Access to Quality Health Services

Persons Under Age 65 Years, 1997	Health Insurance
	Percent
TOTAL	83
Race and ethnicity
American Indian or Alaska Native	62
Asian or Pacific Islander	81
Asian	81
Native Hawaiian and other Pacific Islander	80
Black or African American	80
White	84
Hispanic or Latino	66
Cuban	79
Mexican American	61
Puerto Rican	81
Not Hispanic or Latino	85
Black or African American	80
White	86
Gender
Female	84
Male	81
Family income level
Poor	66
Near Poor	69
Middle/high income	91
Geographic location
Within MSA	83
Outside MSA	80
Disability status
Persons with disabilities	83
Persons without disabilities	83
Sexual orientation	DNC
Select populations
Age groups
10 to 24 years	DNA
10 to 14 years	DNA
15 to 19 years	DNA
20 to 24 years	DNA

Females Aged 15 to 44 Years With a Physician Visit in the Past Year, 1995	1-3f. Counseled About Unintended Pregnancy
	Percent
TOTAL	19
Race and ethnicity
American Indian or Alaska Native	DSU
Asian or Pacific Islander	DSU
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	24
White	19
Hispanic or Latino	20
Not Hispanic or Latino	DNA
Black or African American	24
White	19
Education level (females aged 22 to 44 years)
Less than high school	15
High school graduate	20
At least some college	19
Sexual orientation	DNC
Select populations
Age groups
15 to 24 years	22
25 to 34 years	23
35 to 44 years	10

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.

Substantial gaps remain in the delivery of appropriate screening and counseling services related to health behaviors. Unhealthy diets, smoking, physical inactivity, and alcohol use account for a majority of preventable deaths in the United States.[37] Data indicate that risk assessment and counseling interventions are delivered less frequently than other preventive interventions (for example, cancer screenings).12 In addition, the attention physicians give to specific health-risk behaviors appears to be influenced by the socioeconomic status of their patients.[38] Although time is an important constraint in the primary care setting, evidence demonstrates that brief clinician counseling is effective in getting patients to stop smoking and reduce problem drinking.1, [39] In addition, more intensive dietary counseling can lead to reduced dietary fat and cholesterol intake and increased fruit and vegetable consumption.1 Effective primary care-based interventions to increase physical activity among patients have been more difficult to identify.1, [40]

Some evidence shows that provider counseling can increase the use of seat belts, child safety seats,and bicyclehelmets, especially when directed to parents of infants and young children.1 Brief counseling interventions aimed at high-risk individuals can increase condom use and prevent the spread of sexually transmitted diseases.[41]

Clinician counseling should be tailored to the individual risk factors, needs, preferences, and abilities of each patient.1 For some preventive interventions, such as hormone therapy in postmenopausal women, the optimal strategy depends on how individual women value potential benefits and risks. Counseling of perimenopausal and postmenopausal women should encourage shared decisionmaking based on individual risk factors and patient preferences.1

Primary Care

1-4.		Increase the proportion of persons who have a specific source of ongoing care.

Target and baseline:

Objective	Increase in Persons With Specific Source of Ongoing Care	1998 Baseline*	2010 Target
		Percent
1-4a.	All ages	87	96
1-4b.	Children and youth aged 17 years and under	93	97
1-4c.	Adults aged 18 years and older	85	96

*Age adjusted to the year 2000 standard population.

Target setting method: Better than the best.

Data source: National Health Interview Survey (NHIS), CDC, NCHS.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable. NA = Not applicable.
Note: Age adjusted to the year 2000 standard population.

Access to care depends in part on access to an ongoing source of care. People with a usual source of health care are more likely than those without a usual source of care to receive a variety of preventive health care services.[42], [43] An estimated 15 percent of adults in the United States lack a usual source of care. Thus, more than 40 million persons have no particular doctor’s office, clinic, health center, or other place where they go for health care advice. The National Health Interview Survey (NHIS) does not count emergency departments as a usual source of care.12

An estimated 93 percent of children aged 17 years and under have a specific source of ongoing care. The implementation of the Children’s Health Insurance Program in 1999 provides a mechanism for increasing the proportion of children with an ongoing source of care.12

The usual source of care can vary among groups according to their age, race and ethnicity, and health insurance coverage. Young children and elderly adults aged 65 years and older are most likely to have a usual source of care, and adults aged 18 to 64 years are least likely. Young adults aged 18 to 24 years are the least likely of any age group to have a usual source of care. Among racial and ethnic groups, Hispanic persons are the least likely to have a usual source of care. Some 24 percent of the adult Hispanic population (and 28 percent of the Mexican American population) lack a usual source of care, compared to 15 percent of African Americans and 15 percent of the total adult population.12

Some 88 percent of persons with a usual source use an office-based provider, and 11 percent use a hospital outpatient department or clinic. African Americans and Hispanics are more likely to use hospital-based providers (including hospital clinics and outpatient departments) as their usual source of care.15

Uninsured persons under age 65 years are more likely to lack a usual source of care (38 percent) than those who have either public or private insurance. When compared with their counterparts who have private health insurance, uninsured people under age 65 years are 2.6 times more likely to lack a usual source of care.15

1-5.		Increase the proportion of persons with a usual primary care provider.

