Free Care Is Not Enough: Barriers to Attending Free Clinic Visits in a Sample of Uninsured Individuals with Diabetes

Free care does not always lead to improved outcomes. Attendance at free clinic appointments is unpredictable. Understanding barriers to care could identify innovative interventions. The purpose of this study was to examine patient characteristics, biophysical outcomes, and health care utilization in uninsured persons with diabetes at a free clinic. A sample of 3139 patients with at least one chronic condition was identified and comparisons were made between two groups: those who attended all scheduled appointments and those who did not. Geographic distance to clinic and multiple chronic conditions were identified as barriers to attendance. After one year, missing more than one visit had a positive correlation with increased weight, A1C, and lipids. Additionally, patients who missed visits had higher blood pressure, depression scores, and numbers of medications. Future research should further enhance understanding of barriers to care, build knowledge of how social and behavioral determinants contribute to negative outcomes in the context of rurality. Innovative methods to deliver more frequent and intensive interventions will not be successful if they are not accessible to patients.

Diabetes group medical visits and outcomes of care in low-income, rural, uninsured persons

Purpose: The purpose of this study was to test the effectiveness of Diabetes Group Medical Visits (DGMVs) verses usual care in a sample of low-income patients with diabetes receiving care at a rural free clinic. Methods: Data were collected through chart review, using direct data entry into Microsoft Access. Participants were included if they met the inclusion criteria: 1) age ≥ 18 years;2) diagnosis of diabetes;3) uninsured and received care between May 2007 and August 2009. Fifty-three participants attended DGMVs and were compared to 58 participants who received usual care. Results: The personal characteristics and biophysical measures of this population differed from previously studied Group Visit populations. The majority of patients were female (73.9%), white (95.5%), younger than 50 (53.2%), driving long distances to receive care (mean miles = 21, SD 20.4) and had a high school education or less (95.4%). Participants were severely obese (mean BMI = 37.6, SD 28.48) and had 5 co-morbid conditions other than diabetes (mean = 5.5, SD 2.1). Those attending DGMVs had higher baseline A1C, depression scores, BMIs, and more pain than usual care. There was a statistically significant decrease in systolic pressure from time one to time two in patients who attended DGMVs t(52) = 2.18, (p = 0.03). There was no significant impact on outcomes of patients who received usual care. However, it is important to note that the majority of patients attended three or fewer DGMVs visits in one year. Conclusion: Group visits may not be enough to improve outcomes in this population. Previous studies suggest that improvements are seen in those who attend more frequently. Hence, the lack of improvement in biophysical outcomes may be due to low attendance. The limited impact of this traditional style intervention in relation to low attendance argues the need to test alternative interventions to reach this population.

Primary care clinicians’ strategies to overcome financial barriers to specialty health care for uninsured patients

Objective:This study describes strategies used by federally qualified health centers(FQHCs)to assist medically uninsured patients in obtaining specialty health care services.Methods:Qualitative methods were used to study strategies for obtaining specialty health care for uninsured patients.Data were gathered from 10 primary care clinicians at three FQHC clinics by means of 10 semistructured interviews,23 brief interviews,and 45 h of direct observations.We captured additional data by studying cases of referred uninsured patients.Results:The following six strategies were identified:(1)quid pro quo-a specialist accept-ing the clinic’s medically uninsured patients was rewarded with referrals of the clinic’s insured patients;(2)over referral-clinicians referred insured patients whose needs could have been met at the FQHC;(3)brief hospitalization-when a specialist could not be obtained,high-risk patients were briefly hospitalized;(4)case building-diagnostic tests were conducted at the FQHC to justify a referral;(5)direct communication-communication between clinicians and specialists was neces-sary when requesting a referral;(6)specialty clinics-in return for conducting a specialty clinic at the FQHC,the specialist received all referrals of insured patients.Conclusion:Uninsured FQHC patients encountered difficulties accessing specialty health care,and in response,clinicians developed a range of innovative strategies.