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Table 1 Typology of organizational innovation components to improve access to primary healthcare for vulnerable populationsa

From: Typology of organizational innovation components: building blocks to improve access to primary healthcare for vulnerable populations

Component

Description

Examples

Secondary accessibility dimension

Principal accessibility dimension: Approachability

Organizational mechanism to make it easier for people facing healthcare needs to identify the available services and how they can be reached

1. Proactive identification of need

A mechanism is put in place to proactively identify vulnerable patients’ need for primary healthcare and provide additional support to avoid the negative consequences of unmet needs.

Identifying unmet primary healthcare needs in the emergency department: Patients over the age of 65 with two or more emergency department visits in the previous year not currently in contact with primary care or community services are assigned an advanced practice nurse. The nurse carries out an assessment and physical examination. Case management and referrals are provided as needed [110].

Regular perinatal home-visits for young mothers: Women under the age of 19 or under 24 and experiencing social/financial issues and pregnant with their first child enroll in a free public health program. A nurse visits them at home regularly during their pregnancy and up to two years after the child is born. Through proactive follow-ups, the nurse regularly assesses women’s needs, helps access needed services and supports healthy pregnancy, preparation for childbirth, nutrition, exercise, parenting, child development and future life planning [126].

Canvassing a disadvantaged community for adults living with physical disabilities: To identify adults living with physical disabilities with unmet long-term care needs at risk of entering nursing homes, community health workers go door-to-door, hand out program literature at community events and accept informal referrals from family, friends and church leaders. Identified patients are then assessed and connected to appropriate community-based resources [60].

Appropriateness

2. Navigation & information

A service that provides patients with information and support on where, when and how to access primary healthcare.

Health leads to support low-income patients: Trained volunteer undergraduate students are available at help desks in medical homes to assist families with social needs connect with community-based resources (e.g., food, housing) and provide support through in-person meetings and telephone follow-ups [42].

Web-based information system for homeless youth and young adults: Healthshack has online portals including youth-approved community resources and personal records (health, education, housing and employment, a scanned copy of important documents, contact information). Health information includes medical diagnoses, health conditions, prescriptions for medication, laboratory results and referrals to specialists. Public health nurses are available at a youth shelter to help with orientation on the portal, to enter medical history, to provide health counselling and education, to evaluate acute and chronic conditions and to refer youth to appropriate services [58].

Appropriateness

3. Primary healthcare service brokerage

A service that helps connect vulnerable patients to a primary care provider or primary healthcare service, including single entry points to access with priority queuing by vulnerability indicators.

Enrollment with a primary care provider for uninsured patients visiting the emergency department: Health promotion advocates assist uninsured patients visiting the emergency department without a primary care provider to find one. If patients agree, their information is faxed to a caseworker in the chosen primary care site, who then contacts patients to schedule an appointment [43].

A single-entry model for frail older people with complex needs: A range of services to maintain the autonomy of older people are available through a single entry point that can be accessed through a telephone line or written referral. Patients are then connected to all needed services (e.g., home care, rehabilitation, community action, case management) [96].

Centralized waiting list and transitional clinic for patients with chronic disease: A registered nurse assesses patients who are registered on a centralized waiting list waiting to be connected to a regular primary care provider. Patients with chronic diseases (e.g., diabetes) are prioritized on the waiting list and referred to a transition clinic that provides primary care until patients find a regular provider [125].

 

4. Outreach of primary healthcare services

Extension of primary healthcare services beyond the physical limits of primary care settings to reach vulnerable populations.

Mobile health bus for patients experiencing homelessness: The Alex Health Bus (community health bus, dental health bus and youth health bus) provides direct services, advocacy and education in various locations to reach vulnerable patients living in poverty and experiencing homelessness. Services include full checkups, mental health assessments, follow-up care, health promotion, pregnancy testing, sexually transmitted infection testing and treatment, birth control, lab equipment for cholesterol, glucose and urine tests, and referrals to specialists and community resources [134].

Screening at parish food banks in low-income neighbourhoods: Parish nurses and a pharmacy school collaborate to offer preventive services (e.g., screening for blood pressure, bone density, cholesterol, glucose, body mass index) out of a mobile health van during regular monthly visits to food banks in parish churches [79].

Availability and accommodation

5. Inter-sectoral/organizational care pathways

Primary healthcare organizations collaborate with other organizations (within or outside the health system) to establish procedures that facilitate timely access to needed services for vulnerable groups.

