Use of Enabling Services by Asian American, Native Hawaiian, and Other Pacific Islander Patients at 4 Community Health Centers

Objectives. We sought to examine the utilization and impact of enabling services, such as interpretation and eligibility assistance, among underserved Asian American, Native Hawaiian, and other Pacific Islander (AANHOPI) patients served at 4 community health centers.Methods. For this project, we developed a uniform model for collecting data on enabling services and implemented it across 4 health centers that served primarily AANHOPI patients. We also examined differences in patient characteristics between users and nonusers of enabling services.Results. Health center patients used many enabling services, with eligibility assistance being the most used service. In addition, compared with nonusers, users of enabling services were more likely to be older, female, AANHOPI, and uninsured (P < .05).Conclusions. For underserved AANHOPI patients at community health centers, enabling services are critical for access to appropriate care. We were the first to examine uniform data on enabling services across multiple health centers serving underserved AANHOPI patients. More data on enabling services and evaluation are needed to develop interventions to improve the quality of care for underserved AANHOPI patients.Community health centers (CHCs) are safety nets for some of the country''s most vulnerable patients, but many of these patients are unable to access or use this needed medical care without enabling services.¹ Major barriers to care include an inability to pay, culture and language, and insurance status.^2,3 Enabling services have been identified by the National Association of Community Health Centers as key facilitators to health care delivery and are defined as nonclinical services that are specifically linked to a medical encounter or provision of medical services that aim to increase access to health care and improve health outcomes.⁴ Enabling services at CHCs include language interpretation, health education, and financial or insurance eligibility assistance. Enabling services have long been considered to be critical components of health care delivery for CHC patients, who are disproportionately low-income, uninsured, and of minority backgrounds. However, despite the perceived importance and potential of enabling services for improving health care for vulnerable populations, little is known about the utilization of enabling services at CHCs or the impact of these services on health care access and outcomes among medically underserved populations. In particular, no studies have examined enabling services and their impact on medically underserved Asian American, Native Hawaiian, and other Pacific Islander (AANHOPI) patients at CHCs.Few studies have examined the effect of enabling services at CHCs on health care access and outcomes among people of color.^5–9 The results of these few studies suggest that enabling services can make a significant contribution to improved access and quality of care. For example, case management has been shown to be effective at improving specific disease conditions.^10,11 Interpretation services have been shown to increase both timeliness of care¹² and patient satisfaction and decrease the number of emergency room visits, thereby reducing costs.⁵Medically underserved AANHOPI patients at CHCs, in particular, rely more on enabling services such as interpretation and eligibility assistance for access to medical care. A lack of enabling services leads underserved AANHOPI patients and other people of color to underutilize medical services at CHCs, and causes such patients to be underrepresented in the health care system.^13–15 For example, communication difficulties stemming from language or cultural issues are common reasons for AANHOPI persons to avoid health services^16,17 and to feel less confident that they can get needed care as compared with non-Hispanic Whites.¹⁶ Enabling services at CHCs can help underserved AANHOPI patients obtain culturally and linguistically appropriate and effective health care.Culturally proficient health care reduces health disparities between racial/ethnic groups.¹⁸ Culturally and linguistically appropriate enabling services can help to overcome barriers within the health care system by improving patient–provider interactions, increasing patient knowledge and understanding of treatments, and improving patient safety.¹⁹ Interpretation services can help patients navigate the health care system more easily and can improve patient–provider communication, resulting in increased medical visits and improved health outcomes. Eligibility assistance and enrollment in health insurance programs can alleviate patient financial concerns associated with care.Federally qualified health centers are required to provide annual reports to the US Bureau of Primary Health Care as part of the Uniform Data System and to submit information on some of the enabling services provided by their health centers. However, the current Uniform Data System does not adequately capture the full scope of enabling services provided and needed by federally qualified health centers to demonstrate the critical impact of these services, nor does it document the need to adequately finance health centers to ensure full primary care access and utilization among medically underserved patients. As of 2007, the Uniform Data System report included only the number of full-time equivalent staff and encounters for case managers and education specialists and full-time equivalents only for outreach workers, transportation staff, and a category for “other enabling services.”²⁰Enabling services are often jeopardized during times of political and financial pressures, because the services are usually nonbillable or nonreimbursable.²¹ Although some CHC staffs and federal officials have indicated that enabling services improve health care access and outcomes among medically underserved patients, such services have not been adequately supported or funded.²²Our study aimed to rectify the lack of research in this area by collecting important new data on the needs for enabling services at CHCs and the impact of enabling services on the medical care and outcomes of medically underserved AANHOPI patients.