Health plan selection criteria by people with impaired mobility

Tools for improving clinical preventive services receipt among women with disabilities of childbearing ages and beyond

Efforts to improve clinical preventive services (CPS) receipt among women with disabilities are poorly understood and not widely disseminated. The reported results represent a 2-year, Centers for Disease Control and Prevention and Association of Maternal and Child Health Programs partnership to develop a central resource for existing tools that are of potential use to maternal and child health practitioners who work with women with disabilities. Steps included contacting experts in the fields of disability and women's health, searching the Internet to locate examples of existing tools that may facilitate CPS receipt, convening key stakeholders from state and community-based programs to determine their potential use of the tools, and developing an online Toolbox. Nine examples of existing tools were located. The tools focused on facilitating use of the CPS guidelines, monitoring CPS receipt among women with disabilities, improving the accessibility of communities and local transportation, and training clinicians and women with disabilities. Stakeholders affirmed the relevance of these tools to their work and encouraged developing a Toolbox. The Toolbox, launched in May 2013, provides information and links to existing tools and accepts feedback and proposals for additional tools. This Toolbox offers central access to existing tools. Maternal and child health stakeholders and other service providers can better locate, adopt and implement existing tools to facilitate CPS receipt among adolescent girls with disabilities who are transitioning into adult care as well as women with disabilities of childbearing ages and beyond.

Use of quality information in decision-making about health and social care services--a systematic review

User choice and personalisation have been at the centre of health and social care policies in many countries. Exercising choice can be especially challenging for people with long-term conditions (LTC) or disabilities. Information about the quality, cost and availability of services is central to user choice. This study used systematic review methods to synthesise evidence in three main areas: (i) how people with LTC or disabilities and their family carers find and access information about the quality of services; (ii) how quality information is used in decision-making; and (iii) what type of quality information is most useful. Quality information was defined broadly and could include formal quality reports (e.g. inspection reports, report cards, etc.), information about the characteristics of a service or provider (e.g. number and qualifications of staff, facilities, etc.) and informal reports about quality (e.g. personal experience, etc.). Literature searches were carried out using electronic databases in January 2012. Thirteen papers reporting findings from empirical studies published between 2001 and 2012 were included in the review. The majority of papers (n = 9) had a qualitative design. The analysis highlighted the use of multiple sources of information in decision-making about services and in particular the importance of informal sources and extended social networks in accessing information. There is limited awareness and use of 'official' and online information sources. Service users or family carers place greater emphasis on general information and structural indicators. Clinical or quality-of-life outcomes are often difficult to interpret and apply. Trust emerged a key issue in relation to quality information. Experiential and subjective information is highly valued and trusted. Various barriers to the effective use of quality information in making choices about services are identified. Implications for policy and future research are discussed.

Disparities in patient-physician communication for persons with a disability from the 2006 Medical Expenditure Panel Survey (MEPS)

BACKGROUND

Ineffective patient-physician communication has been shown to result in poorer health outcomes for various vulnerable populations. However, little research has been done on patient-physician communication issues as perceived by persons with disabilities. The purposes of this study are to determine if there is a relationship between disability and patient-physician communication and how disability affects the likelihood of effective patient-physician communication. The research questions for this study are: (1) Is there a significant difference in patient-physician communication for persons with disabilities compared to persons without disabilities? (2) Does having a disability influence the likelihood of ineffective patient-physician communication?

METHODS

Data were obtained from the 2006 Medical Expenditure Panel Survey (MEPS). Chi-square analyses were performed to determine if there a significant difference in patient-physician communication for persons with disabilities compared with persons without disabilities. A series of logistic regression analyses were conducted examining the likelihood of ineffective patient-physician communication with the independent variable of disability status.

RESULTS

Those with a disability are significantly more likely than persons without a disability to perceive that the physician does not listen to them, does not explain treatment so that they understand, does not treat them with respect, does not spend enough time with them, and does not involve them in treatment decisions. Regression analyses further revealed that persons with a disability are from 1.36 to 1.78 times as likely to perceive inadequate patient-physician communication.

CONCLUSIONS

This study revealed that persons with disabilities are at increased risk of experiencing ineffective patient-physician communication, compromising current health status and increasing the possibility of secondary health conditions. Several suggestions were made with regard to incorporation of "disability literacy" mechanisms such as physician training, health facility environmental assessment, and use of technologies such as telehealth and e-health. Further research in partnership with the disability community is needed to determine the effectiveness of these methods in improving patient-physician communication.

Use of qualitative methods in published health services and management research: a 10-year review

Over the past 10 years, the field of health services and management research has seen renewed interest in the use of qualitative research methods. This article examines the volume and characteristics of qualitative research articles published in nine major health services and management journals between 1998 and 2008. Qualitative research articles comprise 9% of research articles published in these journals. Although the publication rate of qualitative research articles has not kept pace with that of quantitative research articles, citation analysis suggests that qualitative research articles contribute comparably to the field's knowledge base. A wide range of policy and management topics has been examined using qualitative methods. Case study designs, interviews, and documentary sources were the most frequently used methods. Half of qualitative research articles provided little or no detail about key aspects the study's methods. Implications are discussed and recommendations are offered for promoting the publication of qualitative research.

