What Influences Free Clinic Usage by the Uninsured

What Influences palliate Clinic Us climb on by the Uninsured? By Shelli Thomason A story Submitted to Dr. Dayna McDaniel question Methods PA6601 Term 5, 2012 Troy University July 27, 2012 TABLE OF CONTENTS CHAPTER 1 basis .. 4 Statement of the Problem. 5 2. 1 Purpose . 6 2. 2 Problem Statement.. .. 6 2. 3 Research Questions 6 2. 4 backdrop. 1. Literature Review.. 9 parasitic change able-bo hapd.. 9 1st drop out lance unsettled 11 2nd In capable varying star.. 13 3rd In open variable 14 quaternary In mutualist variable 16 4Hypothesis.. 18 4. 1 H1 propagateing hotshot.. 18 4. 2 H2 hypothesis two.. 18 4. 3 H3 hypothesis three18 4. H4 hypothesis iv. 18 Chapter II methodology intention.. 18 creation/ precedent. 20 Variables21 leechlike Variable 21 Independent Variables.. . 22 Data battle array.. 22 Measuring Instrument . 22 Materials. 23 Deliin truth Method.. 24Data outline. . 24 Chapter III Anticipated Findings.. 25 Chapter IV culmination. 25 Implications.. 26 R ecommendations26 References28 30 Appendices addendum A ceremonious Model. . .. 31 vermiform appendix B Formula for Calculating Population Sample Size. . .. 32 Appendix C Survey. 33 35 Appendix D Demographics.. 36 Appendix E shell of duple Regression results37 Chapter 1 Introduction M whatever unify States worrynts delay or do without obligatory wellnessc ar beca lend 1self they neglect the resources or k todayledge to access it. There ar 46 million severalize in the nation who rich aboutone no wellness fretfulness reputation progress, and by non giving necessary attention to aesculapian examination checkup examination examination checkup concerns and conditions, low wellness essays increase, on with un cartridge cliply death rate (Darnell, 2010).A Kaiser Commission usage from 2006 identifies on that point atomic number 18 18,000 deaths yearly in the joined States resulting from lack of wellness wish well reporting (Trask, 2011). Recent C ensus business component shows a slightly high issuing of uninsurable indicating there ar 50 million uninsurable, which would be the largest add up on record, resulting from the national economic recession (Krisberg, 2010). According to Darnell (2010), there ar 1007 indigent clinics in the nation, providing services during 3. 5 million clinic piffles, by 1. 8 million uninsurable patient of ofs, demoing approximately 10% of uninsurable adults of working(a) suppurate.The patients open no early(a) wellness carry off alternatives to a take a shit up clinic payable to a variety of factors including no ability to pay, language barriers, lack of or inadequate health check examination indemnity, unsettled personness, inaccessibility, and immigration or heathenishity issues. As private non-profit organizations, bounteous-clinics be not recipients of federal funding, so some rely on state funding, local funding, and put onations. Depaul (2010) notes that t he National Association of exhaust Clinics estimated 4 million patients were befooln in 2008, which doubled in 2009.It is similarly noted that chuck up the sponge clinics wipe out to pull away patients beca perform session they seatnot meet the demands. In a flannel paper for the Ameri tin College of Physicians, Gorman (2004) notes, those who do not receive annual exams and preventative screenings locomote the risk of a delayed diagnosis and subsequent pr all(prenominal)ing, resulting in premature mortality. Addition apiece(pre token(a))y, untreated chronic symptoms result in worsened conditions and appe bothy requisite headache, placing a financial burden on infirmarys, families and ultimately on the community. Further more, workers who experience low health feature light productivity which is pricely to the economy. so, drop by the wayside clinics ar a crucial component in the consortium of health heraldic bearing options in the united States. Isaacs and Jellinek (2007), state that 80 % of patients who receive uncomplicated charge at a physicians office be each uninsurable or dupe Medicaid. Although physicians whitethorn see uninsurable patients in their offices and prepargon on a few of them as charitable cases, this formula is declining effrontery lower redress and Medicaid reimbursements and increased military operational expenses. The nation has what is referred to as a galosh brighten system to provide health dispense services for re expressionnts who be uninsured.This system is lie ind of hospital jot rooms, realityly funded health centers, and guiltless clinics. With costs of health dole out escalating, it is crucial to identify methods to in effect optimize these providers. It has been suggested that accessibility to informal clinics, which whitethorn keep the uninsured from accessing the ER for non-emergent deal, is one such method. Studies show uninsured persons utilizing a idle clinic mode consec p ass judgment fewer emergency room clavers than those who do frequent the ER for their elemental cope, which renders cost savings (Trask, 2011). Statement of the Problem PurposeThe purpose in this research is to devil determinations as to what factors regularize an uninsured persons decisiveness to access the services of a set stop clinic. In an effort to dish out this question, factors testament be recognized, by dint of research, significant to a person qualification the decision to visit a uninvolved clinic for checkup c ar. Un finishing these factors could see in discouraging the mis engagement of an early(a)(prenominal) events of medical checkup guard duty net provisions. maven bailiwick shows if the conclave studied did not down intent of a withdraw clinic, 80% of the visits would have resulted in ER visits for non-emergency discussions (Corso & Fertig, 2011).This selective selective nurture could excessively assist in identifying strategies to r ough-and-readyly consider the health c be take of constituents and provide funding sources with knowledge to make educated decisions on the most effective pulmonary tuberculosis of funds. Problem Statement This labor allow for pinpoint the most acute variables influencing an uninsured person to hear preaching at a handsome health clinic, allowing local government leadership and medical providers to have access to research so they may nevertheless(prenominal) chthonicstand sphere of licks in which to place their focus and funding.Furthermore, an ancillary reason for engage is to show that by providing an uninsured person who is truly ill with a way to achieve wellness, they can establish viable again, thusly decorous a more productive worker, who may regain insurance and no longer need the set free service, or whatever some other type of medical c argon. If a person has a resource within which to address health concerns, that does not present them with barrier s, they are apt(predicate) to receive the necessary criminal maintenance needed, reducing further complications and costs, placing them in a position to live more sustainable.In one wellness sell Georgia ponder, evidence shows that free clinics can halt the escalation of health problems, reducing or eliminating the need for hospitalization (Corso & Fertig, 2011). Research questions This project bequeath focus on four research questions that entrust aide in identifying specific factors that work an uninsured person to expend a free clinic (dependent variable). The radical question to be asked is What factors do work an uninsured person to physical exertion a free clinic? Research questions inquiring intimately those submits ( self- manoeuvered variables) are 1) Does lack of alternative health give concern options influence an uninsured person to use a free clinic? 