2.  Increased life expectancy  Disease prevention  Early diagnosis and treatment of diseases  Improved outcomes  Increased quality of life

3.  Lack of/inadequate insurance  Lack of finances  Lack of transportation  Lack of education  Patient and provider lack of knowledge of available resources  Language Barriers  Lack of providers in rural areas  Excessive wait times or non-conducive appointment times  Cultural or social stigmas and fear

4. Healthy People 2020, a government program, is attempting to address some of these issues. The goals are as follows:  Increase the percentage of people with health insurance  Increase the percentage of insured people with coverage for clinical preventive services  Increase the percentage of people with a regular primary care provider

5.  Increase the number of primary care providers.  Increase the percentage of people who have a specific source of ongoing care  Reduce the percentage of people who are unable to obtain or delay in obtaining necessary medical care, dental care, or prescription medicines  Increase the percentage of people who receive appropriate evidence-based clinical preventive services  Increase the percentage of people who have access to rapidly responding pre-hospital emergency medical services  Reduce the of percentage emergency department visits in which the wait time exceeds the recommended timeframe

6.  Increase the proportion of persons with health insurance The percentage of people under age 65 with health insurance decreased 0.6% between 2001 and 2012, from 83.6% to 83.1%. Insurance coverage varied by race and ethnicity.

7.  Increase the percentages of people with regular primary care providers The percentage of people with regular primary care providers decreased 1.2% between 2000 and 2011, from 78.2% to 77.3%. Rates varied by race and ethnicity. 42.3% of Hispanic or Latino populations did not have a regular primary care physician.

8.  Increase the proportion of persons who have a specific source of ongoing care The percentage of people with a specific source of ongoing care decreased 2.5% between 2001 and 2012, from 88.0% to 85.8%, and varied by sex. For example, in 2012, 89.1% of females had a specific source of ongoing care, compared to 82.5% of males.

9.  Reduce the proportion of persons who are unable to obtain or delay obtaining necessary medical care 4.7 percent of all persons were unable to obtain or delayed in obtaining necessary medical care in 2007. In 2011, this number declined to 4.5% so overall this has improved. However, 7.0% of people with a total family income below the Poverty Threshold (PT) were unable to obtain or delayed in obtaining necessary medical care, nearly two and a half times the rate for those at or above 600% of the PT, 3.1%.

10. No outcome data available for the following:  Increase the percentage of insured people with coverage for preventive services  Increase the number of primary care providers.  Increase the percentage of people who receive appropriate evidence-based clinical preventive services  Increase the percentage of people who have access to rapidly responding pre-hospital emergency medical services  Reduce the percentage of emergency department visits in which the wait time exceeds the recommended timeframe

11. Barriers not addressed  Lack of finances  Lack of education  Language Barriers  Lack of transportation  Patient and provider lack of knowledge of available resources  Cultural or social stigmas and fear

12.  Educate patients on disease processes, possible complications of noncompliance, and self care measures needed to manage the disease.  Involve the patient in the planning process when determining appropriate disease management.  Ask the patient if they will be able and willing to follow the plan of care.  If a patient is non-compliant question why. Ask about finances, types/amount of food available, transportation, and available caregivers.

13.  If transportation is an issue, refer to Net-Trans, People to Places, a church member, or neighbor if no available family or caregiver.  Ask if the patient is a veteran. If so, refer them to a social worker at the Veterans Affair Mountain Home.  Tennessee Area on Aging has a resource booklet for available resources in your area.  Adult Protective Services is available when patients are unsafe conditions or in extreme poverty. They can get available services faster

14.  Refer any homebound patient with uncontrolled disease processes to a home health agency.  If a patient can not afford medications, order a cheaper alternative when possible or call the pharmaceutical company to see if there is a medication assistance program available.  If a patient needs surgery but can not afford it, refer them to Mountain Empire Project Access or they may qualify for a write off from the hospitals.

15.  Have people available for translation before the need arises. College language departments are usually willing to help.  Be conscious of cultural barriers Keys to Success  Collaborate with patients, families, and other disciplines  Educate yourself on available resources in your area  Utilize resources to ensure care is adequate and effective

16. I implemented these strategies at NHC Home Health starting in 2008. Some outcomes were as follows:  Over all improvement in patient compliance  Overall improvement in disease management and functional outcomes upon discharge  Over all improvement in physician and referral source satisfaction  Over all improvement in patient satisfaction with services and staff  Overall improvement in employee satisfaction.  5 out of 6 years the agency was on the Home Care Elite list for the top 100 agencies in the country  For 6 out of 6 years the agency had zero deficiencies from state surveys

17.  Healthy People.gov. (n.d.). Access to health service. Retrieved from https://www.healthypeople.gov/2020/topics- objectives/topic/Access-to-Health-Services  Horton, S & Johnson, R.J. (2010). Improving access to health care for uninsured elderly patients. Public Health Nursing, 21(4), 362-370. DOI: 10.1111/j.1525- 1446.2010.00866.x  DeVoe, J.E., Phil,D., Baez, A., Angier, H., Krois, L., Edlund, C., & Careny, P.A. (2007). Insurance plus access does not equal health care: typology of barriers to health care access for low-income families. Annals of Family Medicine, 5(6):511- 518. Retrieved from http://www.medscape.com/viewarticle/567154

18.  Rural Assistance Center. (n.d.). Healthcare access in rural communities. Retrieved from http://www.raconline.org/topics/healthcare- access  Bryant, R. (2011). Promoting access to health care: a nursing role and responsibility. International Nursing Review, 58(4), 404. doi: 10.1111/j.1466- 7657.2011.00956.x  News-Medical.Net. (n.d.). Disparities in access to health care. Retrieved from http://www.news- medical.net/health/Disparities-in-Access-to- Health-Care.aspx