Background and Objectives This mixed-method case study examined access issues related to physical therapy services among medically underserved adults within an Ohio community.
Design Three community health care clinics served as the units of analysis.
Methods Eleven health care providers and 110 patients participated in the study, and documents from local, state, and national resources were reviewed.
Results Results revealed that structural, utilization of care, and outcome barriers existed. A lack of accessible physical therapy providers for medically underserved adults and a lack of standardized screening or assessment processes to identify physical mobility problems among people with chronic health conditions were found. Inadequate knowledge about the full scope of physical therapist practice existed, which may impede access to those individuals most in need of services.
Conclusions Opportunities are present for physical therapist involvement in screening, wellness and prevention, consultation, education, and program development among medically underserved adults. However, challenges exist due to a lack of human and financial resources and the current structure of our health care system, which focuses on acute and chronic care rather than prevention.
Although the United States boasts the most advanced health care system in the world, millions of Americans continue to lack adequate health care each year. Those especially affected are the medically underserved populations who reside in every community. Medically underserved individuals are described as those who need assistance with improving their health as a result of limited access to health care due to lack of health insurance and low income.1,2 They cross all levels of education and age; however, social and economic factors are key predictors of an individual having health care coverage.3–5 As a result, underinsured and uninsured individuals are medically vulnerable, meaning they experience greater difficulty accessing health care services of any kind and have a greater likelihood of negative health care outcomes as they age.3,4
The Institute of Medicine defined access to health care as:
The timely use of personal health services to achieve the best possible health outcomes. Importantly, this definition relies on both the use of health services and health outcomes to provide yardsticks for judging whether access have been achieved.6(p29)
Many indicators have been used to identify barriers and facilitators to accessing care.7 Four themes identified in the literature that measure access to health care are: structural factors, patient perception issues, utilization of care issues, and outcome measures.7,8 Structural factors include environmental issues such as health insurance and population characteristics such as education and age variables.7,8 Patient perception issues involve patient satisfaction with quality and quantity of services, which are predisposing factors to health. Utilization of care issues include having a usual source of care, entry into the system, preventative service, and emergency service use. Outcome measures include health behaviors and health status.7,8 Thus, when examining health care access in the United States, population-based and individual characteristics, services, and outcomes all affect a person's ability to receive care.
Environmental characteristics, a structural factor, has been shown to be a major barrier to health care access. The environmental characteristics of health insurance coverage and utilization control issues dramatically affect the type and quality of health care services that individuals receive.8,9 Health insurance is both an enabling factor in access to health care and a function of health policy.8 As such, health insurance is targeted as one of the most important measures in accessing health care services.8,9 Generally, medically underserved individuals lack many benefits of health insurance, specifically a structure for obtaining care when it is needed the most.
Many consequences of being uninsured exist, including a lack of a usual source of care; fewer referrals for specialty services, including physical therapy; less access to preventative health services and health education; and less use of interventions for chronic illnesses.2,10–13 Often, the end results of these consequences are a greater risk of poorer health outcomes and higher morbidity and mortality rates.12,14 Poor health outcomes frequently are measured by the presence of chronic health conditions such as musculoskeletal disorders, cardiorespiratory conditions, neurological conditions, and diabetes. These conditions are found among the uninsured populations and are known to increase risk factors associated with development of disabling physical mobility problems with age.15–18 Unfortunately, chronic health conditions often are left untreated, as uninsured individuals often delay or avoid seeking help because of their inability to pay for services, leading to adverse health outcomes and increased health care costs. Even when primary care is sought, referral to specialists is limited because of the structural barriers these individuals face.
Physical therapy services are part of the specialty health care system many medically underserved individuals are unable to access. Physical therapists' expertise in movement and exercise and their in-depth knowledge of the pathophysiology of acute and chronic diseases and injuries make them an obvious choice to address health care needs of the adult population in the United States.19 However, the role of physical therapy in community health care is essentially unknown, as no existing literature discusses access to physical therapy services for medically underserved individuals. Therefore, the purpose of this study was to describe access issues related to physical therapy among medically underserved adults within a community.