2) Does lodging military position influence an uninsured person to use a free clinic? 3) Does Latino e thnicity influence an uninsured person to use a free clinic? 4) Does age influence an uninsured person to use a free clinic? The individual variables panorama to influence the dependent variable are outlined so there is a clear chthonianstanding of their meaning. wishing of other alternatives Many users of free clinics may have no other options for health care than a free clinic. They may be employed, but cannot devote the health care premiums offered by their employer or the employer does not offer health coverage. 83 percentage of the patients seen at free clinics come from a working house save and may h honest-to-goodness two or three part judgment of conviction jobs (DePaul, 2010). Federally funded community health centers, different from free clinics, are typically located in agrestic or inner-city areas and help serve a large bite of patients in high- inevitably communities.In 2009, the Government Accountability Office manoeuverd that even with 8000 community health centers, there were still 43 percent of underserved areas without access (Whelan, 2010). Housing positioning The definition of homeless is a broader scope than merely the people nutrition on the streets and takes individuals in a widespread range of unstable housing scenarios. Homeless individuals do not save live under bridge or in a car, but may also reside in emergency shelters foster homes HUDs terminology of doubling up with relatives or friends or tenants who have been served an eviction notice.Unstable housing status is a high risk factor for health disparities, much like genetic science or eating habits. On average, a homeless person has octet to nine coexisting health problems (Batra et al. , 2009). A analyze of 6,308 homeless Philadelphians primed(p) the mortality rate among the homeless was 3. 5 times that of the citys overall world. Earlier research has also noted the homeless have escalated rates of a vast array of health problems (Lewis, Andersen and Gelberg , 2003). Age diametric clinics have differing eligibility for the patients they serve.Many states have the option to offer an insurance plan covering children through the passage of the Childrens health Insurance Program Reauthorization locomote (Llano, 2011), then those over age 65 have Medicare. Therefore many clinics tend to turn their efforts toward those uninsured patients surrounded by the ages of 18-64. A 2004 paper shows that overall general health significantly declines for those mingled with age 50 and 60 if they are uninsured, underinsured or sporadically insured, compared to their counterparts who have adequate health coverage (Inguanzo and Kaplan, 2011).Hispanic Ethnicity Llano (2011) states the greatest hindrance to health care for Hispanics is the language barrier. Providers of service have difficulty communicating with Spanish speaking patients if there is no instance available, which may cause compromised diagnoses, treatment options and specialisation refer rals. Census Bureau info emits that in 2010, 38. 7 percent of uninsured American residents were Hispanic (Inguanzo & Kaplan, 2011). Scope A come go out be completed, as part of this research. This projects scope testament investigate what influences an uninsured persons visit to a free clinic.It will assist the free clinic face in further developing strategic plans to make determinations on where their efforts should be focuse. It may also contribute to local governments and other potential grantors decisions on making allocations. Free clinic tradition is the primary focus, although the collective information may show related trends and concerns constructive to area healthcare providers and local governments. Each person watch overed will be treated equally. This depicted objects sample tribe will include patients of two free clinics residential district of Hope Health Clinic and Cahaba Valley Health wish well Clinic in Shelby County, aluminium.The clinic only sees uni nsured patients on Mondays from 830 am to 430 pm and Thursdays from 530 pm to 830 pm. They must(prenominal) show proof of residency in Shelby County. Literature Review Dependent variable Free clinic practice session by the uninsured As verbalize earlier, experts concur that there are over 1000 free clinics in the nation, providing services during 3. 5 million clinic visits, by approximately 10% of uninsured adults of working age (Darnell, 2010 Gertz, weenie and Blixen, 2010 George working capital University Report to carnal knowledge, 2012).This equates to approximately 90% of uninsured adults who are not utilizing a free clinic for their medical needs. Gertz, Frank and Blixen (2010) go further to say that since 1980, when there were 30 million uninsured people, there has been a 50% increase to 45 million. From a statewide perspective, Rhode Island upholds consistent with national aims, as uninsured working age adults under age 64 doubled between 2000 and 2005, citing the w aning of employer health care coverage (Gerber, et al. , 2008). The yearly cost associated with uncompensated medical treatment for the uninsured in the nation was $56 million in 2008.Determinations were make to suggest that use of emergency rooms for non-emergent care, along with rising hospitalization which could have been prevented are on the rise and creating costly problems. Communities are pursuance other solutions to provide health care to the uninsured, which might include free clinics, mobile clinics, and church and school sites to dispense treatment (Fertig, A. , Corso, P. & Balasubramaniam, D. , 2011). As stated earlier, free clinics are an consequential part of the United States health safety net, serving mainly the uninsured, working poor.Historically, given minimal resources and relying on inform health care providers, free clinics have foc utilise on bedcover filling, temporary solutions to the populations health problems. Implementing a new paradigm, free clinics are now making unsoundness prevention and health promotion a overtake priority (Scariarti & Williams, 2007). A nationwide cross-sectional study using a look into was conducted by Gertz, Frank and Blixen (2010) which they compared to the only other known publish study of its kind by Nadkarni, et. al from 2005 to determine free clinic characteristics.Both studies revealed a mean of between 4,000 and 6,000 uninsured visits to the free clinics annually, and a one-third study agrees that most (67%) are located in the Southern region of the United States (Gertz, Frank & Blixen, 2010 George Washington University Report to Congress, 2012). Additionally, 