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Mobile health care: An alternative approach in the delivery of preventive health care to the rural elderly in Arkansas

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Mobile health care: An alternative approach in the delivery of preventive health care to the rural elderly in Arkansas

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Content MOBILE HEALTH CARE: AN ALTERNATIVE APPROACH IN THE DELIVERY OF PREVENTIVE HEALTH CARE TO THE RURAL ELDERLY IN ARKANSAS by Jeffrey R. Lewis A Thesis Presented to the FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree MASTER OF SCIENCE IN GERONTOLOGY December, 19 8 3 UMI Number: EP58902 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dtss®rtafeon PvblisWmg UMI EP58902 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 umvERsny of southerh califorhia LEONARD VAVrS SCHOOL OF GERONTOLOGY UNJi/ERSny PARK LOS ANGELES, CALIFORNIA 90007 TkiA WKltt2 .n by Jeffrey Robert Lewis. undeA tkd dJjizdton. k±s CoiTirriyùttee, and app^ov^d by oLl ÂMi mmbdfi^, ha6 bo,2 ,n pK<L- 6Q,nt2 ,d to and aacQ^ptud by tko, Vmn 0| $ Tko, izonoAd Vavt6 Sckoat o { ^ GoAontotogy, tn paAttaZ ^al^ttùnznt ol thz AzquUAmznt6 {^oA thz dzgAzz THtSIS/^OmiTTEE CkaJAman C L l/j/< UNIVERSITY OF SOUTHERN CALIFORNIA 11 ACKNOWLEDMENTS This thesis would not have been completed without the assistance, encouragement, and guidance of Dr. Ruth Weg, Dr. Joel Olah, and my closest friend and companion, Mr. Hiram B. Ottis. I am deeply indebted to each of these individuals for their patience and understanding.> ■ TABLE OF CONTENTS 111 Page ACKNOWLEDGMENTS................................ ii Chapter I. INTRODUCTION ........................ 1 Purpose of the Study Statement of the Problem General Research Questions II. REVIEW OF THE LITERATURE..... 11 The Problems in Obtaining Health Care for the Elderly Rural Health The Effectiveness of Mobile Services III. METHODOLOGY . . . . . . . . . . . . . 22 Experimental Setting and Subjects for the Study Instrumentation and Procedure Specific Research Questions Asked Data Gathering Assumptions Limitations of the Study IV. DATA ANALYSIS AND RESEARCH FINDINGS . 27 V. CONCLUSIONS AND IMPLICATIONS OF THE STUDY ................. 32 BIBLIOGRAPHY....................... 39 CHAPTER I INTRODUCTION According to current population estimates, there are presently more than 25.5 million persons 65 and older in the country today, slightly over 11.3 percent of the total population (Lewis, 1983), Demographers project an increase in this component of the population to over 35 million older persons by the year 2000. Table 1 illu strates the actual and projected growth of the older population. Upon closer examination of these statistics, one finds that: 1. One out of every seven Americans are expected to be 65 and over by the year 2010; 2. By the year 2030, persons 65 and over are projected to represent one out of every five Americans ; 3. By the year 2050, persons 75 and older are expected to comprise about 12 per cent of the total population; and 4. Persons 85 and older are estimated to represent more than 5 percent of the total population by the year 2050. (Taeuber, 1983, p. 25) This projected increase suggests that there will be a number of significant problems, namely accessibility to and the provision of adequate and affordable health < D J3 t a o L O O C V J o o cn t— 1 -o c u 4 - 3 o c u •r-3 O L. C L “ O sz ta to *o ta c 3 ta 4 - 3 to a 3 < O sz 1 — c o c 4 - 3 t T 3 to s- 3 c u CLjQ O E C L 3 Z S - c u T O o c u J= 4 - 3 4- O sz 4 - 3 :5 o S - CD C U JC h- to L. L. C D s s ^ - o ■ LO C O KO t a " 2 1 to s- s- cu ta >■ cu o TO LO c O 00 t T 3 z 'd- 00 o 4 - > t o S- n 3 • LO O ) O 'd- O 4 - > t o L. t a • LO c u o to > » z : to o 4 - > t o L. n 3 . 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(J J3 C U C U 4 - 3 to Q « O to o c to O C "r- 0 ) 4 - > to 4 - > L. O CL C U t o oc c u zs a . 4-Ï O CL M- O C U _c 3 4 - > ta c u 4 - L . O 3 0Û to c « o O J * 1 — U 4 - 3 s- a c u c u M ' S O S- O CL 4 - -O O C ta - 4 - i O CL 0 0 c u cn Q r-l I • o t> 0 o . or - 4 - 3 n 3 3 C L o c u Û - r— T 3 • 4 - 3 -O S - Î L. C U 3 S - O f O to 4-3 -r - 5- 4 - 3 O O C L C U C U C C C U a c tT 3 > * X 3 ■< O L. CL CvJ 00 cn c u a s- 3 O C O 3 care services. As a consequence, the range of health- related problems currently experienced by the older population is expected to increase, widen, and diversify as a function of the increasing numbers of older persons in the population. Research indicates that the now elderly are more likely than younger persons to suffer from multiple chronic conditions (Taeuber, 1983). Concurrently, as the number of older persons with severe conditions who survive over an extended period of time increases, the requirement and necessity for available, accessible, and appropriate medical services must also increase. It is assumed, however, that for the older population of the future who are expected to be healthier if the emphasis on diet, exercise, and stress management continues, that the proportion of elderly persons suffering from severe chronic impairments may be quite different. Thus, there is and will be, into the foreseeable future, a growing need to develop and implement alternate mechanisms into the delivery of health care services to the urban and rural elderly population. Particular attention should be directed toward the rural elderly since they represent a severely neglected portion of the older adult population. There are a number of critical issues arising from the previous demographic summary which should be considered. A composite of these includes : 4 1. The portion of people aged 75 and 85 is getting larger within the older population (Taeuber, 1983) 2. The prevalence of chronic disease and physical impairment increases sharply with age (Taeuber, 1983). 3. The older adult population will need more outpatient care and, in some cases, home delivered services so they can continue to lead active, worthwhile, and independent lives (Packwood, 1981). 4. With an increase in the size of the older population, there is likely to be an increase in the rate of utilization of health care services (Taueber, 1983). The need for development and implementation of alternative mechanisms in delivering health services become critically important since elders are the least likely to utilize hospital outpatient clinics, with less than 10 percent of the visits occurring in such institu tions (Illich, 1976). In addition, significant inroads into the prevention and treatment of the major chronic diseases will not be maintained if older rural Americans, for example, are unable to continue to access available services. It is probable, therefore, that the health- associated problems of older persons will not diminish. It is therefore apparent that a need for change does exist, namely, to develop a comprehensive health care delivery system for plder (rurally-located) Americans. 