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PROMOTING PRIMARY CARE: A CLIENT INFORMATION
, BROCHURE ' ‘ '

Schalariy Praiect for the Degree aims, N.’ i I If
MICHIGAN. STATE UNIVERSITY; ' '
JGSEPHINE LISTER HENDRIX .

I. "1998 I ‘

THESIS

 

LIBRARY

Michigan State
University

 

 

PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6/01 c;/ClFiC/DateDue.p65»p. 15

PROMOTING PRIMARY CARE: A CLIENT
INFORMATION BROCHURE

BY

Josephine Lister Hendrix

A Scholarly Project

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1998

ABSTRACT

PROMOTING PRIMARY CARE: A CLIENT
INFORMATION BROCHURE

BY

Josephine Lister Hendrix

Patients often seek healthcare for non-emergent
problems in emergency departments and urgent care walk-in
centers instead of seeking care with a primary care
provider. This practice may prevent patients from receiving
optimum quality care and may predispose patients to episodic
care and unnecessary work-ups and treatment. This form of
care also increases healthcare costs. This practice,
according to Kasper (1987), is especially problematic in the
lower socioeconomic populations in the United States. This
project outlines some of the barriers to primary care and
discusses the attributes of primary care.

The purpose of this scholarly project was to develop a
tool to increase an awareness of primary care through
patient education. A brochure is designed for the general
public, but targets the lower socioeconomic population of
the Grand Traverse region, and therefore is written in an
easy to comprehend format. The brochure provides a
definition of primary care, benefits of primary care,
examples of care that can be appropriately treated by a PCP
(primary care provider), and examples of a true health care

emergency. There is a section with information on accessing

ii

the PCP during and after office hours and it is formatted
for customizing that information.

The information in the brochure is designed to
encourage patients to seek primary care for non-emergent
health concerns instead of choosing episodic care in
emergency departments and walk-in clinics. The PCP will
review the brochure with patients in an interactive
educational process.

The Innovation-Decision Process Model by Rogers (1995)
was used as a conceptual framework for this scholarly
project. This model represents the diffusion of a new

concept or idea and the path to adoption of that idea, which

in this case, is primary care.

iii

ACKNOWLEDGMENTS

The completion of this scholarly project would not have
been possible without the continued support and
contributions of these special people:

I would like to thank the members of my scholarly
project committee for their patience, guidance and moral
support: Katherine Dontje, RN, MSN, FNP and Catherine Lein,
RN, MSN, FNP, co-chairs; George Allen, PhD, committee
member; and Joan Predko, RN, PhD, committee member. My
special thanks to Patricia Peek, RN, MS, CS, PNP for advice
and cheerful moral support. My appreciation also extends to
Kaye Arnett for preparing the final copy of this scholarly
project.

Sincere thanks to Mark Baranski, RN, BSN, Director of
Emergency Services, Munson Healthcare System, for sharing
demographic data from his study on non-emergent patient
health care choices in the Traverse City area, and to Jim
Munro, RN, Shift Coordinator, Munson Emergency Department,
for sparking the idea for this project.

Finally, my most sincere thanks and love to my husband,
Dan Hendrix, for his technical assistance in producing the
computer generated conceptual models and the Primary Care

Brochure; to my children, Joseph, Warren, and Ariana Hendrix

iv

for their patience and caring support; to my parents,
Margaret and Henry Hose for their belief in me; and to my
friend and classmate, Linda Steltzner, RN, BSN, CCRN for
advice and support. Their love, patience, and strength

bolstered me in this challenge.

TABLE OF CONTENTS

LIST OF FIGURES . . . . . . . . . .

CHAPTER I: ISSUES AND PROBLEM STATEMENT

Introduction . . . . . . . . . . . . . . . . . .
Background and History of the Problem . . . . .
Problem Statement . . . . . . . . . . . . . . .
Goals-and Objectives of this Brochure . . . . .

CHAPTER II: CONCEPTUAL FRAMEWORK
Rogers' Innovation-Decision Process Model . . .
Rogers' Conceptual Definitions . . . . . . . . .
Conceptual Definitions . . . . . . . . . . .

CHAPTER III: LITERATURE REVIEW

Attributes of Primary Care . . . . . . . . . . .
Barriers to Primary Care . . . . . . . . . . . .
Methods Used to Promote Education About Primary

Care . . . . . . . . . . . . . . . . . .

