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Defining ‘Integrated Care’ and ‘Accessibility’ from an Ambulatory Health Care Provider Perspective.

Author(s) Jinani Jayasekera1, Eberechukwu Onukwugha2
Affiliation(s) 1Pharmaceutical Health Services Research, University of Maryland, Colombo, Sri Lanka, 2Pharmaceutical Health Services Research, University of Maryland, Baltimore, Baltimore, United States.
Country - ies of focus United States
Relevant to the conference tracks Clinical Practice and Hospitals
Summary Defining the key elements of primary care and developing tools to assess these key elements in ‘real world’ practice settings plays an important role in the efforts to promote primary care. ‘Integration’ and ‘Accessibility’ are two such key elements of primary care. Since ambulatory health care providers play a pivotal role in the provision and promotion of primary health care, it is necessary to examine the meaning of these key elements as it applies to their settings. This study aims to contribute to the understanding of ‘integrated care’ and ‘accessibility’ by examining the activities of health care providers in ambulatory care (outpatient) settings.
Background Current health care reform in the United States (US) highlights the role of ‘primary care’ in transforming health care delivery which has led to an increased interest in defining the meaning of ‘primary care’. The Institute of Medicine (IOM) defines primary care as the provision of integrated, accessible health care services by clinicians. IOM further describes ‘integrated care’ to encompass the provision of comprehensive, coordinated, and continuous services that provide a seamless process of care. ‘Accessibility’ refers to the ease with which a patient can overcome financial and cultural barriers to initiate an interaction with the physician for any health problem. Health plan administrators, health policy makers and medical educators have sought to assess ‘integrated care’ and ‘accessibility’ of care provided by physicians to guide health planning and inform future policies. Their efforts are limited by the lack of measures of ‘integrated care’ and ‘accessibility’. The direct and generic assessment of the provision of ‘integrated care’ and ‘accessibility’ is necessary to evaluate primary care.
Objectives To identify measures of ‘integrated care’ and ‘accessibility’ from the perspective of a health care provider in the ambulatory care setting.
Methodology Ambulatory health care providers who participated in the 2004 National Ambulatory Medical Care Survey (NAMCS) were included in the study. NAMCS gathers data on a nationally representative sample of visits to office-based physicians’ practices engaged in direct patient care. NAMCS data includes a variety of patient demographic and clinical information as well as characteristics of care provided in ambulatory care settings. The provision of ‘integrated care’ was identified using seven variables that addressed comprehensiveness (physician self-identifies as the provider of comprehensive primary health care, provides preventive care and care through the life cycle), coordination (working in conjunction with other physicians to provide care, patient referrals are made to the physician by another physician or health care provider) and continuity (physician has established patients and follow-up care is provided). ‘Accessibility’ was defined at the physician level using six measures, one each for young and old patients. Specifically, ‘accessibility’ was defined as the proportion of African American, Hispanic, or Medicaid patients as a proportion of the total number of patients seen by a given physician. Medicaid is a federally and state-funded program to provide health care for low-income individuals in the US. Therefore, patients with Medicaid as a proportion of the physician’s patients were used to characterize financial barriers. Previous studies have shown African American and Hispanic patients in the US are less likely to have access to health services than non-Hispanic whites. Therefore, African American and Hispanic patients seen by the physician were used to characterizing cultural barriers. An exploratory factor analysis was conducted to identify the variables which contributed to the constructs of ‘integrated care’ and ‘accessibility’.
Results The sample consisted of 1,121 physicians. The physician specialties represented in the sample included, general/family practitioners (14%), internal medicine doctors (6%), pediatricians (7%), obstetricians and gynecologists (5%), urologist (7%), psychiatrists (9%) and other specialties. Based on the factor analysis, 11 of the 13 variables contributed to the definition of ‘integrated care’ and ‘accessibility’. Variables related to comprehensiveness, coordination and continuity of care (except care through the life-cycle) were interrelated and contributed to a single underlying construct which defined ‘integrated care’. Care provided to African American, Hispanic and those on Medicaid contributed to two factors related to ‘accessibility’. The two variables quantifying the proportion of African American patients seen by the provider defined one accessibility factor while the separate variables quantifying the proportion of Hispanic and Medicaid patients seen by a provider contributed to defining the second accessibility factor. Therefore, cultural and financial barriers identified by the elements could underlie the definition or meaning of ‘accessibility’.
Conclusion Both ‘integrated care’ and ‘accessibility’ are important constructs of primary care. The elements identified in this study capture the characteristics of ‘integrated care’ and ‘accessibility’ in ambulatory care settings. Therefore, these elements could potentially be used to assess the delivery of ‘integrated care’ and ‘accessibility’ in office based physician practices engaged in direct patient care. This study also provides a basis for further empirical work to develop measures of ‘integrated’ care and ‘accessibility’.

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