Teaching health-care trainees empathy and homelessness IQ through service learning, reflective practice, and altruistic attribution.

This article describes a novel inter-professional curriculum designed to address the needs of homeless patients in a Midwestern region of the United States which has high rates of poverty. The curriculum is intended for healthcare trainees coming from undergraduate pre-medical programs, nursing, pharmacy, social work, clinical psychology, medical school and post-graduate medical training in family medicine, medicine-pediatrics, and psychiatry. The clinical component is specifically designed to reach destitute patients and the curriculum is structured to reverse commonly held myths about homelessness among the trainees, thereby improving their Homelessness Information Quotient, the ability to more fully understand homelessness. Participants across all disciplines and specialties have shown greater empathy and helper behavior as determined by qualitative measures. Learners have also developed a greater understanding of health-care systems allowing them to more consistently address social determinants of health identified by the authors as their Disparity Information Quotient. This article outlines the process of initiating a homeless service program, a curriculum for addressing common myths about homelessness and the effective use of narrative methods, relational connections, and reflective practice to enable trainees to process their experience and decrease burnout by focusing on the value of altruism and finding meaning in their work.

Medicaid Disenrollment Patterns Among Children Coming into Contact with Child Welfare Agencies.

Objectives To examine retention of Medicaid coverage over time for children in the child welfare system. Methods We linked a national survey of children with histories of abuse and neglect to their Medicaid claims files from 36 states, and followed these children over a 4 year period. We estimated a Cox proportional hazards model on time to first disenrollment from Medicaid. Results Half of our sample (50 %) retained Medicaid coverage across 4 years of follow up. Most disenrollments occurred in year 4. Being 3-5 years of age and rural residence were associated with increased hazard of insurance loss. Fee-for-service Medicaid and other non-managed insurance arrangements were associated with a lower hazard of insurance loss. Conclusions for Practice A considerable number of children entering child environments seem to retain Medicaid coverage over multiple years. Finding ways to promote entry of child welfare-involved children into health insurance coverage will be critical to assure services for this highly vulnerable population.

Head injury in heroes of the Civil War and its lasting influence.

The Civil War era was an age-defining period in the history of the United States of America, the effects of which are still seen in the nation today. In this era, the issue of head injury pervaded society. From the president of the United States, Abraham Lincoln, to the officers and soldiers of the Union and Confederate armies, and to the population at large, head injury and its ramifications gripped the nation. This article focuses on 3 individuals: Major General John Sedgwick, First Lieutenant Alonzo Cushing, and Harriet Tubman, as examples of the impact that head injury had during this era. These 3 individuals were chosen for this article because of their lasting legacies, contributions to society, and interesting connections to one another.

Catastrophic health expenditure and 12-month mortality associated with cancer in Southeast Asia: results from a longitudinal study in eight countries.

BACKGROUND: One of the biggest obstacles to developing policies in cancer care in Southeast Asia is lack of reliable data on disease burden and economic consequences. In 2012, we instigated a study of new cancer patients in the Association of Southeast Asian Nations (ASEAN) region - the Asean CosTs In ONcology (ACTION) study - to assess the economic impact of cancer. METHODS: The ACTION study is a prospective longitudinal study of 9,513 consecutively recruited adult patients with an initial diagnosis of cancer. Twelve months after diagnosis, we recorded death and household financial catastrophe (out-of-pocket medical costs exceeding 30% of annual household income). We assessed the effect on these two outcomes of a range of socio-demographic, clinical, and economic predictors using a multinomial regression model. RESULTS: The mean age of participants was 52 years; 64% were women. A year after diagnosis, 29% had died, 48% experienced financial catastrophe, and just 23% were alive with no financial catastrophe. The risk of dying from cancer and facing catastrophic payments was associated with clinical variables, such as a more advanced disease stage at diagnosis, and socioeconomic status pre-diagnosis. Participants in the low income category within each country had significantly higher odds of financial catastrophe (odds ratio, 5.86; 95% confidence interval, 4.76-7.23) and death (5.52; 4.34-7.02) than participants with high income. Those without insurance were also more likely to experience financial catastrophe (1.27; 1.05-1.52) and die (1.51; 1.21-1.88) than participants with insurance. CONCLUSIONS: A cancer diagnosis in Southeast Asia is potentially disastrous, with over 75% of patients experiencing death or financial catastrophe within one year. This study adds compelling evidence to the argument for policies that improve access to care and provide adequate financial protection from the costs of illness.