5 The general health problems of the elderly are magnified considerably among the rural elderly population. In rural areas and in some ghettos, the lack of health facilities and health practitioners often leads to delays in seeking care, difficulties in obtaining appointments, long waiting lines, and other barriers to care which result in lower utilization of rates (Schmidt, 1976). Furthermore, in rural areas often characterized by critical maldistribution of resources, inefficient health care delivery systems, and scarce providers, a major concern is the underutilization of existing health-related services by the rural elderly (Schmidt, 1976). As a result of inequities in health service delivery, new and innovative ways of delivering preventive health services to the elderly need to be explored for rurally-based older Americans. Purpose of the Study The need for accessible and available health services is a problem which confronts the entire popula tion, particularly the rural elderly. Development and implementation of flexible intervention mechanisms which will deliver these comprehensive health services is imperative. Such intervention mechanisms must deal with the special problems of the older person, particularly the isblated/homebound person, for whom communication, transportation and financial costs form imposing barriers. 6 The purpose of the study, therefore, is to examine the applicability of a sample health intervention mechanisn|i for the elderly in the state of Arkansas. In April 1976, the Center for Research and Train ing in Los Angeles, California, initiated a medical hot line program for the elderly. The purpose of the program was to provide information regarding medical and/or health related programs for older Americans in Los Angeles County Information was gathered from a random sample (n = 100) of elderly callers whose criticism regarding the use of medical services can be summarized as follows: 1. Inaccessibility due to physical location of services and/or lack of transportation. 2. Unavailability of services; i.e., not knowing where to locate medical services in their area. 3. The high cost of medical services offered by existing programs (Lewis, 1976). These same problems, i.e., lack of transportation, lack of facilities, and the lack of finances, were also identified as barriers preventing the elderly in Arkansas from obtaining health care services. In 1974, the State of Arkansas Office on Aging funded a mobile health screening project which was designed to combat and prevent the three aforementioned problems experienced by the elderly. This original project was called MERCI, or Multiphasic Examinations to 7 Reduce Chronic Illness. In July 1975, however, the MERCI project was reorganized and renamed MEDD, or Medical Examinations for Disease Detention. The MERCI unit acted as a "mobile clinic on wheels" which delivered medical services directly to the client group. The MERCI program was designed to conform to the special needs and problems confronting the elderly who tried to obtain health care services in Arkansas. It should be noted that Arkansas suffers from the dual problems of lack of positions, as well as a misailocation of health resources. Arkansas is a predominately rural state with a majority of its elderly population still living in many scattered communities. The physicians, on the other hand, are found primarily in the seven urban areas of the state. The MERCI unit emphasized bridging the gap between the service providers and the isolated client group of older people. In addition, the MERCI project was initiated to serve as a detection unit as well as intervention mechanism, that is, to detect a problem before it becomes acute. The proponents of this plan believed that successful implementation would not only save the patient money, but also relieve the patient caseload of the rural physician. Without such a system of direct health care delivery, the state of Arkansas and the patient would 8 experience increased health care costs. The elderly patienij: would suffer disproportionately from the lack of such a health delivery system. In contrast to the MERCI program, the MEDD concept was and did utilize stationary health screening clinics. It was designed to bring the rural elderly to the MEDD Clinic, as opposed to the earlier MERCI program which went directly to the rural client. In July 1975, when the MERCI program was converted to the MEDD program, the method of funding and services delivered also underwent a series of changes. As of 1978, the MEDD program was discontinued due to funding problems. The focus of this is on mobile health screening units as alternate mechanisms to the delivery of health care services to the rural elderly as described in the original project (MERCI). As a consequence of the modi fication of MERCI to MEDD, a major portion of the data is taken from the MEDD project. The data from the second year of the MERCI project was destroyed as a result of a fire within the MERCI project headquarters. All of the MERCI data are nine years old. However, as a result of the refocusing of the new program, limited data have been made available and have been combined with the MEDD data in the examination and analysis of the mobile health screening unit concept. Direct observation of the project was not possible and evaluative information was obtained via 9 written correspondence and telephone interviews with MERCI and MEDD project personnel. These limitations placed an obvious restriction on the ability to generalize based on the conclusions and applications of the study. Statement of the Problem This study proposed to investigate four major research areas in the field of health care delivery for a rural, older population, namely : 1. To examine the available literature concentrating upon the health problems of the urban and rural elderly population. 2. To examine the literature in terms of the effectiveness of mobile units as alternative health delivery mechanisms. 3. To explore and analyze the effectiveness of the MERCI and MEDD screening programs in the delivery of health services to the elderly of Arkansas. 