Unit of Analysis
This research study used a mixed-method, sequential, exploratory20 case-study approach.21 The units of analysis were 3 Ohio-based community health care clinics (CHCs) that provided care to medically underserved adults. A community health care clinic is defined as a private, not-for-profit organization that provides a wide range of primary health care services to medically underserved populations within a community, as it accepts patients who lack health insurance and have limited means to pay for services.22 Criteria for choosing the clinics included (1) being geographically located in a community, (2) serving medically underserved adults, and (3) being granted permission to participate in the study. All 3 of the CHCs available to residents within the community agreed to participate in the study.
Two sets of participants were involved in this research study. First, 11 health care providers (HCPs) who worked within the 3 CHCs were recruited by telephone for participation. The selection process was purposeful to include the HCPs who provided consistent care in these clinics. The executive directors for all chosen health care clinics first were contacted to obtain permission to complete the study at their respective clinic and for the names of other HCPs who were available and willing to participate in an interview. At a minimum, requested HCP participants included the medical director, the executive director or other designee, and a nurse who primarily worked directly with the patients of the clinic. The goal of the selection process was to ensure a broad category of HCPs who serve medically underserved individuals and those who were decision-makers in the care provided to the patients served. Participants' years of service ranged from 6 months to 10 years, with a mean of 2.8 years. Ten of the 11 participants were paid employees of the clinics. Informed consent was obtained from each HCP participant prior to each interview session.
The second set of participants was a total of 110 medically underserved adults who were receiving treatment at the CHCs during the time of the study. The patient participants were recruited voluntarily by clinic personnel to complete a patient questionnaire during the last week of August 2004. The clinic staff obtained informed consent from all patient participants.
Completion of the patient survey served as consent for participation. The distribution of patient participants across the clinics was: (1) clinic A, n=38; (2) clinic B, n=47; and (3) clinic C, n=25. The totals represented 75% of the patients treated at 2 of the 3 medical clinics during the selected week of study. Clinic C did not provide a total for the number of patients treated during the week of the study; therefore, the overall percentage of participants was not available.
Data from the 3 CHCs were collected and analyzed individually and were aggregated to present a community perspective. Data from 3 sources—interviews, document review, and patient survey responses—were collected during the summer of 2004.
Semistructured interviews23,24 were completed as one of the primary means of data collection. Topical questions were developed based upon a review of the literature of medically underserved populations and scope of physical therapist practice. The research concepts also followed the Institute of Medicine's25 Conceptual Framework for Evaluating Uninsurance, including resources, characteristics, and needs. An interview guide developed for the study (available upon request) outlined topical questions as well as cues and probes that assisted me in probing for more information from the HCP participants. The primary strength of this data collection strategy was my ability to understand the unique experiences and perspectives of the HCP participants without limiting their responses through closed-ended questions.23,26 A pilot interview with a health care practitioner previously associated with a free medical clinic was completed prior to use of the guide and showed the interview plan to be appropriate. All interviews took place during the final 2 weeks of July 2004. I completed all interviews, which were audiotaped using reliable equipment. I took notes during each interview to prevent data loss in the event of malfunctioning equipment. The tapes were transcribed following each interview session.
The second method of data collection used in this study was data mining. Data mining is the process of extracting data from numerous written documents.23,27 Documents from 3 constituencies—the clinics, the local community, and state and national records—were analyzed. Archival records in the form of service records, organizational records, and maps and charts were analyzed to gather data on community-level characteristics such as community health indicators, community demographics, and social and economic information. Information also was extracted from organizational administrative documents such as proposals, progress reports, and other documents central to the medical conditions addressed and medical care delivered at each center. Review of other formal studies (grant applications) or evaluations of the sites provided by clinic administration were used. Data from community-wide reports, such as census data, health and human services reports, and other vital statistics, also were examined. This method of data collection helped to answer questions about “who,” “what,” “where,” “how much,” and “how many” in regard to medically underserved adults within the community and questions regarding access issues pertaining to physical therapy services.