Limitations of the Review of the Literature . .

CHAPTER IV: METHODS
Overview . . . . . . . .

CHAPTER V: IMPLICATIONS FOR ADVANCED PRACTICE NURSING
Overview . . . . . . . . . . .

Summary and Implications of This Study: Potential

contributions 0 O O O O O O O O I O O O O I O 0
Recommendation for Nurse Practitioners . . . . .

REFERENCES . . . . . . .

APPENDIX A: Primary Care Brochure . . . . . . . . . .
APPENDIX B: Evaluation of the Primary Care Brochure .

vi

Page

vii

\lO‘NH

. 10
O 17

. 19
. 21

. 27
. 32

. 46

LIST OF FIGURES

Page
Figure 1: Roger's Innovative-Decision Process Model . . . 9
Figure 2: Modified Model . . . . . . . . . . . . . . . . 14

vii

CHAPTER I
ISSUES AND PROBLEM STATEMENT
Introduction

The Institute of Medicine (IOM) (1993) noted that
historically, lower socioeconomic populations have a
significantly higher morbidity and mortality from chronic
and acute disease processes because of lack of primary care.
The (IOM) was charged with developing a set of indicators to
monitor access to healthcare by the U.S. public. The first
matter the IOM Committee attended to was the establishment
of the specific indicators to monitor access to personal
healthcare, and they found that little progress had been
made over the past decade. Low socioeconomic populations
were still at risk for disease and death due to a real or
perceived lack of access to proper healthcare. This risk
existed whether there was an actual lack of healthcare
providers, or the patients received inappropriate and
inconsistent episodic healthcare in the emergency
departments.

Educating the public about the primary care benefits of
longitudinal care, continuity of care, and access to care is
a priority of healthcare providers. Without access to care,
certain populations will suffer the effects of poor health

outcomes related to episodic care. Education that focuses

1

2
on the definition and description of primary care can
improve patient's understanding of the healthcare system and
promote effective utilization of primary care providers.

The primary care brochure that was developed for this
project provides education material relevant to these
issues.

Background and History of the Problem

Issues_and_Trends: Patients seeking care for non-
emergent problems/health-concerns often look to the
emergency departments of hospitals to provide that care.
Greene (1996) reported on a recent effort by University of
California-based medical center to curtail inappropriate use
of emergency rooms by non-emergent patients. “Nationwide,
emergency room visits have increased about 5% annually over
the past 10 years? (p. 38). Greene (1995) stated that a
1993 study by the General Accounting Office found that 43%
of all emergency room visits are nonemergency cases and
could be treated by primary providers, thus saving insurance
providers and patients about $7 billion per year in
unnecessary costs.

In the Medicaid population, as well as others, it has
been a common practice to seek any and all care in the
emergency department (ED), and some families have grown up
with this care as the norm. According to Kasper (1987),
this is especially true with lower socioeconomic level of

women and the uninsured or those receiving Medicare. Kasper

3
stated that this patient population has sought care for
themselves and their children in the ED for decades.

With the new healthcare reform, Medicaid recipients are
finding that a PSP (professional service provider) now
appears on their monthly card. PSP is a primary care
provider that the recipient chooses, or one is chosen for
them from a list of providers. These providers are
physicians and nurse practitioners who are approved by
Medicaid, Medicare, and others to provide primary care.
They are the gatekeepers who must authorized treatment in
the ED or other specialty practice. Many healthcare
institutions, Health Maintenance Organizations (HMOs) and
other insurance plans are also involved in the same practice
to help keep non-emergent care with the primary care
providers.

In reviewing the history of primary care, Davis (1991)
noted that from the economic studies of the 19605 through
the early 1980s, it became apparent that one of the
successes in healthcare accessibility was centered around
community health centers; this was especially true with the
ones that served the very young, the very old, those with
chronic illness and African Americans. Davis also stated
that literature published on research in the 19805 showed
that access to proper healthcare was necessary for overall
positive health outcomes of the patient population.

