Change Project

Week 7 Change Project

Access to health care has always been and will be a continuous issue for the United States (US). Under the leadership of President Barack Obama in 2010, the Affordable Care Act (ACA) was passed in order to ensure health care coverage for many Americans regardless of citizenship, pre-existing conditions, or other limiting factors. The ACA extended health care coverage to more than 17 million Americans, however, many insured individuals are still unable to see their providers despites the legislation of ACA (Allen, Call, Beebe, McAlpine, & Johnson, 2017). I, as a future family nurse practitioner, have personally witnessed many patients who are being delay and even being delay seeing their providers due to the limits set by the health plans. With that in mind, I wish to research the barriers to health care in this Change Project and make positive changes to improve health care of the US.

Backgrounds and Target Population

According to Kisling and Das (2020), there are three types of preventions in the current healthcare, and they are primary, secondary, and tertiary prevention. Primary preventions are interventions that use measures such as receiving vaccines, altering risky behaviors, and banning a substance that is associated with a disease. Secondary preventions are interventions that are done to avoid further complications, such as blood pressure screening, mammogram, and colonoscopy. Tertiary preventions are interventions that manages disease, such as chemotherapy, treatment, or rehabilitation (Kisling & Das, 2020). Primary and secondary interventions can prevent patients from deteriorating and being managed in an acute care setting. Practitioners that provide primary and secondary interventions are called primary care providers. The Institute of Medicine defines primary care as the integrated and accessible heath care services that are provided by physicians or practitioners who are capable to manage the personal health care needs, to develop sustained relationships with the patients, and practicing with family and community in mind (Donaldson, Yordy, Lohr, & Vanselow, 2021).

Currently, my clinic rotation hours are done in an urgent care and a family clinic that does some primary women preventative care. Some common medical problems that I have encountered in the family clinic and the urgent care are hypertension, hyperlipidemia, type 2 diabetes mellitus, annual physicals, immunizations, hyper/hypothyroidism, non-complicated infections, fractures, screening, etc. My target population are patients of all ages who live in southern California metropolitan region and are being managed in an outpatient setting, such as clinics and urgent cares. On many occasions, these patients with insurance coverage are not able to see their providers because of their health plans. Given that, the US health care needed to be further examined. The US health care uses a hybrid multi-payer system with some components of single payer system, subsidized private payer system, socialized medicine, and self-pay (Donnelly, Erwin, Fox, & Grogan, 2019). Omitting the government health plans, like Medicare and Medicaid, most insured Americans have either health maintenance organization (HMO) or preferred provider organization (PPO). HMO patients are limited by the size of the network, the inability to choose a preferred provider, and the inability to see specialists without referrals. PPO patients have less restrictions when compared with HMO, but PPO comes with a high monthly fee and copayment. These financial barriers are placing patients with multiple comorbidities in a disadvantage, and in addition, these patients have to handle other barriers such as transportation, limited office hours, and the social distancing guidance due to the Coronavirus pandemic.

Some of these barriers can be address with evidence-based projects, such as telemedicine/telehealth, pre-screen the patients’ insurances, keep an open-community with the patient, and implement new practices to suit the patients’ needs. Nevertheless, more actions are needed to address these barriers. The barriers can be categorized into three levels: provider-level, patient-level, and system-level. In system-level, HMO health plans are restricted patients to see their primary providers annually. Consequently, these patients are seeking care in different settings, such as urgent care clinics and even emergency rooms. In patient-level, many patients have bias and preferences on how to manage and prevent diseases. And patients also are unaware of the details of their health plans. Patients need to be more proactive about their health care. If they are limited by their financial status, reach out to local Medicaid office for resources. Finally, provider-level barriers are usually barriers of reimbursement and health plans. If a provider is being restrained by reimbursement, he/she should show the patient to the appropriate providers to obtain affordable and quality care (Toscos, Carpenter, Flanagan, Kunjan, & Doebbeling, 2018). Ultimately, access to health care is a 3-way relationship between the provider, the patient, and the system.