Utility of evaluating HCV in an uninsured population.

OBJECTIVES: Although effective HCV treatment is available, it can be difficult to access for uninsured, urban patients. Our aim was to assess the utility of evaluation and outcomes in the uninsured with HCV when access to health care and treatment with triple therapy is provided. METHODS: We performed a retrospective review of consecutive patients referred for HCV from 2011 to June 2013 to an indigent HCV clinic. The primary outcomes were assessment of disease severity by noninvasive means and initiation of therapy. RESULTS: We identified 350 patients: mean age 50.6, 84 % with no insurance, 62 % men, 58 % black, 91 % HCV treatment naïve. Of these, 148 underwent liver biopsy and 68 % had F0-F1 and 10 % had F3-F4 fibrosis. FIB-4 and APRI were highly correlated (r = 0.9; p < .0001) and correctly classified patients by fibrosis strata (F0-F1, F2, and F3-F4; p = .0004). When combined, a FIB-4 ≤1.5 and APRI ≤0.5 correctly classified the absence of advanced disease in 97 % (p < .0001). Of those evaluated, 39 (11 %) went on to HCV treatment. Of those not in a clinical trial, 51 % completed treatment with SVR in 61 % with genotype 1 and 75 % in genotypenon-1. Of those not treated (n = 309), the most common reasons were mild disease (16 %), lost to follow-up (23 %), ongoing alcohol or substance abuse (24 %), and uncontrolled depression (10 %). CONCLUSION: Noninvasive assessment can accurately exclude advanced fibrosis. Despite access to care, the utility of evaluating to initiate HCV treatment is low suggesting that eliminating the barrier to health care may not increase HCV treatment.

Charitable pharmacy services: Impact on patient-reported hospital use, medication access, and health status.

OBJECTIVE: To evaluate the impact that Charitable Pharmacy of Central Ohio (CPCO), a pharmacy providing free pharmacy services and medications, had on an indigent patient population by determining the change in patient-reported hospital use, ability to access medications, and perception of health status after receiving CPCO services. DESIGN: Cross-sectional study with face-to-face interviews using a convenience sample. SETTING: Columbus, OH, in January to March 2013. PATIENTS: 206 English-speaking patients 18 years or older at CPCO. INTERVENTION: Free pharmacy services and medications provided by CPCO. MAIN OUTCOMES MEASURES: Number of patient-reported hospital visits before and after CPCO use. RESULTS: In the year before using CPCO, patients reported using the hospital a mean of 2.36 (median, 2.00) times per year versus 1.33 (median, 0.67) times per year after, a decrease of 1.03 hospital visits per year per patient. Before coming to CPCO, 41% of patients were able to have all of their prescribed medications filled; this rose to 85% after using CPCO. A total of 89% of patients reported that not only was their overall health was better, but they also had a better understanding of their medications and believed they were in more control of their own health since receiving CPCO services. CONCLUSION: A charitable pharmacy model has the potential to decrease health care costs and empower patients to be more in control of their health.

[Roma populations and health]. / Populations Roms et santé.

The health status of the so-called "Roma" is usually much poorer than that of neighbouring non-Roma populations with a life expectancy gap of 5-15 years. This results from prolonged exposure to adverse determinants of health and to persistent exclusion from social and political arenas. Scientific and social research has only poorly addressed the health issues of Roma and evidences are scarce. Insufficient access to public services, including to health care and non optimal clinical practices are modifiable factors. If correctly addressed, this could contribute to reduce health disparities, including in Switzerland.

Prescription coverage in indigent patients affects the use of long-acting opioids in the management of cancer pain.