Target: 85 percent.

Baseline: 77 percent of the population had a usual primary care provider in 1996.

Target setting method: Better than the best.

Data source: Medical Expenditure Panel Survey (MEPS), AHRQ.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable. MSA = Metropolitan statistical area.
*Data for office hours, prescription medications, and treatments are displayed to further characterize the practices of primary care providers.

A usual source of primary care helps people clarify the nature of their health problems and can direct them to appropriate health services, including specialty care.[44] Primary care also emphasizes continuity, which implies that individuals use their primary source of care over time for most of their health care needs. More after-hours care, shorter travel time to a practice site, and shorter office waits have been associated with patients’ beginning an acute episode of care with primary care physicians. Greater continuity has been observed for individuals with shorter appointment waits, insurance, and access to more after-hours care.[45] Other advantages of primary care are that a primary care provider deals with all common health needs (comprehensiveness) and coordinates health care services, such as referrals to specialists. Evidence suggests that first contact care provided by an individual’s primary care provider leads to less costly medical care.[46]

1-6.		Reduce the proportion of families that experience difficulties or delays in obtaining health care or do not receive needed care for one or more family members.

Target: 7 percent.

Baseline: 12 percent of families experienced difficulties or delays in obtaining health care or did not receive needed care in 1996.

Target setting method: Better than the best.

Data source: Medical Expenditure Panel Survey (MEPS), AHRQ.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable. MSA = Metropolitan statistical area.

In 1996, according to the Medical Expenditure Panel Survey (MEPS), 12.8 million families (11.6 percent) for a variety of reasons experienced difficulty or delay in obtaining care or did not receive health care services they thought they needed. In addition to a lack of insurance or underinsurance, barriers include a lack of appropriate referrals, travel distance to the provider, lack of transportation, and unavailability of specialists. Families experience barriers to care for a variety of reasons: inability to afford health care (60 percent); insurance-related causes (20 percent), including (1) the insurance company not approving, covering, or paying for care, (2) preexisting conditions for which insurance coverage often is restricted, (3) lack of access to required referrals, and (4) clinicians refusing to accept the family’s insurance plan; and other problems (21 percent), such as transportation, physical barriers, communication problems, child care limitations, lack of time or information, or refusal of services.15

An additional source of information on obtaining services is the Robert Wood Johnson National Access to Care Survey. Results of the 1994 National Access to Care Survey suggest that some studies have missed substantial components of unmet needs by failing to include specific questions about supplementary health care services, such as prescription drugs, eyeglasses, dental care, and mental health care or counseling.[47] When specific questions were added about these services, the findings showed that 16.1 percent of respondents (approximately 41 million) were unable to obtain at least one service they believed they needed. The highest reported unmet need was for dental care. This problem can be attributed partly to insufficient provider reimbursement, which discourages participation in plans even when the service is covered.

1-7.		(Developmental) Increase the proportion of schools of medicine, schools of nursing, and other health professional training schools whose basic curriculum for health care providers includes the core competencies in health promotion and disease prevention.

Potential data source: Adaptation of the Prevention Self-Assessment Analysis, Association of Teachers of Preventive Medicine (ATPM).

Significant changes in the health care system and in the expectations of consumers are influencing the education of health care providers in the United States. For example, many medical schools are assessing the content of their predoctoral and postgraduate curricula.[48] Medical educators and medical schools are recognizing that physicians will need to be prepared to provide population-based preventive health care as well as high-quality medical care to their patients.[49] This challenge exists for other health professionals, including nurses, nurse practitioners, physician assistants, and allied health personnel. This link between medicine and public health is essential to provide the highest quality health care possible to the U.S. population.

A core set of competencies for medical students in health promotion and disease prevention was developed by a task force established by the Association of Teachers of Preventive Medicine (ATPM) and the U.S. Department of Health and Human Services’ Health Resources and Services Administration. The competencies, derived from the ATPM Inventory of Knowledge and Skills Relating to Health Promotion and Disease Prevention,[50] cover four categories: clinical prevention, quantitative skills, health services organization and delivery, and community dimensions of medical practice. Together, they address a wide spectrum of topics, including environmental health hazards and asthma management. This set of competencies will provide medical educators with measurable education outcomes in prevention education. The core competencies will be evaluated for potential adaptability to health provider education curricula in schools of nursing and health professional schools.The core competencies also will be reviewed for potential expansion to cover emerging issues and competencies in evaluating and responding to environmental health concerns and natural and man-made disasters. Because health care providers will have to address new health issues, policies, technologies, and practice guidelines over their careers, continuing education programs also need to be updated periodically.

1-8.		In the health professions, allied and associated health profession fields, and the nursing field, increase the proportion of all degrees awarded to members of underrepresented racial and ethnic groups.