77% of the respondents of the Gertz, Frank and Blixen study (2010) indicated the level of care received at free clinics was superior to prior medical care received, and 24% indicated if there was no free clinic available, they would not seek care, mainly out-of-pocket to cost.A high number of free clinics seem to rifle as a fixed sou rce of medical care for their patients. The majority of free clinics describe the service they provide to their patients as continuing, 20 percent indicate the care as recurrent, and 5 percent depicted the care as irregular, only seeing a patient once (George Washington University Report to Congress, 2012).In contrast, prior to the young national economic recession, a study associated with the utilization of three Massachusetts free clinics was conducted to determine what factors influenced people to use the free clinics, when it appeared there were a variety of ample options for medical care irrespective of health care coverage or income level. Although the study expose the three free clinics saw patients who had insurance, 81% of the respondents were uninsured (Keis, DeGeus, Cashman & Savageau, 2004).Lack of health care coverage, is the sixth-leading cause of death, equating to 18,000 deaths annually for adults between the ages of 25 and 64 (Groman, 2004). The uninsured person may encounter severe financial and wellness obstacles, passing their ability to obtain medical care and many times become indebted and more ill, as a result. A study conducted by Becker (2001) found that not only did uninsured persons with chronic health conditions lack adequate health care their illnesses were also inadequately managed.Other findings were that with deficiencies of education run intoing their health, those persons who are uninsured lacked the information, perceptiveness, and resources that would allow them to manage their illnesses more effectively. Many uninsured patients can pay more than double the cost if they are forced to use a hospital for their care, due to the inability for price leveraging that medical insurance providers can afford (Groman, 2004). 1st independent variable Lack of other optionsThe National Association of Free Clinics indicates they see patients they never conception would come to a free clinic, with 83% of free clinic patients come fro m working home, but cannot afford COBRA if they have lost a job and are now working several part time jobs. Patients have account they would likely go the ER or not seek care if they did not have access to a free clinic (Depaul, 2010). Private practice stretchs are the primary source of health care for the uninsured, mainly because, historically, they have been plentiful in numbers, with 720,000 providing care according to Isaacs & Jellinek (2007).A second expert (Groman, R. 2004), agrees that free care by physicians is decreasing, which will greatly impact the medical safety net with growing numbers of uninsured. As stated earlier, the decline is by and large the result of higher operating costs and inadequate Medicare reimbursement rates, prohibiting the doctors from being able to treat those who cannot pay (Isaacs & Jellinek, 2007). Even though charity from practicing physicians plays a life-sustaining role in treating the uninsured, they are not stand-ins for health insurance . Because of revisions to financing and rganization of medical care systems, doctors indicate in a in the buff York academy of medicament study, they are unable to provide the same class of care to the uninsured, as they provide to patients who have health care coverage (Groman, R. , 2004). A recent report to Congress indicates that free clinics overall see millions of uninsured persons who may not achieve any level of care elsewhere. single study highlighted in the report revealed four main reason listed in install of percentage, people use a free clinic are no health insurance (82%), referrals by others (59%), medications (38%), and no knowledge of where else to go (34%).The report also states that three quarters of free clinic patients do not have a regular method of care except the free clinic or the ER, suggesting free clinics fill voids, offering services not available (or easily reached) someplace else (George Washington University Report to Congress, 2012). The Keis, et al. (2004) study is in accord with the report to Congress in that one-third of survey respondent gave their reason for using a free clinic as not knowing where else to go to receive medical attention.Another one-third cited lack of transportation, long wait times, finding child care or inability to leave work as the primary reasons they could not use other types of medical providers and instead sought treatment at a free clinic. As already learned, access to local safety net providers has limits to readiness in other ways as well. For exercise, in Jeffrey Trasks unpublished dissertation (2011), he cites and agrees with the Keis study stating that other than the emergency room, many safety net providers arent open in the evenings or are scarce, so due to the need to work, a patients only option may be a free clinic open in the evenings.Likewise, clients of free clinics forego after care or specialty care only a hospital can offer due to costs. Trask (2011) gives the example, when a n uninsured person using a free clinic needs superfluous services outside the free clinics scope of care, sometimes old or bad debt is a major obstacle to receiving necessary treatment. Finally, options are limited for people who are not legally residing in the country. A collective characteristic of a free clinic is capacity to treat any patient without documentation regarding immigration status (Keis 2004).In a 2010 national survey, a census, the showtime of its kind in 40 years, 764 clinics were deemed eligible out of 1188 surveys mailed. A finding from the study uncovered that free clinics are a more important aspect of the national safety net, especially in the area of ambulatory care that originally thought. However, only 188 of the clinics surveyed offered all-inclusive services, and the survey conclude that a free clinic is not a replacement for comprehensive primary care (Darnell, 2010). 