Health services utilization, satisfaction, and attachment to a regular source of care among participants in an urban health provider alliance.
Abstract: This study examines the effect of a provider alliance on service utilization, satisfaction , self efficacy, and attachment to a regular source of care for participating low income urban children and their families. The use of Physician Assistants and community health workers to expand community outreach, primary care services, pediatric sub-specialty care, and service coordination within and between care settings improved health services utilization, satisfaction with health services, parental self efficacy in navigating the health care system for their children, and service convenience for an at-risk population. Also, the use of Physician Assistants to provide pediatric sub-specialty services did not have a negative effect on parental satisfaction with a child's care. Parents were slightly more satisfied with services received from a Physician Assistant in comparison with the physician sub- specialists in cardiology and nephrology clinics.

Key Words: Medical Home for Children, Health Services Utilization, Service Coordination, Non Clinical Case Management, Mid Level Providers in pediatric subspecialty settings, and Satisfaction with health services, Community Based Research, Community Outreach.
Article Type: Report
Subject: Patient satisfaction (Analysis)
Urban health (Analysis)
Medical care (Utilization)
Medical care (Analysis)
Authors: Tataw, David B.
Bazargan-Hejazi, S.
James, F.W.
Pub Date: 06/22/2011
Publication: Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2011 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Summer, 2011 Source Volume: 34 Source Issue: 1
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 304050540
Full Text: BACKGROUND

Introduction

The difficulty in navigating a fragmented United States health system is exacerbated in vulnerable urban communities where resources are limited, barriers to health services access are numerous, knowledge of preventive techniques is lacking, awareness of existing services is limited and primary and specialty health services are often not coordinated. Enabling community access sometimes requires community efforts and community partnerships that will provide seamless access and empower vulnerable consumers in urban communities to utilize existing health resources.

Collaborative relationships have become a common phenomenon in medical and public health for social change (Greenberg et al. 2003; Rousos & Fawcett, 2000; Sullivan & Kelly, 2001). The South Central Los Angeles Health Care Alliance (SCHCA) was a strategic initiative between The Charles R. Drew University Department of Pediatrics at King /Drew Medical Center, an academic medical institution, and St. John's Well Child Center, a community primary care provider. This strategic initiative was designed to facilitate the delivery of a coordinated continuum of health services for children and families living in South Los Angeles. The South Central Los Angeles Health Care Alliance was a partnership created to improve health care access, knowledge of preventive health practices and maximum utilization of available health resources by residents of South Los Angeles. This improvement was facilitated through the creation of a medical home for each child in conformity with the six recommended services of the American Academy of Pediatrics encompassing preventive care, acute care, continuity of care, specialty referrals, interaction with school and community, and maintenance of a database with a child's pertinent medical information (AAP,1992). The South Central Los Angeles Health Care Alliance also used mid-level providers (Physician Assistants and Nurse Practitioners) at both the primary care and sub specialty pediatric settings. Though many studies have demonstrated the successful use of mid level providers such as Physician Assistants and Nurse Practitioners in primary care (Lemley & Marks, 2009, Hunter et al., 2009); emergency care settings (Ducharme et al., 2009); and for special procedures such as abortion (Berer, 2009); the authors are not aware of studies which have reported or evaluated the use of midlevel providers to provide pediatric sub-specialty services.

The purpose of this study is to examine and report on the effect of the South Central LosAngeles Health Care Alliance (SCHCA) on service utilization, satisfaction , self efficacy, and attachment to a regular source of care for participating children and their families. Self-efficacy refers to the state of competence to perform certain desired tasks or behavior. Satisfaction with health services refers to the extent to which the patient is comfortable with, or accepts the services of a health provider. Though entrance into the health care system does not guarantee the quality of health services or the elimination of unmet needs, a child who is not attached to a source of care can not have any of their needs met. Satisfaction , self efficacy, and social support/service coordination are important constructs for health services scholars and practitioners because they have been linked to one another as well as to health and clinical outcomes. Satisfaction with health care is an important quality measure because satisfaction has been linked to health status and clinical process outcomes including compliance to medical treatment, prevention interventions, and improvements in health conditions (Cameron, 1996; Hall et al., 1998; Deyo & Diehl, 1986; Winefield et al., 1995; Redekop et al., 2002; Alazri & Neal, 2003). Studies also tie self efficacy to compliance with therapy regimens and positive coping styles. SoEderlund & Lindberg (2001) showed that self efficacy is related to patients' use of different coping styles. Patients with high self efficacy reported less use of "maladaptive" and passive coping styles than patients with low self efficacy.Non-adherence has also been associated with personal factors such as self-efficacy and interpersonal factors such as provider-patient relationship (Remien et al., 2007). Adherence is associated with patients' self-efficacy regarding their medical regimen (Atkinson et al., 2008), which in turn is associated with their social support (Atkinson et al., 2008; Knoll et al., 2009). Self efficacy has been shown to be a predictor of satisfaction (Tataw, Bazargan-Hejazi, Patel, 2009). Also, coordination across settings has been shown to affect patients' clinical outcomes and satisfaction with their care (Weinberg et al., 2007).