Target and baseline:

Objective	Increase in Degrees Awarded to Underrepresented Populations	1996-97 Baseline (unless noted)	2010 Target
		Percent
	Health professions, allied and associated health professions fields (For the baselines, health professions include medicine, dentistry, pharmacy, and public health.)
1-8a.	American Indian or Alaska Native	0.6	1.0
1-8b.	Asian or Pacific Islander	16.2	4.0*
1-8c.	Black or African American	6.7	13.0
1-8d.	Hispanic or Latino	4.0	12.0
	Nursing
1-8e.	American Indian or Alaska Native	0.7 (1995–96)	1.0
1-8f.	Asian or Pacific Islander	3.2 (1995–96)	4.0
1-8g.	Black or African American	6.9 (1995–96)	13.0
1-8h.	Hispanic or Latino	3.4 (1995–96)	12.0
	Medicine
1-8i.	American Indian or Alaska Native	0.6	1.0
1-8j.	Asian or Pacific Islander	15.9	4.0*
1-8k.	Black or African American	7.3	13.0
1-8l.	Hispanic or Latino	4.6	12.0
	Dentistry
1-8m.	American Indian or Alaska Native	0.5	1.0
1-8n.	Asian or Pacific Islander	19.5	4.0*
1-8o.	Black or African American	5.1	13.0
1-8p.	Hispanic or Latino	4.7	12.0
	Pharmacy
1-8q.	American Indian or Alaska Native	0.4	1.0
1-8r.	Asian or Pacific Islander	17.5	4.0*
1-8s.	Black or African American	5.7	13.0
1-8t.	Hispanic or Latino	2.8	12.0

*The Asian or Pacific Islander population group has exceeded its target, which represents the minimum target based on this group’s estimated proportion of the population.

Target setting method: Targets based on U.S. Bureau of the Census projections of the proportions of racial and ethnic groups in the population for the year 2000.

Data sources: Survey of Predoctoral Dental Educational Institutions, American Dental Association; Profile of Pharmacy Students, American Association of Colleges of Pharmacy; AAMC Data Book: Statistical Information Related to Medical Schools and Teaching Hospitals, Association of American Medical Colleges; Annual Data Report, American Association of Schools of Public Health; Annual Survey of RN (registered nurse) programs, National League for Nursing, Center for Research in Nursing Education and Community Health.

Certain racial and ethnic groups and low-income communities lag behind the overall U.S. population on virtually all health status indicators, including life expectancy and infant death. Furthermore, access to health care is a problem, and these groups often lack a specific source of care. Increasing the number of health professionals from certainracial and ethnic groups is viewed as an integral part of the solution to improving access to care.

Members of underrepresented racial or ethnic groups make up about 25 percent of the U.S. population. Their representation among health professionals, however, is in the range of 10 percent. Several studies have shown that minority health professionals are more likely to serve areas with high proportions of underrepresented racial and ethnic groups and to practice in or near designated health care shortage areas.[51], [52]

Despite considerable efforts to increase the number of representatives of racial or ethnic groups in health profession schools (medicine, dentistry, nursing, pharmacy, and allied and associated health professions), the percentage of such entrants, enrollees, and graduates has not advanced significantly and in some cases has not advanced at all since 1990. The targets set for Healthy People 2000 for such enrollment and graduation were not achieved, and achieving the revised targets by 2010 presents a significant challenge. Additional attention will need to be given to such efforts as providing financial assistance for underrepresented racial and ethnic group students to pursue health care degrees, encouraging mentor relationships, promoting the early recruiting of students from racial and ethnic groups before they graduate from high school, and increasing the number of racial and ethnic group faculty and administrative staff members in schools that train health care professionals. Other suggested approaches to improving culturally appropriate care for ethnic and minority populations include increasing cultural competency among all health workers and increasing the number of lay health workers from underrepresented racial and ethnic groups.

1-9.		Reduce hospitalization rates for three ambulatory-care-sensitive conditions—pediatric asthma, uncontrolled diabetes, and immunization-preventable pneumonia and influenza.

Target and baseline:

Target setting method: 25 percent improvement.

Data source: Healthcare Cost and Utilization Project (HCUP), AHRQ.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable. NA = Not applicable.
*Income of patient is the median income for the postal ZIP Code of residence.

Comprehensive primary care services can reduce the severity of certain illnesses. Hospital admission rates for “ambulatory-care-sensitive conditions” serve as an indicator for both limited access to primary care and evidence of low-quality primary care. Disparities in hospital admission rates for racial and ethnic groups and low-income populations have been well documented.[53], [54]

The three indicators selected here represent common problems encountered in primary care and allow monitoring of hospitalization rates for children (asthma), working-age adults (diabetes), and elderly persons (pneumonia and influenza). For each of these conditions, interventions can reduce hospitalization rates. Advances in the management of asthma have reduced its adverse health effects. Primary care can prevent both acute problems and long-term consequences of diabetes. Illness and death from preventable pneumonia and influenza among elderly persons can be avoided through the use of pneumococcal and influenza vaccines. These three conditions have been chosen because coordination of community preventive services, public health interventions, clinical preventive services, and primary care can reduce levels of these illnesses. To be effective, these services must be culturally competent and linguistically appropriate.[55]

This objective can be achieved by targeting high-risk populations. Because multiple factors besides access and quality contribute to the admission rates for ambulatory-care-sensitive conditions, each State will need to examine its rates and interpret them in the context of its population, health system, and community characteristics and will need to implement corresponding strategies. The objective is to improve primary care and preventive services and thereby reduce the need for hospital admission and the extended illness and costs associated with hospitalization.[56], [57], [58], [59]

