Prospectus: Strategies to Improve Access to Quality of Diabetes Care among uninsured and underinsured Who Use Free Clinics.
Problem Statement
Type 2 diabetes mellitus is known as a chronic condition which usually requires multiple office visits, laboratory tests, and pharmacotherapies on an annual basis. As such, diabetes care generates the need for adequate and affordable health insurance to facilitate the access and quality of supplies, medications, and education to manage, prevent, and /or treat the complications related to the disease. Type 2 diabetes mellitus (DM) presents several challenges to healthcare professionals and is a major cause of morbidity and death. According to Belue et al. (2014), Type 2 diabetes mellitus disproportionately affects low-income and minority populations in the United State. The American Diabetes Association (2018) explained that Diabetes usually increases the risk for many serious health problems such as skin infections, nerves damages, glaucoma, cataracts, kidney disease, and high blood pressure. Access to high-quality and affordable prevention measures, including screening and appropriate follow-up, are essential for increasing early diagnosis, and decreasing an individual’s risk of lifelong health complications, which might include blindness, lower-limb amputations, peripheral neuropathy, decreased quality of life, decreased functional status, and emotional distress (ADA, 2018).
According to the Centers for Disease Prevention and Control (2017), in 2017 9.4% of the US population (30.3 million people) dealt with diabetes, 23.1 million people were properly diagnosed with Diabetes while 7.2 million people (23.8%) were not. The problem is that an increasing number of Americans are suffering from Diabetes and most of them do not seek or receive quality of care because they are uninsured or underinsured. According to Cohen, Zammitti, & Martinez (2018), 29.3 million americans were uninsured and an estimated 25 million were reported to be underinsured in 2017. Almost half of these uninsured and underinsured populations are believed to have diabetes. The American Diabetes Association (2018) stated that people with diabetes who do not have health insurance have 60% fewer physician office visits and are prescribed 52% fewer medications than people with insurance coverage. Mallow et al. (2015) explained that diabetes was and still is a significant problem for people who do not have insurance and/or not good enough because of the health disparities they are usually confronted to which most of the time lead to delaying medical treatment. Mallow et al. (2015) explained that uninsured people with diabetes visit the Emergency Department 55% more than people who have insurance because they wait until their illness becomes critical before going to ED to seek care.
Few strategies were developed in the past for the uninsured diabetes care. Huckfeldt et al., (2014) studied the One-Stop Diabetes Care strategy that was a freestanding diabetes management program through which a patient could receive assessment and treatment by a nurse educator and endocrinologist or nurse practitioner all in one visit. Necessary laboratory test results were made available within twenty minutes and prescriptions could be filled at no or low cost in the same clinic building. The second strategy studied by Huckfeldt et al. (2014) was a set of case management and clinical pharmacy programs that were integrated into primary care in a community clinic. This strategy required an initial screening to determine whether a patient meets inclusion criteria (i.e. has diabetes) or does not meet exclusion criteria -specifically that the patient exhibits reasonable cognitive ability, the patient or a proxy can communicate in English or Spanish, the patient is not psychotic, and the patient is not undergoing active chemotherapy-, a calculation of risk scores to determine motivation and desire to participate in the program and screening. This strategy allowed patients to be treated in the diabetes management program for six months or until their blood glucose reaches the targeted level (-8 percent and low-density lipoprotein (LDL) cholesterol (Huckfeldt et al., 2014). Mallow et al. (2015) also implied the need to develop primary care interventions as strategy to improve access, quality and outcomes of diabetes care for people who have no/or not good enough insurance coverage. Although beneficial short-term effects were found and linked to these short-term strategies, it is unclear if the observed and/or anticipated improvement can be sustained in free care settings for a long period of time reason why there is still a need to develop new strategies to address the issue of diabetes care management among uninsured and underinsured once and for all. Also, the question remains of whether primary care interventions would be sufficient enough to address the issue of access to quality of care for uninsured and underinsured people with diabetes.