4. To propose a comprehensive mobile screening program, inclusive of health testing procedures and staffing evaluations. General Research Questions The general research questions in the study are : 1. Which health screening service delivery method was more efficient to operate and control administra tively , MERCI or MEDD? 10 2. Which health screening service method directed more effective health services to the older population, MERCI or MEDD? 3. Which health screening service method was more attentive to the health service and personal needs of the rural elderly population, MERCI or MEDD? 11 CHAPTER II REVIEW OF THE LITERATURE The Problems in Obtaining Health Care for the Elderly In 1970, the President's Task Force on Aging set forth recommendations for providing better health services for the aging. This committee emphasized that any changes in existing health services or plans for new types of services should strengthen health care quality with pre vention and rehabilitation as major objectives (Nixon, 1972). Health care as a basic right of older Americans was stressed by the White House Conference on Aging in 1971 (Flemming, 1971). This Conference underscored the necessity for an accessible and comprehensive health care system for the older adult population. Most of the problems the elderly experience with regard to health care services can be classified into one of the following four categories : 1. Mobility of the individual. 2. Communication/cultural differences. 3. Financial difficulties. 4. Accessibility of facilities or services. 12 Shanas (1965) estimated that 7 to 8 percent of those persons over 65 years of age are either bedfast or homebound, but living in their own residences. The home- bound aged are of particular concern because they most often head the list of the medically unreached. The home- bound elderly are frequently too disabled, frightened or bewildered to seek medical attention, and medical assistance rarely reaches out to them. Many of the urban elderly homebound live in single-room apartments or welfare hotels placing them even further from regular medical care. Both communication and cultural factors have compounded the problems of health care delivery to the aged. Although the elderly, as a population subgroup, probably have the greatest need for health care, the medical professionals tend to ignore their specific needs and have traditionally treated geriatric patients with little respect and even impatience (Classer, 1973). Health care problems of the older adults are further complicated by the fact that neither Medicare nor the majority of private health insurance plans cover the cost of routine physical examinations, cancer screenings, etc. (Solomon, 1973). As a result, many aged persons are financially prohibited from accessing preventive medical care Where it does exist. Effective disease prevention is impossible without an adequate health screening program. In addition, 13 extended care for rehabilitation purposes (after acute care is rendered) is usually not available to the elderly. Furthermore, these health screening services may not be of the quality consistent with modern technology and pharmacol ogy, again due to present financial subsidy policies at governmental and private agencies (Hammerman, 1974). The magnitude of this problem becomes even more apparent when one notes that the national medical bill for the entire U.S. population rose to $322 billion at the end of 1982. Of this, $83 billion was spent on Medicare and Medicaid, health care programs serving the elderly and poor. This means that more than 25 percent of the nation's entire medical bill was spent on the elderly and poor (Rich, 1983), This is an extremely important point because the elderly, persons 65 and over, grew twice as fast as the rest of the population in the last two decades (Taeuber, 1983). Clearly, there are problems with the delivery of health care services to the elderly. Many reasons have been advanced to explain why a coordinated health care delivery system has not been developed. Markson, Levitz, and Gognalons-Caillard (1973) set forth some reasons fbr this lack of coordinated services. They stated that older people are frequently unable to pay the high cost of privât^ home care and must accept what is offered to them by public and private agencies willing to provide and pay for services. This financial inability to "shop" for services 14 has left the aged without a voice in health care policy decisions. As poor, needy, and sometimes confused con sumers, the elderly are particularly dis advantaged in demanding services which permit self-maintenance. Other practitioners in the health care field have restated these facts in many analyses of health care services for the elderly. A few examples from the avail able literature include Librach, Davidson, and Peretz (1972) who have also concluded that the problems of finances, mobility, and availability of services are certain barriers confronting the elderly. Their conclu sions are based upon studies performed by other colleagues as well as on empirical research. The difficulties with financés, mobility, and availability of services intensify for the elderly who often fall into low-income groups, most of whom, at best, have histories of episodic health care. Research indicates that stable emotional and mental health in older people are dependent upon their ability to remain in their own residences (Solomon, 1973). It is, therefore, important to combine community-based health services with such supportive services as homemakers, home chore, and home health aides in order to help older persons maintain their independence. 15 Rural Health In the examination of the problems confronting the rural elderly population, it should be noted that approxi mately 41 percent of the entire older population is com posed of rurally-based older people. Furthermore, 33 per cent of the rural elderly people live in poverty and nearly one-half of all substandard housing units in rural areas are occupied by rural elderly persons. Even after a decade of "official" concern over rural health needs, approximately 138 rural counties still do not have a single doctor serving their health care needs. Moreover, rural areas in general have only one doctor for every 500 persons while urban areas havG one doctor for every 200 persons (Domenici, 1978), Focusing particularly on the health care problems facing the rural elderly, one finds that these problems may be divided into three subject areas. 1. The shortage of physicians, particularly those who will accept Medicare and Medicaid. 