The empowerment of vulnerable individuals entails the matching of "multiple determinants of health with multiple interventions or sources of support (Green & Kreuter, 1999), such as education and ecological factors (social, political, economic, organizational, policy, and regulation). Penchansky and Thomas (1981), conceive access as the fit in the characteristics and expectations of providers and clients. Their discussion of the A's of access to care: affordability, availability, accessibility, accommodation, and acceptability covers cost of care, provider resources to meet consumer's needs, ease of physical contact between consumers and providers, and the extent to which the consumer is satisfied or comfortable with provider services. Improving the provider-patient fit is at the center of the SCHCA program.

Needs Assessment

Just as it is widely documented in the literature, the needs assessment for the South Central Los Angeles Health Care Alliance (SCHCA) project reflected low utilization patterns among low income children. Regardless of insurance coverage, low-income children and children with special needs have been found to have high levels of unmet needs (Janicke, Finney & Riley, 2001, Newacheck, Hughes & Stoddard, 1996, Melnick et al., 2002, Newacheck, Hung & Wright, 2002); and experience poorer quality of primary care (Stevens & Shi,2002a,b, 2003). Parents' self-confidence to voice concerns (Janicke & Finney, 2003, McCarthy et al., 2003); language barriers (Seid, Stevens &Varni, 2003, Weech-Maldonado et al.,2001; 2003); parents' perception of having a regular provider (Weech-Maldonado, 2001); and satisfaction with care (Stevens & Shi 2002a, Christakis et al.,2002, Baltutis & Morgan, 2002); allimpact parents' primary care utilization behavior.

Two needs assessments implemented via the Los Angeles County Survey of 2000, and three focus groups organized by the Department of Pediatrics at Charles Drew University in 1997, involving groups drawn from 10,915 students, parents, school officials and other community members within South Los Angeles ; identified the following top critical health and health care needs : low levels of health services utilization, limited knowledge of identification and prevention of common diseases, lack of patients' voice, lack of specialty care, lack of knowledge of available services to children and adults, lack of health education, substance use problems in families, lack of positive parental involvement in child development, domestic violence, fear of being turned in if services are accessed due to immigration status, lack of access to vision dental care, mental health care and immunizations, lack of knowledge regarding identification and treatment of Tuberculosis, lice, ringworm, scabies, need for strong school based health education and resource program for the parent, and lack of referral to pediatric acute care and subspecialty care.

THE SOUTH CENTRAL HEALTH CARE ALLIANCE (SCHCA)

The South Central Los Angeles Health Care Alliance was an initiative between an academic medical institution and a community primary care provider for the delivery of a coordinated continuum of health services to children and families living in South Central Los Angeles implemented from January 2002 to December 2004. The project was implemented through the creation of a medical home for each child in conformity with the six recommended services of the American Academy of Pediatrics as mentioned above (AAP, 1992).The Alliance created a "one-stop" medical home which enrolled children and families in health programs for which they qualified , attached families to medical homes, provided primary care to children, referred families to specialty services as needed, provided clinic-based health education to families, provided case management support in order to empower families to navigate the health care system, and utilized mid-level providers in pediatric primary care and subspecialty settings.

Expected Outcomes of SCHCA

The specific aim of this study is to examine and report the effect of the South Central Los Angeles Health Care Alliance (SCHCA) on service utilization, satisfaction, self efficacy, and attachment to a regular source of care for participating children and their families. Parents and/or children who participated in the South Central Health Care Alliance project would demonstrate improved knowledge of existing health services, improved knowledge of preventive health practices, improved self-efficacy in preventive practices and utilization of health services, and improved utilization of existing health services including successful completion of specialty care referrals. Participants would also exhibit improved skills in the identification and self-management of health conditions.