The diabetic uninsured patients who transitioned to the Affordable Care Act is also worth studying. The Affordable Care Act (ACA) has made Diabetes Care more manageable for the uninsured population. Burge & Schade (2014) referred to the ACA as the most important federal medical legislation to be enacted since Medicare which goal is to improve healthcare coverage, access, and quality for all Americans, and explained that people with diabetes are especially poised to benefit from the comprehensive reforms included in the act. According to Buschur, Glick, & Kamboj, (2017), although insurance coverage accessibility has increased in recent years with the passage of the Affordable Care Act (ACA), many young adults will experience a period in which they are un-or under-insured. For the diabetic uninsured patients who transitioned to the Affordable Care Act, the question remains as whether they are ensured proper continuum of care or not. Addressing the problem of improving the access to quality of care among uninsured and underinsured individuals would be the logical next step to promote quality of care through early diagnosis and treatments, to decrease the mortality rates related to diabetes, and to take decisive actions to ensure continuum of quality care to people with diabetes that are transitioning from a free clinic to a more structured healthcare setting.
Purpose
The purpose of this Research is to explore and gain a deeper understanding of strategies to improve the quality of diabetes care for uninsured and underinsured people with diabetes. This research would be helpful in understanding the feelings and perspectives of uninsured and underinsured people with diabetes who are struggling to fight the disease in an effective way with limited to no access to quality care. This research would also help to understand if the diabetic uninsured patients that are transitioning to the Affordable Care Act are receiving proper continuum of care. In recent years, several studies have tried to explore different perspectives. Martinez et al. (2018) explored patients’ perspectives on social and goal-based comparisons regarding their diabetes health status and found out that providing patients with diabetes with social and goal-based comparison information may affect motivation, mood, and self-concept in ways that may improve or sustain diabetes self-care behaviors for some patients. Soto et al. (2015), explored an ecological perspective on diabetes self-care support and found out that higher levels of self-support were significantly associated with eating fruits and vegetables most days/week, eating high-fat foods few days/week, engaging in physical activity most days/week, daily feet examinations, and self-reported medication adherence. While diabetes poses a huge health and economic burden to society, effective Diabetes comprehensive and quality management programs should start with easy access for individuals living with the disease whether they do have health insurance coverage or not.
Significance
This study will greatly benefit different professions in the healthcare administration, public health and human services fields. Addressing the problem of improving access to quality diabetes care among uninsured and underinsured individuals would be the logical next step to facilitate and promote easy access to quality of care to uninsured and underinsured individuals who have diabetes and are struggling to fight it, to promote early diabetes diagnosis and treatments, to decrease the mortality rates related to diabetes, to coordinate public response to diabetes, and to take decisive actions to ensure continuum of care to people with diabetes that are transitioning from a free clinic to a more structured healthcare setting. This topic is within the domain of health services program focusing on both patients and peoples centered care.
Background
- American Diabetes Association. (2018). The Cost of Diabetes. The association explained that people with diabetes who do not have health insurance have 60% fewer physician office visits and are prescribed 52% fewer medications than people with insurance coverage—but they also have 168% more emergency department visits than people who have insurance. They further highlighted the components of substantial burden that diabetes imposes on society to include burden associated with undiagnosed diabetes, pain and suffering.
- Brown, D., & McBride, T. (2015). Impact of the Affordable Care Act on Access to Care for US Adults with Diabetes, 2011-2012. The authors explained that uninsured adults with diabetes have less access to health care and lower levels of preventive care, health care use, and expenditures than insured adults. With easy access and coverage, uninsured people with diabetes would significantly increase their health care use, which may lead to reduced incidence of Diabetes complications and improved health
- American Diabetes Association. (2016). Foundations of Care and Comprehensive Medical Evaluation. Diabetes comprehensive medical evaluation includes the initial and ongoing evaluations, assessment of complications, management of comorbid conditions, and engagement of the patient throughout the process. Individuals with Diabetes should participate in the Diabetes Self-Management Education and Support to facilitate the knowledge, skills, and ability necessary for diabetes self-care.
- Howe, R. (2018). Treating Type 1 Diabetes Without Insurance – The Over the counter T1D challenge. The author started The Over the counter challenge to treat Type 1 Diabetes to give hope and make uninsured and underinsured individuals living with Diabetes understand that with or without health insurance coverage one can still properly manage and treat Type 1 Diabetes.