Integrative Literature Review

The focus of the Change Project is to study the barriers to care, and the target population are the insured patients who lives in metropolitan region of Southern California. Disregard the traditional access to care barriers, such as getting appointments, transportations, and limited office hours. The following articles analysis the issue in depth, and they are listed as followed: Barriers to Care and Healthcare Utilization among the Publicly Insured, Insurance + Access≠Health Care: Typology of Barriers to Health Care Access for Low-Income Families, Exposing Some Important Barriers to Health Care Access in the Rural USA, Nonfinancial Barriers and Access to Care for US Adults, Perceived barriers to healthcare and receipt of recommended medical care among elderly Medicare Beneficiaries, Barriers to Primary Care After the Affordable Care Act: A Qualitative Study of Los Angeles Safety-Net Patients’ Experiences, Implications of Language Barriers for Healthcare: A Systematic Review.

Article 1

In the article Barriers to Care and Healthcare Utilization among the Publicly Insured, it looked into the different types of barriers to care, there are the 3 levels of barriers of access to healthcare are patient-level, provider-level, and system-level. The Affordable Care Act expands the access to care to the uninsured, however access to care remains an issue in the low socio-economic population. The article looked into the barriers to access to care in low-income adults of the Minnesota Health Care Program in 2008. The article reported that there were twice as many system-level barriers than the patient-level and provider-level barriers. By grouping the different types of barriers into patient-level, provider-level, and system-level can help to determine what interventions have the greatest impact on improving the barriers to access to health care (Allen, Call, Beebe, McAlpine, & Johnson, 2017). The most complex level is the system-level of access to care, because of the complexity and the multiple-payer health care system United States. The article suggested to address the barriers at the individual level, which can be complicated but that is the most effective way. The article suggested that providing clear, comprehensible coverage and cost information at each interaction with a patient could mitigate many system-level factors that inhibit healthcare utilization.

Article 2

The article Nonfinancial Barriers and Access to Care for US Adults studied the prevalence and predictor of nonfinancial barriers that lead to the delay to care in US adults. The researchers looked into the nonfinancial barriers by removing the financial barriers by the utilization of the Affordable Care Act. However, the study pointed out that eliminating the financial barriers lead to other nonfinancial barriers, which are the location barriers, the long wait time for appointments, diagnostic test, and specialist appointments. They can potentially address through regulation of health insurances in the federal and state levels, similar to the financial barriers. The researchers suggested the accommodation model as a solution, it is done by open scheduling, on-site clinic, after-hours outpatient services, and other types of communications, such as emails, mobile applications, and texting, to accommodate the patients’ needs (Kullgren, McLaughlin, Mitra, & Armstrong, 2012). However, the accommodation model also leads to the issue of shortage of primary care providers. At the state level, California has passed Assembly Bill 890, which goes into effect in 2023. This allows a nurse practitioner with 3 years of experiences under a doctor to practice in primary care setting independently and without the oversight of a physician (Wood, 2020). This state law was aimed to relieve the shortage of providers in the state of California. Other accessibility barriers can be addressed by telemedicine and transportation services.

Article 3

Exposing Some Important Barriers to Health Care Access in the Rural USA, is a research done by the Medical School for International Health in 2015. It is a comprehensive study that examine barriers in seeking and accessing health care in the rural population in the US. The study suggested that besides the cultural and financial constraints, patients of rural areas are often limited by the scarcity of services, the lack of trained providers, inadequate public transportation, and the unavailability of high-speed internet. These barriers are the reasons for rural areas patients to have poorer health. Furthermore, rural areas are very unattractive, simply unable to retain providers, and maintain health care services when compared with the urban areas (Douthit, Kiv, Dwolatzky, & Biswas, 2015). The barriers suggested by the article can be addressed by the Assembly Bill 890, the telemedicine, other methods of communications, and the more availability of high-speed internet.

