Abstract
To describe the prevalence of medical home among American Indian and Alaska Native children (AIAN) compared to non-Hispanic white (NHW) children and identify areas for improvement in the provision of care within a medical home. Prevalence of medical home, defined as family-centered, comprehensive, coordinated, compassionate, culturally effective care, including a personal doctor or nurse and usual care location, was estimated using 2007 National Survey of Children’s Health data. Analyses included 1–17 year-olds in states reporting AIAN race as a distinct category (Alaska, Arizona, Montana, New Mexico, North Dakota, Oklahoma, and South Dakota, n = 9,764). Associations between medical home and demographic (child’s age, household education and income, and state) and health-related [child’s insurance status, special health care need status, and past year Indian Health Service (IHS) utilization] characteristics were assessed among AIAN children. Overall, the prevalence of medical home was 27 % lower among AIAN children (42.6, 95 % CI = 34.4–50.8) than NHW children (58.3, 95 % CI = 56.2–60.4). Child’s age (adjusted OR [aOR] = 2.7, 95 % CI = 1.3–5.6) was significantly associated with medical home. IHS utilization was associated with medical home among AIAN children with private insurance (aOR = 0.2, 95 % CI = 0.1–0.4), but not among uninsured or publicly insured children. Care coordination and family-centered care were noted areas for improvement among AIAN children. Less than half of AIAN children had a medical home. Future studies should further examine the intersection between insurance and IHS to determine if enhanced coordination is needed for this population, which is often served by multiple federally-funded health-related programs.
Keywords: Medical home, Disparities, American Indians, National Survey of Children’s Health
Introduction
Medical home is defined as care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, culturally effective and is delivered or directed by well-trained physicians who provide primary care and help to manage and facilitate essentially all aspects of pediatric care [1]. Although the concept of a medical home was originally promoted for children with special health care needs (CSHCN), its importance for all children has been recognized. Having a medical home has been associated with increased odds of children receiving certain health screenings and parents receiving anticipatory guidance regarding their child’s care as well as reduced odds of unmet medical and dental needs [2, 3].
Reports describing care within a medical home among children in the US estimate the prevalence of medical home to be between 49 and 58 % [2–4]. These reports are based on data from various surveys and survey years; however, they all provide evidence of racial/ethnic, socioeconomic, and health-related disparities with regard to the receipt of care within a medical home [2–4]. Unfortunately, none of these studies have reported on the prevalence or predictors of receiving care within a medical home among American Indian and Alaska Native children. This gap in the literature should be addressed as American Indian and Alaska Native (AIAN) children and adolescents generally experience poor health status more often than children of other racial/ethnic groups. Examples of disparities in health status include a higher prevalence of obesity [5], diabetes [6], asthma [7], suicide [8] and higher incidence of some infectious diseases, such as H1N1 influenza [9]. Many of these are chronic conditions for which early identification and treatment are essential to the prevention of serious complications and premature death. Given the magnitude of these health disparities and the role that aspects of the medical home play in the receipt of timely and appropriate care, receiving care within a medical home may be particularly important among AIAN children [10]. Having a medical home has also been associated with a reduction in disparities related to the receipt of care among black and Hispanic adults [11, 12]. Therefore the objectives of this study are to describe the prevalence of receiving care within a medical home among AIAN children compared to non-Hispanic white (NHW) children residing in the same states and to identify areas for improvement in the provision of health care within a medical home among AIAN children.
Methods
Data Source and Study Sample
The 2007 National Survey of Children’s Health (NSCH) is a population-based, telephone survey of parental perceptions of their child’s health and health care utilization conducted in all 50 states. Selection criteria, sampling methodology, and survey response rates are described elsewhere in greater detail [13]. This analysis was limited to children between the ages of 1–17 years residing in one of the seven states that reported American Indian or Alaska Native race as a distinct category: Alaska, Arizona, Montana, New Mexico, North Dakota, Oklahoma, and South Dakota (unweighted n = 10,997). Analyses were further limited to AIAN and NHW children (unweighted n = 9,764) because previous studies have assessed medical home among black, Hispanic, and other racial/ethnic groups using these data [3, 4]. NHW children were included for comparison.