According to Baraski (1993) et al., a study done at

Munson Medical Center (MMC) in Traverse City demonstrated

4
that in the 1993 fiscal year, visits to Munson Medical Ceter
Emergency Department (ED) for minor emergencies (Levels I &
II care) accounted for an estimated $899,000 in costs.
Minor emergencies at Munson ED accounted for 64% of the ED's
total visit volume in the 1993 fiscal year (p.1). Minor
emergencies cited in a retrospective study on fast track
triage by Baranski et al. (1993) were: headaches,
conjunctivitis, simple bronchitis, sore throats, fevers
gastroenteritis, skin rash, dermatitis, minor burns, insect
bites, or minor lacerations (non-facial or extensive),
suture removal, wound checks, and minor fractures (p.2).
The number of patients who were seen for minor emergencies
was 16,778, a 17.6% decline from the peak volumes in 1988.
Competition of Urgent Care, a walk-in clinic, which opened
in 1988 contributed to the decline of minor emergency
volumes at MMC. According to Baranski et a1. (1993) most
consumers (88%) have a family or personal physician but less
than half choose this option for minor medical emergencies
occurring during the daytime (p.1).

A customer survey done by The T.C. Community Survey
(1993) demonstrated that patients preferred Urgent Care for
ease in parking, cost of visit ($40.00 at Urgent Care
compared to $45.00 at Munson ED) and location. Charges for
primary care providers were not included in this listing.
Urgent Care is more visible for patients, especially
tourists, because it is located on US 31, the main

thoroughfare in Traverse City. Munson is more difficult to

5
locate as it is four blocks from the main street. Primary
care offices frequently are not as accessible due to
location. In summary of this survey, primary care offices
should be more accessible to the public to be competitive to
urgent care centers and the emergency department.

The purpose of this project was to develop a brochure
that has an educational focus on primary care, with
definitions of primary care and attributes of having a
primary care provider. The overall goal of this brochure is
to increase awareness of primary care through patient
education, and focus on the benefits of access to
longitudinal care vs. episodic care. This brochure was
developed for the general public to read, but targets the
underserved populations of the Grand Traverse area. Munson
Healthcare System, the area's regional referral center,
provides healthcare service to this largely rural area that
encompasses Benzie, Grand Traverse, Kalkaska, Leelanau, and
Wexford counties primarily, but also includes surrounding
counties.

According to the Northwest Michigan Council of
Governments (1994), the Grand Traverse Area population
consists of Caucasians (98.05%), Native Americans (0.86%),
Mexican Americans (0.78%), African Americans (0.40%), and
Asians (0.49%). In 1970 that population consisted of 98.88%

Caucasian, 0.56% Native America, 0.33% African American,

6
0.0% Asian, and Mexican Americans was listed as THU
(p.88).*

Leelanau County had a growth of Native Americans
between 1970-1990 of 1.99% and the surrounding Counties
showed similar figures in the 1990 Census Report. The
example above is a trend toward a less homogenous society,
ad with this change comes socioeconomic change and more
difficulties accessing primary care.

Although the minority population is small, they are
growing in number. The Northwest Michigan Council of
Governments noted that there also remains a number of
socioeconomically disadvantaged Caucasians. In 1990 the
mean personal income per capita in the five county area was
$17,000 per year. The high school dropout rate in the 1990
census was 14.1% in Leelenau County, 30.4% in Kalkaska
County, and 51.1% in Grand Traverse County.

Problem Statement

When patients choose emergency departments and urgent
care centers for non-emergent healthcare, they do not access
longitudinal, cost effective, and optimum quality
healthcare.

Although many individuals routinely seek non-emergent
healthcare in emergency departments and urgent care centers,
insurance companies are beginning to limit payments for this
costly delivery of healthcare. Presently, there is a
paucity of literature available to the general public

*These are published percentages.

7
regarding primary care settings as preferred sites for non-
emergent healthcare. This is particularly an issue for some
socio-economically disadvantaged populations.
Goals and Objectives of this Brochure

The purpose of this scholarly project was to develop an
informational brochure on primary care that will facilitate
knowledge on access to primary care. The intended audience
for the brochure is the general public, with special focus
and format designed for the socioeconomically disadvantaged.

The content of this brochure will include the following:

1. Definition of primary care.

2. Description of primary care providers.

3. Instructions regarding access to a PCP.

4. Description of attributes of accessible, longitudinal,

cost-effective, coordinated healthcare.
5. Definitions of a true healthcare emergency.
6. Description of episodic healthcare issues can be

treated by a primary care provider.