Article 4

Insurance + Access ≠ Health Care: Typology of Barriers to Health Care Access for Low-Income Families is a study that tried to identify the barriers to access to care of low-income parents in the state of Oregon. The study concluded that the 3 major barriers are lack of insurance coverage, poor access to service, and unaffordable costs. Besides the barriers of access to health care, these families also struggled with office visit co-pay, deductibles, and prescription drug cost. The study also looked into the 3 types of families and their barriers: families without insurance, families with public coverage, and families with private insurances. Families without insurance, those families are intimidated and feel helpless because of denial care. A lot of times, this group of families will use someone in the family who has insurance to make appointment. Second, the families with public coverage have better access to care. But they are still unable to get access to specialist. Finally, the families with private insurance have little to no issue access care, but they have difficulty obtaining new expensive prescriptions and rely on pharmaceutical samples for treatment (DeVoe, Baez, Angier, Krois, Edlund, and Carney, 2017). The article pointed out that health insurance is an essential foundation for all families, but it does not solve all issues of access to care and the cost of care.

Article 5

The article Perceived Barriers to Healthcare and Receipt of Recommended Medical Care Among Elderly Medicare Beneficiaries highlighted barriers to health care in one of the most vulnerable populations of the US: elderly. The researchers pointed out that elderly patients who lack a source of health care are not likely get screening and preventative care. Elderly patients want their primary care providers to sustain and build meaningful relationship, to communicate better, and to put their trust in their providers in a timely manner. The article also brought up 3 very important barriers of elderly accessing to care, which are the financial barrier, the satisfaction barrier, and transportation barrier. Nonetheless a patient has no issue receiving primary care, the most common reason that the patient is not adherence to the treatment is financial issues. It can be the copayment, prescriptions drugs, medical supplies, or medical services. This can hinder the patient’s health. Second, the satisfaction with the primary care services is another barrier, to be more specific, the care coordination and the quality of care. The article discovered that patient’s satisfaction can positively influence the patient’s medication compliance. Finally, transportation is a barrier of elderly accessing to primary care, but it is a very small portion. However, it can delay of diagnosis, receive of treatment, and participation in education and/or counseling (Kurichi, Pezzin, Streim, Kwong, Na, Bogner, & Xie, 2017).

Article 6

Language can contribute to the barrier to access health care. In the article Implications of Language Barriers for Healthcare: A Systematic Review, language barrier can challenge a patient to receive quality health care and a primary care provider to provide quality patient-centered care. It can even create miscommunication between a patient and a provider. Language barrier is a work-related stress, contribute to incomplete understanding of a patient’s situation, poor patient assessment, delay treatment, and even misdiagnoses, In the US, many large institutes have interpreter services in place for patients who speak different languages, but these interpreter services increase cost and duration of treatment. For many small primary care offices, they cannot afford those services. The article suggested primary care providers use smartphone applications, such as MediBabble, to translate. The benefits of using smartphone translation application are fast and efficient. Most questions of MediBabble can be answers with a yes or a no (Shamsi, Almutairi, Mashrafi, & Kalbani, 2020).

Article 7

The Affordable Care Act help millions of Americans gain health care coverage, but challenges and barriers still exist for patients obtaining and utilizing primary care, especially those patients who are living in the Los Angeles county, low income and in Medicaid program, which is known as Safety-Net, MyHealthLA, and LA care. In Barriers to Primary Care After the Affordable Care Act: A Qualitative Study of Los Angeles Safety-Net Patients’ Experiences, the researchers study Medicaid program patients’ difficulties obtaining and maintaining primary care. These patients simply do not understand the concept of primary care and preferred the speediness of urgent care and emergency department. These Medicaid programs has changed their strategies to emphasis strongly on primary care. However, due to the long, confusing process of enrollment and the limited in-network providers, many patients prefer receiving care in urgent care and/or emergency department.

Project’s Benefits

Primary care setting are family clinics, urgent care, women clinics, and private offices. The main focus of primary care is health promotion, disease prevention, disease management, and patient education. Addressing the issue of barrier to care, I hope to impact providers, patients, and the insurance companies to acknowledge the importance roles of primary care and its ability to prevent more severe and serious complications for both insured and un-insured patients.

