Putting Patients Center Stage

Examining health care from the patient’s perspective to ensure vulnerable populations don’t fall through the cracks.

In their crusade to cut sharply rising healthcare costs, politicians and policy makers frequently lose sight of the patient’s perspective. But researcher Karin Rhodes, MD, MS is on a mission to keep that perspective front and center.

An Assistant Professor and Director of the Division of Emergency Care Policy Research in the Department of Emergency Medicine, with secondary appointments in Psychiatry and the School of Social Policy & Practice at the University of Pennsylvania, Rhodes is a Senior Fellow in both the Leonard Davis Institute of Health Economics and Centers for Public Health Initiatives and Behavioral Health at Penn. As a principal investigator on a number of federal and foundation-funded projects, Rhodes says, much of her research involves trying to measure what patients need compared to what they’re getting. “I try to make sure that patients don’t fall between the cracks, particularly vulnerable patient populations, such as the underinsured,” she says.

Rhodes has conducted several important studies examining access to care. Recently, she and SP2 Ph.D. candidate, Joanna Bisgaier, audited access to specialty care for children with public insurance in Illinois. Their co-authored article, published in the New England Journal of Medicine, was selected by Academy Health, a leading health services research organization, as one of five Noteworthy Articles for 2012. The study found that 66 percent of publicly insured children were unable to get a doctor’s appointment for medical conditions requiring outpatient specialty care including diabetes and seizures, while children with identical symptoms and private insurance were turned away only 11 percent of the time.

Impediments to accessing care are not limited to children or the underinsured. In a similar study with adults, Rhodes found that even having private insurance did not guarantee timely access to follow up care after an Emergency Department visit, even for potentially life-threatening conditions. Only two thirds of the privately-insured were able to get a timely follow- up appointment. “The results of this study indicate serious capacity constraints in access to primary care for all Americans,” says Rhodes.

To shed some light on the effectiveness of recent policy efforts addressing these issues, Rhodes is proposing to investigate access to primary care before and after implementation of the major coverage provisions of the Affordable Care Act (ACA). The study, which will be completed in three phases, proposes to examine variations across 10 states in the proportion of physician offices accepting new patients as well as average wait times for appointments for non-elderly adults overall and by type of insurance. Using a “simulated patient” methodology that tracks the experiences of trained interviewers who pose as new patients, the study will provide insights about the real-world experiences patients have as they seek a new patient appointment for primary care.

Rhodes’ interest in promoting patient-centered approaches to care for vulnerable populations has also focused on patients with behavioral health risks such as those who smoke, drink too much or experience violence in their relationships. Through a grant from the National Institute of Alcohol Abuse and Alcoholism (NIAAA) she is collaborating with SP2 Assistant Professor Andrea Doyle on an interdisciplinary five-year study evaluating the efficacy of motivational interventions in emergency room settings for women involved in abusive relationships who also have issues with alcohol.

“High rates of co-morbidity between intimate partner violence (IPV) and problem drinking have been extensively documented and research suggests that for individuals with both risk factors, one can not be adequately addressed without the other,” explains Rhodes.

As part of the study, Rhodes and her colleagues have developed a manual to address the co-occurrence of intimate partner violence and drinking. The manual describes techniques designed to encourage patients to reduce unhealthy alcohol consumption and address relationship conflict. It also provides an outline of the necessary skills to perform a brief motivational intervention with patients in a medical setting who have been identified as IPV-involved problem drinkers.

“Motivational interviewing with feedback accepts the person where they are and draws on their own strengths and abilities,” says Rhodes “This type of intervention can help with decisional balance and build self-efficacy.”

The researchers will enroll 600 women visiting emergency rooms at Hospital of the University of Pennsylvania and Presbyterian Hospital to participate in the randomized controlled study. Half of the women will receive the intervention from social workers trained in motivational interviewing techniques. Utilizing an interactive voice response program, the research team will then track future incidents of partner violence and days of heavy drinking among both groups.

While the emergency room provides a convenient setting for studying an intervention, Rhodes is gravely concerned that for too many people, acute episodic care is the only care they receive. “Our current system is highly fragmented,” she says. “We don’t provide coordinated care that includes prevention, or screening for mental health and behavioral issues such as depression, exercise, diet, etc. Good health involves a lot more than ‘health care.’”

She notes that advancing social work practice in health care settings can help address this fragmentation. “Currently, many healthcare facilities rely on social workers for utilization review, but they don’t have enough of a therapeutic role,” she says. “Empowering social workers by embedding them in the system with the skill set and mandate to conduct therapeutic interventions will help address the frequently neglected social determinants of health and potentially increase the value of a health care visit.”