Two questionnaires were used to gather data about the HCP and patient participants. First, a HCP demographic questionnaire was used to collect background data (eg, health care specialty, years employed) on the HCP participants interviewed. Next, a patient questionnaire (available upon request) was used to assess characteristics and needs of the actual patients who receive care at the CHCs. The survey was developed specifically for this study. The patient questionnaire was divided into 3 content areas: basic demographic data (6 items), medical history (2 items in “check all that apply” format), and self-reported health care needs about physical mobility problems and access to physical therapy services (6 items). The first 2 content areas (demographics and medical history) were adapted from the American Physical Therapy Association's Documentation Template for Physical Therapist Patient/Client Management.28 The third area was developed to provide information about the patients' views of their needs for and knowledge about physical therapy services in the community. Prior to dissemination of the questionnaire, face validity was assessed by 2 physical therapists who reviewed the instrument, and a pilot study of the instrument was conducted on 10 patients selected at one CHC. Reliability of the instrument was checked using intraclass correlation coefficient (3,1), a single measure of average scores, and found to be .75. Distribution of the questionnaire to patients who sought health care services during the data collection period was provided by an individual identified at each clinic. Each clinic was provided with a self-addressed, stamped envelope to return the completed questionnaires to the planner at the end of the week. The questionnaires were coded according to the clinic; otherwise, all information was kept confidential.
Data Analysis: Building a Chain of Evidence
Data collection and analysis were not mutually exclusive processes, as I worked back and forth between the data and conclusions drawn. A process of data triangulation19,26,29,30 was used during the analysis phase. The 3 sources of data—transcribed interviews, document data, and survey results—were analyzed using a constant-comparative method21 to develop themes and patterns, which provided for meaningful interpretation of the community needs regarding access to physical therapy services. Data verification was offered to each HCP participant through member checking23; however, participants either declined to review transcribed interview sessions or failed to respond to requests for review.
Content analysis and data reduction30 were completed by coding data based upon theoretical themes and concepts identified in the literature. A pattern-matching process was used for this method of analysis, whereby a theoretical pattern and an observed pattern are linked by arrangement to provide new conclusions.31,32 Data conclusion followed the Institute of Medicine's framework for examining community characteristics, resources, and needs.25
A comprehensive analysis of the data is presented that describes: (1) the characteristics of the community, (2) the characteristics of patients who sought treatment at the CHCs, (3) resources available to the medically underserved community, and (4) knowledge of the scope of physical therapist practice.
General Community Characteristics
Three medical clinics serve medically underserved adults in the community. The clinics are separated geographically and are located in the southern, eastern, and western sections of the county. The community has both urban and rural sections; however, the community clinics are located close to the downtown urban areas. Two of the 3 geographic areas are designated medically underserved areas and health professional shortage areas. All 3 clinics are located near residential neighborhoods and some local businesses and churches; however, these neighborhoods appear to be of lower socioeconomic status. The clinics are on local bus routes; but the HCPs reported some patients continue to have difficulty with transportation. Contrary to clinic personnel perception, patient responses from survey data do not indicate transportation is a major barrier for seeking services from these clinics, as only 8% (n=9) of 110 patients reported transportation as an issue.
The 2000 US census reported the community population is roughly 378,000, with 2 main metropolitan cities within its proximity. The racial makeup of the county is rather homogenous, with 90% of the population being white, 7.5% African American, 1.1% Hispanic, 0.5% Asian, and 0.2% American Indian. The age demographics for the county are diverse, with 24.8% under the age of 18 years, 8.3% aged 18 to 24 years, 27.8% aged 25 to 44 years, 24% aged 45 to 64 years, and 15% aged 65 years or older. The median age is 38 years. Women outnumber men (ie, 100 females for every 92.4 males).
Unemployment rates in the county are higher than statewide averages, with 5.8% of the population unemployed in October 2004. The cities where the health care clinics are located report higher averages in unemployment, ranging from a high of 9.5% (clinic B) to a low of 7.3% (clinic C). A trend in manufacturing plant closings within the county over the past few years has driven this growth in unemployment. This trend, in turn, has impaired economic growth within the community and negatively affected the socioeconomic status of community members.
Poverty levels are high in the areas surrounding the clinics as a result of the hardships associated with unemployment. Approximately 7% of the county's adult population falls between 100% and 200% of the federal poverty level, which was $19,350 for a family of 4 in 2005.33 Rates in the communities where the clinics exist, however, are higher. Clinic A reports that in 1 census track (out of 7 it services), the poverty level is 80%, whereas clinic B's poverty level is around 41% and clinic C's poverty level is 11%. Table 1 provides demographic data on the community.