Goals and Objectives

The goal of this Change Project is to gain a better understanding of the different types of access to care barriers and to help providers, patients, and the insurance companies to make positive changes to provide better access to primary care. The objectives of the Change Project to examine the different barriers of access to primary care in all insured patients of the metropolitan areas of southern California, to analyze these barriers at their individual levels, and to construct a proposal for the insurance companies and lawmakers to eliminate the different types of health care insurance approach to improve the access to care for next 2 to 3 years.

Variables: Controlled vs. Not Controlled

For the Change Project, the research data will come from my personal interactions with patients who I have encountered during my clinical rotations, which are an urgent care that treats about 150 to 200 patients daily and a family clinic that treats about 15 to 20 patients daily. Majority of these patients are insured, however, some of these patients are uninsured. The independent variables are the barriers that prevent a patient to receive the proper health care. They can be classified into 3 levels, which are the system-level, the provider-level, and the patient-level. The dependent variable is the patient’s accessibility to health care. Health care includes annual physical examination, preventative screening, specialist visit, supportive services, home health services, nutritional supports, medical device needs, and even transportation needs. Changes at the system-level is continuous and difficult process. It is difficult to achieve for a short 16-week project. But barriers at the patient-level and provider-level can be addressed easier. Budget will definitely determine if the change can be implemented for both the patient’s barriers and the provider’s barriers. It can be resolved by putting the expenses into a proposal and submit the proposal to potential interested sponsors to get the necessary funding or grant. Data gathering would be done in a personal interview with patients. If a patient preferred to write, I will also give him/her the questions in paper format. To determine whether to use qualitative or quantitative method, I would consider the collected data, the prediction of the causal relationships between the variables, and apply results to a wider population. For this Change Project, it would be a quantitative correlational research that look into the effect of insurances influence the access of care for insured patients who lives in the southern California metropolitan areas (Lau, 2017).

Explanation of the Research

This research will provide an insight to the providers and insurance companies about the correlation between different type of health care insurance coverages and the patient accessibility to care for insured patients by applying the cause-and-effect methodology. This study wishes to provide a better understanding for patients, providers, insurance companies, and possibly lawmakers. Hopefully, patients, who live in the communities southern California metropolitan areas, will make more informed decision when choosing their insurance plans whether is preferred provider organization (PPO) or health maintenance organization (HMO) (DeVoe, Baez, Angier, Krois, Edlund, & Carney, 2017). And lawmakers will make positive changes to the current legislature and make health care, which include specialist and supportive care, more accessible to all insured patients.

Desired Outcomes

The purpose of this Change Project is to examine the effects between the different types of insurance plans on the patient’s access to health care with a quantitative correlational method. The Affordable Care Act (ACA) of 2010 expanded and continue to expand health insurance to about 20 million Americans, however, many Americans are still being limited or restrained by the insurance plan when it comes to access health care (Kominski, Nonzee, & Sorensen, 2017). This can lead to delay care, non-compliance, and eventually poor patient outcome. The focus of the study is to improve the current health care system for insured individuals by inspecting different barriers of access to health care. The viewpoint of the study is to provide a better understanding of the United States health care system by investigating the drawbacks of different levels and perhaps proposing some solutions to resolve those barriers.

The goals of the study are listed as followed:

1.    Inform patients of the different type of health care plans, help them to make better decision when it comes to choose health plan, and realize the importance of primary care

2.    Inform health care providers, help them put aside their financial preferences, and take on more patients in primary care setting regardless of reimbursement

3.    Inform lawmakers and health care insurance companies, help them make a more ethical and better decision, and to eliminate the barriers of accessing primary care

The timeline of project goals is intended to conclude in the next 12 weeks.