Early response team for mental health crisis: Policy, Ambulance and Clinical Early Response (PACER) is a joint crisis response unit composed of a police officer and a mental health provider. PACER can be called by ambulances or community police when a person is experiencing a mental health crisis. The unit then provides clinical assessment and advice on appropriate transportation options, de-escalation tactics, intervention strategies and referral options for additional services [123, 124].

Multisectoral space for indigenous women: The Casa de la Mujer Indigena – established through collaboration between non-governmental organizations, local indigenous community members and public institutions – delivers health education and basic healthcare to indigenous women. Indigenous community health workers deliver the services. The space serves as a link to mainstream health services and provides a facilitated referral mechanism for reproductive healthcare. The space also allows community health workers to meet with traditional birthing attendants, medical professionals, non-profit organizations working in reproductive rights and domestic violence to develop services provided to the women of the community [119].

Availability and accommodation

6. Proactive appointment-making and proactive contact

Appointment-making processes in primary healthcare that pull-in vulnerable patients to care and maintain ongoing contact.

Integrated mental health service: A multidisciplinary health team providing integrated mental health services in a primary care setting, use personalized telephone reminders for appointments and schedule the next appointment immediately after consultation to reduce barriers to attendance. In the event of a missed appointment, staff proactively follow-up by contacting the patient, their family members or other professionals [127].

Harm reduction and human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) primary care: HIV/AIDS primary care services are integrated into a harm reduction program already offering services to the target population (syringe exchange, housing, job readiness, support groups). Harm reduction outreach teams help participants immediately access primary care, assist them with making appointments, accompany participants to the clinic, help fill out paperwork at the clinic and provide opportunities for reengagement in primary care after a missed appointment [61].

Availability and accommodation

Principal accessibility dimension: Acceptability

Adaptation of services to enhance the social and cultural factors that determine the possibility for people to accept the aspects of a service.

7. Culturally adapted services

Adapting primary healthcare to the needs of a specific vulnerable group by addressing linguistic or cultural barriers.

Insurance support for uninsured Latinos: The Latino Health Insurance Program recruits community leaders that reflect the countries of origin of the residents to be case managers. The program provides all communications in English and Spanish and reaches out to the Latino community by deploying case managers to public housing, bodegas, beauty salons, churches, laundromats, etc. Case managers hold educational sessions to help fill out insurance forms in trusted community locations where they provide child care and ethnically-appropriate food. They follow-up with families in a local church office to help maintain insurance coverage and facilitate access to other needed services (e.g., legal services, food stamps) [55].

Indigenous health center: The Inala Indigenous Health Service consulted with members of the Inala community to identify barriers and facilitators to accessing care. Indigenous staff, including an aboriginal doctor, nurse and health worker, follow ongoing cultural awareness training. Culturally-adapted health posters and Aboriginal and Torres Strait Islander artifacts are displayed in the waiting room, and an aboriginal radio station is played. The service collaborates with community Elders to build ties to the community. It holds various community-based health activities at the Elders’ building (e.g., rugby league, chronic disease self-management, child playgroups). A range of services are provided in a one-stop-shop approach (e.g., mental health, alcohol and other drug services, child health services, retinal photography) [105].

Pharmacy translation software for non-English speakers: A software created by a social enterprise is used by pharmacists to accurately translate and print bilingual pharmacy labels and medicine summary sheets for ethnic minority patients that have a limited proficiency in English [129].

 

8. Community health worker

A layperson–a trusted member of a community or with a close understanding of it–acts as a frontline worker who helps bridge cultural and linguistic barriers for members of the community and facilitates their access to primary healthcare.

Health promotion by lay community members for disadvantaged families: GO-Healthy aims to promote health, medical examinations and immunization among children from disadvantaged families. Lay women living in the target district who are already involved in community associations – particularly those from migrant or low socioeconomic backgrounds – are trained in health education to lead activities for mothers. Also, personnel from barbershops, nail studios and food stores are recruited and trained to inform and encourage mothers to get a medical examination for their children [120].

Healthcare navigation by community health workers for Hispanic community members: La Vida trains Hispanic community members to act as Promotores to help hard-to-reach Hispanics who have or are at risk for diabetes access social and health services. Promotores enroll participants in educational and physical activities, support lifestyle changes, help participants enroll with appropriate insurance programs and provide family support [80].