2. The inability of many to afford health care (even when older persons are able to utilize Medicare-Medicaid). 3. The problem of obtaining accessible, adequate, and appropriate transportation services (Schmidt, 1976). 16 These problems are even more pronounced in light of the finding that proportionately there are more poor people and more older people in rural areas who require more medical attention than in the general non-rural popu lation (Schmitt, 1976). While 15 percent of all persons 65 years of age and older living in urban areas in 1972 were poor, 25 percent of all persons in the same age group in rural areas were living in poverty (Domenici, 1978). As a consequence, the problem of physical accessibility to health care delivery systems becomes even more pronounced. For example, in larger urban areas where there are hospital outpatient facilities, public health departments and an abundance of available physicians, there is usually a transportation system available which assists individuals entering the health care system. However, in rural areas there is often little or no public transportation, so the older population residing near farming and other small communities often find themselves isolated from physicians and hospitals. In several rural areas, public health services consist of only one nurse in the entire county, while othef counties lack any type of allied hea,lth practitioner (Nelson, 1980) . The nature of the difficulties in heslth mainten ance that point up the different health experiences among urban and rural elderly can be characterized in the following comparisons ; 17 1. Persons over 65 in rural areas have more chronic illnesses than persons living in urban areas. 2. According to the National Center on Health Statistics, asthma, arthritis, hearing and vision impair ment, are more pronounced among rural elderly than their urban counterparts. 3. Dental problems are more severe for the rural elderly. The latest data shows that 47 percent of the urban elderly were without teeth, as compared to 5 6 percent of the rural elderly (Congressional Research Service-^ 1979) Finally, in examining the death rates among the urban and rural elderly, the rates for the rural elderly for persons 65 through 79 are slightly lower than for their urban counterparts. This trend of lower death rates continues until the age of 80, when the rates for the rural group become somewhat higher. The Effectiveness of Mobile Services Mobile medical attention is not an entirely new concept, although most mobile programs have in the past been directed toward the younger consumer. Mobile health screening clinics have only recently been applied to the delivery of preventive health services to the elderly population (Lewis, 1977). One of the earliest forms of "mobile health unit" in the U.S. was the family doctor. With his black bag in 18 hand, he would visit and give personal attention to patients in their homes. However, the days of the house call have all but ended, and as a result, the patient has been forced to rely upon public and/or private transporta tion systems for access to health care services. In 1967, the Canadian National Institute for the Blind initiated a new and progressive program, a mobile eye care unit (Lawton, 1975). The primary goal of this service was the early detection and treatment of eye disease. The unit had the facilities to provide a correction of refractive error, to give on-the-spot medical and minor surgical treatment, and to ensure that people with serious occular diseases or other anomalies (e.g., strabismus) would receive adequate follow-up care. Glaucoma, cataracts, and strabismus were detected during routine examinations by opthamologists in the unit (Lawton, 1975). This form of treatment is particularly significant since occular diseases, such as glaucoma, can be arrested if they are detected in the e^rly stages. In the first year, the Newfoundland, Quebec and Ontario units reported over 9,000 completed examinations. Without the service, patients would either have been without medical eye care, or would have had to travel long distances for such services (Lawton, 1975), This mobile eye care program succeeded in bringing services to areas which were previously not being served. 19 Mobile health services have also been effectively used in counseling and community awareness programs. From January 1978 to April 1970, a Florida university-based medical team brought family planning services to more than 5,000 families living in 13 rural counties of north central Florida. The area is roughly the size of Switzerland, with a population of over 300,000. The per capita income in 1968 was less than $1,500 (Held, 1970). The birth and fertility rates exceeded the national average by one-third to one-half, with prenatal mortality and morbidity rates two times higher than the national average. The mobile team conducted 48 three to four-hour clinic sessions each month in the respective counties. Through this clinic network, residents were able to receive family planning counseling services delivered to locations which were convenient for them. A total of 4,403 new family planning patients were seen from January 1968 to April 1970. In addition, 622 families, which were served in the first part of 1968, had been clients the previous year. As a result, family planning services were introduced to 5,025 women with a total of 8,311 visits over the 27-month period. It is also considered significant that the mobile program demonstrated a need for the estab lishment of local community clinics, which would administer family planning services (Held, 1970). 20 Multiphasic mobile cancer screening is another type of health service which has been tested in Japan and England. In both countries, such mobile units have been effective in the early detection of cancer. This particulaif- project was based on the premise that individuals with cancer (in the early stages) or other diseases rarely have symptoms, and for this reason many persons seek medical attention only after they have reached an advanced, and often incurable, stage (Lynch, Harlan, Swartz, Marley, Becker, Lynch, Kraft, & Krush, 1972). Therefore, it is evident that a method for actively seeking patients and testing for early symptoms of disease is imperative if mortality and morbidity for such diseases are to be significantly diminished and functional levels maintained for a longer time. In Oklahoma, the promise of improved health care for rural Americans is gradually becoming a reality as the result of a mobile health clinic. The unit was initiated in 1971 by the Oklahoma State Department of