A 2001 community needs survey, the most current information at the time of the study, revealed that the uninsured and underinsured population and the low income population of this county were in need of additional resources to address health and wellness needs, as services and resources were seriously lacking. The high cost of health insurance premiums and insurance coverage expenses were some of the most pressing issues that affected this population.
The high poverty rate, the high unemployment rate, and insufficient access to health care services all contributed to adverse health conditions. Health indicators that were measured consistently throughout the county and state reveal this Ohio community ranked higher than average for people with diabetes, heart disease, respiratory infections, and overall mortality rate. The overall death rate in the county exceeded state standards, reaching 10.4 per 1,000 people, compared with 9.6 in Ohio.
The Patient Population
General patient characteristics.
The target population for the 3 clinics was primarily adult men and women who lived and worked in the communities where the clinics are located. Clinics A and C were classified as free clinics, and clinic B was a federally qualified health care center.34 Individuals were required to show proof of income below a predetermined level to qualify for free medical services at the clinics. Clinic personnel described their patient population as uninsured and unemployed or holding low-paying jobs that did not qualify them for health insurance benefits. Physician A reported,
We are seeing more and more people that have lost their jobs or their medical insurances have been cut, so there has been more of an increase in those types of people, where the economic impact has hit them.
Clinic reports and interviews revealed most individuals lived in private or public housing; however, clinic C provided countywide services for homeless individuals through its mobile health van. Health care providers who worked at these clinics across the county similarly classified the patients who sought medical care as either the working poor or the indigent poor (ie, below the federal poverty level). Neither of these groups had access to health insurance, nor did they have a usual HCP beyond the clinic doors and, therefore, used the services of the CHCs.
Health care providers and services offered.
The clinics were staffed with a combination of medical and administrative personnel. Medical personnel who provided periodic health care services included: internal medicine physicians, family practitioners, cardiologists, chiropractors, counselors, dentists, medical interns and residents, nurse practitioners, and physician assistants; however, the extent to which they are available at the clinics varied. In regard to physical therapy services, only one clinic had access to one volunteer physical therapist on a limited basis. Two clinics reported utilizing a free physical therapy clinic once housed in a local community college's physical therapist assistant program; however, the clinic closed in 2004 due to a lack of operational funding. The HCPs were not aware of other physical therapy providers who accepted patients from or provided consistent physical therapy care to this population. The common structural barrier was the inability of the patient to pay for these services and the inability of the providers to accept many patients who are unable to pay for services. As a result, patient referrals to physical therapy services were severely limited. One HCP reported,
We don't offer PT [physical therapy] services because we haven't found a physical therapist willing to work with underprivileged [people]. That's our biggest problem here … finding area providers that we can refer patients to.”
The 3 CHCs offered care for a variety of medical problems, with the most common problems categorized as chronic health conditions. Patients were described in interviews as having multiple health issues, including physical mobility problems. The 3 chronic medical conditions most frequently mentioned by HCPs and in clinic documents were hypertension, diabetes, and high cholesterol. Patient self-reports revealed hypertension as the most common medical diagnosis treated at the clinics, followed by arthritis and being overweight. Table 2 provides the distribution of medical diagnoses self-reported by patients.
Medical management of the patients served by these clinics was similar across the community; the specific needs of the individual guided interventions. Table 3 outlines the common services provided. A pattern found across all 3 CHCs related to the lack of identification of impairments or functional limitations that may impede current or future function of the patients they treated. Nurse A reported:
I would probably send [those with chronic health conditions] earlier; however, I have to recommend to the doctor first. I'm not allowed to do that. He [the physician] thinks he has to do all the diagnosing and referring. It's a very fine line.
Although more than 35% of the patients surveyed reported problems with physical mobility, the CHCs did not follow a standardized screening program to identify impairments or functional limitations. Instead, HCPs relied on patient self-reports during an examination to ascertain whether physical mobility problems were a cause for concern. Physician A reported:
[w]e don't usually assess functional mobility, except, of course, for those who come in with musculoskeletal problems, low back pain, or neck problems. Then we go through the range of motion, the usual things we do. It is not as extensive as a physical therapist would do. We only have limited personnel and limited time to deal with problems.