PURPOSE: We tested the hypothesis that prescription coverage affects the prescribing of long-acting opiates to indigent inner city minority patients with cancer pain. MATERIALS AND METHODS: We conducted a chart review of 360 patients treated in the Oncology Practice at University of Medicine and Dentistry of New Jersey University Hospital, who were prescribed opiate pain medications. Half the patients were charity care or self-pay (CC/SP), without the benefit of prescription coverage, and half had Medicaid, with unlimited prescription coverage. We evaluated patients discharged from a hospitalization, who had three subsequent outpatient follow-up visits. We compared demographics, pain intensity, the type and dose of opiates, adherence to prescribed pain regimen, unscheduled emergency department visits, and unscheduled hospitalizations. RESULTS: There was a significantly greater use of long-acting opiates in the Medicaid group than in the CC/SP group. The Medicaid group had significantly more African American patients and a greater rate of smoking and substance use, and the CC/SP group disproportionately more Hispanic and Asian patients and less smoking and substance use. Hispanic and Asian patients were less likely to have long-acting opiates prescribed to them. Pain levels and adherence were equivalent in both groups and were not affected by any of these variables except stage of disease, which was equally distributed in the two groups. CONCLUSION: Appropriate use of long-acting opiates for equivalent levels of cancer pain was influenced only by the availability of prescription coverage. The group without prescription coverage and receiving fewer long-acting opiates had disproportionately more Hispanic and Asian patients.

Compliance with surgical follow-up does not influence fistula maturation in a county hospital population.

BACKGROUND: The purpose of this study is to examine follow-up rates and maturation rates after dialysis access surgery using a fistula-first approach in a county hospital with an indigent population. METHODS: A prospectively maintained dialysis access database was queried for cases performed between August 1, 2009 and September 30, 2011. The follow-up period ended on December 31, 2011. An attempt was made to contact patients who did not have complete follow-up data recorded to the point of fistula maturation for arteriovenous fistulas (AVF). Patients were contacted directly or through their dialysis center. Maturation was defined by successful use of the AVF for hemodialysis for at least 2 weeks for patients who are dialysis dependent or by the clinical assessment of an attending vascular surgeon for those not on dialysis. RESULTS: Two hundred three dialysis access cases were performed. The mean age was 51.4 years. One hundred twenty-six (62%) were male and 175 (86%) were Hispanic. Of these, 194 (95.6%) were AVF. Three AVF were ligated in the postoperative period for steal. Of the remaining 191 AVF, 94 (49%) patients completed their scheduled follow-up appointments. Sixty-six (35%) patients did not come to clinic but were contacted. Twenty-six (14%) patients were completely lost to follow-up and 5 (2.6%) died. Maturation data was obtained on 160 AVF. Of those, 123 (77%) reached maturation with a mean maturation time of 112 ± 99 days (range, 21-483). Twenty patients who completed follow-up underwent at least 1 additional surgical or endovascular procedure in an attempt to achieve maturation. Seventeen (85%) patients who underwent a secondary procedure went on to achieve maturation. There was no significant difference in maturation between the group that completed follow-up and those who were contacted by phone (69 [73%] vs. 54 [81%], P = not significant). CONCLUSIONS: In this indigent population, follow-up does not influence maturation rates of AVF. Despite poor compliance with follow-up in the setting of a public hospital, the maturation rate of an aggressive fistula-first approach is acceptable.

Fund helps CMs find resources for patients.

Tampa General Hospital has created a fund that case managers can use to pay for post-discharge services for unfunded patients when there is no other option. Case managers can use the fund to pay for home health services, a short stay in a skilled nursing facility, or other post-discharge services to free beds for other patients. Case managers and social workers huddle with the treatment team every day and identify challenging patients early in the stay. The case management and social work team tries to identify family or other community support that can help care for undocumented patients after discharge.

Meet the challenge of discharging patients with no way to pay.

Case managers and social workers have to look for creative solutions as hospitals struggle with finding a safe discharge for uninsured, undocumented, and homeless patients. It's often more cost-effective for hospitals to pay for post-discharge care rather than keeping unfunded patients as inpatients after they no longer meet acute care criteria. Undocumented patients sometimes want to go back to their home country for post-discharge care, but many have families in this country who are willing to care for them. Some homeless patients have families who are looking for them, but some have been on the street for many years and want to be discharged to the only living situation they know.

SWs become detectives when patients have no ID.

As a Level 1 trauma center, Lutheran Medical Center treats a lot of patients who come in unconscious, appear to be homeless, or are confused as to their identify. In those cases, social workers search to find families and funding sources. Many unidentified patients have loved ones who are looking for them and want to care for them after discharge. Some homeless patients are eligible for Social Security, but the checks stopped coming when they were with no permanent address. The hospital contacts an attorney to determine if undocumented patients who have lived in the U.S. for a long time or who have been in the hospital for six months with no change in condition may qualify for Medicaid under Permanent Residence Under Color of Law (PRUCOL) status.