Measures
Medical Home
Medical home was defined as family-centered, comprehensive, coordinated, compassionate, culturally effective care in addition to an established relationship with a personal doctor or nurse and usual care location. This differs from the definition of a medical home described in the 2002 American Academy of Pediatrics Policy Statement because elements of accessible and continuous care were not explicitly assessed in the NSCH. Specific questions from the NSCH which were used to assess the components of a medical home are presented in the online appendix. The degree to which care was deemed family-centered was measured using four questions that asked the respondent to describe how often their child’s health care provider spent enough time with them, listened carefully, provided specific information about the child’s health, and made the family feel like a partner in the child’s care. Comprehensiveness of care was ascertained using a single item describing the ease of getting referrals to see other providers. Coordination of care was assessed using four questions which asked those respondents whose children received two or more health-related services to describe his/her experience with arranging and organizing care between health care providers as well as between health care providers and other programs and services utilized by the child. Compassionate care, which includes expressing concern for the well-being of the child and family and making efforts to understand and empathize with the feelings and perspectives of the child and family [1], was not explicitly measured but was indirectly included in the assessment of family-centered care. Cultural effectiveness and whether the child had a personal doctor or nurse and a usual source of care were each measured by a single question.
Child Sociodemographic Characteristics
Child’s race/ethnicity was categorized as: AIAN or NHW. Child’s age was categorized intro three groups: 1–5, 6–11, 12–17 years. Highest household education was categorized as less than high school, high school, or greater than high school. Household income was defined as the percentage of the 2007 federal poverty level and grouped into four categories: less than 100, 100–199, 200–399, and greater than or equal to 400 %. Multiply imputed household income data, available from the National Center for Health Statistics (NCHS), were used when household income was not reported by the respondent (8.5 % of sampled households) [10].
Child Insurance Status, Indian Health Service Utilization, and Health
Child’s insurance status was categorized as none, public, or private. Past year Indian Health Service (IHS) utilization was only asked for AIAN children; this variable was characterized as yes/no. CSHCN were identified from a set of screening questions used to ascertain functional limitations or an increased need for services greater than that of other children.
Statistical Analysis
Descriptive analyses of demographic characteristics, IHS utilization, and special health care need (SHCN) status among AIAN and NHW children included in the sample were conducted. Prevalence of having a medical home among AIAN children was estimated after adjustment for child’s age, highest level of household education, household income, child’s insurance status, and child’s SHCN status and reported by state. Prevalence estimates for NHW children were also reported for comparison. Next, unadjusted and adjusted prevalence estimates for specific components of the medical home were reported by race/ethnicity. Per the study objectives, regression analyses were limited to AIAN children. Bivariate logistic regression analysis was used to describe associations between medical home and demographic characteristics, IHS utilization, and health status. Multivariate logistic regression analysis was used to describe independent associations between having a medical home and each of these variables, after adjustment for all other variables in the model. New Mexico was chosen as the reference in both the bivariate and multivariate regression models because prevalence of medical home was lower than all other states included in analysis. We hypothesized that IHS utilization would differ among children based on demographic characteristics, including state of residence, child’s age, household income and insurance status. A separate model was used to test for interaction between IHS utilization and each of the selected demographic characteristics. Only the interaction between IHS utilization and insurance status was significant (p < 0.05); therefore, the final model included state, child’s age, highest level of household education, household income, IHS utilization × insurance status, and SHCN status. Analyses excluded all children with missing data. All analyses were conducted using SAS-callable SUDAAN (Research Triangle Institute, Research Triangle Park, NC) to account for the complex survey sampling design.