2nd independent variable Hispanic ethnicity Hispanic persons comprise approximately 16 percent of the population in the U.S. but make up 25 percent of free clinic patients. Experts agree that unbalanced layer of Hispanic patients in free clinics indicates higher rates of lack of health care coverage among this group (George Washington University Report to Congress, 2012 Isaacs & Jellinek, 2007), with the latter authors citing an example from a Racine, Wisconsin clinic who had a one percent Hispanic patient grip in late 1980s and a 50 percent Hispanic patients in 2006. Results were compared from two student-run free clinic studies on clinic characteristics and concurred that most of the patients were minorities.One study of 59 clinics account that 31% of the patients seen were Hispanic, while the other study of 39 clinics revealed 53% of patients were Hispanic. The student run clinics demographic is quite different from non-student run clinic who report a client base of mainly non-Hispanic people (Gertz, Frank & Blixen, 2010). Studies indicate that Hispanic perso ns are more likely than non-Hispanics to fail to complete the Medicaid screening and miss important dates for submitting required documentation.Furthermore, 43 percent of Hispanics who speak Spanish had communication problems with physicians compared to 16 percent of Caucasians and non- side of meat speakers had more difficulty in comprehending doctor orders (Llano, 2011). Because of non-existent health insurance and consequently no immunizations, a considerable extravasation of rubella plagued a Hispanic community in New York in the late 90s. The outbreak spread to adjacent communities and those with insurance were just as affected. In communities with high numbers of uninsured residents, it becomes more ifficult to provide disease control, and medical personnel have fewer opportunities to identify early trespass of outbreaks, hampering containment efforts (Groman, 2004). In a report examining the unmet medical needs of the nations Latino population conducted by the American Co llege of Physicians and the American Society of upcountry Medicine, it was discovered that uninsured women had twice the likelihood as their non-Latino peers to be diagnosed with pap pubic louse in the later stages and uninsured Latino men were four times as likely to receive a prostate pubic louse diagnosis compared to non-Latino men.It is suggested that Hispanic and Latino immigrants are very unlikely to have the ability to access health care services due to governmental restrictions of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, and caution that their citizenship opportunities will be compromised by attempting to secure public aid aid (Inguanzo and Kaplan, 2011). 3rd independent variable Homelessness According to Wilson (2009), there are cultivation to 800,000 homeless people in the nation, many of which have multiple disorders to include asthma, nutritional deficiencies, skin infections, wounds, and diabetes, to name a few.Wilsons and OCon nells research goes on to say that the homeless persons ailments which are largely left untreated and worsen, lead to devastating illness. The mortality rate is excessively high in the homeless populace. OConnell (2005) agrees with Wilsons conclusions with regard to high mortality rates, and that homeless people are three to four times more likely to die than the general population. The risk is greatly increased in those homeless persons between the ages of 18 and 54, and that younger homeless women are four to 31 times more likely to die than their housed counterparts.Life expectancy in the general population is 78 years of age, and go to between 42 and 52 years of age for the homeless population (OConnell, 2005). Approximately 9 to 15% of the US population becomes homeless during their lifetime. Those who are truly without a place to stay and are considered literally homeless may be included in this figure, although the homeless are fugacious and in and out of shelters. Addition ally, this figure may include those who HUD calls doubled up or couch-homeless. Other developed countries have a lower rate of this ategory of homelessness than the United States (Hoback and Anderson, n. d. ). For the U. S. overall in 2000, the estimate is 1. 65% of the population is couch-homeless (Census Bureau, 2000). One study highlights the capital of South Carolina-Harlem Homeless Medical Partnership (CHHMP), a free clinic run by students, that targets Manhattans homeless, providing medical students with a service learning prospect and simultaneously, providing a medical home for homeless patients. Free student-run clinics are an intrinsical piece of the medical safety net.In these learning settings, the indispensabilitys of medical students and in-need patients transect with the outcome of feature medical care. The disordered lifestyle of the homeless patient requires outreach to this population and a need for consanguinity building. This type of need is not feasible in the medical school setting but can be met at a student-run free clinic. Students are able to deal with the human side of public health disparity and learn more about other services and make referrals that can assist the whole patient, such as housing, health screenings, mental health providers, etc. (Batra, et al. , 2009).In congruency with the independent variable of other options stated earlier, an interview study of 2578 homeless and sporadically housed persons indicated that housing instability, demoralise, multiple arrests, physical and mental conditions, as well as substance abuse were contributing forces to causing h eighterened usage of emergency rooms with a exertion study group revealing on average seven visits per year. Galwankar (2004) and Whitbeck (2009) two conducted studies which emphasized the need to decrease emergency room use among the homeless populations, by focusing on identified risk factors from a public health standpoint (Galwankar, 2004).A large percenta ge of the homeless use hospital emergency departments for their primary care, even though it is not the most effective method of medical care for them, as it cannot provide continuity. Additionally, for hospitals and governments it is not cost effective (Whitbeck, 2009). Independent variable Age Eighty percent of free clinic patients are between the ages of 18-64 with 12% being children and elderly being eight percent (George Washington University Report to Congress, 2012). Two pieces of literature agree with he statistic that one in every six people ages 51 to 61 parpickings in the National Academies Health and Retirement Survey who were at the make of the survey, uninsured, developed a new finding of stroke, cancer or stock ticker disease, over the next six year period (Institute of Medicine, 2012 Inguanzo & Kaplan, 2011). In reason with an IOM report cited, a national trend study from 2007, looking at 10,088 uninsured older working age adults, found that this group is less lik ely to receive regular preventative screenings for breast cancer, prostate cancer and cholesterol that those with insurance in the same age group.Additionally, women who are uninsured or are on Medicaid have a more march on stage of breast cancer at first diagnosis and lower survival rate than their counterparts who have private health coverage (Gerber, et al. , 2008). In a 2009 Kaiser report, 30 percent of people between the ages of 19 and 29, are uninsured, the highest proportion of any age group. Though the majority of these young adults are working, they experience lower pay scales, and much find health coverage too expensive for their budget.Most people in this age group reported they were in good health, but 10 percent indicated they were in poor or fair health twice as many as those with medical insurance (Weaver, 2010). Now, in 2012, many of this age group, because of provisions under the Affordable Care Act, will now be able to remain a dependent on their parents insuranc e indemnity until age 26, thus likely reducing the high percentage of uninsured in this age group (The White House, 2010). The number of children nationwide with no healthcare coverage is on the rise, but the impact from being uninsured on a childs health has not been hard explored.According to a ledger of Public Health article, in 2006 over one million children became uninsured, raising the total to 9. 