Case-mix adjustment and enabled reporting of the health care experiences of adults with disabilities

OBJECTIVES

To develop activity limitation clusters for case-mix adjustment of health care ratings and as a population profiler, and to develop a cognitively accessible report of statistically reliable quality and access measures comparing the health care experiences of adults with and without disabilities, within and across health delivery organizations.

DESIGN

Observational study.

SETTING

Three California Medicaid health care organizations.

PARTICIPANTS

Adults (N = 1086) of working age enrolled for at least 1 year in Medicaid because of disability.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Principal components analysis created 4 clusters of activity limitations that we used to characterize case mix. We identified and calculated 28 quality measures using responses from a proposed enabled version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. We calculated scores for overall care as the weighted mean of the case-mix adjusted ratings.

RESULTS

Disability caused a greater bias on health plan ratings and specialist ratings than did demographic factors. Proxy respondents rated care the same as self-respondents. Telephone and mail administration were equivalent for service reports, but telephone respondents tended to offer more positive global ratings. Plan-level reliability estimates for new composites on shared decision making and advice on healthy living are .79 and .87, respectively. Plan-level reliability estimates for a new composite measure on family planning did not discriminate between health plans because respondents rated all health plans poorly. Approximately 125 respondents per site are necessary to detect group differences.

CONCLUSIONS

Self-reported activity limitations incorporating standard questions from the American Community Survey can be used to create a disability case-mix index and to construct profiles of a population's activity limitations. The enabled comparative report, which we call the Assessment of Health Plans and Providers by People with Activity Limitations, is more cognitively accessible than typical CAHPS report templates for state Medicaid plans. The CAHPS Medicaid reporting tools may provide misleading ratings of health plan and physician quality by people with disabilities because the mean ratings do not account for systematic biases associated with disability. More testing on larger populations would help to quantify the strength of various reporting biases.

Enabling a survey of primary care to measure the health care experiences of adults with disabilities

PURPOSE

To enable an existing survey on primary care so that it can be used to assess the healthcare experiences reported by adults living with disabilities, and to evaluate its properties.

METHODS

Mixed-methods study. We first identified content areas for measurement as compared to the items in the existing instrument and then developed new candidate items. Cognitive testing was conducted in English and Spanish. After revisions to the primary care instrument based on the cognitive testing results, the draft-enabled instrument was field-tested by mail with telephone follow-up, in English and Spanish.

RESULTS

Consumer focus groups and a technical expert panel identified eight content areas in primary care that are particularly important to maximise function and well-being of people of with disabilities. Cognitive testing also revealed serious problems with several items in the existing survey when answered by or about people with disabilities. Field testing yielded 1086 surveys, of which 40% were completed by a proxy respondent. Learning disabilities were reported by 38% of respondents. Item non-response for revised and new questions was less than 4%.

CONCLUSIONS

It is feasible to enable a survey of primary care and its administration. Survey administration instructions should be modified to accommodate proxy respondents. The screener item to identify people with mobility impairments on walking a distance should be replaced with walking for 6 min. Adding questions from the American Community Survey about functional ability will allow survey sponsors to identify respondents with various limitations, and to compare their experiences to those of people with no limitations. Careful development and testing of the items with input from interested parties throughout the design and testing stages yielded a survey with good psychometric properties and content validity in multiple languages. Health delivery systems can use the survey data to identify clinical processes needing improvement to provide high quality care for people with disabilities.

Access and Coordination of Health Care Service for People With Disabilities

Individuals with disabilities often have multiple complex medical and nonmedical needs. Furthermore, in the current facility-directed health care system, they are at enhanced risk of receiving poorly coordinated, suboptimal care. This is especially problematic because individuals with disabilities face multiple barriers to receiving quality health care services, ranging from structural barriers (e.g., physical access to doctors' offices) to procedural barriers (e.g., difficulty scheduling appointments, problems obtaining insurance coverage). By contrast, a consumer-directed approach to health care (distinct from facility-directed health care) can be effectual, cost-effective, and subjectively satisfying. This brief commentary addresses the importance of a consumer-directed approach to the delivery of health care to individuals with disabilities and the need for specific assessments of the experiences of people with disabilities regarding their care. As such, it proposes recommendations for future policy interventions.

Meeting information needs to facilitate decision making: report cards for people with disabilities

BACKGROUND

Several states within the United States offer low-income adults with disabilities a choice of health plans. No states issue comparative 'report cards' specifically for adults with disabilities.

OBJECTIVE

To explore conceptualizations of quality, information needs, and report card preferences from the perspective of people with disabilities.

RESEARCH DESIGN

Eight focus group interviews were conducted in 2003. Existing report cards for California, Maryland, Michigan and Texas were shared for feedback.

SUBJECTS

34 women and 15 men with various behavioural, physical or sensory disabilities in Oregon, California, Virginia, Maryland and the District of Columbia.