Conceptual Framework

The South Central Health Care Alliance is a variation of the Preventive Health Education and Medical Home Project (PHEMHP) which is a contextual and predictive health services utilization improvement approach designed by faculty in the Department of Pediatrics at Charles R. Drew University (Tataw, James, Bazargan, 2009). A key focus of the Preventive Health Education and Medical Home Project is the strengthening of the fit between provider and client characteristics. This is done by coordinating and maximally utilizing existing health and medical services within the community for improving the health of a child. This task is accomplished by being an information resource, providing health education, engaging a network of providers and community volunteers, and focusing on establishing a medical home for the child and family (Tataw, James, Bazargan, 2009). The alliance provided a one stop medical home consisting of primary care and specialty pediatric services centered on consumer advocacy and empowerment; and implemented within a network of community collaborators.

METHODS AND PROCEDURES

Target Population and Setting

The Department of Pediatrics was an academic department at Charles R. Drew University and a clinical service of the Los Angeles County King/Drew Medical Center. At the time of SCHCA implementation (January, 2002- December, 2004), the Department of Pediatrics operated a comprehensive secondary and tertiary pediatric service at the King/Drew Medical Center including a 24-hour pediatric service for acute care. Sub-specialty services included adolescent Health and Medicine, Allergy Immunology, Child Development, Critical Care Medicine, Cardiovascular Health and Medicine, Endocrinology, Gastroenterology, General Pediatrics, Infectious Disease, Neonatology, Nephrology, Hematology, and Emergency Medicine. Inpatient services included Neonatal Intensive Care Unit, Medical Unit, Pediatric Intensive Care Unit and Acute Care Nursery Unit. Outpatient services included Pediatric Ambulatory Care, Pediatric Emergency Care and Sub Specialty Clinics covering all the Physician Services mentioned above. Special Programs included Multidisciplinary screening services and OASIS Clinics which targeted AIDS related complications.

St. John's Well Child Center provided a full range of pediatric primary care services at two clinics. These services included: complete physical examinations, including hearing, vision and tuberculosis tests; immunizations for such common childhood diseases as diphtheria, pertussis, tetanus (DPT), measles, mumps, rubella (MMR), polio, H-influenza and hepatitis; pharmaceutical services; expanded care and treatment; primary dental services and dental hygiene and health education which had as its primary focus nutrition, oral care, and detection of lead exposure.

Both St. John's Well Child Center and the Department of Pediatrics at Charles R. Drew University served the South Los Angeles region, covering the communities of Compton, Crenshaw, Lynwood, Paramount, South Central Los Angeles and University area. This is the service area of Charles R. Drew University and King/Drew Medical Center. The service community covers 124.2 square miles of the County of Los Angeles with an estimated population of 1.7 million. The population of children in the service area is estimated at approximately 727,000 in a total population of approximately 1.7 million. The demographics are as follows: 30% African American, 67% Hispanic and 3% Asian/Other (U.S Census Bureau, 2002. Forty percent are at poverty rate, 95% of the children receive subsidized school lunch, 71% rent their primary residence, less than 10% have a college education or degree, and 50% have not completed high school (LACDHS, 2000). The children have the lowest scores in Los Angeles County on the Stanford test, and Scholastic Aptitude Test (SAT) scores are below the district average. Prevalence and intensity of disease is the highest in the county of Los Angeles. Health problems of concern to children in these areas include diabetes, obesity, asthma, childhood lead poisoning and low immunization rates (United Way, LA, 2000).

Program Design

The South Central Los Angeles Health Care Alliance was implemented using a prospective quasi experimental design with three intervention sites (St. John clinic located at down town Los Angeles; St. John clinic located in Compton, and King/Drew Medical Center pediatric sub-specialty site. The project also included many community-wide outreach activities. The project was implemented from January 2002 to December 2004.

The Alliance (i.e. SCHCA) created a "one-stop" medical home which enrolled children and families in health programs they were qualified for, attached families to medical homes, provided primary care to children, referred families to specialty services as needed, provided clinic- based health education to families, provided case management support to families as they learned to navigate the health care system, and utilized mid-level providers in pediatric primary care and sub-specialty settings.

During a primary care clinic intake, written or verbal consent from the parents were obtained and children were screened using California and American Academy of Pediatrics well-child care standards. Based on the outcome of the initial screening, enrollees were provided with treatment, and clinic based education, as well as referral to any needed sub-specialty services. They were also mentored through non-clinical case management while navigating subspecialty services.

From December 1 to 31, 2003 we conducted telephone interviews with the parents of children who received both primary care services at St. John's Well Child Center and pediatric sub-specialty care at King/Drew Medical Center Department of Pediatrics from January 2002 to November 2003. The survey instrument included 30 items using 5-point Likert scale response categories to assess parent's perceptions of their children's difficulties in accessing primary and pediatric services as well as satisfaction with medical services. It also included items to assess parents' satisfaction with services provided by their child's sub-specialty health provider. Other data on community outreach, source of referral to primary care services, enrollment to payer sources, attachment to medical homes, wait time in completing appointments, and sub-specialty appointment completion rates were collected and stored in the program database.