4 million, or 12. 1% of all children in the United States. The spike in numbers can be credited to decreases in employer health coverage without corresponding growths in swan provided by Medicaid or the State Childrens Health Insurance Program (SCHIP) (Abdullah, 2010). One study analyzed information from more than 23 million children, under age 18, in the United States, using two large patient entropybases, to evaluate the effect of health care coverage status on pediatric hospital stays.The study resulted in findings that the rate of death for children who were uninsured was ov er 37 percent of the deaths studied (Abdullah, 2010). Hypotheses H1 The fewer options for medical treatment will influence an uninsured person to use a free clinic for health care. The more alternative options for medical treatment will influence less free clinic usage by an uninsured person. Other options is an independent variable that has a direct birth with the dependent variable of free clinic usage by the uninsured.H2 Hispanic ethnicity will influence an uninsured person to use a free clinic for their medical care needs. Hispanic ethnicity will not influence an uninsured person to use a free clinic for their medical care needs. Hispanic ethnicity is an independent variable that has a direct family with the dependent variable of free clinic usage by the uninsured. H3 Homelessness will influence a person to visit a free clinic. Homelessness will not influence a person to visit a free clinic. Homelessness is an independent variable that has a direct relationship with the depend ent variable of free clinic usage by the uninsured.H4 Age is a factor that influences free clinic usage by the uninsured. Age does not influence free clinic usage by the uninsured. Age is an independent variable that has an rearward relationship with the dependent variable of free clinic usage by the uninsured. Chapter II Methodology Design This study will concentrate on one central research question What impacts do availability of other medical care options, Hispanic ethnicity, homelessness and age have on the usage of a free clinic by people who are uninsured?These questions will pose the following hypotheses H1 The fewer options for medical treatment will influence an uninsured person to use a free clinic for health care. The more alternative options for medical treatment will influence less free clinic usage by an uninsured person. Access to other options is an independent variable that has a direct relationship with the dependent variable of free clinic usage by the uninsured. H2 Hispanic ethnicity will influence an uninsured person to use a free clinic for their medical care needs.Hispanic ethnicity will not influence an uninsured person to use a free clinic for their medical care needs. Hispanic ethnicity is an independent variable that has a direct relationship with the dependent variable of free clinic usage by the uninsured. H3 Homelessness will influence a person to visit a free clinic. Homelessness will not influence a person to visit a free clinic. Homelessness is an independent variable that has a direct relationship with the dependent variable of free clinic usage by the uninsured.H4 Age is a factor that influences free clinic usage by the uninsured. Age does not influence free clinic usage by the uninsured. Age is an independent variable that has an inverse relationship with the dependent variable of free clinic usage by the uninsured. A schematic exemplification illustrates the correlation between these variables. The model can be reviewed i n Appendix A. The research question and problem will be answered by using a survey design study conducted by a convenience sample over a six calendar week period.The reason behind using a cross-sectional design is that entropy on all variables of interest can be collected at the same time and is an efficient method for a large group (OSullivan, Rassel & Berner, 2008). The three page survey, written at a fifth cross off level, in English and in Spanish, will make inquiries and gather information about the independent variables, and about the dependent variable. Attempts will be do to approach every patient gestural in at the clinics during the study period. Internal and external validness, then, are important to maintain when surveying a sample population and asking questions on sensitive issues.The goal is to tally that the independent variables of interest indeed caused changes to the dependent variable and not something else along with certifying the outcomes are general of the population and can be reproduced in any location. The development and reliability of the research questions are integral to maintaining internal validity within the study. Cognitive pretesting of 10 patients will be performed before ancestor the study to ensure the questions are commonly understood and to confirm that the survey questions are capturing the intended outcomes.Additionally, in order to ensure external validity, the results of the study can be implemented by other governments and non-profit agencies. Population/Sample The population for this study is patients visit two free clinics in Shelby County, Alabama, ages 19-64. This limits the population to a specific age range of persons in the county, as it has been unflinching that those outside this age range are eligible for coverage through government offered insurance curriculums, even if they have not applied for it.A Shelby County development Services Department Profile indicates from 2010 Census data the popul ation for Shelby County, Alabama is 195,084 residents. Of those approximately 7% are uninsured, equating to around 10,000 uninsured residents. County demographics reveal an almost even division of males (49. 3%) to females (50. 7%). 83. 6% of the population is white, 10. 6% is Black/African American and 1. 5% is Asian ( limit Appendix D). An anomaly in demographics is observed in ethnicity, specifically Hispanic/Latino residents who are documented at 4. % (8,389) of the total population with an additional 4. 2% who speak non-English language at home and 1. 