- Jackson, Y., Lozano, J.C., & Carpentier, B.C. (2016). Quality of diabetes care and health insurance coverage: a retrospective study in an outpatient academic public hospital in Switzerland. The authors studied the variable of Diabetes treatment among insured and uninsured in Switzerland and did not find any difference in quality of diabetes care between insured and uninsured patients in a public hospital enforcing health-equity policies for access to and for delivery of standard diabetes care.
- Soto, S., Louie, S., Cherrington, A., Parada, H., Horton, L., & Ayala, G. (2015). An Ecological Perspective on Diabetes Self-care Support, Self-management Behaviors, and Hemoglobin A1C Among Latinos. The authors explored an ecological perspective on diabetes self-care support and found out that higher levels of self-support were significantly associated with eating fruits and vegetables most days/week, eating high-fat foods few days/week, engaging in physical activity most days/week, daily feet examinations, and self-reported medication adherence.
- BeLue, R., Figaro, K., Peterson, J., Wilds, C., & William, P. (2014). The Diabetes Healthy Outcomes Program: Results of Free Health Care for Uninsured at a Federally Qualified Community Health Center. The authors explained how Type 2 diabetes mellitus disproportionately affects low-income and minority populations in the United States.
- Martinez, W., Wallston, K., Schlundt, D., Hickson, G., Bonnet, K., Trochez, R., & Elasy, t. (2018). Patients’ perspectives on social and goal-based comparisons regarding their diabetes health status. The authors explored patients’ perspectives on social and goal-based comparisons regarding their diabetes health status and found out that providing patients with diabetes with social and goal-based comparison information may affect motivation, mood, and self-concept in ways that may improve or sustain diabetes self-care behaviors for some patients.
- Zhang, X., McKeever Bullard, K., Gregg, E., Beckles, G., Williams, D., Barker, L., Albright, A., & Imperatore, G. (2012). Access to Health Care and Control of ABCs of Diabetes. The authors acknowledged that access to health care, including insurance coverage, plays a crucial role in the receipt of preventive services and booth lack of insurance coverage and inadequate coverage have been associated with lower use of preventive services by people with Diabetes. They further implied that there is a need to improve access to health care among persons with diabetes who lacks insurance coverage
- Cohen, R., Zammitti, E., & Martinez, M. (2018). Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2017. The authors explained that 29.3 million americans were uninsured and an estimated 25 million were reported to be underinsured in 2017. Almost half of these uninsured and underinsured populations are believed to have diabetes.
- Huckfeldt,P., Meeker, D., Peters, A., Guterman, J., Diaz, G., & Goldman, D. (2014). Diabetes Management for Low-Income Patients in Los Angeles: Two Strategies Improved Disease Control In The Short Term.
- Burge, M., & Schade, D. (2014). Diabetes and the Affordable Care Act. The authors explained that people with diabetes are especially poised to benefit from the comprehensive reforms included in the ACA.
- Buschur, E., Glick, B., & Kamboj, M. (2017). Transition of care for patients with type 1 diabetes mellitus from pediatric to adult health care systems. The authors explained that although insurance coverage accessibility has increased in recent years with the passage of the Affordable Care Act (ACA), many young adults will experience a period in which they are un-or under-insured.
Framework
The conceptual framework for investing in human capital or the human development framework developed by Van der Gaag respectively in 1997 and 2003, would be well suited for this dissertation topic. Van Der Gaag (1997) identifies the dimensions of human development to include education, health, nutrition, social development, and growth. For healthcare administrators and public health professionals, this framework would help to educate them to view access to quality of care as the opportunity to identify healthcare needs, and for individuals with Diabetes to express their healthcare needs, to seek healthcare services, to reach, to obtain a more qualifiable comprehensive of care related to Diabetes. This framework would also help to conceptualize different dimensions of accessibility including: approachability, acceptability, availability and accommodation, affordability, appropriateness, quality and health outcomes.
Research Questions
Main Research Question:
What strategies to use to increase access to quality Diabetes care among uninsured and underinsured individuals living with Type 2 diabetes who use free clinics?
Sub Research Questions:
How to promote Type 2 Diabetes early diagnosis among uninsured and underinsured and decrease the mortality rate related to the disease?
How to ensure quality continuum of care to people with diabetes that are transitioning from free clinics to a more structured healthcare setting under the ACA?