Results
The sample represented approximately 313,000 AIAN children (unweighted n = 832) and 2.3 million NHW children (unweighted n = 8932) (Table 1). The majority of the sample resided in Arizona and Oklahoma. The distribution of child’s age and the proportion of CSHCN were similar among AIAN and NHW children. However, the distributions of household education, household income, and insurance status differed between the two groups. Over 59 % of the sampled AIAN children had received services through IHS in the past year.
Table 1.
Demographic characteristics, Indian Health Service utilization, and health status of American Indian/Alaska Native and non-Hispanic white children aged 1–17 years: National Survey of Children’s Health, 2007
| American Indian/Alaska Native % (se) | Non-Hispanic White % (se) | p | |
|---|---|---|---|
| Unweighted N | 832 | 8,932 | |
| Weighted N | 313,130 | 2,336,958 | |
| State | |||
| Alaska | 8.5 (1.0) | 4.4 (0.2) | <0.001 |
| Arizona | 33.1 (4.4) | 42.3 (0.9) | |
| Montana | 5.6 (0.7) | 7.6 (0.2) | |
| New Mexico | 17.6 (2.4) | 11.6 (0.4) | |
| North Dakota | 4.1 (0.6) | 4.8 (0.1) | |
| Oklahoma | 23.3 (2.4) | 23.1 (0.7) | |
| South Dakota | 7.9 (1.0) | 6.2 (0.2) | |
| Age, years | |||
| 2–5 | 36.0 (3.8) | 29.7 (1.0) | 0.28 |
| 6–11 | 30.2 (3.1) | 34.2 (1.0) | |
| 12–17 | 33.8 (3.4) | 36.2 (1.0) | |
| Highest household education | |||
| <High school | 10.7 (2.8) | 7.5 (0.7) | <0.001 |
| High school | 37.4 (3.8) | 20.0 (1.0) | |
| >High school | 51.9 (3.9) | 72.6 (1.1) | |
| Household income (% 2007 federal poverty level) | |||
| <100 | 40.3 (3.7) | 15.7 (0.9) | <0.001 |
| 100–199 | 28.5 (3.1) | 21.8 (1.0) | |
| 200–399 | 23.8 (3.1) | 36.3 (0.9) | |
| ≥400 | 7.4 (1.6) | 26.2 (0.8) | |
| Insurance status | |||
| None | 17.8 (3.0) | 11.3 (0.8) | <0.001 |
| Public | 53.1 (3.7) | 23.3 (1.0) | |
| Private | 29.0 (3.0) | 65.4 (1.1) | |
| Indian Health Service utilization | |||
| Yes | 59.2 (3.6) | – | – |
| No | 40.8 (3.6) | – | |
| Child health status | |||
| No special health care needs | 20.2 (2.8) | 19.9 (0.8) | 0.93 |
| Special health care needs | 79.8 (2.8) | 80.13 (0.8) |
Overall, the prevalence of medical home was 27 % lower among AIAN children (42.6, 95 % CI = 34.4–50.8) compared to NHW children (58.3, 95 % CI = 56.2–60.4), after adjustment for child’s age, insurance status, and SHCN status; household poverty level and highest level of education; and state of residence (Table 2). This was true in all states included in the analysis, with the exception of Arizona, where 53.2 % of AIAN children and 53.8 % of NHW children had received care within a medical home.
Table 2.