One health care practitioner specifically mentioned reliance on other medical or rehabilitative specialists, such as physical therapists, to identify these problems areas; however, a concern existed, as most patients were referred to specialists only if a problem was detected during a scheduled patient visit. Table 4 outlines patient self-reports on select impairments and functional limitations.
Entry Into the System
Knowledge of the scope of physical therapist practice.
Three themes emerged that described the scope of physical therapist practice as known by the population studied: (1) the type of patients whom physical therapists treat, (2) the services provided by physical therapists, and (3) the process for accessing physical therapy services once a need is identified.
First, interview data suggested the scope of physical therapy was defined by the type of patients who were most frequently referred for services. The most often mentioned candidates for physical therapy services were those with musculoskeletal injuries such as sprains, strains, arthritis, or spinal injuries to the neck or low back. A few references to people with neurological disorders such as stroke, multiple sclerosis, or Parkinson disease were found, but there was no mention of patients with cardiovascular, pulmonary, or integument problems who would need physical therapy services. Nurse B stated:
My weakness lies in orthopedics, because I don't have a very strong background in it. If they [the patients] have a weakness or a pain that limits mobility and range of motion, I would be more inclined to refer for physical therapy than if it seems nerve oriented. I don't know whether I'm right or not [in her decision-making process about what type of patients to refer for physical therapy].
Second, the types of interventions provided by physical therapists were similarly described in HCP interviews and written comments from patients. Interventions pertaining to exercise prescription focused on stretching and strengthening the body, and pain reduction modalities such as ice or heat were cited most frequently. One health care provider interviewed used the broad word “rehabilitation” to describe what physical therapists do; however, no other specific interventions were stated. Patient comments included, “flexibility and strengthening exercises” and “things to help me walk correctly and stand up correctly.”
Finally, the common mechanism used within the community health care system to identify patients who would benefit from physical therapy services, if accessible, was physician clinical judgment. All of the physician extenders (nurses and medical assistants) and administrative staff interviewed reported they rely on physicians to decide whether a patient should be referred for physical therapy services. Two nurses reported instances when they identified possible physical therapy candidates; however, the referral was not made because a physician did not recommend it. Nurse A reported:
Some of the physicians aren't highly educated in that regard [in reference to a patient who fell and was in need of physical therapy], and sometimes even if you suggest it, they can shoot you down. We have a lot of volunteer docs, and generally they're older. I don't think they're up on what can be done from a physical therapy standpoint. That's a little discouraging from a nurse's standpoint.
Knowledge of Ohio legislation that permits direct access to physical therapy services was lacking. Clinic personnel at only one site were familiar with the law that allows patients to seek services by physical therapists without the need for physician referral. Even with this knowledge, however, these HCPs indicated they would still rely on a physician referral versus discussing this option with patients. The patient questionnaire did not ask about knowledge of direct access or other processes to access physical therapy services; therefore, patient knowledge about the processes of accessing physical therapy is unknown. Data reveal, however, that 31.8% (n=35) of the patients surveyed reported they were not referred for physical therapy services when a self-identified need was expressed. Another nurse shared:
[i]f there was anything I could say about the field of physical therapy and particularly with the new regulations [in Ohio], [it] is that we need more educational opportunities for nurses [about what physical therapists do] because we are the front line. We don't generally come in contact with them [physical therapists]. I mean, I do here, but we don't usually, as a general rule, in outpatient. If you worked for [a cardiovascular group in the county], those nurses see their patients all the time, and they get to know them very well, and they may be seen for cardiology issues; however, they see them one day coming in and then 3 months later they come in for a checkup, and they're hobbling; they should be able [to refer patients for physical therapy], and they're front line, they shouldn't just be limited to the heart…. We're generally the first line of contact, and the community, I don't think, some of them would, but most of them wouldn't [refer them for physical therapy].
These results indicate that access barriers to physical therapy services exist for medically underserved adults who sought care at community health clinics.