Recruitment and Selection

Community outreach. Trained Community Health Workers conducted outreach activities involving community education which consisted of an awareness/notification campaign. These workers were equipped with a resource manual to inform the community about the benefits of receiving healthcare, the availability of health services at St John's Well Child Centers, and sponsoring/insurance programs for children's health services. The Community Health Workers attended parents and teachers meetings, participated in health fairs, collaborated with other community agencies and churches, and distributed printed health materials at shopping malls.

SCHCA participation eligibility..To be able to enroll in the program, parents/guardians had to meet the following criteria: (1) have a child between the ages of 0-18 or are adolescents; (2) reside within the geographic area of South Los Angeles; (3) provide consent signature or verbal consent indicating that they were aware of the objectives of the program and were willing to be a part of it; (4) had no definite plans to leave the area in the next year.

Intervention Components

The program was made up of four intervention components: health assessment and medical treatment; clinic-based education; sub-specialty fast-track referral and non-clinical case management.

health assessment and medical treatment. This was conducted in the Medical Home, which was the central site of coordination of all aspects of the patient's medical care. The Medical Home for the patients in SCHCA was St John's Well Child Center. The SCHCA utilized Physician Assistants at both Primary and Sub-specialty sites

clinic-based education. Clinic-based education was provided by the primary care provider when the patient's health assessment and condition deemed it necessary. Decisions on the type and topics of health education were made after the patient's initial health screening at the intake.

A "fast-track" referral system between primary and sub-specialty sites. This system was created to shorten the waiting time between the child's first encounter with a primary care source or the emergency room to when he/she would receive sub-specialty care at the King/Drew Medical Center. The St. John's Well Child clinic(s) would refer patients in need of specialty care to the Pediatric subspecialties at the King/Drew Medical Center where St. John's clinic(s) were listed as the preferred community providers. The Alliance staff stationed at the Department of Pediatrics, from that point on, facilitated smooth transition and communication between the Department's subspecialty services, primary care providers and the patients.

non-clinical Case management. Non-clinical case management for parents was implemented by the community health workers. Community health workers were drawn from the same community as the participants and had an average educational level of an associate degree. They had no formal clinical training but received training on specific disease conditions and in case-management techniques. SCHCA case management was made up of assessment/screenings, referrals, service coordination, individualized planning, coaching, monitoring, and third party advocacy for the purpose of maintaining a continuum and a regular source of care. This approach is distinct from clinical case- management which includes treatment plans and implementation and is usually physician driven and nurse implemented (Huber 2000, Birmingham & Colon, 2005).

EVALUATION MEASURES

Data were collected to assess the impact of the program on participants' attachment to a regular source of care and existing payer source; utilization of primary and specialty care; and satisfaction with pediatric sub- specialty care provided by a Physician Assistant versus a physician (MD). A 30 item parent survey instrument was administered in the second year of the program. Items in the survey assessed parent's perceived difficulty in accessing primary and subspecialty pediatric services. Parents were asked to respond on a 5-point Likert scale (extremely difficult.... not difficult at all) stating how difficult it was for them to get: medical care; routine checkup; referral for subspecialty care; and an appointment with a pediatric sub-specialist. Using a 5-point likert scale, participating parents were also asked to respond how satisfied they were with the services received. (Extremely satisfied.... not satisfied). The survey instrument also assessed consumer satisfaction with specialty services provided by the Physician Assistant in comparison to the Physician (MD). In this section of the survey, parents were asked to rate their satisfaction with subspecialty providers in terms of the overall services received, friendliness of the provider, helpfulness of provider , time spent with provider, provider's explanation of health condition, provider's explanation of treatment, and provider's respect for parents. In the years 2002, 2003, and 2004, a patient database was used to collect service utilization and financial data including number of children attached to medical homes, number of outreach activities to children and families, number of children enrolled in existing payer sources, number of patients receiving clinic based education, number of sub-specialty referrals, number of completed sub-specialty referrals and the interval between the time a sub-specialty appointment was made and the visit was completed. Data entered into the data base was retrieved from numerous operational and administrative tracking instruments and reports at both the primary and specialty care sites.