Unadjusted and adjusted prevalence of medical home among American Indian/Alaska Native and non-Hispanic white children aged 1–17 years by state: National Survey of Children’s Health, 2007
| State | Unadjusted % (95 % CI)
|
Adjusted % (95 % CI)
|
||
|---|---|---|---|---|
| American Indian/Alaska Native | Non-Hispanic White | American Indian/Alaska Native | Non-Hispanic White | |
| Alaska | 27.4 (19.9–36.3)* | 60.1 (56.1–64.0) | 26.1 (17.5–34.7)* | 57.2 (53.3–61.1) |
| Arizona | 54.6 (36.4–71.7) | 53.0 (48.8–57.2) | 53.2 (37.6–68.8) | 53.8 (49.7–57.9) |
| Montana | 37.5 (27.1–49.3)* | 64.3 (61.3–67.2) | 38.2 (25.7–50.7)* | 63.6 (60.5–66.7) |
| North Dakota | 38.9 (27.4–51.7)* | 67.5 (64.7–70.1) | 39.4 (24.8–54.0)* | 64.0 (61.1–66.9) |
| New Mexico | 23.8 (14.3–37.0)* | 58.2 (53.9–62.4) | 26.7 (13.4–40.0)* | 59.6 (55.3–63.9) |
| Oklahoma | 41.2 (31.7–51.3)* | 58.9 (55.1–62.7) | 45.7 (34.6–56.8)* | 61.1 (57.4–64.8) |
| South Dakota | 35.3 (24.7–47.6)* | 68.6 (65.7–71.4) | 39.7 (26.8–52.6)* | 65.5 (62.6–68.4) |
| Overall | 40.8 (33.8–48.6)* | 57.8 (55.7–59.9) | 42.6 (34.4–50.8)* | 58.3 (56.2–60.4) |
Prevalence statistically different from that of non-Hispanic white children at p<0.05; State-specific prevalence estimates are adjusted for child’s age, highest level of household education, household income, child’s insurance status, and child’s special health care need status; overall prevalence estimates are adjusted for state of residence, child’s age, highest level of household education, household income, child’s insurance status, and child’s special health care need status
Most children had a personal doctor or nurse (AIAN: 89.0 %, NHW: 89.2 %) and a usual care location (AIAN: 92.5 %, NHW: 92.1 %) (Table 3). Elements of care coordination, including ease of getting referrals, effective coordination, getting needed help, communication among health care providers, and communication between health care providers and other service providers, were noted areas for improvement among both AIAN and NHW children. Parents of AIAN children were less likely than parents of NHW children to report that their child’s health care provider spent enough time with them (AIAN: 69.8 %, NHW: 80.8 %, p = 0.02), listened to them (AIAN: 80.6 %, NHW: 88.6 %, p = 0.03), was sensitive to their family’s values (AIAN: 85.1 %, NHW: 91.1 %, p = 0.05), and made them feel like a partner in their child’s care (AIAN: 80.8 %, NHW: 88.9 %, p = 0.03).
Table 3.
Adjusted prevalence of medical home components among American Indian/Alaska Native and non-Hispanic white children aged 1–17 years: National Survey of Children’s Health, 2007
| Medical home items | Adjusted % (95 % CI)
|
|
|---|---|---|
| American Indian/Alaska Native | Non-Hispanic White | |
| Family-centered care | ||
| PDN spends enough time | 69.8 (62.0–77.6)* | 80.8 (78.9–82.8) |
| PDN listens carefully | 80.6 (74.0–87.2)* | 88.6 (87.0–90.2) |
| PDN provides needed information | 78.5 (71.7–85.3) | 85.2 (83.6–86.8) |
| PDN treats family as a partner in care | 80.8 (74.0–87.6)* | 88.9 (87.3–90.5) |
| Comprehensive | ||
| No referral problems | 82.9 (69.3–96.6) | 75.1 (70.2–80.0) |
| Coordinateda | ||
| Effective care coordination | 64.5 (52.8–76.2) | 68.7 (65.6–71.8) |
| Gets help with care coordination | 70.5 (58.6–82.4) | 77.1 (72.6–81.6) |
| Doctors communicate with each other | 63.2 (47.6–78.8) | 68.5 (64.8–72.2) |
| Doctor communicate with programs | 52.7 (35.5–69.9) | 56.4 (48.8–64.0) |
| Culturally effective | ||
| PDN is sensitive to family values | 85.1 (79.6–90.6)* | 91.1 (89.7–92.5) |
| Personal doctor or nurse | ||
| Has personal doctor or nurse (PDN) | 89.0 (84.3–93.7) | 89.2 (87.6–90.8) |
| Usual care location | ||
| Has usual care location | 92.5 (88.0–97.0) | 92.1 (90.7–93.5) |