The purpose of this study was to describe issues that affect access to physical therapy services by medically underserved adults. Currently, there are few published reports on demographic or clinical characteristics of free clinic patients,35,36 and to date there are no published reports on access to physical therapy services for medically underserved adults. This study, therefore, brings physical therapy into the discussion on access issues for medically underserved adults.
An examination of community, clinic, and patient characteristics, resources, and needs provided the basis for analysis. The results revealed 3 primary themes in regard to gaps in access to physical therapy services: (1) a lack of physical therapy providers for medically underserved adults, (2) inadequate knowledge by HCPs and patients about the scope of physical therapy services, and (3) a lack of standardized screening or assessment processes related to physical mobility problems for patients with chronic health conditions. These gaps indicate structural, utilization of care, and outcome measure barriers exist (Tab. 5). Each thematic gap is addressed in the context of this study.
First, structural factors, such as population characteristics that inhibit individuals from obtaining a needed service, were found to be similar to those in national reports.6 Medically underserved adults within this study were described as the poor or working poor who did not have access to health insurance. These individuals did not have the financial means to obtain needed health care services, including physical therapy. In this study, 54% of the patients reported they could not afford physical therapy services if a need was present. It is well documented in the literature that referrals to medical specialists for uninsured patients is problematic as the result of a patient's inability to pay for services and a lack of providers willing to accept little to no reimbursement for services delivered.2,13 It appears that physical therapy services can be included in the list of specialty services out of reach for many medically underserved patients who receive care at CHCs. All 3 clinics involved in this study struggled to provide referrals to those individuals in need of physical therapy services. This situation is in sharp contrast to that of individuals with access to public or private health care insurance plans offering physical therapy as a common benefit and living in communities with available and accessible providers. The difference for individuals who sought services at the CHCs is a lack of health insurance benefits and being at risk for health-related problems as they age.9,16,17,37,38
Second, access barriers were noted with utilization of care measures. Barriers existed at numerous levels involving entry into a system and availability of preventative services for medically underserved adults. First, an absence of available and accessible physical therapy providers existed within the community. Clinic HCPs reported that the most significant gap in service was the absence of physical therapy providers available within the community. It was found that a shortage of physical therapists who provided pro bono care existed and a lack of knowledge of community-based physical therapists who would accept a limited number of patients on a pro bono or sliding scale basis was present. Five percent (n=5) of the patients surveyed reported that they could not find a physical therapist for treatment, and 32% reported they had not been referred for physical therapy when a self-reported need was detected. At the time of the study, only one volunteer physical therapist in the county provided limited services at one CHC. With the closing of the local community college's physical therapy clinic run by the physical therapist assistant education program, the community does not have a “go to” place to refer patients in need of physical rehabilitative services.
Although the limited availability of physical therapists hampered the ability to refer patients, the data suggest that when a need was identified, the primary mechanism for patients to access physical therapy services would be through physician judgment, rather than a direct access process. Some physician extenders reported they discussed possible needs for referrals with physicians; however, many times action was not taken, and others relied solely on physician judgment concerning needs of the patients. Reliance on physicians as the sole decision makers regarding the need for physical therapy services may prevent some referrals for therapy if physicians have limited knowledge of the scope of physical therapist practice.
Although referrals for physical therapy services for medically underserved adults appear to be minimal, it is important to note that factors other than the availability of providers also may have an impact. Clinic HCPs and patients treated both appear to have only basic knowledge of the services provided by physical therapists, and a comprehensive understanding of physical therapist scope of practice is lacking. Similar to Foster and Tilse's39 research, clinical factors such as the type and severity of disease and degree and type of impairment were mentioned in reference to candidates for physical therapy services. As expected, referrals for physical therapy services for chronic health conditions were not as commonly cited as musculoskeletal conditions. The results revealed musculoskeletal conditions were the most common conditions considered for physical rehabilitation, which is consistent with Sheppard's40 findings.
The results also suggest physical therapy is referenced by the type of interventions provided, with prescription of exercise programs for stretching and strengthening purposes and pain relief as the most commonly mentioned. Little reference by HCPs in this study was found about the need for physical therapy services for people with functional mobility problems related to difficulty walking or transferring or impairments such as impaired balance, which may affect the mobility problems.
