Determinants of Access to Specialty Care for Community Health Clinic Patients

Monday, 9 November 2015: 2:25 PM

Mabel Ezeonwu, PhD, RN
School of Nursing and Health Studies, University of Washington Bothell, Bothell, WA, USA

Purpose:To explore the factors that determine access to off-site specialty care services for community health clinic/center (CHC) patients.

Background: Community health centers and clinics (CHC) constitute a critical part of the United States health care system. In Washington State for example, 10.1% of its population were served by CHCs in 2008 (Adashi, Geiger & Fine, 2010).  CHCs provide primary care to anyone that walks through their doors.  Individuals served by the clinics on average have poor health status (Schauffler & Wolin, 1996) and higher prevalence of chronic disease conditions than the general population (Ferrer, 2007).  The patients often need follow-up care with specialists for continued and consistent recovery or health maintenance. CHCs however are limited in their abilities to provide diagnostic and specialty services, and other important aspects of care that go beyond primary care (Gusmano, Fairbrother & Park, 2002; Weissman et al, 2003). Studies suggest that CHC patients have difficulty accessing specialty and diagnostic services that are not provided directly by the CHCs (Cook, et al, 2007; Cook, Ayanian, Orav & Hicks, 2009; & Adashi, Geiger & Fine, 2010). This study aims to explore the factors that restrict or facilitate access to specialty care for CHC patients.

Majority of CHC patients are from vulnerable populations. Seven out of ten community health center patients live in poverty, and well over half are minorities (Adashi et al., 2010). Specialty care referral and follow-up for these patients are not well studied and documented. Cook et al. (2007) evaluated access to specialty care by CHC patients from the point of view of medical directors. No study has examined the perspectives of frontline personnel that take on the day-to-day responsibilities of coordinating specialty care referrals and therefore understands the nuts and bolts of the process. This study fills this gap by examining the views of community health clinic Nurse Managers, Directors, and Referral Coordinators on factors that determine access to specialty care for CHC patients.

Method: For this qualitative descriptive study, face-to-face and phone interviews were conducted with personnel who oversee and conduct specialty care coordination and referrals at community health clinics/centers in Washington State. Thirty five community health clinics were represented in the study. Qualitative content analysis was used to analyze the data.


  • The key patient factors that determine access to specialty care include: Type of insurance coverage, language, access to transportation services, socio-economic status and education/literacy level. Among these factors, insurance is by far the most impactful. The study shows that there is significant gap or disparity in access between private insurance carriers and those on Medicaid/Medicare, and those with no insurance. CHC personnel spend the greatest part of their work time searching for specialists that could accept the patients’ insurance and those willing to provide charity care for the uninsured.
  • Several clinic or systems factors that delay the process include: Shortage of CHC personnel who actively participate in care coordination and referral, high patient volumes, location, and shortage of specialists. The shortage of personnel, particularly specialists, has a direct negative effect on health outcomes due to unnecessary delays in specialty care access.
  • Centralized electronic health records, clinic-hospital affiliations, centralized pool of available specialists, and availability of interpreters are major clinic/systems’ level factors that enhance specialty care coordination, referral and access.
  • There is a high demand for all specialty services in Washington State. The most frequently requested specialty is orthopedics followed by cardiology, neurology, rheumatology, ophthalmology, and gastroenterology and pain management.

Conclusion/Policy Implications

Continuity of care is essential for improved patient outcomes. Both primary care and specialist care providers have important roles to play in ensuring the best possible outcomes for underserved populations globally. As more people obtain health insurance coverage through the Affordable Care Act (ACA) in the United States, CHCs will see increased number of patients. It is however still uncertain whether increased access to primary care translates into easier, faster and increased access to specialty care. Although the ACA addresses issues related to insurance coverage, other policy approaches should support clinic-hospital affiliations, improving workforce shortages, and promoting an expanded use of the electronic health records in all CHCs. An integrative model of care is essential in all policy agenda to ensure timely and unrestricted access to specialty care.