent Dialogue,” a July 17 forum sponsored by the Morehouse School of Medicine and the Sullivan Alliance.
“We now have an opportunity to dramatically increase coverage,” he said. “But adding dental benefits will not translate into access to care if we do not have providers in place to offer treatment.” More than five million additional children will be entitled to dental health benefits under the Affordable Care Act, according to a news release from the Morehouse School of Medicine.
“I think we need more dentists and I think we need more professionals who are not dentists but who can contribute to oral health care services,” Satcher said. He was referring to mid-level dental providers, known as dental therapists.
Though improvements have been made in the 12 years since then-Surgeon General Satcher issued a report offering a framework for improving access to oral health, problems persist. Tooth decay is still common among children, he said, and many people do not have easy access to oral health providers.
Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:
A study by RWJF Physician Faculty Scholar Reshma Jagsi, MD, DPhil, finds female physicians considered to be among “the cream of the crop” make an average of $12,000 less a year than their male counterparts. The disparity persists even after accounting for physicians’ specialties, productivity, family status and other factors. HealthDay, Reuters, the Washington Post, Fox News and the Associated Press are among the outlets to report on the findings. Read more about the study.
Nurse.com reports on a study led by RWJF Interdisciplinary Nursing Quality Research Initiative (INQRI) grantees Michele Balas, RN, PhD, APRN-NP, CCRN, and William Burke, MD, that finds a series of evidence-based practices employed by a nurse-led health care team can reduce the risk of delirium for ICU patients and speed recovery after discharge.
Ruchi S. Gupta, MD, MPH, a Physician Faculty Scholar, is the author of a study that finds children who live in rural areas are less likely to have food allergies than children who live in cities. The study is the first to examine the prevalence of child food allergies by geographical region. CBS News, HealthDay, Parents Magazine’s High Chair Times blog and the Scientific American are among the outlets to report on the findings.
Tamar Mendelson, PhD, is an assistant professor at the Johns Hopkins Bloomberg School of Public Health, and an alumnus of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program (2004-2006). Her research interests include the development of prevention and intervention strategies for reducing mental health problems, with a focus on underserved urban populations. This post is part of a series on the RWJF Health & Society Scholars program, running in conjunction with the program’s tenth anniversary. The RWJF Health & Society Scholars program is designed to build the nation’s capacity for research, leadership and policy change to address the multiple determinants of population health. Mendelson is a member of the program’s 2nd cohort.
Anyone who's ever spread a yoga mat across a floor will tell you that it's about more than flexibility. One of many benefits of yoga is that it helps those who practice it deal with stress in their lives. An emerging body of research points to the conclusion that yoga can have a stress-relieving effect.
One problem with the research base is that it's mostly focused on adults. But grown-ups aren’t the only ones who deal with stress in their lives. Children face it as well, and they often do it without the same resources—emotional, financial and otherwise—that adults have.
By Daniel L. Howard, PhD, executive director of the Robert Wood Johnson Foundation Center for Health Policy at Meharry Medical College. The Center’s mission is to provide leadership in health policy education, research and reform, while improving the health and health care of underserved communities.
On May 17th, the U. S. Census reported a dramatic and historic shift in the nation’s demographics. For the first time, babies born from multicultural groups—African Americans, Hispanics, Asians, and others—comprise the majority of new births in the United States. This trend indicates that the nation will soon transform from a white-majority-dominated population of approximately 85 percent, just a generation ago, to a minority-majority-dominated country.
The population shift also has great implications for the nation’s overall health. The groups that will soon make up the majority of our citizens suffer from significant health care disparities by almost every indicator—access, quality of care and health status.
The New America
In the 1950’s, the U. S. Census reported that whites were roughly 90 percent of the population, while Blacks were 10 percent. In the 1970’s, whites were approximately 84 percent of the population, Blacks 11 percent, and Hispanics 5 percent. By 1990, whites were less than 79 percent and Blacks and Hispanics were 12 percent and 9 percent, respectively.
As of 2011, African Americans, Hispanics, Asians and other minority groups account for 50.4 percent of births, 49.7 percent of all children under five years old and slightly more than half of the 4 million children under one year old. A key reason is that a greater share of the minority population is of child-bearing age. Striking median age differences exist between races; Hispanics (27.6) and whites (42.3) are on either end of this spectrum, while African Americans (30.9) and Asians (33.2) are in between.
Yet, we live in a country where, “African Americans live sicker and die younger than any other group of Americans,” according to noted medical sociologist Thomas LaVeist, PhD, director of the Hopkins Center for Health Disparities Solutions at the Johns Hopkins Bloomberg School of Public Health. And many other diverse groups struggle to obtain needed care and manage a range of chronic health problems—a situation that greatly contributes to national health care costs and underscores the need for health care policies and institutions capable of addressing health disparities.