It should be noted that persons who are privately insured have admission rates that are half those of the national average, indicating what is potentially achievable. Because of data limitations and potential access barriers to hospital admission among the uninsured, the Medicaid rate is artificially high and the uninsured rate is artificially low. (See Tracking Healthy People 2010 for more information.) Data by race are not included because these data are reported at the State level. State-level hospital discharge databases can provide accurate estimates of racial and ethnic disparities in hospital admission rates at the State level. There are substantial disparities in hospital admission rates for pediatric asthma and uncontrolled diabetes by race and ethnicity. The magnitude of this disparity also fluctuates by State, suggesting that access to care and quality may play a role. Specifically, among seven States for which rates were determined, the age- and gender-adjusted relative risk of hospitalization for pediatric asthma ranged from 2.3 to 5.8 for African Americans and 1.3 to 2.6 for Hispanics compared to non-Hispanic whites. For uncontrolled diabetes, the relative risk of hospitalization ranged from 3.0 to 4.4 for African Americans and 1.2 to 2.0 for Latinos compared to non-Hispanic whites.[60] AHRQ is developing a “minority national inpatient sample” as part of HCUP that will provide national estimates of disparities in avoidable hospitalization rates by race and ethnicity.

Emergency Services

1-10.		(Developmental) Reduce the proportion of persons who delay or have difficulty in getting emergency medical care.

Potential data source: National Health Interview Survey (NHIS), CDC, NCHS.

Emergency services are a vital part of access to health care in the United States. All population groups, regardless of their socioeconomic, health, or insurance status, want to know that emergency services will be available and will function quickly and effectively when needed.[61] This broadly shared social expectation was reinforced by landmark Federal legislation, the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986. EMTALA stipulates that anyone seeking care at a hospital emergency department (ED) must receive a medical screening examination for an emergency medical condition and appropriate stabilizing measures.[62]

For many people, however, a variety of barriers continue to block access to emergency departments when the need for emergency medical care arises.9 Among these barriers are psychological and cultural factors that may keep some people, even if insured, from seeking care promptly; financial constraints that may inhibit some people, even if insured, from seeking care promptly; and shortcomings in the number, location, or capability of EDs in a specified geographic area.

A significant component of this objective is to reduce the proportion of people whose access to emergency services is blocked by their health insurance coverage or payment policies. These policies affect access to hospital emergency departments and, in some instances, use of prehospital emergency services.[63] Typically, these policies stipulate that unless an enrollee’s condition is life threatening, the enrollee or the ED must obtain authorization before an ED visit or risk that a claim for services will be denied.In some cases, claims for ED visits can be denied retroactively if they are deemed medically unnecessary. The rationale for these coverage and payment policies is clear: to manage care and contain costs. These policies, however, discourage some enrollees from receiving emergency treatment when and where it is warranted.[64]

Concerns about access barriers have prompted Federal, State, and organizational groups to seek assurances that health coverage or payment policies will provide payment when people go to an ED with acute symptoms of sufficient severity—including severe pain—such that a prudent layperson could reasonably expect that the lack of medical attention could result in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

1-11.		(Developmental) Increase the proportion of persons who have access to rapidly responding prehospital emergency medical services.

Potential data source: Annual Survey of EMS Operations, International Association of Fire Fighters.

The outcome of many medical emergencies depends on the prompt availability of appropriately trained and properly equipped prehospital emergency medical care providers. In urban areas, this capability is defined by an interval of less than 5 minutes from the time an emergency call is placed to arrival on the scene for at least 90 percent of first-responder emergency medical services and less than 8 minutes for at least 90 percent of transporting EMS. In rural areas, this capability is defined as an interval of less than 10 minutes from the time an emergency call is placed to arrival on the scene for at least 80 percent of EMS responses.

Assuring a prompt response requires a well-coordinated system of care involving a variety of organizations and agencies, some of which are outside the traditional health care arena. The components include public awareness of how and whom to call for emergency assistance and public education concerning initial lifesaving emergency care procedures to be followed until the arrival of EMS providers. They also include access via a 911 or enhanced 911 system or, in rural areas, a uniform addressing system that allows emergency responders to locate the person requesting emergency assistance quickly; the availability of well-trained and appropriately certified response personnel, who are frequently from law enforcement or fire services; transportation (ground, air, or water ambulance); medical direction and oversight; and destination hospitals that are well-equipped and appropriately staffed.

1-12.		Establish a single toll-free telephone number for access to poison control centers on a 24-hour basis throughout the united states.

Target: 100 percent.

Baseline: 15 percent of poison control centers shared a single toll-free number in 1999.

Target setting method: Total coverage.

Data source: American Association of Poison Control Centers Survey, U.S. poison control centers.

Poison control centers (PCCs) are staffed on a 24-hour basis by toxicologists and specialists in poison information who respond to requests from the general public and health care professionals for immediate information and treatment advice about poisonings and toxic exposures. Local or toll-free telephone calls to PCC hotline numbers provide primary access to these services. Each year more than 2 million callers seek telephone assistance from PCCs throughout the United States.[65] When a caller reports a poisoning or toxic exposure, a PCC toxicologist or specialist in poison information assesses the severity of the incident, advises the caller about treatment, and makes referrals for further medical attention when necessary. PCCs respond to inquiries in languages other than English by using language-translation services, interpreters, or bilingual staff members. PCCs manage most incidents by providing telephone advice to a caregiver at home, avoiding the need for more costly care at a hospital emergency department or another health care facility.