RESULTS

Table one below presents the number of children attached to medical homes, number of children reached through outreach activities, sub-specialty services completion rate, average length of time it takes to complete sub-specialty appointments and number of children attached to existing payer sources. After two years of community outreach services, 404 outreach events were completed reaching 11,533 children. Two years of community outreach efforts led to 80,000 children (10% of the children in the service area) ,who previously did not have a regular source of care being attached to a medical home and 8,545 children being enrolled in available payer sources. The growth in new patients for the down town Los Angeles primary care location averaged 50 % in the first two years before leveling off in the third year. In the Compton primary care location, the growth was about 200% annually. A bonus to the program was the linkage of 20,000 adults to medical homes in the last two years of the program. Sub-specialty referral completion rate increased from 25% in 2001 to 78% in 2002, and 80% in 2003 then fell to 20% in 2004. The difference between the time a pediatric sub-specialty appointment was made and the time the patient was seen reduced from four months in 2001 to two and a half months in 2002, and one month in 2003, before rising to nine months in 2004.

Table 2 shows patterns of distribution among measures that were used for program evaluation. Though some questions could have multiple responses, participants had to select only the single response which best represented their experience. Nearly 39% of the sample reported having a child that required continuous medical care and the majority of the sample used St. John's community clinic as a regular source of care for their children (74.2%). Also, the overwhelming majority reported that they prefer to have the same doctor for their child (84%).

In general, Table 2 reveals a positive trend in the responses of participants. In reference to the perceived difficulty reported, the majority of the respondents reported less difficulty to obtain medical care (48.4%), less difficulty to obtain routine checkups for their children (58%), and less difficulty to obtain referral (48%). Also, the majority of the respondents reported being more satisfied with the services received for their children including general medical care (52%), routine checkup (48%), and were holding the same level of satisfaction with subspecialty care in comparison to the past 12 months (44%).

In addition, whereas the majority of the respondents reported that making an appointment for the child to receive sub-specialty care was less difficult compared to the previous 12 months (48%), a slightly higher number of participants reported that wait time to receive a visit from a sub-specialty care has been longer in comparison to the previous 12 months.

Table 3(column 1), presents participants' mean level of satisfaction and difficulties with services received and needed across participants who reported having a child who needed continuous medical care with those who reported their child didn't have any health condition that would require such care. It appears from Table 3 that, overall, participants who reported having a child who needed continuous medical care (column 1) compared to those who reported their child did not need such services, reported higher levels of satisfaction with the services received and less difficulty accessing needed services.

Furthermore, Table 3 (column 2) reveals mean differences between the responses of those who had received medical care for their child from a community clinic compared with those who reported receiving medical care from other places (i.e. private doctors' office, private medical group, hospital clinic, urgent care, and emergency room). We detected that that those who received care from places other than the community clinic were more likely to report difficulty with making an appointment for their children to receive sub-specialty care (-.14), and more likely to report that the time between receiving a referral and seeing a sub-specialty care for their child was much longer in comparison to the previous 12 month (-.43).

In addition, column 3 in Table 3 presents the overall mean score of the participants regarding their perception of satisfaction with care received and difficulties receiving services needed. The total mean scores shows an overall positive trend in the responses of the participants, with the exception of the item related to differences in the time period between receiving a referral and seeing a subspecialty care, where no change was indicated.

Lastly, we detected a positive trend in the mean score of the parents who reported having a child who needed continuous medical care in comparison to those who didn't report such need (2.32 vs. 2.75), as well as a positive trend between those who use community clinic versus those who reported using other medical care places (1.14 vs. 2.87).

Tables 4 and 5 present satisfaction with subspecialty services by the provider types (N=71). Table 4 shows high levels of satisfaction with both the Cardiology and Nephrology clinics. Table 5, shows the results of the sample t-test comparing clients' satisfaction across the services received from the Physicians and the Physician Assistants. We were not able to detect any statistically significant differences between the two groups. However, satisfaction based on the summated scores for the seven items revealed that parents who receive services from a Physician Assistant were more likely to report a slightly higher level of satisfaction in comparison to the their counterpart who received services from the Physician.

DISCUSSION

The South Central Los Angeles Health Care Alliance successfully attached thousands of South Los Angeles children and their families to a regular source of primary and sub-specialty care within a three year period. Thousands more were enrolled in existing payment programs. Participants in the program reported high levels of satisfaction with the primary and sub-specialty care they received. Patients' level of satisfaction with care did not change when sub-specialty services were provided by a Physician Assistant. Rather, parents as a whole reported greater levels of satisfaction with the care provided by a Physician Assistant in comparison to a Physician.