6% who speak English less than very well. If the results of a University of Alabama at Birmingham study are applied to undocumented Hispanics in Shelby County, the total would be more accurately reported at 37,314 (Patino, 2002). Given the fact that both clinics have eligibility requirement for the patients they see, the sampling frame will include only people ages 19-64, who have no insurance and who reside in Shelby County or i ndicate they are homeless.The sample will consist of those who randomly visit the clinic, and are signed in on a first come, first served basis and are waiting to receive treatment at the clinics during the study period, representative of the draw close 2000 patients who actually received treatment in 2011. This total number of patients is captured from clinic data gathered and reported by the clinics. The sample will be elect through convenience sampling methods. This method was chosen for its ease of exercise and cost effectiveness, although it has a higher risk of bias.The sample size was chosen using a formula that calculated a 95 percent confidence level that the sample size will accurately represent the total population of patients. The sample size will be 563 patients. make Appendix B. Variables Dependent Variable For this study, a free clinic is operationally defined as being a privately run non-profit agency not receiving any federal funding, that offers general medical services, medication and dental care to individuals who have no health care coverage. Volunteer, licensed medical providers circularise the care at minimal or no cost (Darnell, 2010).The dependent variable is measured using nominal scales, with letters of the alphabet used as labels instead of numerals. Questions in the survey that address the dependent variable specifically are Question 4 and Questions 9-13 (see Appendix C). Independent Variables The first independent variable lack of other options, can be conceptually defined as locations where the uninsured might seek medical treatment, other than a free clinic. To measure this variable, use of other options will be measured using a series of questions asking questions related to medical care history.Since the survey will be given to uninsured patients who may not have a high level of education, literacy, or understanding of terminology, the operational definition for the second independent variable of housing status in the sur vey will measure sustentation arrangements. This will be courtly by measuring the frequency of responses using nominal scales. The third independent variable, ethnicity, especially Hispanic ethnicity, has been defined as being of Hispanic origin. Per the US Census Bureau, persons of Hispanic origin are determined on the basis of question that asked for self-identification of the persons origin or descent.Persons of Hispanic origin, in particular, are those who indicated that their origin was Mexican-American, Chicano, Mexican, Mexicano, Puerto Rican, Cuban, Central or South American, or other Hispanic (U. S. Census Bureau). The fourth and final independent variable, used in this model is age, and is intended to measure which age groups of working age adults visit a free clinic most a great deal and if age is a factor for visiting the clinic. In the study, variable is operationally defined as working age adults between the ages of 19-64.Free clinics trends have shown most patients are non-elderly adults (Darnell, 2010). This will be accomplished by measuring the frequency of responses using nominal scales. Data Collection Measuring Instrument The use of free clinics by the uninsured between ages of 19-64 and the relationships of the factors that influence usage, will be gauged by using a survey comprised of 20 questions (Appendix C), consisting of issues related to accessibility, reasons for use, medical insurance status, health status, employment status, housing status, current diagnoses, and general demographic information.These questions include both ordinal and nominal scales. Two questions will provide an open-ended answer option where blank shell will be provided to write in an answer. Some questions for the survey were extracted from previously tested and validated instruments, such as the National Health call into question Survey. The survey will be translated into Spanish, and for those who need assistance, an already on-site Spanish interpreter will assist in the introduction of the study as well as offer explanation for completion of the survey.The survey should take no longer than 10 minutes to complete. Materials The materials and expense necessary to carry the survey are marginal. Copies required for each respondent total 4 pages (one page is the introduction and confidentiality notice and three pages for the survey) each totaling 2252 multiplied by $. 05 equals approximately $112. 60. Office supplies including three dozen writing pens and a stapler and staples will also be purchased for around $25. 00. Additionally, incentives in the form of refreshments are an additional cost.Bottled piss and healthy snacks such as granola bars, pretzels or fruity will be purchased in volume to reduce costs. 25 cases of water totals $180. 00 and snacks will be approximately $150. 00. Therefore the total cost to administer the survey with incentive is approximately $467. 60. The study will be given during clinic operating hours wh ere clinic volunteers will be recruited to administer the introduction and surveys providing additional cost savings. Delivery Method In order to allow every patient in the convenience sample the same chance to move into in the survey, upon their arrival and egistration, a clinic caseworker will share with them a pen introduction explaining the purpose for the survey and assure them it is voluntary and it will in no way cause them any risk and will in no way compromise their clinic visit nor treatment. The introduction will also discuss confidentiality. These measures will help to ensure internal validity since the taste may provide a level of comfort for the respondent who in turn may be inclined to answer the questions more honestly.The survey will be administered to the patients during regular clinic hours on Mondays between 830 am and 430 pm and Thursdays between 530 pm and 830 pm, while they wait to be seen. To remediate response rates, healthy refreshments will be provide d to participants. Patients who have been waiting to memorialize for hours, to be one of 30 patients seen during a given clinic, have likely not eaten and may welcome refreshment as incentive to participate in the study. Dr.Eleanor Singer, a population studies professor and researcher at Columbia University summarized the evidence on incentives from the standpoint of the survey literature in the use of incentives in her 2002 book. She uncovered that incentives improve response rates crosswise all approaches. The effect has proven to be undeviating, larger incentives have superior make on response rates. Those patients who are first in line to see a medical provider will have equal opportunity to participate in the incentive and the study upon completion of their visit. Data AnalysisOnce the surveys are collected the data will first be cleaned. It is very important that the data collected from the surveys be able to be interpreted justly in order to accurately measure the relation ships between the dependent and independent variables. Each question on the survey will be coded with a value prior to being administered. Data will be entered into a SDSS program and a multiple aggression analysis will be performed. From this analysis it will be possible to find the correlating relationships between each individual independent variable and the dependent variable to show significance.Ultimately the estimator program will show which factors strongly influence free clinic usage, which ones are less influential and which factors together may increase the relationship further. See the example in Appendix