Theoretical/Conceptual Framework

The theoretical framework provides an overall representation of relationships between a proposed theory and the research problem. The two frameworks that is backbone of this Change Project are the IOWA model and the Framework of Advancing and Reducing Health Disparities. The IOWA model of evidence-based practice is the theoretical framework that is used in this research. The conceptual framework is a useful and powerful analytical tool to organize and guide a research. Conceptual framework of advancing and reducing health disparities, which was proposed by the Institute of Medicine (IOM), is the best approach to analysis the barriers of access to care issue (Kilbourne, Switzer, Hyman, Matoka, & Fine, 2018).

IOWA Model

The IOWA model is the use of evidence-based practice in health care setting. It consists of 7 steps, which are in a continuous circular motion. It starts with select a topic, form a team, evidence retrieve evidence, grade the evidence, develop an evidence-based practice (EBP) standard, implement the EBP, and evaluate. The benefits of this framework are better patient outcomes and provide measurable data for continuous evaluation. The IOWA also promotes a holistic approach for all parties that are involved with a patient to share their specialized knowledge to improve patient outcomes (Doody, 2011).

For my Change project, my topic is barriers to health care in the insured population who live in southern California metropolitan areas. I personally witnessed this problem many times in my current clinical rotation. The IOWA model is applied throughout this proposed project extensively. This model allows researchers to focus on a known problem, to question the current practice, to develop practical explanation of the problem, and to improve the practice by current research findings. This model is applied from the selection of topic phase to the evaluation phase (Doody, 2011).

The assumptions of the IOWA model include working a group/team to apply EBP, evaluation is a part of the EBP, EBP is an ongoing process, and EBP requires multiple clinicians to align and participate to deliver the chances (Titler & Moore, 2010). The key component of the IOWA model is the seven steps of the process of evidence-based practice.

EBP has been utilized since the 1990s in the US. I will apply the 7-step of IOWA model to my Change Project. At the first step, I have noticed that insured patients are unable to access primary care or specialty care due to restriction of the insurance. For this reason, I selected barriers to care as my change project. The second step is to assemble a team. The personnel who I want to be involved in the project are the office manager, the providers, the patients, and research staff. Third step is to retrieve evidence, which is done by having research staff collect data from the providers and patients. Grading the evidence is the fourth step, which is when research staff grading the effectiveness of the data. The fifth step is to come up with a recommendation for future practice. The sixth step is the implementing the EPB with the support of the providers, the patients, and the office staff. At this step, it is important for participants to provide feedback. Finally, the last step is evaluation, which is to assess the newly implemented EBP is beneficial to the patient outcome (Doody, 2011). To select the sample of the project, it would be patients who had interaction with me during clinic.

Framework for Advancing and Reducing Health Disparities

The conceptual framework of this project is the Framework for Reducing Disparities in Health Care Systems. This phenomenon that I have noticed is affecting insured patient of all ages, especially for those vulnerable population. Identifying a health disparity in multilevel is the key focus of this conceptual framework. It can be at the patient-level, the provider-level, and the system-level. The assumption of the framework is that the lack of health care occurs because of group bias and low socioeconomic. The theory has a linear and sequential 3 steps, which are detecting, understanding, and reducing. At the first step, researchers need to define the health disparities, define vulnerable populations, measure disparities in vulnerable population, and to consider selection effect and confounding factors. The second step is to identifying determinants of health disparities in the patient-level, provider-level, health care system level, and clinical encounter level. The last step is reducing, which is to intervene, evaluate, translate & disseminate, and change policy. This Change Project is important because of the limitation of insurance, many insured patients are experiencing delay care, it can be costly to their health, and it is part of Health People 2020 (Kilbourne, Switzer, Hyman, Matoka, & Fine, 2018). The sample selection is same to the IOWA model.

Intervention for Proposed Clinical Change Project

The United States has one of the most complex and complicated multi-payer health care system in the world, but it is progressing and improving continuously. In fact, better access to primary care can decrease the utilization of emergency department, decrease inpatient admissions, and even lower the cost of health care for both government-funded and privately funded insurance. Throughout my clinic rotation, there are mainly 2 types of insurance plans: health maintenance organization (HMO) plan or preferred provider organization (PPO) health plan. Patients with HMO are being treated differently because of the lower reimbursement rate of HMO plan. On the other hand, PPO patients have very little to no restrictions on choosing the provider, seeing specialists, and getting supportive care. The objective of my Change Project is to investigate the barriers of access to primary care and to provide some potential solutions for facilitating the barriers.