Linking all PCCs in the United States through a single toll-free telephone number and consolidating several key PCC functions can make contacting PCCs easier and more cost-effective.[66], [67] When PCCs are linked through a common telephone number, callers can be routed automatically to the nearest PCC based on their area code, telephone exchange number, and ZIP Code. Educational efforts could focus on a single easy-to-remember emergency number that permits callers to access PCCs quickly. Incorporating all PCCs under the umbrella of a toll-free nationwide telephone number will help ensure access to poison control services when and where they are needed.

1-13.		Increase the number of Tribes, States, and the District of Columbia with trauma care systems that maximize survival and functional outcomes of trauma patients and help prevent injuries from occurring.

Target: All Tribes, States, and the District of Columbia.

Baseline: 5 States had trauma care systems in 1998.

Target setting method: Total coverage. (Tribal trauma systems are measured differently because they frequently are regional and often are linked to a State EMS.)

Data sources: State EMS Directors Survey, National Association of State EMS Directors; IHS (Tribal data are developmental).

A trauma care system is an organized and coordinated effort in a defined geographic area to deliver the full spectrum of care to injured patients. The main goals of the system are to match the available trauma care resources in a community, region, or State with the needs of individual patients and to ensure that patients have rapid access to the acute care facility and rehabilitation services they need. In a trauma care system, prehospital, acute care, and rehabilitation services are integrated and administered by a public agency that provides leadership, coordinates service delivery, establishes minimum standards of care, designates trauma centers (which offer 24-hour specialized treatment for the most severely injured patients), and fosters ongoing system evaluation and quality improvement.

Trauma care systems traditionally have focused on preventing adverse outcomes in the event of injury. Many trauma care professionals and people in the public health field believe that trauma care systems also should contribute to the prevention of injuries.[68] Trauma care professionals are in a good position to provide leadership in injury surveillance, clinical preventive services, and communitywide injury prevention programs. Recent Federal initiatives in trauma care have resulted in the design of a model system that incorporates public information, education, and prevention of injuries as key features.[69]

Results of a national survey conducted in 1993 indicated that only 5 States had complete trauma systems, but 19 other States and the District of Columbia had at least some trauma system components in place.[70] A survey of all 50 States and the District of Columbia in 1998 again indicated that only 5 States satisfied all trauma care system criteria.[71] However, results from this survey also showed that 37 other States and the District of Columbia had at least some trauma system components in place.

1-14.		Increase the number of States and the District of Columbia that have implemented guidelines for prehospital and hospital pediatric care.

1-14a.  Increase the number of States and the District of Columbia that have implemented statewide pediatric protocols for online medical direction.

Target: All States and the District of Columbia.

Baseline: 18 States had implemented statewide pediatric protocols for online medical direction in 1997.

Target setting method: Total coverage.

Data source: Emergency Medical Services for Children Annual Grantees Survey, HRSA.

Emergency medical service systems try to bring essential prehospital medical treatment to patients as quickly as possible. Emergency care of children presents a particular challenge because prehospital providers often treat fewer children and have limited pediatric experience and assessment skills. It can be more difficult to assess the severity of illness or injury because characteristic changes in vital signs that signal deterioration in adults may not occur in children. Important anatomic, physiologic, and developmental differences exist between children and adults that affect their responses to medical care and their risk of injury and illness.[72] Most EMS systems operate independently of hospitals or other facilities and typically have few physicians to ensure appropriateness of care.

Experienced providers can offer medical direction in two ways, either online or offline. Online direction involves direct communication (for example, voice) between EMS medical directors (for example, at hospitals) and emergency medical technicians (EMTs) and paramedics to authorize and guide the care of patients at the scene and during transport. Offline medical direction includes the development of guidelines, protocols, procedures, and policies, as well as planning for, training in, and evaluation of their use.

1-14b.  Increase the number of States and the District of Columbia that have adopted and disseminated pediatric guidelines that categorize acute care facilities with the equipment, drugs, trained personnel, and other resources necessary to provide varying levels of pediatric emergency and critical care.

Target: All States and the District of Columbia.

Baseline: 11 States had adopted and disseminated pediatric guidelines that categorize acute care facilities with the equipment, drugs, trained personnel, and other resources necessary to provide varying levels of pediatric emergency and critical care in 1997.

Target setting method: Total coverage.

Data source: Emergency Medical Services for Children Annual Grantees Survey, HRSA.

Emergency care for life-threatening pediatric illness and injury requires specialized resources, medical direction, equipment, drugs, trained personnel, and properly staffed and equipped hospitals.72 Children, however, receive emergency care in a variety of settings—from rural community hospitals to large urban medical centers. Hospitals vary in terms of their readiness to treat children’s emergencies. If the hospitals are properly equipped and staffed, children frequently can receive the care that they need at local hospitals, but some children require the advanced care available only at regional specialty centers. Categorization is essentially an effort to identify the readiness and capability of a hospital and its staff to provide optimal emergency care.[73] Compliance can be voluntary or assigned by official agencies.