Health to test the effectiveness of a mobile unit program (Lewis, 1977). This mobile health screening system was operating in McCurtain County, Oklahoma. Since there is no intra- county bus or train service in McCurtain County, the mobile clinic enables residents to receive health services unavailable to them at a local level. This mobile clinic provides a wide-range of services such as; 21 1. chest x-rays 2. diabetes screening 3. blood pressure measurements, etc. 4. cancer screening The mobile clinic conducts a follow-up to ensure that its patients are receiving the proper treatment, and to provide a continuum of care. The McCurtain County Healtlji Department views the favorable responses to this project as proof that such a project can deliver health directly to a target population as well as make health care more acces sible and comprehensive (Lewis, 1977). McCurtain County health officials base their preliminary conclusions upon a number of people who were able to utilize the mobile unit, those persons who otherwise would have found health ser vices unavailable or difficult to obtain due to distances and a lack of adequate transportation. 22 CHAPTER III METHODOLOGY Experimental Setting and Subjects for the Study The population of this study consisted of a state wide sample of residents 60 years of age and older who participated in two health screening programs sponsored by the State of Arkansas during September 1973 and May 1977. The first group of participants was screened under the Medical Examinations to Reduce Chronic Illness program (MERCI), July 1973 through June 1975, and the second group under the Medical Examinations for Disease Detection (MEDD) from July 1975 to June 1977. The two sampled groups of older adult residents were of different sample sizes and the data obtained did not indicate the frequency with which the individuals availed themselves of either screening programs after initial registering. The total number of subjects available for the study was 10,875 persons 60 years of age and older. Approximately 4,891 were taken from the first year of the MERCI project and 5,984 from the MEDD project (3,321 for the first year and 2,663 for the second year). A statistical breakdown by race and sex (the only two 23 population characteristics made available to this investi gation) was utilized for the MEDD project. No population data was available for the MERCI project. Instrumentation and Procedure Data from the two health screening programs, MERCI and MEDD, were obtained from registration records compiled by projects* staff. The registration data were divided into two population characteristics: sex (male and female) and race (black and white) for the MEDD project but not for MERCI. Supplemental population data were obtained through numerous written exchanges and several telephone conversations with the project directors of the two screening programs. Sample data for the two health screening pro:^rams were collected and organized prior to this investigation. Since the experimental subjects of this study were not available for direct contact, a decision was made by this investigator to utilize the existing data set as arranged by the project staff. Specific Research Questions Asked 1. From the point of view of project staff; which health screening service delivery method was preferred terms of operational efficiency and overall ease of project administration? in 24 2. In terms of service delivery: Which health screening program served the sampled older population more effectively, MERCI or MEDD? 3. From the point of view of the sampled older population: Which health service delivery method was more attentive to their health services and personal needs, particularly in terms of service accessibility and avail ability? 4. Which health screening program was more comprehensive in terms of the number and type of health screening examinations provided? Data Gathering All experimental data for the study were provided by the directors of the MERCI and MEDD projects. Health screening project data were arranged prior to this investigation. No formal research instrument was employed. The analysis of the data was based upon the first year of operation (September 1973 to August 1974) for the MERCI project and the first two years of operation (July 1975 to May 1977) for the MEDD project. The data for the second year of operation (September 1974 to August 1975) for the MERCI project were permanently destroyed as a result of a fire. Therefore, comparisons between projects were limited by data availability. 25 Sample data for this study were tabulated on a daily basis by project staff and summarized monthly^ Data from the MERCI project contain no specific population characteristics. However, both projects did identify several major problem areas experienced in the referral process. Simple percentages were used to analyze the data for research questions 1 through 4, This study was predicated on the following assumptions : 1. More elderly patients can be screened per month by a mobile health screening plan which delivers health services directly to the populationr than other screening services which are not mobile. 2. Flexible mobile health screening^ programs designed to deliver services according to the needs of a specific client population, will attract greater numbers of that population than comparable centralized programs. 3. Mobile health screening programs which consider the special nature and personal needs of the older adult population may reduce client anxiety and promote favorable acceptance of health screening services. 4. Comprehensive mobile health screeniug programs can employ and deliver comparable testing procedures found in centralized health screening programs. 26 5. In terms of direct service delivery to a given target population, mobile health screening programs may cost less per client than centralized health screening programs. Limitations of the Study The following limitations were part of this study: 1. Each group of experimental subjects in the study was exposed to a given health screening method for a limited period of time. 2. Data for the second year of the project operation for the MERCI program was destroyed and hence unavailable for analysis. 3. Generalizability from the data are limited to the two sampled groups of older adult clients in this study. 