 

9. Group visits

Primary healthcare provided to a group with similar vulnerabilities or conditions rather than on an individual basis.

Group medical visits for low-income minorities: In community health centers serving low-income minorities, women ages 40–64 with at least one chronic disease who had six or more clinic visits in the previous year are invited to participate in six 90-min visits over nine months. Visits are facilitated by nurse practitioners and physicians and are intended to replace visits to patients’ primary care providers. Each visit consists of a check-in (review action plan, physical examination, discussion), group learning on a specific topic (e.g., exercise, healthy eating), a brief one-on-one encounter to discuss individual treatment plans (discussed in the group), a question period and optional private examinations [81].

Appropriateness

Principal accessibility dimension: Availability & Accommodation

The organizational mechanisms that make services available and reduce the space, time and process barriers for the services to be reached and used in a timely manner by a wide range of persons.

10. Expanded hours

A primary healthcare organization expands its opening hours beyond 9-to-5 business hours to accommodate the needs of vulnerable populations.

Mobile clinics offering primary care in the evening: Services are offered in the evening or on weekends to accommodate the schedules of marginalized populations such as migrant populations, asylum seekers and the homeless [59, 133].

Expanded hours and 24/7 telephone triage for uninsured patients: A managed care plan (enrollment with a primary care provider, case management, co-location of social and mental health services, reduced medication costs, etc.) is offered to uninsured patients below the poverty line, including a large proportion of working poor. Primary care services have expanded hours to cover evenings and provide a 24-h telephone triage service, so patients do not have to miss work to access care [44].

 

11. Advanced access

A scheduling system that provides urgent care by a known primary healthcare team, triggers planned appointments where needed and allows patients to schedule an appointment at the appropriate time.

Advanced access for patients with depression: Primary care settings offer advanced access (also known as open or same-day access) to mental health services for patients suffering from depression. This system is intended to allow patients to access care when they need it and feel ready to engage [83, 113].

Appropriateness

12. Virtual health services

Use of videoconferencing, phone, email, text message, apps, etc. for consultations or for monitoring health conditions.

Telehomecare to support self-monitoring in elderly patients: Elderly patients suffering from severe chronic conditions (e.g., chronic obstructive pulmonary disorder, cardiac insufficiency) with frequent emergency visits or hospitalizations are provided with monitoring equipment at home (e.g., scale, thermometer, sphygmomanometer, oximeter, pulse). Patients are responsible for taking and sending required measures daily to a nurse in a primary care organization, who responds to alerts and follows-up with patients over the phone or during a home visit [94].

Telehealth expertise to support rural primary care providers caring for complex patients: Primary care providers in rural communities or remote settings use ECHO–a telehealth technology–to co-manage their patients with Hepatitis C and discuss best practices and treatment options with a “knowledge network” of interdisciplinary specialists (e.g., psychiatry, infectious disease, gastroenterology, addiction medicine) [57, 122].

Interprofessional videoconference for patients with complex needs: The Telemedicine IMPACT Plus program offers patients with multiple chronic diseases and their family physician a one-time videoconference with an interprofessional team (e.g., psychiatrist. Dietician, pharmacist, geriatrician, internist, social worker). The team helps coordinate care planning and identify new solutions for addressing the patient’s needs. A dedicated nurse coordinates the videoconference consultation and provides support to implement recommendations resulting from the consultation [131].

 

13. Drop-in services

Services are offered to patients who drop-in, without an appointment.

Drop-in services for youth: At the Backdoor Clinic located in a youth center, counsellors and a family doctor provide young people with general health and medical services–sexual health, nutrition, mental health–on a drop-in basis [135].

 

14. Transportation services

Arranging transportation for patients facing barriers getting to primary healthcare settings.

Community-based screening program for immigrants: A screening program to detect unmet health needs among African refugees is held twice a week by a nurse in an apartment complex, where refugees can drop in without an appointment to be evaluated. A translator is available on-site, and a van can transport refugees to a local clinic as needed [82].

 

15. Role expansion or task shifting

Upskilling of a healthcare worker who has ongoing contact with vulnerable patients to enhance workforce capabilities. May be expansion of the scope of practice for formal providers or training of laypersons.

Community paramedics for high-risk patients: Paramedics provide primary care services (e.g., oral and intravenous medication administration, wound care, routine urinary and blood samples, vital sign monitoring) to patients with chronic health concerns who have difficulty getting to their primary care provider or who have low social support [121].