CHAPTER II

CONCEPTUAL FRAMEWORK

Rogers' Innovation-Decision Process Model

The Inn2xati2nznecision_2regess_n2del (Figure 1) is the
conceptual model created by Rogers (1995) to demonstrate
decision-making as a process rather than a random
instantaneous act. The following concepts are the series of
actions that occur during diffusion of an innovation. In
the case of this project, these are the series of
occurrences involved in diffusion of the innovation of
primary care to the lower socioeconomic populations of the
Grand Traverse and surrounding areas.

Changing an individual's concepts, traditions, or
beliefs regarding choices in acquisition of non-emergent
healthcare is an educational process. The model of the
Innovation-Decision Process is a depiction of the process
that occurs over time, during a decision to accept and adopt
a new idea/innovation. This process is begun by educating
the individual or group about the innovation. This model
has an anthropological basis and is especially applicable in
the Traverse City and the Grand Traverse region where the
heterogeneous population exists with a moderate number of

lower income persons who may not have access to primary care

8

ROGERS' MODEL OF STAGES IN THE INNOVATION-DECISION PROCESS

PRIOR CONDITIONS

1. Previous practice

2. Felt needslproblems

3. lnnovativeness

4. Norms of the social systems

COMMUNICATION CHANNELS

__ .— ._____. .— .— — .— _ _ — —_ — _.... .— — __ _-._ _ _ — — _—
l

| I
l- KNOWLEDGE u. PERSUASION m. DECISION > V- 35%;? >

l l
i i ‘—-—> 1- AdOPfiOB——" Continued Adoption
Characteristics of perceived ‘ —> Later Adoption
the Decision- Characteristics -> Discontinuance
Making Unit of the Innovation: . . . ' . _
1. Socioeconomic 1. Relative advantage ——>2 Rejection———> Continued Rejection
Characteristics 2. Compatibility
2. Personality 3. Complexity

  

N. IMPLEMEN-
TATION

 
   
 

 

variables 4. Trialability
3. Communication 5. Observability
behavior

Eignre_1: Model of Stages in the Innovation-Decision .
Process. Rogers (1995) Diffusion of Innovations

(p.162)

10

because of traditional, cultural or economic reasons. Some
are in need of education about primary care in order to
modify their beliefs about episodic health care that is
neither an optimum choice for healthcare, nor cost effective
healthcare. Education about primary care, utilizing the
primary care brochure as a tool, may enable the population
to seek primary care for non-emergent healthcare problems.
Rogers' Conceptual Definitions

Inngyatign: As defined by Rogers (1995), the concept of
innovation is “an idea, practice, or object that is
perceived as new by an individual or another unit of
adoption? (p.xvii). A unit of adoption, according to
Rogers, is an individual, an organization, a family, or a
social system. The structure of a social system can either
facilitate or impede the diffusion of an idea, or change in
a particular social system, depending upon the communication
that occurs in the system. Patterns of communication
predict, to a large degree, the behaviors of the individuals
in the social system, including if and when they adopt an
innovation. Rogers also stated that an innovation may take
years to be accepted depending on the type of diffusion,
rate of diffusion, or involvement of a change agent, in this
case, the primary care provider.

Wm: 1) W of
the innovation is the degree to which an innovation is

perceived as better than the idea it supersedes; 2)

compatibility is the degree to which an innovation is

11
perceived as being consistent with the existing values, past
experiences, and needs of potential adopters; 3) Complexity
is the degree to which an innovation is perceived as
difficult to understand and use; 4) Trialability is the
degree to which an innovation may be experienced, tried, and
sampled on a limited basis; 5) Qbsgryahility is the degree
to which the results of an innovation are visible to the
others in the group.

Diffusion: The concept of diffusion, as defined by
Rogers (1995) , is “the process by which an innovation is
communicated through certain channels over time among the
members of a social system” (p.5) . An innovation causes
social change when the process of an intention or idea
occurs and is diffused, then is accepted or rejected. In
some instances, a change agent must be utilized in order to
bring about change through education hence the primary care
provider can be utilized as the change agent to communicate
and educate patients about primary care. A primary care
brochure can be the educational tool used by primary care
providers (change agent) in an attempt to persuade the lower
socioeconomic groups to adopt primary care over episodic
care.

