NRNP 6654 Week 3 Access Barrier Analysis Example

Access Barrier Analysis: Six Stages From Noticing a Problem to a Second Visit, for a Man Living in a Shelter, Each Barrier Attributed and Then Ranked

Student Name

College of Nursing, Walden University

NRNP 6654: Psychiatric Mental Health Advanced Practice Nursing Care of Vulnerable/Special Populations

Instructor Name

Month Day, Year

Access Barrier Analysis: Six Stages From Noticing a Problem to a Second Visit, for a Man Living in a Shelter, Each Barrier Attributed and Then Ranked

The Route and the Person Walking It

The person on this route is constructed for the page: a 44-year-old man staying in an emergency shelter in a mid-sized city, with depression that has worsened over the winter and heavy drinking on weekends. No appointment record, referral log, or cancellation report was consulted. The route follows the process of access described by Levesque et al. (2013), who treat access as a sequence of opportunities: to perceive a need, to seek care, to reach it, to obtain it, and to benefit from it, with a dimension of the service and an ability of the person meeting at each step. I divide it into six stages.

Stages One and Two: Recognizing the Problem, Asking Someone

Recognizing. He knows he feels worse but thinks of it as the winter and the shelter, not as an illness, and each day's first tasks are food and a bed for the night. Attribution: partly the person, and mostly material circumstances, since a problem that is not an emergency waits behind needs that are. This is patterned rather than personal: in a national sample of adults using health care for the homeless clinics in 2003, 21% reported being unable to get mental health care they needed in the past year, and food insufficiency was one of the independent predictors of unmet need (Baggett et al., 2010).

Asking. He mentions it to a shelter staff member, who suggests the clinic. Attribution: the service, because asking depends on who is there to ask and whether they know where to send him.

Stages Three and Four: Referred, Scheduled

Referred. The clinic requires a referral form from a case manager, and he does not have one. Attribution: the system, through a rule that assumes each person has a case manager. He waits two weeks to be assigned one.

Scheduled. The clinic offers an appointment three weeks out and says it will text a reminder. By then his phone number has changed. This is the barrier that looks like his fault on the clinic's records and is not. In a study of 421 homeless adults moving into permanent supportive housing, 94% owned a cell phone, but 56% had changed phones and 55% had changed numbers in the prior 3 months (Rhoades et al., 2017). Attribution: the service, which designed its contact method for people whose number stays the same.

Stages Five and Six: Arriving, Returning

Arriving. The clinic is across town; the appointment is at 10:00, and the shelter requires him to leave by 7:00 and to line up by 16:00 to keep his bed. Getting there is possible; getting there and back before the bed line is harder. Attribution: material circumstances and the service's hours. Insurance adds to this: in a national survey of homeless adults, about a quarter reported going without necessary medical care over the previous 12 months, and those with health insurance reported fewer barriers (Kushel et al., 2001).

Returning. He goes once, is started on a plan, and is asked to return in four weeks. He does not. Attribution: the service, which asked him to repeat the whole route without changing any part of it. Among homeless adults in the same survey who were prescribed medicine, 32.1% could not take it as prescribed (Kushel et al., 2001), which tells us the second visit is where many plans stop.

Why Motivation Is Not the Explanation

At every stage, his behavior could be written as a lack of motivation: he did not come, he did not answer, he did not return. The evidence points the other way. He noticed, he asked, he waited, and he went once, and each point where the route broke was a point where the service or system required something his circumstances did not allow. A clinic reading its no-show list as a list of unmotivated patients will change nothing on the route.

Ranked by What Removal Would Change

First: scheduling by phone. Removing it, by offering same-day or walk-in visits at set times, or by sending reminders through the shelter, would fix the stage where the most people are lost after they have already asked for help. The phone evidence suggests the loss is large and predictable, not occasional (Rhoades et al., 2017).

Second: the return visit. Holding the second visit at the shelter, or on the same day each week at the clinic, would remove the need to walk the whole route again, and the medication figures suggest this is where treatment most often stops (Kushel et al., 2001).

Third: the referral rule. It delays care by weeks but affects only those without a case manager.

Fourth and fifth: arriving and asking. Real but partly addressed by the two changes above, since care brought closer or made walk-in removes much of the travel and some of the need to ask.

Last: recognizing. It matters, but the same national sample suggests that the larger drivers of unmet need were conditions such as food insufficiency and lack of insurance (Baggett et al., 2010), which the service cannot fix by persuading him that his mood matters. Two stages, scheduling and returning, carry most of the loss, and both are the service's to change.

References

Baggett, T. P., O'Connell, J. J., Singer, D. E., & Rigotti, N. A. (2010). The unmet health care needs of homeless adults: A national study. American Journal of Public Health, 100(7), 1326-1333. https://doi.org/10.2105/AJPH.2009.180109

Kushel, M. B., Vittinghoff, E., & Haas, J. S. (2001). Factors associated with the health care utilization of homeless persons. JAMA, 285(2), 200-206. https://doi.org/10.1001/jama.285.2.200

Levesque, J.-F., Harris, M. F., & Russell, G. (2013). Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. International Journal for Equity in Health, 12, Article 18. https://doi.org/10.1186/1475-9276-12-18

Rhoades, H., Wenzel, S. L., Rice, E., Winetrobe, H., & Henwood, B. (2017). No digital divide? Technology use among homeless adults. Journal of Social Distress and the Homeless, 26(1), 73-77. https://doi.org/10.1080/10530789.2017.1305140