E. Chapter III Anticipated Findings The literature that has been reviewed in relation to the variables in this study, along with the suggested approaches, in tandem offers backing to the outcomes that are expect of this study.It is judge that there will be a relationship between use of a free clinic by the uninsured and each of the four independent variables provided lack of other options for health care, age, Hispanic ethnicity and homelessness. The prediction is that the computer software used in analyzing the findings will show relationships between the variables, contradicting the null hypotheses. A multiple aggression analysis would be used to show these relationships by entering the data into a computer program designed to perform the computations and ends up showing a prototype of realness (Simon, 2003).Each of the four independent variables, are believed to have direct relationships with the dependent variable. Ultimately, it is anticipated that each of the four corresponding hypotheses will be conclusive. Chapter IV Conclusion Studies provide support for the need to address reasoning behind free clinic usage by the uninsured population. The literature review has assisted in understanding each variables definition, emphasizing the ideas and findings of other critical studies, and establishing the integrity of the links between each in dependent variable and the dependent variable.As an example, the Kaiser report assists with understanding of the independent variable of age being a factor in why uninsured use a free clinic for their health care needs. It showed that younger working age adults in a certain age range were the group who are most often uninsured, and that this age group is forced to use free health care or have none at all, ultimately having medical conditions worsen, thus costing hospitals and tax payers more in the end. There is currently a staggering estimated $70 billion in uncompensated medical care from 2008 alone by uninsured patients (US Dept. f Health and Human Services, 2011). Therefore it is imperative that those with no medical insurance have access to some form of free or affordable health care in their community, with free clinics being an important piece of the equation. Implications The findings of this research are expected to be beneficial to the Shelby County local government, healt h and human service non-profit agencies and the medical system as the study will be proving assumed information, along with providing ancillary supportive data about the health care needs and gaps to serve uninsured residents of Shelby County, Alabama.In knowing information about what factors contribute to the free clinic usage among the uninsured, the community collaborative can propose modifications, improvements and additions for programming that may assist in lessening the burden, and ultimately solving the problem. While the outcomes from the study may not be exact to national trends, they should be very reflective and allow for reproduction of successful interventions. RecommendationsThe provided research will give evidence on four factors that contribute to the use of free clinics for medical treatment by the uninsured population of Shelby County, Alabama thus allowing for a community collaborative to be formed from local government, health care providers, faith based communi ty, caseworkers, immigration and homelessness advocates, university department heads and others. Therefore, it is strongly suggested that this study be performed in order to gather this necessary information to determine if a more detailed needs assessment should be conducted.While there are additional independent variables that may contribute to the usage of a free clinic, only four have been highlighted for this study. Others additional factors should be investigated to identify other challenges that strain the health care system, ultimately contributing to the occurrence of free clinic use. REFERENCES Abdullah, F. et al. , (2009). Analysis of 23 million US hospitalizations uninsured children have higher all-cause in-hospital mortality. Journal of Public Health, 32 (2), 236244. inside10. 093/pubmed/fdp099 Batra, P. , Chertok, J. , Fisher, C. , Manseau, M. , Manuelli, V. , & Spears, J. (2009). The Columbia-Harlem homeless medical alliance A new model for learning in the service of those in medical need. Journal of Urban Health Bulletin of the New York Academy of Medicine, 86 (5). doi10. 1007/s11524-009-9386-z Becker, G. , (2001). Effects of being uninsured on ethnic minorities management of chronic illness. West Journal of Medicine, 175(1), 1923. Corso, P. & Fertig, A. , (2011). ROI and free clinics in Georgia.HealthVoices, University of Georgia College of Public Health, Healthcare Georgia Foundation, Publication 51. Darnell, J. S. (2010). Free clinics in the United States A nationwide survey. ARCH Intern Medicine, 170 (11), 946-956. Depaul, J. (2010). Free clinics Americas scoop up-kept secret. The Fiscal Times. Retrieved from http//www. thefiscaltimes. com/Articles/2010/05/03/Free-Clinics-Lifeline-for-America. aspxpage1 Fertig, A. , Corso, P. , & Balasubramaniam, D. (2011). Benefits and costs of a free community-based primary care clinic.Retrieved from http//hogwarts. spia. uga. edu/afertig/policy1/FreeClinic_JHHSArevision_singlespace1. pdf Galwankar, S. , (2004). Role of homeless and uninsured patients in overcrowded emergency departments. Retrieved from http//www. bmj. com/rapid-response/2011/10/30/role-homeless-and-uninsured-patients-overcrowded-emergency-departments George Washington University, Department of Health Policy, drill of Public Health and Health Services (2012). Quality incentives for federally qualified health centers, rural health clinics and free clinics A report to Congress.Washington, DC. Gerber, R. et al. , (2008). A place to be healthy Blueprint for a new free clinic for the medically uninsured of Rhode Island. Medicine & Health/Rhode Island, 91(4), 105-108. Gertz, A. , Frank,S. & Blixen, C. (2011). A survey of patients and providers at free clinics across the United States. Journal of Community Health, 36, 83-93. doi 10. 1007/s 10900-010-9286-x Groman, R. , (2004). American College of Physicians white paper on the cost of lack of health insurance White Paper. Retrieved from http//www. acponline. rg/ advocacy/ where_we_stand/access/cost. pdf Hoback, A. & Anderson, S. (n. d. ). Proposed method for estimating local population of precariously housed. Retrieved from http//www. nationalhomeless. org/publications/precariouslyhoused/index. html Inguanzo, M. & Kaplan, M. , (2011). The neighborly implications of health care right reducing access barriers to health care services for uninsured Hispanic and Latino Americans in the United States, Harvard Journal of Hispanic Policy, 23, 83. Institute of Medicine (2003). Hidden costs, values lost Uninsurance in America.The National Academies Press. Washington, D. C. Retrieved from http//www. nap. edu/catalog. php? record_id=10719 Isaacs, S. L. & Jellinek, P, (2007). Is there a (volunteer) doctor in the house? Free clinics and volunteer physician referral networks in the United States. Health Affairs, 26 (3), 871-876. doi 10. 