Long-Term Care and Rehabilitative Services

1-15.		(Developmental) Increase the proportion of persons with long-term care needs who have access to the continuum of long-term care services.

Potential data sources: National Long-Term Care Survey, Medicare Current Beneficiary Survey, HCFA; National Health Interview Survey (NHIS), CDC, NCHS; Medical Expenditure Panel Survey (MEPS), AHRQ.

The long-term care population needs access to a range of services, including nursing home care, home health care, adult day care, assisted living, and hospice care.[74] Persons with long-term care needs require the help of other persons to perform activities of daily living (personal care activities) and instrumental activities of daily living (routine needs). Access problems are viewed as a need for specified long-term care services that were not received in the past 12 months.

Long-term care crosses the boundaries of different types of care—from health to social—and intensity of services—from periodic home health and homemaker visits to round-the-clock subacute care. Access to the full range of long-term care services continues to be a problem because of financial barriers and the limited availability of specific services.11, [75] Although people in the long-term care population and their caregivers prefer long-term care to be delivered in the least restrictive environment, limited access and limited knowledge about care options can result in a long-term care population that is more dependent than necessary. The long-term care services selected cover key services in institutions, in the home, and in the community. Access to this range of services in rural areas is often difficult.

1-16.		Reduce the proportion of nursing home residents with a current diagnosis of pressure ulcers.

Target: 8 diagnoses per 1,000 residents.

Baseline: 16 diagnoses of pressure ulcers per 1,000 nursing home residents were made in 1997.

Target setting method: Better than the best.

Data source: National Nursing Home Survey (NNHS), CDC, NCHS.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable. MSA = Metropolitan statistical area.

Pressure ulcers in all settings are sufficiently common to warrant concern, particularly as a quality-of-care issue. A significant number of people are at risk for pressure ulcers in nursing homes. Older adults are particularly prone to pressure ulcers as a result of decreased mobility, multiple contributing diagnoses, loss of muscle mass, and poor nutrition. About 24 percent of the Nation’s 1.4 million nursing home residents require the assistance of another person to transfer from bed to chair.

According to studies of the treatment of pressure ulcers, it is difficult to determine the exact extent of the problem, including the number of new cases and the number of people who have pressure ulcers. Pressure ulcers have long been recognized as a serious quality-of-care problem in both acute care facilities and nursing homes.[76], [77] The prevention of pressure ulcers depends on close observation, appropriate nutrition, and effective nursing care. The number of new cases of pressure ulcers could indicate the overall quality of care provided to nursing home residents. Evidence-based guidelines have been issued on the prevention and treatment of pressure ulcers.[78]

Related Objectives From Other Focus Areas

2.	Arthritis, Osteoporosis, and Chronic Back Conditions

	2-2.		Activity limitations due to arthritis
	2-3.		Personal care limitations
	2-6.		Racial differences in total knee replacement
	2-7.		Seeing a health care provider
	2-11.		Activity limitations due to chronic back conditions

3.	Cancer

	3-10.		Provider counseling about cancer prevention
	3-11.		Pap tests
	3-12.		Colorectal cancer screening
	3-13.		Mammograms

5.	Diabetes

	5-1.		Diabetes education
	5-4.		Diagnosis of diabetes
	5-11.		Annual urinary microalbumin measurement
	5-12.		Annual glycosylated hemoglobin measurement
	5-13.		Annual dilated eye examinations
	5-14.		Annual foot examinations
	5-16.		Aspirin therapy

6.	Disability and Secondary Conditions

	6-7.		Congregate care of children and adults with disabilities
	6-10.		Accessibility of health and wellness programs

7.	Educational and Community-Based Programs

	7-2.		School health education
	7-3.		Health-risk behavior information for college and university students
	7-5.		Worksite health promotion programs
	7-7.		Patient and family education
	7-8.		Satisfaction with patient education
	7-12.		Older adult participation in community health promotion activities

9.	Family Planning

	9-1.		Intended pregnancy
	9-2.		Birth spacing
	9-3.		Contraceptive use
	9-5.		Emergency contraception
	9-6.		Male involvement in pregnancy prevention
	9-10.		Pregnancy prevention and sexually transmitted disease (STD) protection
	9-11.		Pregnancy prevention education
	9-13.		Insurance coverage for contraceptive supplies and services

11.	Health Communication

	11-2.		Health literacy
	11-6.		Satisfaction with health care providers’ communication skills

12.	Heart Disease and Stroke

	12-1.		Coronary heart disease (CHD) deaths
	12-15.		Blood cholesterol screening

13.	HIV

	13-6.		Condom use
	13-8.		HIV counseling and education for persons in substance abuse treatment
	13-9.		HIV/AIDS, STD, and TB education in State prisons
	13-10.		HIV counseling and testing in State prisons

14.	Immunization and Infectious Diseases

	14-5.		Invasive pneumococcal infections
	14-22.		Universally recommended vaccination of children aged 19 to 35 months
	14-23.		Vaccination coverage for children in day care, kindergarten, and first grade
	14-24.		Fully immunized young children and adolescents
	14-25.		Providers who measure childhood vaccination coverage levels
	14-26.		Children participating in population-based immunization registries
	14-27.		Vaccination coverage among adolescents
	14-28.		Hepatitis B vaccination among high-risk groups
	14-29.		Influenza and pneumococcal vaccination of high-risk adults