Prevalence statistically different from that of non-Hispanic white children at p<0.05; Adjusted for state of residence, child’s age, highest level of household education, household income, child’s insurance status, and child’s special health care need status
Unless indicated, these questions were only asked for children who used more than two services
In unadjusted analyses, AIAN children residing in Arizona (OR = 3.9, 95 % CI = 1.5–10.2) and Oklahoma (OR = 2.2, 95 % CI = 1.1–4.7) had higher odds of having a medical home compared to children residing in New Mexico. AIAN children ages 1–5 had higher odds of having a medical home than 12–17 year-olds (OR = 2.9, 95 % CI = 1.4–6.2); however, odds of having a medical home among 6–11 year olds did not differ from 12 to 17 year-olds (Table 4). AIAN CSHCN were less likely than children with no special health care needs to have a medical home (OR = 0.2, 95 % CI = 0.1–0.4). Among AIAN children with private insurance, those who had utilized IHS services in the past year had lower odds of having a medical home compared to those who had not used IHS (OR = 0.4, 95 % CI = 0.2–0.8). Household education and household income were not significantly associated with medical home among AIAN children. In adjusted analysis, only the associations between medical home and child’s age (adjusted OR [aOR] = 2.7, 95 % CI = 1.3–5.6) and IHS utilization among children with private insurance (aOR = 0.2, 95 % CI = 0.1–0.4) remained significant.
Table 4.
Predictors of medical home among American Indian and Alaska Native children aged 1–17 years: National Survey of Children’s Health, 2007
| % with medical home | Unadjusted OR (95 % CI) | Adjusted ORa (95 % CI) | |
|---|---|---|---|
| State | |||
| Alaska | 27.4 | 1.2 (0.6–2.6) | 1.0 (0.4–2.6) |
| Arizona | 54.6 | 3.9 (1.5–10.2)* | 2.2 (0.8–6.3) |
| Montana | 37.5 | 1.9 (0.9–4.2) | 1.5 (0.6–4.0) |
| North Dakota | 38.9 | 2.0 (0.9–4.6) | 1.4 (0.5–3.9) |
| New Mexico | 23.8 | 1.0 | 1.0 |
| Oklahoma | 41.2 | 2.2 (1.1–4.7)* | 2.3 (0.9–5.5) |
| South Dakota | 35.3 | 1.8 (0.8–3.9) | 1.6 (0.6–4.1) |
| Age, years | |||
| 1–5 | 53.9 | 2.9 (1.4–6.2)* | 2.7 (1.3–5.6)* |
| 6–11 | 38.7 | 1.6 (0.8–3.1) | 1.2 (0.6–2.6) |
| 12–17 | 28.5 | 1.0 | 1.0 |
| Highest household education | |||
| <High school | 40.6 | 1.0 | 1.0 |
| High school | 36.4 | 0.8 (0.2–3.3) | 1.0 (0.3–3.2) |
| >High school | 46.3 | 1.3 (0.3–4.7) | 1.8 (0.6–5.8) |
| Household income, % 2007 dederal poverty level | |||
| <100 | 42.3 | 1.0 | 1.0 |
| 100–199 | 28.4 | 0.5 (0.3–1.1) | 0.7 (0.3–1.5) |
| 200–399 | 45.6 | 1.1 (0.5–2.7) | 1.1 (0.4–2.9) |
| ≥400 | 64.6 | 2.5 (0.9–6.8) | 2.1 (0.6–8.2) |
| Insurance status | |||
| None | 41.8 | 1.0 | – |
| Public | 39.6 | 0.9 (0.3–2.4) | – |
| Private | 44.6 | 1.1 (0.4–2.9) | – |
| Indian Health Service (IHS) utilization | |||
| Yes | 37.8 | 0.8 (0.4–1.5) | – |
| No | 42.7 | 1.0 | – |
| Interaction between insurance and IHS utilization | |||
| Uninsured, IHS=Yes | 40.2 | 2.6 (0.5–14.3) | 2.0 (0.4–11.2) |
| Uninsured, IHS=No | 20.6 | 1.0 | 1.0 |
| Public insurance, IHS = Yes | 45.1 | 2.0 (0.8–4.9) | 1.7 (0.8–3.8) |
| Public insurance, IHS = No | 29.7 | 1.0 | 1.0 |
| Private insurance, IHS = Yes | 26.2 | 0.2 (0.1–0.4)* | 0.2 (0.1–0.4)* |
| Private insurance, IHS = No | 68.0 | 1.0 | 1.0 |
| Special health care needs | |||
| Yes | 26.8 | 0.5 (0.2–0.9)* | 0.6 (0.3–1.3) |
| No | 44.4 | 1.0 | 1.0 |
n = 832
p<0.05
Model included state of residence, child’s age, highest level of household education, household income, child’s insurance status, child’s IHS utilization, the interaction between insurance and IHS utilization, and child’s special health care need status
Discussion