There are many means of educating the public and each
method appeals to different populations. Lifestyle,
culture, and values play a very important role in how
individuals obtain information about healthcare. Rogers

(1995) stated that diffusion of information is necessary for

12
change to occur. The diffusion process is made up of four
steps: 1) The Innovation is introduced to the person or
social group; 2) Communication over time is necessary for
diffusion to occur and is related to the dimension of
diffusion from the time the innovation was introduced,
through the acceptance and adoption of the innovation; 3)
Communication of the innovation occurs through interpersonal
communication channels; 4) Communication occurs among the
members of a social system or culture who are a problem
solving entity, congregated to accomplish a common goal.
The NP, as educator and change agent, can understand and
somewhat predict the success and time frame required for
diffusion of the idea of primary care.

The Innovation-Decision Process Model (Rogers, 1995)
has a linear configuration, but the model demonstrates an
overall continuum of communication that interacts along the
phases of the diffusion of a concept or idea (innovation).
The decision to accept or reject the innovation is also a
characteristic of the model which allows the individual to
change a decision about the innovation, i.e., to later
accept or reject once an initial decision is made.

The Innovation-Decision Process Model consists of five
stages: 1) Knowledge that occurs when an individual or group
involved in a decision making process is exposed to the
existence of an idea or innovation; 2) Persuasion of an
individual or decision-making group occurs after knowledge

and thus a favorable or unfavorable attitude toward the

13
innovation is formed; 3) Decision is reached when the
individual group is involved in activities that lead to a
choice to accept or reject the innovation; 4) Implementation
occurs after the decision is reached to put the innovation
into use; 5) Confirmation of the decision to implement the
innovation occurs when the individual or decision-making
group, according to Rogers (1995) “seeks reinforcement of an
innovation-decision- already made” (p.162).

In examination of the Innovation-Decision Process
Model, it is apparent that the activities from the time the
decision was made, through the implementation, and to the
confirmation stage, involves multidirectional movement
possibilities. It is possible to reject an innovation
initially and adopt it at a later date, or to adopt an
innovation early on, then discontinue it later. Therefore,
the model is not a closed or one-way system, but an open,
multidirectional system. It is with this premise that the
primary care provider can educate and increase the knowledge
base of the individual patient or of a family to help them
reach a decision to adopt primary care for their non-
emergent health care needs.

The adapted Innovation-Decision Process Model (Figure
2) depicts the premises of the original diffusion model
(Figure 1). These premises were utilized to develop an

educational tool, the primary care brochure.

14

ADAPTATION OF ROGERS’ MODEL OF STAGES
IN THE INNOVATION-DECISION PROCESS

PRIOR CONDITIONS

1. Previous practice of seeking health care

2. Felt needs/problems of episodic health care

3. lnnovativeness to change behavior

4. Norms of the social systems: visits to non-primary care providers
(emergency departments. walk-in clinics)

COMMUNICATION CHANNELS

I ‘ ‘ l I
l . I
I. KNOWLEDGE II. PERSUASION III. DECISION >N‘ mgr?"- > V- 3:3:

I
PC‘ Brochure Change Agent —>1-Afdgpélgm\——> Continued Adoption
‘ O .~> Later Adoption

| \
i \
\

Characteristics of Perceived / w Discontinuance

 

the Decision- Characteristics —>2. R 'ectm/—_.- Continued R 'ection
Making Unit: of the innovation (PC) ofe’PC* e]
1. Low lncorne 1. Relative advantage

caucasian 2. Compatibility

and minorities 3. Complexity

2. Personal, cultural. 4. Trialability
and ethnic variables 5. Observability
3. Education,
communication
behavior

*Primary Care

Eignre_2f Adaptation of Model of Stages in the Innovation-
Decision Process. Rogers (1995) DifquIOn of

Innovations (p.162).

15
The section in the upper left corner is labeled Prior
Conditions. Before education can begin, these prior

conditions must be addressed:

1. Previous practice of seeking healthcare.

2. Felt needs/problems of episodic healthcare.

3. lnnovativeness to change behavior.

4. Norms of the social systems: visits to non-primary care

providers (emergency departments, walk-in clinics).

Steps of the Innovation-Decision Process are shown as a
continuum linked by communication channels. The steps in
the process are depicted by five arrow-shaped boxes. The
first box is titled knowledge. This portion of the model is
the foundation for a decision process, i.e., one must have
knowledge of primary care in order to make a decision.
Knowledge is conveyed by education. The area directly under
the knowledge box has PC brochure blended with the arrow
that is pointed toward knowledge. The primary care brochure
describes primary care, benefits of primary care, etc. This
is connected to the area entitled, Characteristics of
Decision-Making Unit. These characteristics are 1) low
income Caucasians and Minorities; 2) personal, cultural, and
ethnic variables; and 3) education and communication
behaviors of the individuals who would obtain knowledge of
PC.