15.	Injury and Violence Prevention

	15-7.		Nonfatal poisonings
	15-8.		Deaths from poisoning
	15-10.		Emergency department surveillance systems
	15-12.		Emergency department visits
	15-19.		Safety belts
	15-20.		Child restraints
	15-21.		Motorcycle helmet use
	15-23.		Bicycle helmet use
	15-24.		Bicycle helmet laws

16.	Maternal, Infant, and Child Health

	16-1.		Fetal and infant deaths
	16-2.		Child deaths
	16-3.		Adolescent and young adult deaths
	16-17.		Prenatal substance exposure
	16-18.		Fetal alcohol syndrome
	16-20.		Newborn bloodspot screening
	16-22.		Medical homes for children with special health care needs
	16-23.		Service systems for children with special health care needs

17.	Medical Product Safety

	17-3.		Provider review of medications taken by patients
	17-5.		Receipt of oral counseling about medications from prescribers and dispensers

18.	Mental Health and Mental Disorders

	18-6.		Primary care screening and assessment
	18-7.		Treatment for children with mental health problems
	18-8.		Juvenile justice facility screening
	18-9.		Treatment for adults with mental disorders
	18-10.		Treatment for co-occurring disorders
	18-11.		Adult jail diversion programs
	18-12.		State tracking of consumer satisfaction
	18-13.		State plans addressing cultural competence
	18-14.		State plans addressing elderly persons

19.	Nutrition and Overweight

	19-1.		Healthy weight in adults
	19-2.		Obesity in adults
	19-3.		Overweight or obesity in children and adolescents
	19-4.		Growth retardation in children
	19-17.		Nutrition counseling for medical conditions
	19-18.		Food security

21.	Oral Health

	21-7.		Annual examinations for oral and pharyngeal cancers
	21-10.		Use of oral health care system
	21-11.		Use of oral health care system by residents in long-term care facilities
	21-13.		School-based health centers with oral health component
	21-14.		Health centers with oral health service components
	21-15.		Referral for cleft lip or palate
	21-16.		Oral and craniofacial State-based surveillance system
	21-17.		Tribal, State, and local dental programs

22.	Physical Activity and Fitness

	22-12.		School physical activity facilities
	22-13.		Worksite physical activity and fitness
	22-14.		Community walking
	22-15.		Community bicycling

23.	Public Health Infrastructure

	23-1.		Public health employee access to the Internet
	23-2.		Public access to information and surveillance data
	23-3.		Use of geocoding in health data systems
	23-8.		Competencies for public health workers
	23-9.		Training in essential public health services
	23-10.		Continuing education and training by public health agencies
	23-12.		Health improvement plans
	23-13.		Access to public health laboratory services
	23-14.		Access to epidemiology services

24.	Respiratory Diseases

	24-6.		Patient education
	24-7.		Appropriate asthma care
	24-11.		Medical evaluation and followup

25.	Sexually Transmitted Diseases

	25-11.		Responsible adolescent sexual behavior
	25-13.		Hepatitis B vaccine services in STD clinics
	25-14.		Screening in youth detention facilities and jails
	25-15.		Contracts to treat nonplan partners of STD patients
	25-16.		Annual screening for genital chlamydia
	25-17.		Screening of pregnant women
	25-18.		Compliance with recognized STD treatment standards
	25-19.		Provider referral services for sex partners

26.	Substance Abuse

	26-18.		Treatment gap for illicit drugs
	26-20.		Treatment of injection drug use
	26-21.		Treatment gap for problem alcohol use
	26-22.		Hospital emergency department referrals

27.	Tobacco Use

	27-5.		Smoking cessation by adults
	27-7.		Smoking cessation by adolescents
	27-8.		Insurance coverage of cessation treatment

28.	Vision and Hearing

	28-1.		Dilated eye examinations
	28-2.		Vision screening for children
	28-10.		Vision rehabilitation services and devices
	28-11.		Newborn hearing screening, evaluation, and intervention
	28-13.		Rehabilitation for hearing impairment
	28-14.		Hearing examination
	28-15.		Evaluation and treatment referrals

Terminology

(A listing of abbreviations and acronyms used in this publication appears in Appendix H.)

Access: According to the Institute of Medicine, “The timely use of personal health services to achieve the best possible health outcomes.”[79] This definition includes both the use and effectiveness of health services. The concept of access also encompasses physical accessibility of facilities.

Activities of daily living (ADL): Personal care activities, such as bathing, dressing, eating, and getting around (with special equipment, if needed) inside the home.

Acute care facility: A health facility that provides care on a short-term basis. Included are community hospitals with an average length of stay of less than 30 days for all patients.

Ambulatory care: Health care that does not require the patient to stay in a hospital or other facility, such as care provided on an outpatient basis.

Ambulatory-care-sensitive conditions: Conditions resulting in hospitalization that could potentially have been prevented if the person had improved access to high-quality primary care services outside the hospital setting.

Asymptomatic: Without symptoms. This term may apply either to healthy persons or to persons with preclinical (prior to clinical diagnosis) disease in whom symptoms are not yet apparent.

Clinical care: The provision of health care services to individual patients by trained health care professionals.