Overall, 42.6 % of AIAN children received care within a medical home; this was 27 % lower than NHW children. Older children had higher odds of having a medical home. Among privately insured children, the odds of having a medical home were lower among children who had used IHS services in the past year compared to those who had not. We did not observe any differences in medical home by IHS utilization among uninsured or publicly insured children. Arizona was the only included state where a disparity in medical home was not observed between AIAN and NHW children. Of note, Arizona had the highest prevalence of medical home among AIAN children, but the lowest among NHW children. The factors contributing to the higher prevalence of medical home among AIAN children in Arizona are not known, but they may warrant further investigation in order to develop a framework for potentially increasing medical home access among AIAN children in other states.
Child’s age was a strong predictor of having a medical home among AIAN children, such that younger children were more likely than older children and adolescents to receive care within a medical home. This observation has been made in the general population as well [3, 4]. This finding may be related to the higher prevalence of any insurance but also adequate insurance coverage among younger children compared to older children, which has been observed in other population-based survey samples [14, 15]. However, we did not expect age to be associated with medical home because American Indians and Alaska Natives have treaty rights to federal health care services, regardless of insurance status. Furthermore, we failed to observe an association between medical home and insurance status. We hypothesize that this difference is ultimately related to care-seeking behaviors of parents of younger children compared to parents of older children. Although not statistically significant, our findings were suggestive of an interaction between IHS utilization and insurance status. IHS utilization alone was not associated with medical home; however, privately insured children who used IHS had significantly lower odds of having a medical home than those who had not used IHS. Closer examination of the data revealed that privately insured AIAN children who had used IHS in the past year were less likely to have a personal doctor or nurse compared to privately insured children who had not utilized IHS for care. Furthermore, elements of family-centered care and effective care coordination were lacking more often among privately insured children who used IHS. However, we are unable to determine if participants’ survey responses regarding these medical home components were in reference to private healthcare providers or IHS providers. Conversely, children who used IHS and had no insurance or public insurance had marginally higher odds of having a medical home compared to those who had not used IHS. It follows that IHS utilization is protective among the most vulnerable.
Care coordination was noted as an area for improvement among all children in these states. Others have suggested the use of electronic medical records as a mechanism to improve care coordination by increasing providers’ ability to monitor referrals and follow-up care [16, 17]. The extent to which electronic medical records currently are being used in health care settings that primarily serve American Indians and Alaska Natives has not been documented; therefore, it is unclear whether this is a feasible recommendation for this population. However, it is clear that effective coordination of care is essential as IHS is a critical point of health care access, serving about 57 % of the AIAN population [18]. It is likely that some health care services to American Indians and Alaska Natives are provided in non-IHS health care establishments. Nearly $780 million of the IHS budget for FY 2010 was appropriated for contract health services, which are used to purchase health care that IHS is unable to provide through its own network, including specialty care, surgeries, and medical care for tribes that do not have an IHS facility nearby [19].