RESULTS

Quality was mostly defined in terms of choice and disability sensitivity of service providers. Respondents identified various obstacles to receiving appropriate health plan and service information. All beneficiaries were keenly interested in the comparative health plan report cards, but did not think the report cards provided enough pertinent information, especially with regard to provider ratings, accessibility, disability competence and reasons for participating in the Medicaid program.

CONCLUSIONS

Existing comparative report cards omit several major content domains important to people with disabilities. Organizations providing decision support to people with disabilities should cultivate novel avenues for distribution, such as food banks, libraries and places of worship.

Rural residents with disabilities confront substantial barriers to obtaining primary care

OBJECTIVE

To learn about the health care experiences of rural residents with disabilities.

STUDY SETTING

Rural areas in Massachusetts and Virginia.

STUDY DESIGN

Local centers for independent living recruited 35 adults with sensory, physical, or psychiatric disabilities to participate in four focus group interviews.

DATA COLLECTION METHODS

Verbatim transcripts of interviews were reviewed to identify major themes.

PRINCIPAL FINDINGS

Interviewees described the many well-recognized impediments to health care in rural America; disability appears to exacerbate these barriers. Interviewees reported substantial difficulties finding physicians who understand their disabilities and sometimes feel that they must teach their local doctors about their underlying conditions. Interviewees described needing to travel periodically to large medical centers to get necessary specialty care. Many are poor and are either uninsured or have Medicaid coverage, complicating their searches for willing primary care physicians. Because many cannot drive, they face great difficulties getting to their local doctor and especially making long trips to urban centers. Available public transportation often is inaccessible and unreliable. Physicians' offices are sometimes located in old buildings that do not have accessible entrances or equipment. Based on their personal experiences, interviewees perceive that rural areas are generally less sensitive to disability access issues than urban areas.

CONCLUSIONS

Meeting the health care needs of rural residents with disabilities will require interventions beyond health care, involving transportation and access issues more broadly.

Disability in everyday life

The authors explored how persons with disabilities perceived the experience of disability in their everyday lives. The findings suggest that the current models in the literature do not address disability adequately. Instead, disability was described as a multifaceted, complex experience that is integrated into the lives of persons with disabilities. The degree to which integration was possible was influenced by three disability-related factors: (a) the fundamental effects of the disabling condition, (b) others' perceptions of disability, and (c) the need for and use of resources. Important contextual conditions included the environment, time, and experience. Ultimately, it was the match between how these persons perceived themselves and what was important in their lives, and the influence of the three factors that determined how well they were able to integrate disability into their lives. The findings suggest the need for a conceptual model that reflects the personal experience of disability.

Primary care experiences of people with psychiatric disabilities: barriers to care and potential solutions

This study examined the barriers that 16 focus group participants with psychiatric disabilities confront in obtaining primary care services and their recommendations on improving quality of care. They cited a) difficulty identifying a primary care physician with good empathic and communication skills, b) physicians' misunderstanding of the nature of psychiatric disability, c) inadequate information about the side effects of psychotropic medications, and d) costs due to inadequate insurance coverage. In addition to suggestions for improving patient-physician communication and expanding physician knowledge, participants emphasized strategies to become empowered in their relationships with physicians and to obtain personal support.

Experiences with care co-ordination among people with cerebral palsy, multiple sclerosis, or spinal cord injury

PURPOSE

To describe the experiences with care co-ordination of people with cerebral palsy, multiple sclerosis, or spinal cord injury; to determine barriers to effective care co-ordination; and to compare experiences across disability and health plan types.

METHOD

Qualitative, semi-structured telephone interviews with 30 people with cerebral palsy, multiple sclerosis, or spinal cord injury. Interviews focused on the care co-ordination experience of individuals in managed care and traditional indemnity health insurance plans in the USA and were analysed using NVivo.

RESULTS

Half of the respondents reported that they had a health professional who co-ordinated their care. Participants identified barriers that prevented effective care co-ordination, including a lack of disability specific knowledge, providers' limited time and effort related to care, and insufficient communication among providers. There were few differences between managed care and fee-for-service respondents with regard to these barriers.

CONCLUSIONS

Study findings reveal few differences in the care co-ordination experiences amongst people with cerebral palsy, multiple sclerosis, or spinal cord injury in both plan types. All providers need to become more literate about the health care needs of people with physical disabilities, and health plans need to reward communication among providers and the time and effort invested in care co-ordination.

The organization and financing of health services for persons with disabilities

Americans with disabilities are rarely considered a distinct group of health care users in the same way as are older Americans, children, racial and ethnic minorities, and others who are perceived to have different needs and access issues. Indeed, to some extent individuals with disabilities overlap with all these groups. But they also have distinct needs with material implications for the organization, delivery, and financing of health care services. Despite the disproportionate health care needs and expenditures of many--though not all--individuals with disabilities, the mainstream health services research community has largely neglected them. This article outlines the most pressing health service research issues in addressing the health care needs of individuals with disabilities.