The U.S. Department of Health and Human Services, Office on Women’s Health has designated May 13 to May 19 as National Women’s Health Week. It is designed to bring together communities, businesses, government, health organizations and others to promote women’s health. The goal in 2012 is to empower women to make their health a top priority. The Robert Wood Johnson Foundation (RWJF) Human Capital Blog is launching an occasional series on women’s health in conjunction with the week. This post is by Rebekah Gee, MD, MPH, RWJF Clinical Scholars alumna and an assistant professor of public health and obstetrics and gynecology at Louisiana State University (LSU). She is director of the Louisiana Birth Outcomes Initiative.
Louisiana is a fantastic place to live. It’s one of the most culturally rich and enchanting places in the United States. The state, however, also faces some of the greatest challenges in our nation.
Louisiana has a long history of poverty, poor education, and social problems that affect the health of too many of its citizens. And for women—particularly African American women—the challenges are even greater. We are 49th in the nation in terms of overall birth outcomes, like infant prematurity and mortality, and we get failing grades on report cards that measure those indicators of health.
In 2010, Bruce Greenstein, Secretary of the Louisiana Department of Health and Hospitals (DHH), recognized the importance of poor birth outcomes as a crucial public health issue—and named it his top priority. We were the first state in the nation to offer birth outcomes this kind of backing from our government officials. In November, 2010, we launched the Birth Outcomes Initiative, which I direct. It engages partners across the state—physicians, hospitals, clinics, nurses—and provides them with the best evidence and guiding principles to achieve change. We have made significant progress already.
We are working with the state’s hospitals on maternity care quality improvements, including ending all medically unnecessary deliveries before 39 weeks gestation. We have partnered with 15 of the largest maternity hospitals to provide them with the support and resources to make this a reality. Now, every maternity hospital in the state (there are 58) has signed on to the 39-Week Initiative.
Soon, we will be publishing perinatal quality scores—available to the public—so hospitals and physicians are held accountable for outcomes. In our pioneer facilities, we have seen the rates of elective deliveries drop by half. Many facilities have had as much as a 30-percent drop in the number of babies who needed to go to the NICU. The efforts of the Birth Outcomes Initiative are improving lives day after day.
By Cheryl Chun, MS, MA, Health Policy Scholar, Robert Wood Johnson Foundation (RWJF) Center for Health Policy at Meharry Medical College
Being a public school teacher was one of the most challenging and rewarding experiences of my life. I spent my days trying to not only excite my students about mathematics, but also to help change their life trajectory by encouraging them to go to college.
Neither of these tasks was easy. Many of my students cited math as their least favorite subject in school. And despite the college atmosphere my colleagues and I worked diligently to create, many of my students struggled to accomplish the necessary coursework and SAT scores they needed for college.
I realized that teaching high-needs students was more complicated than having a good lesson plan. While I will always believe in the importance of having a good teacher in the classroom and up-to-date resources for them to use, my time in the classroom has showed me that often good students fall behind in school because of obstacles they face outside school. My students had to deal with guns and gang violence, not enough money for basic needs, and inadequate access to medical care. Many had no medical insurance and would miss class to spend all day waiting in line at free clinics to translate for their sick parent; or be too exhausted to come to class after spending all night with their sick child in the Emergency Room. I also saw how inadequate nutrition could affect students’ behaviors and their ability to learn.
Witnessing these needs in my classroom inspired me to go back to school and become a physician.
While I hope that I made an impact on my students while I was their teacher, I know they made an impact on me and changed my life trajectory. I hope to one day practice in a medically underserved area and help provide care to those who need it most.
Former Health & Human Services Secretary Louis Sullivan, MD, penned an op-ed in yesterday’s New York Times making the case for devising more effective ways to deliver dental care to poor or rural communities across the nation.
The Secretary notes that, in 2009, 83,000 emergency room visits resulted from preventable dental problems. “In my state of Georgia,” he writes, “visits to the ER for oral health problems cost more than $23 million in 2007. According to more recent data from Florida, the bill exceeded $88 million. And dental disease is the No. 1 chronic childhood disease, sending more children in search of medical treatment than asthma. In a nation obsessed with high-tech medicine, people are not getting preventive care for something as simple as tooth decay.”
He goes on to list several reasons: 50 million of us live in poor or rural areas without a dentist; most dentists do not accept Medicaid; and we have a dentist shortage that will only be exacerbated when 5.3 million children are added to Medicaid and the Children’s Health Insurance Program by way of the Affordable Care Act.
Sullivan argues that the federal government should put programs in place to train more dentists. But more than that, he argues for training dental therapists “who can provide preventive care and routine procedures like sealants, fillings and simple extractions outside the confines of a traditional dentist’s office.” He says such an approach has been particularly effective in Alaska, where the state has recruited and trained dental therapists to serve many of that state’s most remote communities, including many that are accessible only by plane, dogsled or snowmobile.
A recently announced effort by the Robert Wood Johnson Foundation (RWJF) takes aim at the very same problem. The Oral Health Workforce initiative is designed to improve access to oral health care by identifying and studying replicable models that make the best use of the health and health care workforce to provide preventive oral health services.