SW follows patients with discharge challenges.

Patients at Medical City Dallas Hospital who are likely to have discharge challenges are assigned a dedicated social worker who spends time with patients and family members and starts to identify resources early in the stay. In some cases the patient's psychosocial issues take more time to address than their clinical needs. Whenever possible, the social workers encourage patients and families to pay a portion of the cost of their post-discharge medications. Social workers and case managers educate unfunded patients about resources such as clinics for low-income patients and the new healthcare exchange.

Lack of access to health care for African indigents: a social exclusion perspective.

BACKGROUND: Lack of access to health care is a persistent condition for most African indigents, to which the common technical approach of targeting initiatives is an insufficient antidote. To overcome the standstill, an integrated technical and political approach is needed. Such policy shift is dependent on political support, and on alignment of international and national actors. We explore if the analytical framework of social exclusion can contribute to the latter. METHODS: We produce a critical and evaluative account of the literature on three themes: social exclusion, development policy, and indigence in Africa-and their interface. First, we trace the concept of social exclusion as it evolved over time and space in policy circles. We then discuss the relevance of a social exclusion perspective in developing countries. Finally, we apply this perspective to Africa, its indigents, and their lack of access to health care. RESULTS: The concept of social exclusion as an underlying process of structural inequalities has needed two decades to find acceptance in international policy circles. Initial scepticism about the relevance of the concept in developing countries is now giving way to recognition of its universality. For a variety of reasons however, the uptake of a social exclusion perspective in Africa has been limited. Nevertheless, social exclusion as a driver of poverty and inequity in Africa is evident, and manifestly so in the case of the African indigents. CONCLUSION: The concept of social exclusion provides a useful framework for improved understanding of origins and persistence of the access problem that African indigents face, and for generating political space for an integrated approach.

Studying complex interventions: reflections from the FEMHealth project on evaluating fee exemption policies in West Africa and Morocco.

BACKGROUND: The importance of complexity in health care policy-making and interventions, as well as research and evaluation is now widely acknowledged, but conceptual confusion reigns and few applications of complexity concepts in research design have been published. Taking user fee exemption policies as an entry point, we explore the methodological consequences of 'complexity' for health policy research and evaluation. We first discuss the difference between simple, complicated and complex and introduce key concepts of complex adaptive systems theory. We then apply these to fee exemption policies. DESIGN: We describe how the FEMHealth research project attempts to address the challenges of complexity in its evaluation of fee exemption policies for maternal care. We present how the development of a programme theory for fee exemption policies was used to structure the overall design. This allowed for structured discussions on the hypotheses held by the researchers and helped to structure, integrate and monitor the sub-studies. We then show how the choice of data collection methods and tools for each sub-study was informed by the overall design. DISCUSSION: Applying key concepts from complexity theory proved useful in broadening our view on fee exemption policies and in developing the overall research design. However, we encountered a number of challenges, including maintaining adaptiveness of the design during the evaluation, and ensuring cohesion in the disciplinary diversity of the research teams. Whether the programme theory can fulfil its claimed potential to help making sense of the findings is yet to be tested. Experience from other studies allows for some moderate optimism. However, the biggest challenge complexity throws at health system researchers may be to deal with the unknown unknowns and the consequence that complex issues can only be understood in retrospect. From a complexity theory point of view, only plausible explanations can be developed, not predictive theories. Yet here, theory-driven approaches may help.

Perspectives of family physicians on the care of uninsured pregnant women.

OBJECTIVE: No official provisions are made for the medically uninsured under provincial public health programs in Canada. Studies have shown that uninsured pregnant women have inadequate access to prenatal and obstetrical services that favour healthy maternal and child outcomes. This qualitative study aimed to explore the perspectives of family physicians who provided care to uninsured pregnant women. METHODS: Eight family physicians affiliated with two Montreal-based primary-care clinics and one tertiary care hospital between 2004 and 2007 were interviewed using a semi-structured interview guide. Data were assessed using thematic analysis. RESULTS: Uninsured pregnant patients were characterized by physicians as socially vulnerable, with precarious immigration status that limited their access to health services. Uninsured patients were thought not to benefit from the same standard of perinatal care as their insured counterparts. Care of uninsured women was generally thought to be a professional obligation, regardless of the woman's ability to pay. Caring for this population was considered by family physicians to be challenging, engendering psychological stress, increased workload, and occasional tensions with other health care providers. CONCLUSION: In the present context, family physicians are left to negotiate the health care system in an attempt to provide adequate perinatal care for uninsured pregnant patients. This situation has repercussions for physicians, for patients and, ultimately, for infants. Leadership is required to ensure that all pregnant women in Canada have access to appropriate health care during the perinatal period.