Parents who reported taking their children to St. John Well Child Clinics also reported reduced difficulty in obtaining a sub-specialty appointment and a reduction in the difference between the time a sub-specialty appointment was made and a specialist was seen, at a statistically significant level. The survey results correspond to the operational data patterns that showed a dramatic drop in the difference between the time a sub-specialty appointment was made and the time the patient saw a specialists in the first two years of the program. Operational data also showed a dramatic increase in the sub-specialty appointment completion rates in the first two years of the program. The findings presented above are strengthened by the similarity of patterns across data sources.

The data also shows a dramatic change in subspecialty outcomes in the third year of the program. Appointment completion rates dropped to levels lower than pre intervention years. The difference between the times an appointment is made and when a sub-specialty is completed also increased to pre intervention levels. This reversal of positive trends in the third year of the program was due to the significant institutional instability at King/Medical Center which was the only site in the program that offered sub-specialty care. Therefore, new sub-specialty providers were added to the sub-specialty panel even though receiving medical services from these new sites involved greater travel and greater wait time for the patients. This changed the implementation design from a one subspecialty provider and one primary care source to a multiple sub-specialty providers and one primary care source design. This change created challenges to the program since new sub-specialty providers were not part of the original plan, did not follow the same protocols as the sub-specialty providers at Charles R. Drew University and were not necessarily amenable to advocacy on behalf of consumers in their organizations.

CONCLUSION AND IMPLICATIONS FOR COMMUNITY BASED RESEARCH AND PRACTICE

The findings in this study add to the existing evidence in support of the positive effects of community outreach, service coordination, and the use of midlevel providers on health services utilization, satisfaction with health services and self efficacy among vulnerable populations. It introduces the successful use of Physician Assistants to expand pediatric cardiology and pediatric nephrology services and underscores the limitations of innovative service delivery practices in the face of unstable and limited provider capacity in vulnerable communities. The ability to adapt the implementation of the program to the realities of unanticipated pediatric sub-specialty resource shortage in South Los Angeles, speaks to the strengths of a contextual and adaptive model- based program such as the South Central Los Angeles Health Care Alliance. On the other hand, the delayed access to sub-specialty care that followed the resource shortage, illuminated the fact that even the smartest delivery system cannot overcome some of the effects of inadequate and unstable health resources in vulnerable communities.

The evaluation results of the South Central Health Care Alliance above demonstrate that community outreach and coordination of services within and between care settings can increase health services utilization, satisfaction with health services, parent self efficacy in navigating the health care system for their children, and service convenience for at-risk populations. Other studies have linked self-efficacy to social support (Atkinson et al. 2008, Knoll et al. 2009); and coordination across settings has been shown to affect patients' clinical outcomes and satisfaction with their care (Weinberg et al., 2007).

The results of this study also point to the potential for expanding pediatric sub-specialty resources through the use of Physician Assistants without undermining patient satisfaction. Other studies have shown the successful use of mid-level providers (Physician Assistants and Nurse Practitioners) with high levels of satisfaction and other positive outcomes such as safety in a variety of care contexts: including primary care settings (Lemley & Marks, 2009, Hunter et al., 2009); emergency care settings (Ducharme et al., 2009); and in performing special procedures such as abortion (Berer, 2009). The authors are not aware any studies that have focused on Physician Assistants as pediatric sub-specialty providers. If replicated with a bigger sample, these findings could offer important practice and policy implications for the expansion of pediatric sub-specialty resources in low income urban communities through the use of Physician Assistants . Expansion of sub-specialty pediatric provider resources through the use of Physician Assistants will be more cost effective and can be achieved in a timelier manner than policy efforts to increase the number of physicians because it takes less time and it cost less to train a Physician Assistant compared to a Physician.

The fact that sub-specialty care from King/Drew Medical Center became threatened and unreliable, therefore, creating a negative trend in the outcomes for the program during the third year of implementation, underscores the limits to the benefits of coordination, community outreach and other interventions in the face of scarce and fragile provider resources in low income urban communities such as South Los Angeles. Stable and adequate provider resources in low income urban communities are a critical precondition if utilization-enabling interventions are to work well. The crisis at King/Drew Medical Center in the third year of the program revealed the risks to vulnerable consumers when a community relies almost exclusively on a single provider for critical services such as pediatric sub-specialty care. For the alliance patients, trouble at the King/Drew Medical Center meant waiting longer to access health services, higher probability of missing appointments, or not completing specialty referrals.

Our findings are also important for institutional health providers in low-income urban communities. Incorporating community outreach and service coordination as a routine component of operations can improve health services outcomes such as utilization and satisfaction. This can be done using non-clinical case management implemented by community health workers at lower cost than clinical staff.

