Indicators of access to healthcare and preventative services give part of the picture of the overall health of Alaskans and shine a light on important health inequities. According to the 2019 Healthy Alaskans State Health Assessment, compared to the US, Alaska adults have less access to health care and preventative services than other areas of the country. Among all Alaskans, 12.6% are without health insurance coverage, compared to 8.8% in the US Thirty percent of Alaska adults do not have one person they consider their personal health care provider, and 14% report being unable to seek health care services in the past 12 months due to cost. The HA2020 plan contained 3 leading health indicators (LHIs) focused on healthcare access (LHIs 21, 22, 23), relating to prenatal care, preventable hospitalizations, and ability to afford to visit a doctor.

The HA2030 team decided to keep the HA2020 LHI on prenatal care in the first trimester since little progress was made on that indicator and it did not reach the target by 2020. This objective is considered a significant prevention measure where the access to early prenatal care can prevent life-long health complications and outcomes. The team noted the many Alaskan organizations actively working to improve the issues this objective addresses and decided to keep the objective so the work will remain in the strategic plans and actions of organizations engaged in this area.

The HA2030 team decided to keep the HA2020 LHI on preventable hospitalizations since the 2020 target was not met. It was noted that the measure for this objective has improved and the strategies under this objective can prevent avoidable hospitalizations from acute and chronic conditions. The measure can also show if care is being provided in a timely and efficient manner and therefore can illustrate how well our health care system is performing.

The HA2030 team also decided to keep the HA2020 objective focused on healthcare affordability for the HA2030 plan. Although there was significant progress on that HA2020 LHI and it met its 2020 target, the HA2030 teams were concerned that future policy work in this area would benefit from having this objective future and wanted to continue to monitor data to protect the significant efforts being made to improve healthcare affordability.

The HA2030 teams also decided to add 2 additional objectives for healthcare access: one concerning well-child checkups and the other focused on health insurance coverage. The HA2030 teams are focusing more on early childhood health to prevent the healthcare issues that present later in life, so a well-child checkup objective can act as a measure of the social determinants of health and prevention. The objective on reducing the percentage of people without health insurance also gives an overall picture on healthcare access issues in Alaska, allowing for progress in Medicaid and insurance reforms to be tracked and measured.

The Agency for Healthcare Research and Quality describes components of health care access as follows: Access to health care means having “the timely use of personal health services to achieve the best health outcomes” (source: Millman M, ed. Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to health care in America. Washington, DC: National Academy Press; 1993).

Health care access is measured in several ways, including:

• Structural measures of the presence or absence of specific resources that facilitate health care, such as having health insurance or a usual source of care.
• Assessments by patients of how easily they are able to gain access to health care.
• Utilization measures of the ultimate outcome of good access to care (i.e., the successful receipt of needed services).

Sources:

• http://www.ahrq.gov/research/findings/nhqrdr/nhqr08/Chap3.html
• http://ibis.dhss.alaska.gov/indicator/complete_profile/PNC.html

The Agency for Healthcare Research and Quality describes components of health care access as follows: Access to health care means having “the timely use of personal health services to achieve the best health outcomes” (source: Millman M, ed. Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to health care in America. Washington, DC: National Academy Press; 1993). Health care access is measured in several ways, including:

• Structural measures of the presence or absence of specific resources that facilitate health care, such as having health insurance or a usual source of care.
• Assessments by patients of how easily they are able to gain access to health care.
• Utilization measures of the ultimate outcome of good access to care (i.e., the successful receipt of needed services).

Sources:

• http://www.ahrq.gov/research/findings/nhqrdr/nhqr08/Chap3.html

The Agency for Healthcare Research and Quality describes components of health care access as follows: Access to health care means having “the timely use of personal health services to achieve the best health outcomes” (source: Millman M, ed. Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to health care in America. Washington, DC: National Academy Press; 1993). Health care access is measured in several ways, including:

• Structural measures of the presence or absence of specific resources that facilitate health care, such as having health insurance or a usual source of care.
• Assessments by patients of how easily they are able to gain access to health care.
• Utilization measures of the ultimate outcome of good access to care (i.e., the successful receipt of needed services).

Sources:

• http://www.ahrq.gov/research/findings/nhqrdr/nhqr08/Chap3.html

Healthcare costs in Alaska are high, much like other elements of the “cost of living” in the last Frontier. There are many factors that contribute to the high cost of healthcare in Alaska and to the high cost of health insurance. There is no one solution to the complex problem of high healthcare and health insurance costs but there are some underlying issues that can be addressed one by one in order to make progress.

Sources:

• http://www.akhealthcaretransformation.com/goals/
• https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services

Access to health services means “the timely use of personal health services to achieve the best health outcomes.”