1377/hlthaff. 23. 3. 871 Keis, R. M. , DeGeus, L. G. , Cashman, S. , & Savageau, J. (2004). Characteristics of patients at three free clinics. Journal of Health Care for the vile and Underserved, 15 (4), 603-617. Krisberg, K. , (2010).Jump in uninsured signals need to implement health reform Economy takes a toll on health coverage. The Nations Health, 40 (9), Retrieved from http//go. galegroup. com. libproxy. troy. edu/ps/i. do? id=GALE%7CA241780634&v= 2. 1&u=troy25957&it=r&p=AONE&sw=w Lewis, J. H. , Andersen, R. M. & Gelberg, L. , (November 2003). Health care for homeless women Unmet needs and barriers to care. Journal of General Internal Medicine, 18, 921-928. Llano, R. , (2011). Immigrants and barriers to healthcare Comparing policies in the United States and the United Kingdom.Stanford Journal of Public Health, Retrieved from http//www. stanford. edu/group/sjph/cgi-bin/sjphsite/2011/06/immigrants-and-barriers-to-healthcare-comparing-policies-in-the-united-states-and-the-united-kingdom/ OConnell, J. , (2005). Premature mortality in homeless populations A review of the literature. National Health Care for the Homeless Council, Inc. , Nashville. Patino, F. , (2002). Material and child health services utilization by Hispanics in Alabama (doctoral dissertation). Birmingham, AL The University of Alabama School of Public Health. Scariarti, P. & Williams, C. , (2007).The good of a health risk assessment in providing care for a rural free clinic population. Osteopathic Medicine & Primary Care, 1(8). doi 10. 1186/1750-4732-1-8 Simon, G. , (2003). Multiple degeneration basics. Retrieved from http//people. stern. nyu. edu/wgreene/Statistics/MultipleRegressionBasicsCollection. pdf Singer, E. , (2002). The use of incentives to reduce nonresponse in household surveys. Survey Nonresponse, John Wiley & Sons, Inc. , New York, 163-177. Trask, J. , (2011). The relationship between primary care access to free clinics and emergency room usage (Unpublished doctoral dissertation). potassium alum College of the University of Illinois at Urbana-Champaign. United States Census Bureau (2001). Households an d families 2000, Census 2000 brief. US Department of Commerce. United States Census Bureau. Hispanic population of the United States. Retrieved from http//www. census. gov/population/www/socdemo/hispanic/ho00def. html U. S. Department of Health and Human Services (2011). ASPE Research Brief The value of health insurance Few of the uninsured have adequate resources to pay potential hospital bills. Weaver, C. , (2010).How health overhaul would affect the uninsured. Kaiser Health News. Retrieved from http//www. kaiserhealthnews. org/stories/2009/september/21/uninsured-explainer-npr. aspx Whelan, E. M, (2010). The importance of community health centers Engines of economic activity and job creation. Center for American Progress. Whitbeck, L. (2009). Mental health and emerging adulthood among homeless young people. psychology Press, Taylor & Francis Group, New York. White House, (2010). Department of Health and Human Services. Retrieved from http//www. whitehouse. ov/blog/2010/05/10/a-l ong-overdue-change-help-young-adults-get-coverage pic pic Appendix B Required Sample Size 0. 05 0. 035 0. 025 0. 01 0. 05 0. 035 0. 25 10 10 10 10 10 10 10 10 20 19 20 20 20 19 20 20 30 28 29 29 30 29 29 30 50 44 47 48 50 47 48 49 75 63 69 72 74 67 71 73 100 80 89 94 99 87 93 96 150 108 126 137 148 122 cxxxv 142 200 132 160 177 196 154 174 186 250 152 190 215 244 182 211 229 300 169 217 251 291 207 246 270 400 196 265 318 384 250 309 348 500 217 306 377 475 285 365 421 600 234 340 432 565 315 416 490 700 248 370 481 653 341 462 554 800 260 396 526 739 363 503 615 900 269 419 568 823 382 541 672 1,000 278 440 606 906 399 575 727 1,200 291 474 674 1067 427 636 827 1,500 306 515 759 1297 460 712 959 2,000 322 563 869 1655 498 808 1141 2,500 333 597 952 1984 524 879 1288 3,500 346 641 1068 2565 558 977 1510 5,000 357 678 1176 3288 586 1066 1734 7,500 365 710 1275 4211 610 1147 1960 10,000 370 727 1332 4899 622 1193 2098 25,000 378 760 1448 6939 646 1285 2399 50,000 381 772 1491 8056 655 1318 2520 75,000 382 776 1506 8514 658 1330 2563 100,000 383 778 1513 8762 659 1336 2585 250,000 384 782 1527 9248 662 1347 2626 500,000 384 783 1532 9423 663 1350 2640 Appendix C Health Care Survey Questionnaire Circle your answer 1. What is your age? a. 19-24 b. 25-34 c. 35-44 d. 45-54 e. 44-64 2. What would you classify your ethnicity? a. Caucasian or white b.African American or morose c. Hispanic/Latino d. Asian e. Other________________ 3. What is your employment status? a. Full time employee b. Part time employee c. Self employed d. Unemployed looking for work e. Unemployed f. Retired 4. Reason for no health care coverage/insurance? a. Employer does not offer b. Dont work enough hours c. Became out of work and lost coverage d. Cannot afford 5. What is your highest level of completed education? a. Di d not complete High school/did not obtain GED b. High School Diploma / GED c. Technical/Trade school d. Some college e. College degree f. Graduate degree g. Doctoral degree 6. What is your housing status? a.Own home b. absorb home/apartment c. Live with family/friends d. Reside at shelter/transitional housing e. Not housed 7. What language do you speak most often at home? a. English b. Spanish c. Other__________________ 8. Are there children living in your household ages 18 and younger? a. Yes b. No 9. When was the conk time you received medical care before todays visit? a. in spite of appearance last week b. Within last month c. Within last three months d. Within last six months e. Within last year f. Longer than one year 10. Where did you last receive medical treatment before todays visit? a. Doctor office b. Hospital ER c. Public health department d. Free Clinic 11.Which best describes the reason you chose the location for your last medical treatment? a. Location b. Hours of o peration c. Recommended by family/friend d. Did not know where to go 12. Did you have medical insurance the last time you received medical treatment? a. Yes b. No c. I dont know 13. How would you rate your satisfaction level of your most recent medical treatment? a. Very satisfied b. middling satisfied c. Somewhat dissatisfied d. Not satisfied 14. How would you describe your health? a. Excellent b. Good c. Fair d. Poor 15. Are you experiencing an ongoing health problem? a. Yes b. No c. I dont know 16. stand you had a diagnosis for your health problem? a. Yes b. No c. I dont know 17.Are you taking prescription medications? a. Yes b. No 18. If you are taking prescription medications, is a needed refill the reason for your visit today? a. Yes b. No c. Not applicable 19. How are you able to afford your medications? a. medicament assistance b. Lower cost generics c. Samples d. Self-pay full price e. I cannot afford them 20. Please discuss any other issues you are having where assistanc e may be needed, so referrals may be offered. 21. Please describe in detail what you hope to receive from your visit today. Appendix D pic Shelby County victimization Services Profile Appendix E Example of a Multiple Regression results chart pic pic