The second box is titled Persuasion. An individual may

require education in order to be persuaded to accept the

innovation of primary care. Persuasion may occur through a

16
change agent, who can be the NP or a member of a social
group. The NP can review the brochure with an individual
and elaborate on the perceived characteristics of PC which
are located in the area below the words Change Agent. An
arrow connects the characteristics and points toward
persuasion. The perceived characteristics are: a) relative
advantage; b) compatibility with values; c) complexity; d)
trialability of PC provider and system; and e) Observability
of others who have PCP.

The third box is titled Decision, and interfaces with
an area depicted as Adoption of PC and Rejection of PC.
These two variables interface with variables of continued
adoption, later adoption, discontinuance, and continued
rejection. This process is a representation of the dynamics
and multidirectional characteristics of decision making.

For example, a person may initially reject the innovation of
primary care, but may later adopt the behavior of seeking
primary care if a change agent persuades the person to adopt
that behavior.

The implementation box represents the action of putting
the innovation to use. For example, a woman makes a
decision to seek primary care and reserved an appointment
with a primary care provider, thus implementing her decision
to trial primary care.

The confirmation box represents the individual seeking
reinforcement for the decision he/she made to visit a PCP.

If the visit was a positive experience that behavior will

17
continue and the innovation of primary care will not be
rejected. If the experience does not meet the person's
expectations, or if there are negative or conflicting
messages about PC by family or social system, the person may
reject primary care.
Conceptual Definitions

The concept of primary care is defined by the Michigan
Primary Care Association (1989) as:

A basic level of healthcare usually rendered by

general practitioners, family practitioners,

internists, obstetricians and gynecologists, and
pediatricians, as well as non-physician health
practitioners with specialized training and

skills. Primary care includes those services

people receive on first contact with the

healthcare system, i.e., prevention, maintenance,

diagnosis, limited treatment, management of

chronic problems and referral. Primary care

services are provided in ambulatory settings,

i.e., outpatient clinics and physician's offices

(p. 149).

The definition of provider, according to Starfield
(1992), is a healthcare professional with licensure to
practice medicine as a physician (DO or MD), or licensure to
practice as an advanced practice nurse, known as a nurse
practitioner (NP). Calking (1984) defined advanced nursing

practice as the “deliberative diagnosis and treatment of a

18
full range of human responses to actual or potential health
problems” (p.27) . Other healthcare providers are physician
assistants (PAs), who are board certified and function as
providers under the supervision of a physician. Although
PAs are not licensed providers, they can provide care and
bill under the physician's personal identification number
for Medicare and Medicaid, the insurance most often provided
for the lower socioeconomic population.

In summary, this adapted model of stages in the
Innovation-Decision Process may assist providers to evaluate
reasons why primary care is adopted or rejected by the lower
socioeconomic populations in the Grand Traverse area or in
other areas with similar demographics. The adapted model
also assists the provider to understand his/her role as
change agent in educating the patient about the benefits of

primary care. The primary care brochure is a tool to

promote this innovation.

CHAPTER III

A REVIEW OF THE LITERATURE

The review of literature is organized to: overview the
attributes of primary care, identify some
cultural/socioeconomics drive barriers to accessing primary
care, and provide an overview of methods to promote
education about primary care.

Attributes to Primary Care

Starfield (1992) stated that the four key attributes of
primary care are: first contact care, longitudinality,
coordination, and comprehensiveness.

First contact care implies accessibility to and the use
of services for each new problem or episode of an old
problem for which people seek healthcare. A facility does
not provide first contact care unless the potential users
believe this care will be accessible to them for further
care.

Longitudinality implies the existence of a regular
source of care, and the patient uses this source of care
over time. Thus longitudinality is possible when the
patient remains with the primary care provider who will care
for the patient in all forms of health and illness care.