• It requires 3 distinct steps:
  1. Gaining entry into the health care system (usually through insurance coverage)
  2. Accessing a location where needed health care services are provided (geographic availability)
  3. Finding a health care provider whom the patient trusts and can communicate with (personal relationship)
• Access to health care impacts one’s overall physical, social, and mental health status and quality of life. Barriers to health services include:
  1. High cost of care
  2. Inadequate or no insurance coverage
  3. Lack of availability of services
  4. Lack of culturally competent care
• These barriers to accessing health services lead to unmet health needs, delays in receiving appropriate care, inability to get preventive services, financial burdens and preventable hospitalizations

Sources:

• https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services

Chronic disease management (CDM) programs are proactive, organized sets of interventions focused on the needs of a defined population of patients. Program design varies, but CDM programs are usually multi-component efforts that include planned visits to teach patients about their disease, coach them on healthy behavior change including medication adherence, and skills for self-management of chronic conditions in partnership with a coordinated, multidisciplinary care team. Interventions may be based on the Chronic Care Model, which identifies links to community resources, health system support, health care system redesign, self-management and provider decision support, and the use of clinical information systems as essential elements for health care systems to support high quality chronic disease care. CDM programs can support patients with illnesses such as diabetes, hypertension, heart failure, and depression, and can be delivered in various health care settings (CCM). Reducing hospitalization rates is a key to controlling health-care costs. Populations with the highest rates of potentially preventable hospitalizations have the largest potential for lower rates and inpatient costs. Communities with high rates of potentially preventable hospitalizations might see the benefit of investing in primary care, care coordination, and community health worker strategies that can lower inpatient costs.

Sources:

• https://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a23.htm
• https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/strategies/chronic-disease-management-programs

In a case management model, health professionals, often nurses, manage multiple aspects of patients’ care, including status assessment, monitoring, advocacy, care planning, and linkage to services, as well as transmission of information to and between care providers. Case managers often care for vulnerable individuals who live independently. Patients from vulnerable populations often have complex health needs that require care from multiple providers, and are at increased risk of adverse outcomes from conditions that could be prevented with early detection and treatment (Eklund 2009*).

Sources:

• There is strong evidence that case-managed care reduces use of nursing homes (Cochrane-Reilly 2015, Berthelsen 2015*, Samus 2014, Eloniemi-Sulkava 2009*, Allen 2000*, Bernabei 1998*) and hospital utilization (Armold 2017*, Bronstein 2015*, Meret-Hanke 2011*, Marek 2010*, Bernabei 1998*, Schifalacqua 2000*), and improves functioning among community-dwelling frail elders more than usual care (Marek 2010*, Trivedi 2012, Tappen 2001*, Marshall 1999*, Bernabei 1998*).
• Case-managed care can extend the time before frail elders move to nursing homes (Berthelsen 2015*) and reduce length of stay (You 2013*).Such care can also reducehospital admissions (Armold 2017*, Bernabei 1998*, Schifalacqua 2000*, Duke 2005*, Hammer 2001*, Landi 2001*, Landi 1999), readmissions (Bronstein 2015*), and length of stay for frail elders using case-managed care (Marek 2010*, Bernabei 1998*, Schifalacqua 2000*, Duke 2005*, Hammer 2001*, Landi 2001*, Landi 1999).
• Case management can improve patients’ health outcomes (Trivedi 2012, Samus 2014) and reduce mortality (Coburn 2012). Such care may reduce falls, preserve mobility and the ability to maintain a household (Scharlach 2015) and complete activities of daily living (ADL) (Hammer 2001*), and improve quality of life (Lim 2003*, Hammer 2001*). Case management may also increase patient satisfaction (Trivedi 2012, Samus 2014, Hallberg 2004, Lim 2003*), caregiver satisfaction (Cochrane-Reilly 2015, Eklund 2009*, Callahan 2006Sandberg 2015), and caregivers’ confidence (Berthelsen 2015*, Sandberg 2015). In some circumstances, case management can improve quality of care and reduce the use of emergency services (Marek 2010*) and emergency room visits (Armold 2017*).
• Case management can also improve cognition, reduce depression (Marek 2005*) and dementia symptoms in patients with Alzheimer disease (Callahan 2006), and reduce behavioral disturbances for patients with dementia (Cochrane-Reilly 2015).
• Some case management interventions appear to reduce total costs of care; however, outcomes vary by program, case manager, and duration of program (Cochrane-Reilly 2015, Trivedi 2012), (Joo 2014a). Municipalities (Berthelsen 2015*), Medicare (De Jonge 2014), and informal caregivers may benefit from cost reductions (Sandberg 2015).

This has been a proved strategy by Bright Futures, who has been providing education for nearly 25 years.