Clarify the Issue under Study

Barriers to health care access can lead to delay to health care and even lead patients deteriorate. Barriers to care needed to be address in 3 different levels, which are patient-level, provider-level, and system-level. Patient-level barriers are limitations of the family and the patient’s work. Provider-level barriers are the provider’s bias and discrimination. System-level barriers are coverage, financial, and access barriers. The reason for dividing the barriers in different levels and addressing them separate is to observe the effectiveness of each intervention. The article Barriers to Care and Healthcare Utilization among the Publicly Insured even mentioned the barriers to care is significantly higher in the low-income population. In fact, low-income patients are more likely to be affected by transportation, prolonged wait time, and/or getting an appointment (Allen, Call, Beebe, McAlpine, & Johnson, 2017).

Propose Solutions or Interventions Based on Literature Review

The American Hospital Association (AHA) task force identified 9 emerging strategies to ensure health care access in low-income, vulnerable communities. According to the article Ensuring Access to Quality Health Care in Vulnerable Communities, the 9 strategies are primary care, psychiatric and substance use treatment services, emergency department and observation care, prenatal care, transportation, diagnostic services, home care, dentistry services, and robust referral structures. One of the essential services that the article focus on is the addressing the social determinants of health. Economic stability, education, health care, and health behavior are help shapes the health of the community. These are all basic needs of the patient’s daily essential needs, such as food, security, housing, employment, income, language & literacy, education levels, access to health care, access to specialty, affordability, personal health practices, personal behaviors, etc. (Bhatt & Bathija, 2018).

The article recommended 3 important strategies to facilitate access to health: adopting the virtual care, utilize a global budget payment, and use inpatient/outpatient transformation strategy. Virtual care can bring immediate, around-the-clock access to physicians, specialists, and other health care providers regardless of locations and distance. Global budget payment model is harder to achieve, because the different types of payment levels, the type of services provided, the types of health care providers participation, and the types of services to be included. However, a global payment model allows providers the flexibility to create a unique plan to meet their budget and create solutions for the community. Finally, the inpatient/outpatient transformation strategy is to use hospitals to align their services to the community in 3 simple steps, which are:

(1) reduce the inpatient capacity to a level that reflects and address the community needs (Bhatt & Bathija, 2018),

(2) shift community and financial resources to enhance outpatient and primary care services (Bhatt & Bathija, 2018), and

(3) continue to offer emergency services (Bhatt & Bathija, 2018).

One of the solutions to facilitate the provider-level barrier to health care that was proposed by the article Insurance + Access ≠ Health Care: Typology of Barriers to Health Care Access for Low-Income Families is to train office staff to avoid asking screening questions. For example, what is your insurance. Many low-income patients feel intimidated, helpless and judged. Sometimes, low-income patients will have their family members with better insurance to make appointment for them (DeVoe, Baez, Angier, Kronos, Edmund, & Carney, 2017). In some cases, an insured patient will seek medical advice during his/her visit for the uninsured family member. Primary care providers need to be sensitive, compassionate, and put themselves in the patient’s shoes.

Compare other Views on the Problem and Solutions

The United States has one of the most expensive, technological advanced, and specialized health care system of the world, but the health status is worse than the rest of the world. With the rising health care cost, the high rate of waste, and the trend towards chronic disease, there is a need for change in health care that is guided by primary care. The article The Coming Primary Care Revolution proposed that changes needed to focus on the following 4 principles:

(1) payment must be adequately support primary care and reward value, even non-visit-based care,

(2) primary care will be promoted teamwork, improve clinical operation, and utilization of new technology,

(3) generalist providers will focus on high acuity and high complexity, and primary care providers will manage conditions that specialist focused on in the past, and

(4) primary care focus on holistic care and address health behaviors, such as vision, hearing, dental, and social services (Ellner & Philips, 2017).