Nature of the Study
This study will use a Qualitative Approach to help capture expressive information that are not usually conveyed in quantitative data and that are related to beliefs, values, feelings, and motivations that underlie behaviors (Patton, 2015; Berkwits & Inui, 1998). According to Rossman & Marshall (2012), the qualitative approach helps to gain insight into altitudes, values systems, cultures and lifestyles by exploring issues and getting pertinent information from case studies. The selected research design is a Case Study. This research design would help to define the purpose and approach of the study, to concentrate efforts on individuals during a period of time and could be achieved from either a positivist, or constructivist perspectives (Patton, 2015).
Possible Types and Sources of Data
This study will be conducted through the use of observations, field notes and databases to categorize and reference data. I’m also planning to conduct face-to-face interviews. I’m planning on using interviews, audio and video recordings as data collection tools. To analyze the data, I’m planning on using open coding which would make it possible to examine and identify the data by asking questions, making comparisons, and looking for similarities and differences between the comments (Patton, 2015).
References
American Diabetes Association. (2016). Foundations of Care and Comprehensive Medical Evaluation. Retrieved from http://care.diabetesjournals.org/content/39/Supplement_1/S23
American Diabetes Association. (2018). Complications. Retrieved from http://www.diabetes.org/living-with-diabetes/complications/
American Diabetes Association. (2018). Our Mission: To prevent and cure diabetes and to improve the lives of all people affected by diabetes. Retrieved from http://www.diabetes.org/
American Diabetes Association. (2018). The Cost of Diabetes. Retrieved from http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html
BeLue, R., Figaro, K., Peterson, J., Wilds, C., & William, P. (2014). The Diabetes Healthy Outcomes Program: Results of Free Health Care for Uninsured at a Federally Qualified
Community Health Center. Retrieved from http://journals.sagepub.com/doi/pdf/10.1177/2150131913481807
Berkwits, M., & Inui, T. (1998). Making Use of Qualitative Research Techniques. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1496926/
Brown, D., & McBride, T. (2015). Impact of the Affordable Care Act on Access to Care for US Adults with Diabetes, 2011-2012. Retrieved from https://www.cdc.gov/pcd/issues/2015/14_0431.htm
Burge, M., & Schade, D. (2014). Diabetes and the Affordable Care Act. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4074744/
Buschur, E., Glick, B., & Kamboj, M. (2017). Transition of care for patients with type 1 diabetes mellitus from pediatric to adult health care systems. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682376/
Cohen, R., Zammitti, E., & Martinez, M. (2018). Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2017. Retrieved from https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201805.pdf
Howe, R. (2018). Treating Type 1 Diabetes Without Insurance – The Over the counter challenge. Retrieved from https://beyondtype1.org/treating-type-1-diabetes-without-insurance-overthecountert1dchallenge/
Huckfeldt,P., Meeker, D., Peters, A., Guterman, J., Diaz, G., & Goldman, D. (2014). Diabetes Management for Low-Income Patients in Los Angeles: Two Strategies Improved Disease Control In The Short Term. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3883628/
Jackson, Y., Lozano, J.C., & Carpentier, B.C. (2016). Quality of diabetes care and health insurance coverage: a retrospective study in an outpatient academic public hospital in Switzerland. Retrieved from https://link.springer.com/article/10.1186/s12913-016-1801-z
Martinez, W., Wallston, K., Schlundt, D., Hickson, G., Bonnet, K., Trochez, R., & Elasy, t. (2018). Patients’ perspectives on social and goal-based comparisons regarding their diabetes health status. Retrieved from https://drc.bmj.com/content/6/1/e000488
Patton, M. Q. (2015). Qualitative research & evaluation methods: Integrating theory and practice. (4th, Ed.) Thousand Oaks, CA: Sage.
Rossman & Marshall (2012). Designing qualitative research (5th.ed).Thousand Oaks, CA:
Sage Publications, Inc.
Soto, S., Louie, S., Cherrington, A., Parada, H., Horton, L., & Ayala, G. (2015). An Ecological Perspective on Diabetes Self-care Support, Self-management Behaviors, and Hemoglobin A1C Among Latinos. Retrieved from http://journals.sagepub.com/doi/abs/10.1177/0145721715569078?journalCode=tdea