Health
Services
for
Special
Populations
Chapter
11
Learning Objectives

Learn the 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
women

Appreciate the challenges faced by rural health and the
homeless

Understand the nation’s mental health system.

Understand the AIDS epidemic in America,


the groups affected by it, and
the services available to HIV/AIDS patients
Introduction

Certain population group at greater risk of
poor:
 physical
 psychological
 social

health
Terms used:
 underserved
 medically
underserved
 medically disadvantaged
 underprivateileged
 American underclasses
Population Groups
uninsuranceured children
 women
 rural area residents
 homeless
 mentally ill
 chronically ill
 disabled
 HIV/AIDS

Racial Ethnic
Minorities

30% of U.S. population is minority
 Black Americans
 Hispanic
- 12.3%
Americans - 12.5%
 Asian Americans
 American
- 3.6%
Indians and Alaska Natives - .9%
Racial Ethnic
Minorities Stats

Asian less likely to smoke during
pregnancy

Hispanics over 45+ years old consume
more alcohol

Mammography use of women 40+ years
old is:
 greatest
among white females,
 lowest in Hispanics
Racial Ethnic
Minorities Stats
 Look
at Fig 11-1, page 425
 Look at Tbl 11-1, page 426
 Look at Fig 11-2 and Fig 11-3, page 427
 Look at Fig 11-4 and Fig 11-5, page 428
 Look at Tbl 11-2, page 429 - 430
 Look at Fig 11-6, page 431
 Look at Tbl 11-3, page 431
 Look at Fig 11-7, page 432
The Uninsuranceured

9.2 million (12.1%) are children

40.9 million (16%) are non elderly

Tend to be:




Medically uninsuranceured: employed but not covered due to:




less educated, poor
working in part-time jobs and/or employed by small firms
younger 25-40 year olds
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

19% covered under Medicaid
67% covered under private insurance
5-20% of children have disabilities

Developmental Vulnerability




Dependency


the rapid and cumulative physical and emotional changes that
characterize childhood, and the potential impact that illness, injury,
or disruptive family and social circumostances can have on a child’s
life course trajectory.
children’s circumostances that require adults to take responsibility
for recognizing and responding to their health needs.
New morbidities

drug, alcohol abuse, violence, emotional disorders, learning
Children and the US
Health Care System

Health care for children is patchwork,
disconnected programs

US characterizes children’s into 3 sectors:
 personal medical and preventive
• primary and specialty care
 population-based
services sector
community health services
sector
• immunization, abuse prevention, rehab, case management,
referrals
 health related support services
• nutrition, rehab, family support
sector
Women

The leading providers of care in the nursing profession

also in allopathic and osteopathic medicine, dentistry, podiatry, and
optometry
•
Look at Fig 11-9, page 444

Women in the US live 8 years longer than men, but they
suffer
greater morbidity and have poorer health
outcomes.

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
only 24% for men
Women

Women account for approximately 23% of AIDS cases

Women are more likely to be depressed than men

Women are at substantially greater risk for Alzheimer’s
than men

Substance Abuse and Mental Health Services
Administration are targeting 6 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 65-74 and 75 and older, women have higher physician
utilization rates than men
hospitalization rates are comparable for men and women
Women work more part-time jobs than men, receiving lower wages,
and having interruptions in their work histories;

they are at a higher risk to be uninsured

Women are more likely to be covered as dependants under there husbands plans
Women are twice as likely to be covered under Medicaid because the
program is linked to Aid to Families with Dependant 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.

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.
 Focusing on major causes of death and disability among women
Rural Health

Poor access by:
 poverty,
long distances, topography,
weather, availableability 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
1) The National Health
Services 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 20,000 have been placed in medically underserved
communities.
2) Health Manpower
Shortage Areas (HMSA)

The Health Professions Educational Assistance
Act
of 1976 provided for HMSAs

Three different types of HMSAs:
 geographic
area, population groups, and medical
facilities

DHHS designated 1955 primary care physician
shortage areas
 68%
were in rural areas
3) 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

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
4) Community and
Migrant Health Centers

Service to low income populations on a
sliding-fee scale

Serve 9 million patients per year:
 25%
black
 33% Hispanic
 8% other minorities

Offers primary and prevention

Hard to attract physicians here
5) 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
Practioners do not need physician oversight

There are over 400 currently operating
6) 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

Est 3.5 million people are without a home






Single men – 40%
Single women – 14%
Adolescents – 2%
Children – 39%
Families with children – 40%
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
The Homeless

Barriers to Health Care
 Barriers to ambulatory services
 High hospitalization rates

Reasons for barriers:
1) Individual factors
• Competing needs
• Substance dependence
• Mental Illness
2) System factors
• 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 5 Americans have a mental disorder in a
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:
1) build science base
2) overcome stigma
3) improve public awareness
4) ensure supply of mental health
5) ensure state-of-the-are treatment
6) tailor treatment to demographics
7) facilitate treatment
8) reduce financial barriers
Mental Disorders

Managed care
 Managed
 State
care is also expanding into mental health.
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
 postgrad
training in mental health
 have power
•
•

can prescribe prescriptions
admit patients
Psychologists
 usually
have doctoral degree, some
masters
 interpret and change people’s behavior
 cannot issue prescriptions
Mental Health

Depression
 The
most common illness among primary care
patients
•
affects approximately 18.8 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,
The Chronically Ill
and Disabled

Unique challenges to our health system that is oriented
toward
acute care

In 2000, 10+% of Americans had chronic conditions





40 million have limitations in ability to perform ADLs
12 million disabled, can’t work, go to school, or maintain a household
By 2010, 141 million will have a chronic condition.
Estimated are that 1/3 with chronic illnesses do not get proper care.
Chronic
 an
illness if disease or injury with long-term symptoms, 3
or more months

Disability
a
person’s short-term or long term limitation / inability to
perform tasks that were previously done unaided; a gap
HIV / AIDS

July 1982, a disease was officially named:
 acquired
immuno deficiency syndrome (AIDS)

AIDS caused by human immunodeficiency
virus (HIV)?

Leading cause of death in US women, 25-44
years old
 due
to hetero exposure to HIV, injection drugs...
HIV / AIDS

Risk factors:
 male-to-male
sexual encounters
 male to female sexual contact
 injection drug use
 blood product exposure
 perinatal transmission frm mother to
infant
•
during pregnancy, delivery or possible
breastfeeding
HIV / AIDS

HIV testing is anonymous or
confidential
 39
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
•
(ie tuberculosis)
 Includes
cocktails
Cost of HIV / AIDS

The course of AIDS:
a
gradual decline in a patient’s physical,
cognitive, and emotional function and wellbeing.

Medical care is very expensive
•
$119,000 per person on average due to inpatient care
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)