Objectif : Il n'existe aucune disposition officielle en ce qui concerne les personnes qui ne sont pas couvertes par les régimes publics d'assurance-maladie provinciaux au Canada. Des études ont démontré que les femmes enceintes non assurées ne disposent pas d'un accès adéquat aux services prénataux et obstétricaux qui favorisent l'obtention de résultats maternels et infantiles sains. Cette étude qualitative avait pour but d'explorer les points de vue de médecins de famille ayant offert des soins à des femmes enceintes non assurées. Méthodes : Des entrevues semi-structurées ont été menées auprès de huit médecins de famille affiliés à deux cliniques montréalaises de soins primaires et à un hôpital de soins tertiaires de la même région entre 2004 et 2007. Les données ont été évaluées au moyen d'une analyse thématique. Résultats : Les patientes enceintes non assurées ont été caractérisées, par ces médecins, comme étant des personnes vulnérables sur le plan social dont le statut précaire en matière d'immigration limitait leur accès aux services de santé. Ces médecins estimaient que les patientes non assurées ne bénéficiaient pas du même standard de soins périnataux que leurs homologues assurées. D'ordre général, ils estimaient que l'offre de soins aux femmes non assurées constituait une obligation professionnelle, sans égard à la capacité de payer. Les médecins de famille considéraient que l'offre de soins à cette population était une activité complexe, qu'elle engendrait du stress psychologique, qu'elle entraînait une augmentation de la charge de travail et qu'elle donnait occasionnellement lieu à des tensions dans leurs relations avec d'autres fournisseurs de soins de santé. Conclusion : Dans le contexte actuel, les médecins de famille sont laissés à eux-mêmes dans leurs efforts visant à utiliser le système de santé pour tenter d'offrir des soins prénataux adéquats aux patientes enceintes non assurées. Cette situation a des répercussions pour les médecins, les patientes et, en bout de ligne, les enfants. Les décideurs doivent faire preuve de leadership pour s'assurer que, au Canada, toutes les femmes enceintes obtiennent accès à des soins de santé appropriés au cours de la période périnatale.

Binational utilization and barriers to care among Mexican American border residents with diabetes.

OBJECTIVE: To assess whether U.S.-Mexico border residents with diabetes 1) experience greater barriers to medical care in the United States of America versus Mexico and 2) are more likely to seek care and medication in Mexico compared to border residents without diabetes. METHODS: A stratified two-stage randomized cross-sectional health survey was conducted in 2009 - 2010 among 1 002 Mexican American households. RESULTS: Diabetes rates were high (15.4%). Of those that had diabetes, most (86%) reported comorbidities. Compared to participants without diabetes, participants with diabetes had slightly greater difficulty paying US$ 25 (P = 0.002) or US$ 100 (P = 0.016) for medical care, and experienced greater transportation and language barriers (P = 0.011 and 0.014 respectively) to care in the United States, but were more likely to have a person/place to go for medical care and receive screenings. About one quarter of participants sought care or medications in Mexico. Younger age and having lived in Mexico were associated with seeking care in Mexico, but having diabetes was not. Multiple financial barriers were independently associated with approximately threefold-increased odds of going to Mexico for medical care or medication. Language barriers were associated with seeking care in Mexico. Being confused about arrangements for medical care and the perception of not always being treated with respect by medical care providers in the United States were both associated with seeking care and medication in Mexico (odds ratios ranging from 1.70 - 2.76). CONCLUSIONS: Reporting modifiable barriers to medical care was common among all participants and slightly more common among 1) those with diabetes and 2) those who sought care in Mexico. However, these are statistically independent phenomena; persons with diabetes were not more likely to use services in Mexico. Each set of issues (barriers facing those with diabetes, barriers related to use of services in Mexico) may occur side by side, and both present opportunities for improving access to care and disease management.