LIMITATIONS

The South Central Los Angeles Health Care Alliance as a variation of the Preventive Health Education and Medical Home Project (PHEMHP) had a number of limitations in its intervention components and evaluation strategies. First, the content and delivery of patient education was not standardized so it was not clear how and what doses of patient education were delivered to patients. Second, providers were not given any kind of orientation as to the special needs of the population and the expectation of the program. Third, there was no process evaluation and the primary care settings did not receive any orientation for data collection. These limitations were taken into consideration during the future implementations of the Preventive Health Education and Medical Home Project (PHEMHP) (Tataw et al. 2007; Tataw & Bazargan-Hejazi, 2010). The above limitations should also be considered by researchers implementing interventions in collaboration with community health providers.

Acknowledgements: This Project was supported by Unihealth Foundation.

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DAVID B. TATAW

Indiana University, Kokomo

S. BAZARGAN-HEJAZI

F W. JAMES

Charles R. Drew University
Table 1
                         Four Year Summary of Program Services

                          2001     2002     2003     2004

Medical Homes for
Children
Down Town Location       13,753   17,983   21,665   16,099
New Patients
Compton Location New     1,869    5,898    12,740   13,224
Patients
Medical Homes for        0                 2,226    17,711
Parents
Clinical-Based Health    100%     100%     100%     100%
Education
Number of Children and   0        4,855    6,678    None
Families Reached
through the Outreach
Activities
Number of Outreach       0        195      209      None
Activities
Specialty Services       25%      78%      80%      20%
Completion Rate
Average Wait Time to     4        2.1      1        9
Receive Specialty        months   months   month    months
Appointments
Healthy Family and       326      1689     2,422    4,434
MEDICAL Enrollment

Table 2
Patterns of Distributions among Measures Used to
Evaluate SCHCA (n = 71)

1. Does your child have a medical condition?              %

[] Yes                                                   38.7
[] No                                                    61.3

2 In the past 12 months, which of the following
places did you receive most of the medical care
services for your child?                                 3.2

[] Private/group medical group                           9.7
[] Hospital clinic                                       74.2
[] St John's Community clinic                            6.5
[] Emergency room

3. Do you prefer to have the same doctor for your
child?                                                   12.9

[] No                                                    3.2
[] Doesn't make a difference                             83.9
[] Yes

4. Compared to 12 months ago, how difficult is it for
you to get medical care for your child?                  19.4

[] More difficult                                        32.3
[] Just as difficult                                     48.4
[] Less difficult

5. Compared to 12 months ago, how satisfied are you
with the medical care for your child?

[] More satisfied                                        51.6
[] Just as satisfied                                     35.5
[] Less satisfied                                        12.9

6. Compared to 12 months ago, how difficult is it for
you to get routine check up for your child?

[] More difficult                                        16.1
[] Just as difficult                                     25.8
[] Less difficult                                        58.1

7. Compared to 12 months ago, how satisfied are you
with your child's routine check up for preventive
care?

[] More satisfied                                        48.4
[] Just as satisfied                                     41.9
[] Less satisfied                                        9.7

8. Compared to 12 months ago, how difficult is it for
you to get a referral for subspecialty care for your
child?

[] More difficult                                        9.7
[] Just as difficult                                     22.6
[] Less difficult                                        48.4

9. Compared to 12 months ago, how difficult is it for
you to make an appointment for your child to receive
subspecialty care?

[] More difficult                                        12.9
[] Just as difficult                                     22.6
[] Less difficult                                        48.4

10. Compared to 12 months ago, would you say the
time period between receiving a referral and visiting
a subspecialist was:

[] Much longer                                           30.8
[] Just as long                                          38.5
[] Less longer                                           30.8

11. Compared to 12 months ago, how satisfied are
you with the subspecialty care for your child?

[] More satisfied                                        44.0
[] Just as satisfied                                     44.0
[] Less satisfied                                        12.0

12. Does your child have dental insurance now?

[] Yes                                                   50.0
[] No                                                    50.0

13. Did he/she have dental insurance 12 months ago?

[] Yes                                                   43.3
[] No                                                    56.7

14. Does your child have insurance for eye care now?

[] Yes                                                   41.4
[] No                                                    58.6

15. Did he/she have insurance for eye care 12 months
ago?                                                     34.5

[] Yes                                                   65.5
[] No

16. In the past 12 months, were you prevented from
seeking medical care because you didn't know where
to go or who to talk to?

