Med-Surg · chapter 9 · Management of Chronic Illness
Access and Barriers to Health Care
The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 3 practice questions with the reasoning.
Key points
Access barriers
Many barriers may limit health care access for individuals with disabilities. These barriers can be financial, geographic, or social, in addition to other external environmental factors.
Social and financial factors
Social and financial factors that may influence an individual’s ability to access health care include employment status, transportation, and geographic location.
Chronic illness complexity
Coupled with a chronic illness or disability, these factors become even more complex, making it more difficult to access necessary health care services and manage their illness.
Employment and insurance
First, individuals with chronic illness and disabilities may have limited employment options, forcing them to take lower paying jobs without adequate health insurance coverage.
ADA accommodation noncompliance
Though employers are required to provide reasonable accommodations because of the ADA, they do not always comply with the law, and government regulators may lack the resources to catch and remedy noncompliance.
Transportation delays
Findings from a 2020 national survey show that 5.8 million Americans annually delay health care because they do not have transportation (Wolfe et al., 2020). This survey also determined that individuals living in poverty and those with chronic health conditions are disproportionately affected.
Public transportation barriers
The ADA requires reasonable accommodations, including public transportation, but the provided accommodations are not always adequate to allow all people with disabilities to use them. This inadequacy of resources is related to multiple factors, including a lack of funding and the wide diversity of disabilities experienced in society.
Geographic distance
Just as with a lack of transportation, living too far away from health care facilities can decrease an individual’s ability to obtain necessary services. An additional challenge in rural areas is the lack of the appropriate health care specialists.
Telehealth limitations
Unfortunately, they are not always appropriate or practical, because not all individuals have access to high-speed Wi-Fi or other necessary technology for telehealth. Furthermore, not every medical service or procedure can be administered remotely.
ADL assistance needs
Although some people with disabilities and chronic conditions can live independently or with family members, others may reside in skilled nursing facilities or other assisted living institutions, where they require extra help in performing ADLs and getting to and from appointments.
Reliance on caregivers
This makes health care access more difficult because these individuals may have to rely on others to take them to their appointments or to interpret or implement their treatment plan.
Facility staffing constraints
Most assisted living facilities have programs in place to help with these needs, but many facilities are short-staffed, and caregivers are not always able to effectively assist patients with their health care needs (Heiks Sabine, 2022).
Home nursing care
Although some people with disabilities are unable to work, those with severe, debilitating disabilities may not even be able to leave their homes. In these situations, home nursing care may be required, but certain criteria must be met first.
Discharge level-of-care evaluation
It is important to note that patients with chronic illness and disability who are admitted to an inpatient setting for care will require an evaluation before discharge to determine the appropriate level of care after leaving the hospital.
Terms to know
- social determinants of health
- These barriers are closely related to the social determinants of health, which are defined as the conditions in which people are born, work, grow, live, and age (CDC, 2022b).
- telehealth
- Partly to address this problem, there has been a shift in recent years to use more telehealth, which refers to the provision of health care remotely via telecommunication devices and technology.
- Outcome and Assessment Information Set (OASIS) tool
- The Outcome and Assessment Information Set (OASIS) tool was created in 1999 and has been proven to be a reliable and valid instrument to determine reimbursement.
Practice questions
Stuck on select-all-that-apply? How to take them one option at a time.
The graded version needs JavaScript. Every question is below anyway, with the answer and why.
Every question here, with the answer
At 0900, a nurse reviews follow-up access with a patient who lives far from a specialist. The patient's insurance covers telehealth, but the patient reports having neither high-speed Wi-Fi nor the technology needed for a remote visit. Which note best describes the current access problem?
- Telehealth coverage confirmed; remote follow-up can replace travel to the specialist.
- Telehealth may reduce the travel barrier, but access to the necessary technology remains unresolved.
- Distance limits specialist access; transportation assistance is the only remaining access need.
- Telehealth is not an option for this patient; future follow-up must occur in person.
Answer: Telehealth may reduce the travel barrier, but access to the necessary technology remains unresolved.
Insurance coverage does not make telehealth practical when the patient lacks the necessary connection and technology. The first option assumes access is established, the third overlooks the technology barrier, and the fourth treats a current limitation as a permanent restriction.
At 1100, a nurse interviews a patient for a possible home care referral. The patient reports that leaving home requires major effort and that a walker is needed because of substantial illness. The patient also reports having a part-time job without health insurance benefits, limited bus routes, and no nearby specialist. Which findings should the nurse document specifically as support for the Medicare home care criteria described in the section? Select all that apply.
- The patient lives far from an appropriate specialist.
- The patient's part-time job does not provide health insurance benefits.
- Available bus routes do not serve all needed destinations.
- Leaving home requires major effort.
- The patient needs a walker to leave home because of substantial illness.
Answer: Leaving home requires major effort., The patient needs a walker to leave home because of substantial illness.
The listed Medicare criteria include major effort to leave home and difficulty leaving without assistance because of substantial illness or injury. Employment-related insurance gaps, limited bus routes, and geographic distance are access barriers, but the section does not list them as Medicare home care eligibility criteria.
At 1500, a nurse updates the discharge plan for an older adult admitted after a fall. The patient previously lived alone, but the interdisciplinary evaluation has identified a need for a higher level of care. Resources have not yet been arranged. Which entry best reflects the next step described in the section?
- Return to the previous living arrangement planned because the patient lived independently before admission.
- Transfer to rehabilitation required because the patient experienced a fall while living alone.
- Higher level of care identified; the interdisciplinary team will coordinate resources to support a safe discharge.
- Discharge home planned; the appropriate level of care will be determined during the initial home care visit.
Answer: Higher level of care identified; the interdisciplinary team will coordinate resources to support a safe discharge.
After the required level of care is determined, the interdisciplinary team works to obtain the necessary resources for a safe discharge. Previous independent living does not override the current evaluation, and determining care needs should not be deferred until after discharge. A fall alone does not establish that rehabilitation is the required destination.
Where every quote comes from
Section 9.4 Access and Barriers to Health Care of Medical-Surgical Nursing by Christy Bowen, Bridget Carey, Jessica Palozie, Maren Reinholdt, OpenStax, 2024. Read the whole section free at openstax.org.
The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.