In addition, IHS receives over $700 million annually in revenue from the Centers for Medicare and Medicaid Services (CMS) for services provided to Medicaid, Medicare, and Children’s Health Insurance Program-eligible patients [20]—creating the additional challenges of coordinating with other federal programs and issues surrounding reimbursement.
Furthermore, given the high rates of obesity, diabetes, and asthma in this population, specialty care dedicated to the treatment of these conditions should be not only accessible, but also tailored to the inclusive needs of the specific child—further underscoring the importance of care coordination. Early identification and effective management of these conditions in childhood should reduce some of the burden associated with these diseases in adulthood. Preventive care visits should include a complete assessment of the child’s health, including height and weight measurement, vision and blood pressure screening, and monitoring of cognitive and physical development. It is also recommended that evaluation of mental and emotional health be integrated into primary care visits in light of the elevated rate of suicide attempts and completion in this population [21, 22].
Aspects of compassionate and family-centered care were absent more often among AIAN families compared to non-Hispanic whites. In general, AIAN parents reported that their child’s health care providers were sensitive to their family’s values and customs; however, this sentiment was reported less often among caregivers of AIAN children compared to those of NHW children. The advancement of cultural competence and diversity as key components in public health and clinical service delivery in the past two decades has perhaps had a positive impact on the sensitivity of health care providers [23, 24]. Continued efforts in the area may be worthwhile. In this analysis, the amount of time that health care providers spend with their patients emerged as an issue. Nationally, there is a shortage of health care providers, resulting in difficulty getting appointments and a limited, often insufficient, amount of time for visits [25, 26]. This shortage is even more of a problem in rural areas, where it is more difficult to attract and retain health care providers [27]. Programs, such as the National Health Service Corps, do exist to aid in addressing health care worker shortages in rural areas. The included states may benefit from targeted recruitment efforts through these types of programs in order to increase the number of health care providers in these areas. Mechanisms to improve caregivers’ perceptions that their child’s provider listens carefully to the family and treats them as a partner in care should be investigated and implemented. A guiding principle in the delivery of health care services should be that families are the ultimate decision makers for their children and as such are entitled to complete information and to having their questions and concerns adequately addressed.
These findings should be considered in light of several limitations. We could not distinguish between AIAN children residing in urban settings versus on reservations, which likely has an impact on insurance status and IHS utilization. Nor could we differentiate between those who had access to IHS services and chose not to use them and those who did not have access. Although the NSCH consisted of a population of over 90,000 children, this analysis was limited to only a segment of that population because only seven states reported AIAN race as a distinct category. Approximately 43 % of AIAN children reside in these seven states; therefore, our findings may not be generalizable beyond the included states. The small sample size also hampered our ability to conduct state-specific analyses, which might have been particularly useful to programs within the included states. Finally, although NSCH covers a wide range of topics, the depth of the survey items may not have been sufficient to capture all data necessary to complete an exhaustive analysis of medical home. As an example, comprehensiveness of care was measured using a single item.
This analysis provides estimates of medical home among AIAN children in the seven states that have sizeable AIAN populations. Less than half of AIAN children received care within a medical home. Formative research on what constitutes compassionate and family-centered care among AIAN families is needed. Future studies should also examine the intersection between insurance and IHS to determine if there is a need for enhanced care coordination for this population, which is often served by multiple federally-funded health-related programs.
Supplementary Material
Acknowledgments
Many thanks to Drs. Deborah Rosenberg, Ph.D., and Kristin Rankin, Ph.D., for their statistical expertise and support, and to Jennifer Irving, M.P.H, for her thoughtful review of this manuscript. The findings and conclusions found in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Footnotes
Electronic supplementary material The online version of this article (doi:10.1007/s10995-012-0990-2) contains supplementary material, which is available to authorized users.
Contributor Information
Danielle T. Barradas, Email: dbarradas@cdc.gov, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, MS K-22, Atlanta, GA 30341, USA.
Charlan D. Kroelinger, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, MS K-22, Atlanta, GA 30341, USA
Michael D. Kogan, Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD, USA
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