27 CHAPTER IV DATA ANALYSIS AND RESEARCH FINDINGS The purpose of this study was to explore and compare the effectiveness of a mobile health screening concept with a stationary health screening clinic in the delivery of preventive health screening services to an older adult client group in Arkansas. This study also explores the practicality of mobile health screening as a concept. The mobile health screen concept, MERCI, was examined against the MEDD program. The general character istics of each program have been described in Chapter I. The differences between the two health screening programs were based upon their approaches to delivery of health care services. The MERCI project was characterized by direct health screening service delivery to the general area or to the individual homesites of the elderly. The MERCI project featured direct health screening services to individuals which increased its availability and access ibility to the target population. The MEDD program utilized stationary county health screening units that involved busing the older population to the screening clinic. Travel time and stress resulting 28 from the travel were characteristic of MEDD. The pro vision of health screening services under the MEDD program was dependent upon the existing county transpor tation system which brought the elderly clients to and from the MEDD screening clinic. The following analysis of the research questions and the experimental results incorporates data gathered from the two health screening projects and includes a summary of several conferences with both project directors. 1. From the point of view of project staff, which health screening service delivery method (MERCI or MEDD) was preferred in terms of operational efficiency and overall ease of project administration? As a result of discussions conducted with the project directors of both projects, sufficient information was not generated through the interview and correspondence process to provide enough substantive data to answer this question comprehensively. When questioned, each project director argued that their approach was more efficient and easier to administer than the competing project. Other members of each staff were not available for comment. However, an examination of the nature and scope of each project produced a number of conclusions by inference. 29 The overall purpose of both projects was to pro vide free multiphasic screening for elderly persons living in Arkansas, particularly rural areas. As stated pre viously, each project employed a different health screen ing method, that is, mobile versus stationary. Yet it is the method, or how services are delivered, that provided the most accurate indicator of operational efficiency. The MERCI project was able to deliver health- related services directly to the target population or in close proximity to their homes, whereas, recipients of the MEDD program were bused to a particular MEDD clinic. Further, by utilizing the mobile clinic, the MERCI project was able to deliver its health-related operations with greater ease and to more persons than the MEDD method. The MEDD project frequently moved its operation from clinic to clinic, and was forced to employ additional teams of project personnel at various times of peak usage. Therefore, this researcher's evaluation would suggest that the MERCI project was preferable in terms of opera tional efficiency and overall ease of project administra tion. 2. In terms of service delivery, which health screening program serves the sampled older population more effictively, MERCI or MEDD? According to data gathered on a number of persons screened (per year) by each project, the MERCI program 30 was able to reach more elderly persons than the MEDD program. During the first project year of the MERCI program (September 1973 to September 1974) 5,298 persons were screened as compared to 3,321 persons (July 1975 to July 1976) and 2,663 (July 1976 to May 1977) for the first two years of the MEDD project. 3. From the point of view of the sampled older adult population, which health service delivery method was more attentive to their health service and personal needs, particularly in terms of service accessibility and avail ability? Since this researcher was unable to survey the project participants directly (geographic limitations), both project directors were questioned on the health service delivery issue. When questioned, both project directors stated their respective projects adequately met the health service and personal needs of the participants involved. Unfortunately, neither project had conducted an evaluation of its own program, nor had they developed any criteria to do so. However, an examination of demonstrated project accessibility and service delivery provided a more accurate and impartial answer to this question. The statistics employed in research question 2 illustrated that the MERCI project with its mobile unit was able to screen more older persons, bringing health 31 screening services to the older client and in close proximity to their homes. Therefore, the MERCI project demonstrated that it was more accessible to the client group than the MEDD method. However, it can be stated that neither project demonstrated a "better approach" in terms of making health-related services available to the older population on a 24-hour basis. Thus, the older population in Arkansas had been, and continues to be, dependent upon hospital emergency room service, providing that local hospital and transportation systems exist for the rural elderly residents. 4. Which health screening program was more com prehensive in terms of the number and type of health screening examinations provided? Since the older clients of the MERCI project were unable to make use of localized health services because of distances, the MERCI project had to accomplish a more comprehensive examination for its clients. Further, since health services were not generally accessible to the rural elderly in Arkansas, this increased the neod for the MERCI program to deliver a comprehensive and efficient health screening examination. 