Clinical preventive services (CPS): Common screening tests, immunizations, risk assessment, counseling about health risk behaviors, and other preventive services routinely delivered in the clinical setting for the primary prevention of disease or for the early detection of disease in persons with no symptoms of illness.

Continuum of care: The array of health services and care settings that address health promotion, disease prevention, and the diagnosis, treatment, management, and rehabilitation of disease, injury, and disability. Included are primary care and specialized clinical services provided in community and primary care settings, hospitals, trauma centers, and rehabilitation and long-term care facilities.

Core competencies: A defined set of skills and knowledge considered necessary in the educational curricula for training health care providers. Examples of core competencies include skills in prevention education; skills in using sources of health data to identify what clinical preventive services should be delivered to the individual patient based on that person’s age, gender, and risk factor status; an understanding of the U.S. public health system (local and State health departments) and its role in monitoring and maintaining the health of the community; and skills to evaluate and translate medical and scientific research reports into clinical practice.

Emergency services: Health care services that are or appear to be needed immediately because of injury or sudden illness that threatens serious impairment of any bodily function or serious dysfunction of any bodily part or organ.18

Functional assessment: A health care provider’s review of a patient for the ability to perform activities of daily living (personal care activities) and instrumental activities (routine needs) of daily living. (See also Persons with long-term care needs.)

Health insurance: Any type of third party payment, reimbursement, or financial coverage for an agreed-upon set of health care services. Includes private insurance obtained through employment or purchased directly by the consumer, or health insurance provided through publicly funded programs, including Medicare, Medicaid, CHAMPUS/CHAMPVA, or other public hospital or physician programs.

Health intervention: Any measure taken to improve or promote health or to prevent, diagnose, treat, or manage disease, injury, or disability.

Health outcomes: The results or consequences of a process of care. Health outcomes may include satisfaction with care as well as the use of health care resources. Included are clinical outcomes, such as changes in health status and changes in the length and quality of life as a result of detecting or treating disease.

Instrumental activities for daily living: Routine activities, such as everyday household chores, shopping, or getting around for other purposes, that enable a person to live independently in the community.

Long-term care (LTC): A broad range of health and social services delivered in institutions, in the community, and at home. Long-term care services include institutional services, such as those delivered in nursing homes, rehabilitation hospitals, subacute care facilities, hospice facilities, and assisted living facilities; services delivered in the home, such as home health and personal care, hospice, homemaker, and meals; and community-based services, such as adult day care, social services, congregate meals, transportation and escort services, legal protective services, and counseling for clients as well as their caregivers.10

Managed care: According to the Institute of Medicine, “a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decisionmaking through case-by-case assessments of the appropriateness of care prior to its provision.”[80]

Patient barriers: Any mental, physical, or psychosocial condition that prevents an individual from accessing needed health care. Examples include attitudes or biases, mental disorders or illnesses, behavioral disorders, physical limitations, cultural or linguistic factors, sexual orientation, and financial constraints.

Persons with long-term care needs: Persons who need the help of other persons to perform activities of daily living (personal care activities) and instrumental activities of daily living (routine needs).

Primary care: According to the Institute of Medicine, “The provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”[8]

Primary care provider: A physician who specializes in general and family practice, general internal medicine, or general pediatrics, or a nonphysician health care provider, such as a nurse practitioner, physician assistant, or certified nurse midwife.

Primary prevention: Health care services, medical tests, counseling, and health education and other actions designed to prevent the onset of a targeted condition. Routine immunization of healthy individuals is an example of primary prevention.1

Provider barriers: Any mental, physical, psychosocial, or environmental condition that prevents or discourages health care providers from offering preventive services. Examples of provider barriers include a poor practice environment, lack of knowledge, and lack of efficacy studies.

Quality: According to the Institute of Medicine, “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”79 Simply stated, it is doing the right thing, for the right patient, at the right time, with the right outcome.

Rehabilitative services: Services to restore specific skills, including overall physical mobility and functional abilities.

Secondary prevention: Measures such as health care services designed to identify or treat individuals who have a disease or risk factors for a disease but who are not yet experiencing symptoms of the disease. Pap tests and high blood pressure screening are examples of secondary prevention.1

System barriers: Conditions within a health care system that prevent people from accessing needed services or prevent health care providers from delivering those services. System barriers include physical, cultural, linguistic, and financial barriers as well as the availability of health care facilities or providers with special skills, such as eye, ear, nose, and throat specialists.

Tertiary prevention: Preventive health care measures or services that are part of the treatment and management of persons with clinical illnesses. Examples of tertiary prevention include cholesterol reduction in patients with coronary heart disease and insulin therapy to prevent complications of diabetes.1

Usual source of care: A particular doctor’s office, clinic, health center, or other health care facility to which an individual usually would go to obtain health care services. Having a usual source of care is associated with improved access to preventive services and followup care.

Vulnerable and at-risk populations: High-risk groups of people who have multiple health and social needs. Examples include pregnant women, people with human immunodeficiency virus infection, substance abusers, migrant farm workers, homeless people, poor people, infants and children, elderly people, people with disabilities, people with mental illness or mental health problems or disorders, and people from certain ethnic or racial groups who do not have the same access to quality health care services as other populations.

References