The scope of physical therapy was viewed mostly as a curative service or more commonly categorized as secondary and tertiary prevention, whereas restoration of function is used for people with short-term functional problems as the result of an injury or illness. Results indicate the physical therapist's role in primary care or primary prevention is not as well understood. Health care providers reported physical therapists can play a role in educating patients in risk-factor management, such as exercise prescription for patients with chronic health conditions; however, referral for patients with these types of conditions was not ascertained in this study.
Lack of referral to physical therapists for prevention and wellness services could be related to the current practice of medicine, where prevention and wellness services are not commonly reimbursable by third-party payers, or it could be related to a lack of understanding of the full scope of current physical therapist practice. The physicians interviewed in this study treated patients in both a third-party sector and the free care sector; therefore, referral patterns may be similar among these physicians in both practices, although this question was not directly asked. According to Ryan et al,41 most physicians do not have formal training about the practice of physical therapy or the advancements that occur in the field; however, they are expected by third-party payers to oversee the services provided to patients. This situation could leave patients untreated for various physical mobility problems, especially if referrals for physical therapy are not made because of a lack of understanding about physical therapist practice or because of cost constraints. It could be hypothesized that HCPs may not even consider physical therapy as an option for these patients seeking care at the community clinics because they do not have the financial means to pay for services, although this question was not directly investigated.
Also absent were screening services to identify functional mobility problems for people who may be at risk for disability or for those who may already experience mobility problems and may need rehabilitation services. No formal systems existed in any of the clinics to identify such individuals. Some educational handouts on disease processes, health risks, dietary guidelines, and exercise guidelines were used within the clinics, but limited time with individual patients prevented in-depth education in any one area. Survey results revealed 19% of patients reported a physical mobility problem that was not being addressed. Patient data on self-reported impairments and functional limitations (Tab. 5) appeared to indicate a large number of patients with chronic health conditions. Assessing the need for services to address these issues, however, was outside the scope of this study.
The utilization of care results is consistent with research documenting the needs of medically underserved individuals.12,42 Uninsured individuals are more likely to receive fragmented health care, with less focus on tests and screening for disease and health promotion/disease prevention activities to improve or maintain current health status.2,36,43,44 Although screening programs to identify functional mobility programs are limited in the sample studied, a true comparison to similar services offered to insured individuals cannot be made, as literature to describe such services is lacking. A large amount of literature is available, however, that describes specific tools that can be used to measure functional mobility problems in the adult population.15,45 Overall, it appears a need exists across the community to help identify medically underserved adults who may have early risk behaviors and factors associated with functional mobility problems that can lead to long-term health problems.
Finally, the outcome measures available for analysis in this study revealed negative health outcomes for many of the medically underserved individuals. Chronic health conditions and associated impairments and functional limitations were present among the sample population studied. Similar to the National Academy on an Aging Society's46 report on common chronic health care conditions, illnesses or injuries stemming from the musculoskeletal, cardiorespiratory, and neurological systems were prevalent among the patients. The presence of these conditions should be a concern, as individuals with chronic health conditions, such as those identified in this study, have a greater likelihood of developing related mobility disability as they age.15–17 Although the focus of this study did not address the correlation of adults with chronic health conditions and related functional mobility problems, it was noted that a number of people identified impairments and functional limitations as a problem (Tab. 4). These individuals may be at risk for developing further mobility problems as they age as a result of the early presence of chronic health conditions and a lack of medical and rehabilitative providers to address problem areas. Overall, it appears a need exists across the community to help identify medically underserved adults who may have early risk behaviors and factors associated with functional mobility problems that can lead to long-term health problems. Physical therapists are prime HCPs to give direction to this movement.
Andrulis47 reported a combination of uninsurance and access issues significantly contributed to adverse health outcomes among medically underserved populations. It appears the medically underserved adults in the community studied are at similar risk for such adverse health outcomes. Prevalence of physical mobility disability is predicted to increase with advanced age and for people who experience periods of uninsurance.48 Many times, declines in physical mobility go unnoticed until the progression of disease impairs overall function.17 When this occurs, tertiary care is needed to prevent further decline, which is more costly than primary preventative care. A better process is needed that would be an incentive to enhance primary care.