32 CHAPTER V CONCLUSIONS AND IMPLICATIONS OF THE STUDY This investigation examined two health care pro grams designed to provide preventive health screening to older Americans in Arkansas. The first was the Multi- phasic Examinations to Reduce Chronic Illness (MERCI) project, developed as an alternative approach in pre ventive health services to the elderly. The MERCI project utilized the concept that a mobile health unit could deliver preventive health services to older persons in rural areas of the state, who were at least 20 miles from the nearest physician. The other was the Medical Examinations for Disease Detection (MEDD) project. MEDD, unlike the MERCI concept, utilized stationary county health units and bused the older population to each site during the preventive health screening process. The sample population for the study consisted of persons 60 years of age and older, from predominately rural areas of Arkansas who participated in either the MERCI or MEDD project. Due to travel restrictions, this investigator was unable to conduct a detailed breakdown 33 of the demographic characteristics of the sample popula tion in Arkansas of interview clients. Data for the two health screening programs were limited. The MERCI program (which was discontinued in July 1975) produced only one year of substantive data (1973 to 1974). Statistics for the second year were destroyed in a fire. Subsequent statistical information from the MEDD program was compiled by MEDD staff. Based upon the analysis of the data obtained from both health screening programs (MERCI and MEDD), the following conclusions are suggested. 1. The Multiphasic Examinations to Reduce Chronic Illness (MERCI) project was able to screen more persons per month than the Medical Examination for Disease Detec tion (MEDD), since it provided preventive services directly to rural-based elderly persons in Arkansas. 2. The MERCI project was able to attract more participants than any stationary health unit concept employed by MEDD because of its unique ability to locate health screening sites where the client group resided. As a result, the MERCI program was considered to be more effective by this investigator. 3. By adopting its delivery of health services to the special nature of the population, the MERCI project was able to reduce the potential anxiety of the elderly client population. In contrast, the MEDD project 34 subjected the older clients to prolonged and often stress ful bus rides to gain access to county health screening units. 4. The MERCI mobile screening unit provided as many medical testing procedures as did the MEDD program, and was, in many instances, able to provide an individual with an equally as comprehensive examination as the MEDD program. 5. Minimal differences can be associated with the per patient cost between the two health screening programs. The MEDD project director estimated the per patient cost at $14 to $16, while the MERCI estimate was $17 to $19 per patient. 35 CHAPTER VI A PROPOSED HEALTH CARE DELIVERY PROGRAM Based upon the results of the study, it can be stated that certain deficiencies and service gaps exist with regard to available health care delivery in rural areas. Following is a proposal which attempts to estab lish a new, specific type of mobile health screening program. The aim of this proposal is to alleviate exist ing deficiencies and close major gaps in effective service delivery to older Americans. This proposed mobile health screening project details the following: specific medical examinations, project personnel, general criteria for program evaluation, and a method of program assessment. This proposal will also attempt to demonstrate how and why a mobile health screening program can be utilized as an alternate mechanism in the delivery of preventive health screening services to the elderly. The proposed mobile health screening project should provide a comprehensive physical ex^ination, including a complete medical and social or family history for each elderly person, CBC urinalysis, Snell eye examination, 36 cancer screening (including breast examination and pap smear), EKG and an audiometric examination. There are two basic reasons these specific examin ations are included. First, the medical history of an individual often provides relevant information about the individual's past medical history, chronic conditions, and current drug use, and establishes some familiarity with the patient. Second, these examinations will provide a comprehensive screening of the older person as well as allow for certain flexibility among the specific tests. The GBC/blood urinalysis should be used because they result in a thorough examination of the blood and urine, and these tests can provide considerable important information. For example, if there is a low red cell count in the blood, this is an indication of possible anemia. A high white cell count suggests the possibility of diabetes or an infection. Diabetes is an increasingly understated problem among the aged. A glucose tolerance test is suggested for those persons who have high white cell counts. Moreover, Levin (1976) noted that the number of elderly diabetics continues to increase at a significant rate, in part due to the apparent or real increase of glucose tolerance. Visual screening should be administered to assess the individual's sight problems in a short time period. However, it must be remembered that some older people may 37 be illiterate and therefore require a less sophisticated type of visual acuity test. Individuals are asked when they last saw an opthomalegist, since many sight-related problems increase with medical neglect. The conditions causing the deterioration of vision in the aged are of different varieties. There may be functional changes such as modification of the patient's refractive status. Increasing need for glasses with advancing years has become one of the most universally accepted manifestations of aging (Smith, 1976). As illustrated in the review, cancer is one of the most undetected diseases among older persons, and is the second greatest cause of death in the United States. Each year it is expected to kill approximately 350,000 Americans, and about one-half will be between 50 and 70 years of age (Wright, ‘ Mersheimer, Miller, & Rotman, 1976). Death rates from cancer have continued to rise since 1900, especially deaths caused by lung cancer. Cancer accounted for about one-fourth of all deaths for those aged 65-74 years, a little less than a fifth of the deaths for the 75-84-year-old group, and about 10 percent for the very old. The following four cancer screening examinations are proposed; X-ray for lung cancer among men and women, prostatic screening for men, and breast and papanicolau (pap smear) for women. The prostrate screening is used 38 for two reasons; because prostrate Cancer is the second most common form of malignant neoplasm among American males, and because it is especially prevalent in men over age 50 (Wright et al,, 1976), breast examination is undertaken because breast cancer is a frequent cause of illness and death among females in the United States, particularly women over age 35, and because some breast cancer detection can be self-administered. A pap smear should be used to test for cervical cancer, particularly since the rate of reported incidence is higher in women between the ages of 45 snd 69 (Wright et al,, 1976). 