Shifting the focus on the importance of primary care will improve patient care, lead to better patient outcome, and better patient satisfaction at affordable cost. However, with any chances, it will require better technology, increase payment, effective leadership, management, advocacy, and continuous process of improvement from front line workers and policy makers. The new providers should view these changes in primary care with optimism and excitement, because they can lead closer to ideal of humanism and scientific advancement.

APRN Role and Implications for Clinical Practice

The advanced practice registered nurse (APRN) master’s program started in the United States back in 1960s. As the demand of primary care providers increase, the role of APRN also extends to different disciplinary of health care, especially primary care. Recently, the patient satisfaction is highly valued for enhancement of health care delivery and facilities improvement (Woo, Lee, & Tam, 2017). Hospitals in the “Inland Empire”, which is area that overlap the Los Angeles county, the Riverside county, and San Bernardino county, utilized nurse practitioners (NP) in both inpatient and outpatient settings. NPs are rated better at educate patients, answer patient’s questions, listen actively, and manage pain than physicians. The patient satisfaction does not necessarily equivalent to the quality-of-care delivery or the patient outcome, and hence the need for collaboration and cooperation with physicians. Moreover, utilizing NPs in primary care is cost effective for the US health care system. In 2020, the state of California passed Assembly Bill No. 890, which granted NPs full practice authority without the oversight of physicians. There are more than 11 million Californians who live in areas that has shortage of primary care providers. Nonetheless, the California Board of Registered Nursing (BRN) outlines the standards for a NP to practice independently. The minimal standards are:

(1) pass a national board examination and/or other supplemental examination required by the state of California (Wood, 2020),

(2) maintain a NP certificate from a national governing body (Wood, 2020),

(3) show proof of education and training consistent with the BRN standards and regulations that is relevant to the clinical practice hours (Wood, 2020), and

(4) complete “transition to practice”, which is 3 years of full-time employment or 4,600 hours (Wood, 2020).

AB-890 authorized NP to practice in 6 health care settings, which are health facilities, clinics, medical group practices, county medical facilities, home health agencies, and hospices (Wood, 2020).

Implications of the Change Project

My Change Project was transpired during my clinic rotation hours. A numerous interaction with the patients at an urgent care clinic and at a family clinic that offer some women health revealed the need for evolve in the current US health care system. Patients with PPO plans have little to no restrictions of access primary care and specialist care. Contrarily, patients of HMO plans have many obstructions to obtain care. These challenges include transportations, deductibles, co-payments, referrals, insurances requirements, location restrictions, provider restrictions. To make a positive change in the US health care system, a receptive context of change framework is needed. Dr. Andrew Pettigrew, PHD developed the framework in 1990s that promote receptive context (Woo, Lee, & Tam, 2017). Pettigrew has 8 key factors to facilitate changes, and they are (1) the quality and coherence of policy, (2) the availability of key people leading change, (3) long-term environmental pressure, (4) supportive organizational culture, (5) effective managerial-professional relations, (6) cooperative inter-organizational networks, (7) simplicity and clarity of goals and priorities, and (8) change agenda and its locale (Woo, Lee, & Tam, 2017).

Recommendations and Implications for Clinical Practice

The barriers of access to care can be addressed in 3 different levels, which are patient-level, provider-level, and system-level. First, some patient-level barriers are obtaining referral for a specialist, transportation issues, limited office hours, and a patient’s preference. Second, the provider-level barriers are discrimination due to over a certain health plan, the language barriers, the lack of understanding of a patient’s culture/preference/religion, and the provider’s bias. And finally, the system-level barriers are the most complex. Insured patients often do not know about their health plans coverage, do not know where to ask questions, and unsure about the affordability of treatments or prescribed medications (Allen, Call, Beebe, McAlpine, & Johnson, 2017).