[] Yes                                                   6.5
[] No                                                    93.3

17. State the place you get information about your
child's health
Word of mouth from friends or family                     19.4
member                                                   58.1

[] A health professional                                 3.2
[] St. John case manager                                 -
[] Community Centers/seminar/classes                     12.9
[] Newspaper/magazines/books/library                     19.4
[] TV/Radio/Video                                        -
[] Internet                                              6.5
[] Health fairs                                          -
[] Church                                                -6.5
[] Spiritual/traditional healer                          -
[] I don't know where to get them

18. Reported problems regarding current living
conditions

[] Having Problems with running water                    -
[] Having problems with sewers                           -
[] Having problems with heat and air-conditioning        10.0
                                                         -
[] Having problems with electricity                      3.3
[] Having problems with lead paint                       -
[] Unsafe physical structure                             33.3
[] Unsafe neighborhood

19. Reported problems in the family

[] Smoking                                               9.7
[] Alcoholism                                            6.5
[] Bad diet                                              32.3
[] Lack of exercise                                      41.9
[] Too much fighting between members of the family       12.9

21. Length of time living in the current address

[] Less than five year                                   77.4
[] Five or more                                          19.3

22.Number of adults living in the household

[] Less than five                                        80.6
[] Five or more                                          19.3

23. Number of children under the age of 18 living in
the household.

[]   Two or less                                         36.7
[]   Three or more                                       63.3

Table 3
Mean Changes in Perceived Satisfaction or Difficulties by
Medical Problems and Regular Visits.

                         Child having
                           medical
                          condition
                          requiring
                          continuing    Receiving Care in
                         Medical care   Community Clinic     Overall

SURVEY ITEMS              No    Yes       No       Yes        Mean

1.Difficulty to get      .26    .33      .14       .33         .29
medical care

2. Satisfaction with     .26    .58      .57       .33         .39
medical care

3. Difficulty to get     .32    .58      .57       .38         .42
routine check up

4. Satisfaction with     .37    .42      .14       .46         .39
getting routine check
up

5. Difficulty to get a   .37    .42      .14       .46         .39
referral to receive
subspecialty care

6. Difficulty with       .32    .42      -.14 **   .50         .35
making a subspecialty
appointment

7. Differences in the    .16    -.25     -.43 **   .12         .00
time period between
receiving a referral
and seeing a
subspecialty care

8. Satisfaction with     .26    .25      .14       .29         .26
specialty care

TOTAL SCORE *            2.32   2.75     1.14      2.87        2.48

-1 = Less satisfaction/more difficulty
0 = No change
1 = More satisfaction, or less difficulty
* Summated index of items (1-8) with Range score = -1, 0 +1
** Statistically significant at P= [less than or equal to].05

Table.4
Satisfaction with Provider of Sub-specialty Services
Received by Items (N-71)

SATISFACTION ITEMS                             %

Site Received Services -- Cardiology Clinic   69.0
Site Received Services -- Nephrology          31.0

Satisfaction With Services Received

[] Poor                                       31.3
[] Average                                    18.8
[] Excellent                                  50.0

Satisfaction With Provider Friendliness

[] Poor                                       18.8
[] Average                                    31.3
[] Excellent                                  50.0

Satisfaction With Provider Helpfulness

[] Poor                                       12.5
[] Average                                    25.0
[] Excellent                                  62.5

Satisfaction With Provider Time Spent

[] Not Appropriate                            18.8
[] Somewhat Appropriate                       62.6
[] Very Appropriate                           18.8

Satisfaction With Explanation of Health
Condition

[] Poor                                       12.5
[] Average                                    50.0
[] Excellent                                  62.5

Satisfaction With Explanation of Treatment

[] Poor                                       18.8
[] Average                                    43.8
[] Excellent                                  37.5

Satisfaction With Respect Received

[] Poor                                       6.3
[] Average                                    25.0
[] Excellent                                  68.8

Table 5
Mean Satisfaction with Sub-Specialty Services Received by
Type of Providers.

                                  TOTAL    MD        PA

SATISFACTION ITEMS                MEAN    MEAN      MEAN

Services Received                 3.19    3.0      3.0
Provider Friendliness             3.3     2.8      3.6
Provider Helpfulness              3.5     3.3      3.6
Provider Time Spent               2.5     2.3      2.6
Explanation of Health Condition   2.8     2.7      3.0
Explanation of Treatment          2.8     2.5      3.0
Respect                           3.6     3.8      3.4
TOTAL SCORE *                     21.7    15.00    27.00 **

* Summated index for seven satisfaction items with Range
= 7-27, and acceptable reliability alpha= .76
** Statistically significant at P= [less than or equal to].05
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