39 BIBLIOGRAPHY 40 BIBLIOGRAPHY Block, D. A mobile audiometric testing unit. Journal of Occupational Medicine, April 1968, 3^(4), 185-188. Brotman, H. Series facts and figures on older Americans. In Income and Poverty in 1970. Washington, D.C.: U.S. Department of Health, Education and Welfare, June 1971. Brotman, H. The fastest growing minority; The aging. American Journal of Public Health, March 1974, 64(3), 249-252. Butler, R. Why survive? Being old in America. New York; Harper & Row, 1975. Corey, L., Sahman, S., & Epstein, M. Medicine in a changing society. New York; C.V. Mosby Company (2nd IdTT 1972. " Denny, P. Cellular biology of aging. In J. E. Birren and D. Woodruff (Eds.), Aging; Scientific perspectives and social issues. New York ; D. Van Nostrand Co., 1975. Domenic, P. Rural health care and hospitals. Speech delivered before the New Mexico Hospital Association, Albuquerque, New Mexico, October 1978. Flemming, A. The 1971 White House conference on aging; The end of a beginning? Speech delivered and prepared by the National Retired Teachers Association/American Association of Retired Persons, 1971. Classer, M. Statement before the U.S. Senate Special Committee on Aging, Subcommittee on Health of the Elderly. Washington, D.C.; U.S. Government Printing Office, 1973. Goldfarb, A. The evaluation of the geriatric patient following treatment. In Evaluating of psychiatric treatment. Proceedings of the Fifty-second Annual Meeting of the American Psycho-Pathological Association, New York, February 1962. New York; Grune & Stratton, 1964. 41 Hammerman, J. Health services: Their success and failure in reaching older adults. American Journal of Public Health, March 1974 , 6_4 (3) , 253-256. Held, B. Florida: A University-based mobile medical team. Family Planning Perspectives, June 1970, 2^(3), 32-34. Illich, I. Medical nemesis. New York: Pantheon Books, 1976. Jackson, H. C. Barriers to health care for older Americans Report to Subcommittee on Rural Development of the Committee on Agriculture, Nutrition, and Forestry. Washington, D.C.: Congressional Research Service, 1979. Kastenbaum, R. Re reluctant therapist. In Robert Kasten- baum (Ed.), New thoughts on old age. New York: Springy Publishing Co., 1976. Kerschner, P., & Hirschfield, I. Public policy and aging; analytic approaches. Ih J. E. Birren and D. Woodruff (Eds.), Aging; Scientific perspectives and social issues. New York ; D. Van Nostrand Co., 1975, Lawton, R. CNIB mobile medical eye care units in Canada. Canadian Journal of Qpthalmology, June 1975, 1^, 334- 335. Levin, M. Diabetes mellitus. In Franz U. Steinberg (Ed.), Cowdry's the care of the geriatric patient (5th Ed.). New York; C. V. Mosby Co., 1976. Lewis, J. Health care re rural black elderly; Mobile health screening units--An alternate approach in delivering health services to the rural elderly. Paper given at Fifth Annual Conference on National Center on the Black Aged, May 26, 1977. Lewis , J. Long term care ; What we need to do. Speech given before the Kentucky Long Term Care Meeting, Frankfort, Kentucky, August 2, 1983. Librach, G., Davidson, C., & Peretz, A. A community home care program. Journal of the American Geriatrics Society, October 1972, 20(10), 500-504. 42 Lynch, H., Harlan, W. , Swartz, M. , Marley, J.., Becker, W. , Lynch, J., Kraft, C., and Krush, A. Multiphasic mobile cancer screening: A positive approach to early cancer detection and control. Cancer, September 1972, 30(3), 774. Manney, J. Aging in an American society. Ann Arbor, Michigan: The Institute of Gerontology, The University of Michigan-Wayne State University, 1975. Markson, E., Levitz, G., and Gognalons-Gaillard, M. The elderly and the community: Reidentifying unmet needs. Journal of Gerontology, July 1973, 38(4), 503-509. National Council on the Aging. Fact book on aging. Washington, D.C.: Author, 1978. Nelson, G. Social services to the urban and rural aged: The experience of area agencies on aging. The Geron tologist, February 1980, 20^{2) , 200-207. Nixon, R. Toward a brighter future for the elderly. The Report of.the President's task force oh the aging. Washington, D.C.: U.Si'Government Printing Office, April 1970. Packwood, B. Long-term care: Costs, financing and alter native services public and private sector policy options. National Journal, June 6, 1981, 2^, 1039-1043. Pollard, A. The ecnomics of multiphasic screening. The Medical Journal of Australia, October 28, 1972, 10(4), 1025-1028. Rich, S. Nation's medical bill rises to $322 bil— 10.5 percent of GNP. Washington Post, Saturday July 16, 1983, Section A, page 3. Schmidt, H. Health of and health services for rural people. Prepared at the request of the Congressional Rural Caucus, September 7, 1976, pp. 15-16. Shanas, E. Health care and health services for the aged. The GerontologiSt, December 1965, 5^(4), 240. Smith, M. Ophthalmic aspects. In Franz U. Steinberg (Ed.) Cowdry's the care of the geriatric patient. New York; C. V. Mosby Company, 1976. 43 Solomon, N. Keeping the elderly in the community and out of institutions. Geriatrics, September 1973, 46-51. Taeuber, C. America in transition : An aging society . In Developments in aging; 1982 (Vol. 1). Washington, D.C.; U.S. Government Printing Office, 1982. Thorner, R. Health program evaluation in relation to health programming. Technical Reports, June 1971, 86 (6) 525-532. U.S. Congressional Research Service. Rural development ; An overview. Washington, D.C.; Author, 1979. U.S. Department of Commerce. Bureau of the Census. Decehnial Censuses of Population 1900-1980 and Projec- tions of the Population of the United States; 1982 to 2050 (Advance ReportU Washington, D.C.; U.S. Dept.of Commerce, 1982. U.S. Department of Health, Education and Welfare. Public Health Service, Office of the Assistant Secretary of Health. Health; United States, Publication 78-1232. Washington, D.C.; U.S. Government Printing Office, 1978. L

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Creator Lewis, Jeffrey R. (author)

Core Title Mobile health care: An alternative approach in the delivery of preventive health care to the rural elderly in Arkansas

Degree Master of Science

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Health and Environmental Sciences,OAI-PMH Harvest,Social Sciences

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Permanent Link (DOI) https://doi.org/10.25549/usctheses-c37-409908

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