• “The Bright Futures Guidelines provide theory-based and evidence-driven guidance for all preventive care screenings and well-child visits. Bright Futures content can be incorporated into many public health programs such as home visiting, childcare, school-based health clinics, and many others. Materials developed especially for families are also available. ” (link below)

The “Learn the Signs. Act Early” campaign strives to improve parents and health care provider’s knowledge on early child development by research, training videos, free materials, apps, and more. (link below)

RAND research program studied nine early intervention education programs and found that:

• “programs demonstrated significant and often sizable benefits in at least one of the following domains: cognition and academic achievement, behavioral and emotional competencies, educational progression and attainment, child maltreatment, health, delinquency and crime, social welfare program use, and labor market success.” (link below)

Sources:

• https://brightfutures.aap.org/Pages/default.aspx
• https://www.cdc.gov/ncbddd/actearly/about-research.html
• https://www.rand.org/pubs/research_briefs/RB9145.html

The CDC has proven this to be an effective strategy in identifying behavior concerns.

• “Research shows that early intervention treatment services can greatly improve a child’s development. Early intervention services help children from birth through 3 years of age (36 months) learn important skills. For children age 3 and older with an identified developmental delay or disability, special education services may be needed.” (link below)

Medicine Net efforts are to educate parents on what to expect and check for during early development and more.

• “Early detection and treatment can be critical for a child’s prognosis; all children should undergo developmental screening at every well-child checkup. Studies have shown that children who receive early intervention and treatment for developmental disorders are more likely to graduate from high school, to hold jobs as adults, and are less likely to commit criminal acts than those who do not receive early intervention.” (link below)

The American Family Physician supports this strategy.

• “Many barriers exist to implementing initial screening and referral, but screening tools can be easily incorporated into the workflow of the primary care practice with preparation.” (link below)

The American Academy of Pediatrics provides documents that supports this strategy. (link below)

Sources:

• https://www.cdc.gov/ncbddd/childdevelopment/screening.html
• https://www.medicinenet.com/developmental_screening_-_critical_for_every_child/views.htm
• https://www.aafp.org/afp/2017/0701/p36.html
• https://pediatrics.aappublications.org/content/pediatrics/128/1/14.full.pdfhttps://pediatrics.aappublications.org/content/pediatrics/118/1/405.full.pdf

The American Academy of Pediatrics has proven studies that continuous coverage makes a difference.

• “Children with insurance gaps experience notable problems: they fail to get medical care, go without prescriptions filled or do without preventive visits. Continuous insurance coverage, whether public or private, eliminated or substantially reduced access problems.” (link below).

The County Health Ranking and Roadmaps are supporting health insurance enrollment.

• “Health insurance enrollment outreach and support programs assist individuals whose employers do not offer affordable coverage, who are self-employed, or unemployed with health insurance needs. These strategies have been tested more than once and results trend positive overall.”

The Center for American Progress has proved this to be an effective strategy.

• “First, research has shown that, in addition to receiving essential health services, children in low-income families with access to Medicaid experience long-term benefits, including better health status, greater academic achievement, and increased future earnings.” (link below)

Sources:

• https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/strategies/health-insurance-enrollment-outreach-support
• https://www.aap.org/en-us/professional-resources/Research/Pages/The-Importance-of-Continuous-Health-Insurance-for-Children%27s-Access-To-Care.aspx
• https://www.americanprogress.org/issues/healthcare/reports/2019/06/12/470996/childrens-health-care-access-improve-universal-coverage-plans/

Access to health services means “the timely use of personal health services to achieve the best health outcomes.”¹ It requires 3 distinct steps:

1. Gaining entry into the health care system (usually through insurance coverage)
2. Accessing a location where needed health care services are provided (geographic availability)
3. Finding a health care provider whom the patient trusts and can communicate with (personal relationship)²

Access to health care impacts one’s overall physical, social, and mental health status and quality of life. Barriers to health services include:

• High cost of care
• Inadequate or no insurance coverage
• Lack of availability of services
• Lack of culturally competent care

These barriers to accessing health services lead to unmet health needs, delays in receiving appropriate care, inability to get preventive services, financial burdens and preventable hospitalizations

Sources:

• https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services

Health insurance enrollment outreach and support programs assist individuals whose employers do not offer affordable coverage, who are self-employed, or unemployed with health insurance needs. Such programs can be offered by a variety of organizations, including government agencies, schools, community-based or non-profit organizations, health care organizations, and religious congregations. Outreach activities vary greatly, and can include community health worker (CHW) efforts, other person-to-person outreach, mass media and social media campaigns, school-based efforts, case management, or efforts in health care settings. Outreach can occur at local events, via hotlines, or at fixed locations (e.g., community centers, non-profit offices, etc.) and are often supported through grants from federal agencies or private foundations.

Sources:

• https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/health-insurance-enrollment-outreach-support