From my personal observation, barriers of each level needed to be resolved at its individualized level. For example, the patient-level barriers of access to care because of unsure where to get help can be tackle with the involvement of the patient’s family member and even the provider’s office members. At one of my clinics, the officer manager will often call the health plan for the patients to figure out where to get resources. Lately, she even will call nearby pharmacy to schedule COVID vaccine for older, non-English speaking seniors. Second, the provider-level barriers can be resolved by the provider self-reflection and extend office hours to better-tailor the patient’s needs. At last, the system-level barriers can be address with the federal-level and/or the state-level lawmakers and the insurance companies. Regardless, I have witnessed insurance improvement on the access to specialist cares for a patient who requires multiple specialist’s management. The patient is a 30-year-old woman, G4P3 and with a history of hypothyroidism with require constant endocrinologist’s management, presented at the clinic for an obstetrician specialist referral for 8 weeks of gestations. Due to changes of coverage, her HMO allowed her to keep one of her specialists, endocrinologist. Permitting the patient to keep one specialist can eliminate life-threaten condition, such as myxedema, infertility, and even heart problems.

My suggestion to future research is to study the barriers at each level individually. By doing so, this can tell researchers whether an intervention is effective on a barrier. This will also allow researchers to dive into a patient’s experience who is living in an understudied and low-income community. One example of improvement that can be done in the provider-level is be aware certain questions. For example, patients who are low-income feel timid and helpless when being ask, “What is your insurance?”. These patients dreaded of denial of care and unaffordability of care. In some instances, an insured individual will make an appointment for someone in the family who is under-insured (DeVoe, Baez, Angier, Kronos, Edmund, & Carney, 2017). Providers and future providers, such as nurse practitioners, should train office staff to be more mindful sensitive questions.

Summary of Study and Limitation of Study

This Change Project wishes to study and inform providers, patients, insurance companies, and state- and federal-level lawmakers about the shortcomings of the current United States health care system. And hopefully, this research will help reduce and even eliminate the different types of barriers to care. This project plans on using the quantitative correlational method to examine the cause-and-effect of how access to care can positively and/or negatively affect a patient’s health outcome (Lau, 2017). The two frameworks are being utilized in the project are the IOWA Model and the Framework for Reducing Disparities in Health Care Systems. The IOWA Model provides a researcher to notice a known problem, to question the current practice on this problem, to develop explanation of the problem, and to improve the current practice in a team approach (Doody, 2011). This framework is applied throughout the study, in addition, it is very similar to the “Nursing Process”. Next, the Framework for Reducing Disparities in Health Care Systems is also being implemented in the study. This model consists of three linear, sequential, and simple steps, which are detecting, understanding, and reducing (Kilbourne, Switzer, Hyman, Matoka, & Fine, 2018). These two frameworks are binded together in this Change Project.

Suggestions for Public Policy Changes

The United States’ health care system is complex and yet it progresses constantly. It is complex because of its multiple payer system, the advancement of new treatments, and its inability to measure and to balance the cost, the quality, and availability of care (Bhatt & Bathija, 2018). The Coronavirus pandemic did not relief the access to care. Some has suggested to implement a single-payer or global payment system. Nevertheless, this is unachievable because single payer system suspends advancements and improvements of health care technology. For example, LASIK became widely available in 2008 and the average cost per eye is $4,000. In 2020, it cost about $2,200 per eye (Segre, 2018). It is almost 50% decrease. This is a perfect example of the benefit of advancement of multiple-payer system and the advancement of the US health care system.

Conclusions

In conclusion, the US health care system is intricating, but it is constantly improving. Despites the improvement, many insured Americans continue to be affected by access to health, which can be distinguished into three levels: patient-level, provider-level, and system-level. This Change Project wishes to use the IOWA model and the Framework for Reducing Disparities in Health Care Systems to study the cause-and-effect of barriers to health care and to inform patients, providers, and even system organizations, such as lawmakers and insurance companies about the research findings and hopefully make positive changes to current laws and policies to make access to care more widely available.

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