Mobility is a critical aspect of maintaining functional independence throughout a person's lifetime, and chronic health conditions such as heart disease, diabetes, and osteoarthritis increase the risk of occurrence of physical mobility disability.49,50 Access to physical therapy providers, who are specialists in the examination and treatment of problems that affect individuals' ability to move and function to their maximum potential, may help alleviate some current mobility problems and prevent future physical mobility disability. Access could improve if opportunities are provided to integrate screening and prevention services into contemporary physical therapist practice. Challenges exist, however, as financial resources are lacking in the current health care system to provide preventative services overall, let alone to the underserved populations. Consideration should be given to expanding the role of physical therapists in our health care system to be primary care providers to help identify individuals most at risk for mobility disability associated with chronic health conditions.
A few limitations should be considered when interpreting the results of this study. First, CHCs are dynamic in nature due to funding and staffing issues and simply because of the nature of the services provided. The results of this study were based upon the views and beliefs of the HCPs who provided consistent services within the 3 CHCs during July and August 2004. Staffing or other internal clinic changes may have occurred since this time, and these views and beliefs may not be representative of those of all HCPs who work with medically underserved adults. Second, self-report studies have some limitations related to the truthfulness of responses. It is assumed the HCPs interviewed and the patients surveyed responded to questions openly and honestly; however, true prevalence is not known. Third, only the needs of medically underserved adults who sought health care services at CHCs were focused on in this study. There may be a population of medically underserved adults within the community who did not seek health care services at these clinics, or at all; therefore, the results may not be representative of all medically underserved adults in the community. Finally, generalization of the results to other communities should be done with caution. Although the results revealed some relationship to national data on patient characteristics, resources, and needs, many variables may account for differences or similarities in other communities.
As a result of this study, it is apparent that access barriers exist for medically underserved individuals in need of physical therapy services. Access to physical therapy services within the community studied can be measured by the gaps in services provided and the barriers that impede access to the services that exist. Access to physical therapy services by medically underserved adults within a community were limited by: (1) an absence of available and accessible physical therapy practitioners to provide services; (2) insufficient knowledge of the full scope of physical therapist practice; and (3) inadequate screening programs to identify functional mobility problems within the population, especially for individuals with chronic health conditions. As a result, unmet needs of medically underserved adults within the community existed.
Physical therapists can play a larger role in meeting the needs of medically underserved adults, especially within the Ohio community studied. Opportunities exist for physical therapist involvement in screening, wellness and prevention, consultation, education, and program development; however, challenges also exist, as resources are lacking. Future consideration should be given within the health care system to utilize physical therapists for screening individuals for functional mobility problems and for treating people with chronic health care conditions who exhibit potential for development of mobility disability, especially among medically vulnerable populations.
The Bottom Line
What do we already know about this topic?
Underinsured and uninsured individuals experience more difficulty accessing health care services of any kind when a need exists. Many lack a usual source of care, have less medical visits, and receive fewer referrals to specialty services when needed.
What new information does this study offer?
This was the first study that examined physical therapy access issues for medically underserved individuals. The results reveal that individuals experience access barriers to physical therapy services. Physical therapy can be included in the list of specialty services out of reach for many medically underserved patients.
If you're a patient, what might these findings mean for you?
Individuals who do not have comprehensive health care insurance may lack access to physical therapy services if they are in need of these services. These individuals may need to advocate for themselves to receive appropriate care.
The author thanks the community clinic health care providers and patients who took part in this study. Their willingness to participate allowed the author to gain insight into their world and the needs of those who are less fortunate than others.
This study was completed in partial fulfillment of the requirements for the author's Doctor of Philosophy degree in the College of Education at the University of Akron.
This study was approved by the Institutional Review Board for Protection of Human Subjects at the University of Akron.
A Health Care Policy and Administration Section platform presentation of this research was given at the Combined Sections Meeting of the American Physical Therapy Association; February 9–12, 2009; Las Vegas, Nevada.
- Received July 20, 2009.
- Accepted January 19, 2010.
- © 2010 American Physical Therapy Association