Financial hardship in settling medical bills among households in a Semi-Urban Community in Northwest Nigeria.

BACKGROUND: An equitable health care system that responds to the needs of its people is important to break the cycle of poverty and ill-health. However, rising health care cost, and the preponderance of user fees to finance health care have often limited access to needed health services. STUDY DESIGN: A cross-sectional descriptive study design was employed, using a pretested, semi-structured, interviewer-administered questionnaire. RESULTS: The study was carried out among 188 respondents. Majority (88.2%) of the respondents were within the age-group 20-49 years, about two-thirds 63.8% were married and about half (42.8%) had family size between 5 and 9. The study revealed that about a quarter (26.1%) experienced hardship in settling their medical bills. While one-third (31.1%) had to sell their assets, about half (45.2%) had to secure loan while 16.6% had to resort to begging because of hardship encountered in settling the medical bills. Furthermore, of those who sold theirs asset; 46.2% sold their farmlands, 38.5% sold a piece of land, while 16.3% sold their vehicles. CONCLUSION: This study has revealed that inhabitants of Samaru community experience hardship in settling their medical bills. Consequently, innovative strategies like deferment of payment and fee exemption, enrolling into community-based health insurance schemes as well as voluntary contributory health insurance schemes etc need to be considered, in order to alleviate the hardship in settling the medical bills.

Costs, equity, efficiency and feasibility of identifying the poor in Ghana's National Health Insurance Scheme: empirical analysis of various strategies.

OBJECTIVES: To analyse the costs and evaluate the equity, efficiency and feasibility of four strategies to identify poor households for premium exemptions in Ghana's National Health Insurance Scheme (NHIS): means testing (MT), proxy means testing (PMT), participatory wealth ranking (PWR) and geographic targeting (GT) in urban, rural and semi-urban settings in Ghana. METHODS: We conducted the study in 145-147 households per setting with MT as our gold standard strategy. We estimated total costs that included costs of household surveys and cost of premiums paid to the poor, efficiency (cost per poor person identified), equity (number of true poor excluded) and the administrative feasibility of implementation. RESULTS: The cost of exempting one poor individual ranged from US$15.87 to US$95.44; exclusion of the poor ranged between 0% and 73%. MT was most efficient and equitable in rural and urban settings with low-poverty incidence; GT was efficient and equitable in the semi-urban setting with high-poverty incidence. PMT and PWR were less equitable and inefficient although feasible in some settings. CONCLUSION: We recommend MT as optimal strategy in low-poverty urban and rural settings and GT as optimal strategy in high-poverty semi-urban setting. The study is relevant to other social and developmental programmes that require identification and exemptions of the poor in low-income countries.

Hardship financing of healthcare among rural poor in Orissa, India.

BACKGROUND: This study examines health-related "hardship financing" in order to get better insights on how poor households finance their out-of-pocket healthcare costs. We define hardship financing as having to borrow money with interest or to sell assets to pay out-of-pocket healthcare costs. METHODS: Using survey data of 5,383 low-income households in Orissa, one of the poorest states of India, we investigate factors influencing the risk of hardship financing with the use of a logistic regression. RESULTS: Overall, about 25% of the households (that had any healthcare cost) reported hardship financing during the year preceding the survey. Among households that experienced a hospitalization, this percentage was nearly 40%, but even among households with outpatient or maternity-related care around 25% experienced hardship financing.Hardship financing is explained not merely by the wealth of the household (measured by assets) or how much is spent out-of-pocket on healthcare costs, but also by when the payment occurs, its frequency and its duration (e.g. more severe in cases of chronic illnesses). The location where a household resides remains a major predictor of the likelihood to have hardship financing despite all other household features included in the model. CONCLUSIONS: Rural poor households are subjected to considerable and protracted financial hardship due to the indirect and longer-term deleterious effects of how they cope with out-of-pocket healthcare costs. The social network that households can access influences exposure to hardship financing. Our findings point to the need to develop a policy solution that would limit that exposure both in quantum and in time. We therefore conclude that policy interventions aiming to ensure health-related financial protection would have to demonstrate that they have reduced the frequency and the volume of hardship financing.