Nurse-led clinic in disadvantaged neighbourhood: A cooperative clinic is led by a nurse practitioner specialized in primary healthcare. Through collaboration with nurses, volunteers, psychosocial counsellors and a social worker, the clinic provides comprehensive primary healthcare services to patients living with Hepatitis C or HIV/AIDS and to patients who live in the low-income neighbourhood near the clinic and face multiple barriers accessing the health system [132].

Interpreter-navigators for refugees: At an international health clinic that offers primary healthcare to refugees, in-person translators are favoured over a translation phone line. In-person translators have been trained and developed an expertise in how to navigate the system: in addition to translating, they can explain to patients where to go, who to talk to, what to do before tests, financial eligibility requirements, paperwork, etc. [128].

Acceptability

Affordability

16. One-stop shop

Multiple health and social services are provided in one location to deliver comprehensive care to meet hard-to-reach vulnerable patients’ complex needs at the point of contact.

In-reach from specialized services to primary healthcare for complex patients: A visiting geriatrician offers expertise to support a primary health team (family physician, nurses, pharmacist, dietitian and social worker) and, as needed, provides direct care to patients for seniors at risk of cognitive impairment or falling [95].

One-stop-shop for lesbian, gay, bisexual and transgender (LGBT) and HIV/AIDS patients: A primary care clinic caters to the needs of LGBT and HIV-positive communities by offering a wide range of safe and inclusive general practice and sexual health services, including HIV prophylaxis treatment, HIV/AIDs management, contraception, sexually transmitted infection screening, hormone therapy, osteopathy (e.g., injuries due to binding), psychology and speech pathology (e.g., for voice feminization) and referrals to LGBT-friendly specialists [130].

Community center for people at risk of or experiencing homelessness: The Living Room’s team–community development workers, family doctors, nurses, podiatrist, psychologist, nutritionist, mental health counsellors, etc.–provides a range of free services, including health care, food and material aid, phone and internet, mail services, housing support and referrals, legal support, contraception, locker storage, support groups, mental health, alcohol and other drug counselling, podiatry, optometry, hairdressing, yoga, life skills training and art therapy [136].

Acceptability

Appropriateness

Principal accessibility dimension: Affordability

Organizational processes and structures that adapt to the economic capacity of people to spend resources and time to use appropriate services.

17. Defraying costs to patients

Partially or entirely covering direct or indirect costs of accessing primary healthcare.

Free and low-cost primary healthcare for patients below the poverty level: Patients 200% below the poverty level are enrolled in a program that allows them to access free visits, laboratories, x-rays and low-cost medications through a network of volunteer primary care providers and specialists [56].

 

Principal accessibility dimension: Appropriateness

Appropriateness denotes the fit between services and clients’ needs, its timeliness, the amount of care spent in assessing health problems and determining the correct treatment, and the technical and interpersonal quality of the services provided.

18. Case management

A healthcare provider (e.g., nurse, social worker) is assigned to individual patients to assess needs, help create care plans, facilitate access to comprehensive services (including but not limited to primary healthcare), coordinate ongoing care, monitor patients and advocate on their behalf.

Community case management program for vulnerable chronically ill patients: Chronically ill patients experiencing confusion with medication or treatment plans, frequent emergency department visits or hospitalizations, poor coping skills, in need of education on their condition, inadequate social support, insufficient financial resources or frequently missed appointments are referred to the program. The program is free-of-charge to patients. An advanced practice registered nurse or social worker is assigned to each patient to assess needs, develop care plans, support communication with providers, assist with medication management, coordinate care, help with transportation, focus on development of coping strategies, promote self-advocacy, connect patients with better social support (e.g., health providers, family members, community resources) and conduct regular home visits and telephone follow-ups. Patients are discharged when identified goals are met, and physiological status is stable but are encouraged to contact the case manager if new needs develop [78].

Post-incarceration case management: Within two weeks of their release from prison, patients are approached by a community health worker who has completed a 6-month training to enroll in a primary care-based case management program. The community health worker provides referrals to housing, education, employment support, medical and social service navigation; accompanies patients to pharmacies, social services, and medical or behavioural appointments; and supports patients self-manage through home visits, health education and medication adherence support [54].

 
  1. aGrouped by principal dimension of organizational accessibility