Starfield (1992) also stated that having longitudinal care

19

20
means that persons will identify with a provider as their
provider, and that the provider or groups of providers do
identify the existence of a relationship or contract as that
person's regular source of care. While longitudinality
implies continuity of care, there exists a difference in
actual definitions. Starfield (1992) explained that
longitudinality refers to successive events of care, is
time-bound and across the full spectrum of potential
problems or reasons for visits to the provider. Continuity
is then defined as the succession of events between provider
visits, without regard to “where or why they occur" (p.79) .
Starfield also noted that people who have longitudinal care
have fewer emergency hospitalizations and shorter
hospitalizations, as demonstrated by a study by Wasson et
al. (1984), in which men over the age of fifty-five were
randomly assigned to two different groups for care, one
longitudinal and the other not. Those persons who chose
primary care over visits to an emergency department for
treatment lessened any time spent in the hospital if they
were later admitted for serious problems.

Comprehensiveness refers to primary care that provides
initial and follow up care by that primary care provider, or
referral to specialists if the condition warrants, and
follow up thereafter. The endpoint is a return to the
primary care provider for assessment and continued care.

Coordination of care is an integration of care that

requires some form of continuity, either by practitioners,

21
medical records, or both, as well as problem recognition.
Coordination of care is essential for good outcomes of
healthcare.

Barriers to Primary care

Barriers to accessing primary care exist within the
lower socioeconomic population, and are barriers to the
diffusion of primary care. Melnyk (1990) defined barriers
to care as intrinsic or extrinsic. That author stated that
barriers perceived by the client/patient are intrinsic
barriers. Examples of these are the inconvenience of
seeking healthcare, previous adverse healthcare experiences,
or social, cultural, or religious issues. These are the
most difficult to modify since they are usually rooted in
the patient's beliefs or values. Extrinsic barriers are
negative relationships with healthcare providers, lack of
providers, lack of transportation to health care facilities
or other site related barriers, and financial concerns.

Financial problems prevent access to primary care for a
significant percentage of the population. Hastings (1995)
reported that.fiA 1987 survey of the uninsured revealed the
poor, or near poor, constituted approximately 37.3% of the
population. Low income Americans made up 21.4%, middle
income persons comprised 27.8%, and high income earner
comprised 13.5%” (p. 53).

Patients with lower socioeconomic status tend to visit
emergency departments instead of choosing a primary care

provider. Many of these patients have gone from one

22
provider to another because they owe money that they cannot
pay from previous visits. Hulen (1995) states that many of
those patients have tried to do the right thing and have
exhausted all resources in seeking healthcare. Hulen also
observed that these patients feel that they have no other
option but to come to the emergency department for acute,
nonurgent problems.

Patients who seek care in emergency departments do not
receive longitudinality and continuity of care. Kelly
(1994) stated that “one of the most disturbing problems we
observed as the “shotgun therapy" received by so many
patients who returned to the emergency department over and
over with varied complaints such as abdominal pain,
headache, or back pain” (p.455) . The author also found that
patients repeatedly received extensive workups because of
their poor history and a lack of access to complete medical
records. Kelly also noted that definitive care and follow-
up in a primary care setting would have been better care and
would not have exposed these patients to endless workups,
poor compliance on the patients' part and ongoing medical
problems. Kelly was instrumental in organizing Peach Tree
Clinic in 1992. The clinic was built to care for persons
seeking non-emergent care and was staffed with primary care
physicians, physician assistants and nurse practitioners.
Inner city clinics are more accessible for urban poor.

According to Mezy and McGivern (1993) national surveys

have demonstrated that 15% of the U.S. population does not

23
have a regular care provider. Nursing surveys found that
17% of Americans had inadequate access to physicians.
Children from low income families are especially vulnerable
to lack of adequate healthcare. Kleinman et al. (1981)
found that children from low income families were twice as
likely to have not seen a physician in the past five years
and that children from low income families had 47% fewer
physician visits overall. These authors also noted that
such families need education on how they can access primary
care and what financial arrangements can be individualized
for them.

Stevensen et al. (1994) stated that America's
healthcare system is failing to meet the needs of children
and the health status of children is declining. Medically
indigent children are lacking adequate healthcare because
there is a lack of providers and insurance. Stevenson noted
that persons with public insurance (Medicaid) were more
likely to use hospital emergency departments and government
clinics for health care. While Medicaid assists low income
parents to obtain healthcare for their children, it may not
be cost-effective care. Medicaid insurance (public
insurance) and medical care use were correlated by Butler et
al. (1985) in a stratified, four stage, area probability
sampling design. In a study of children ages 0-18 in the
Northeast section of the United States (U.S.), a sample of
5,662 children was correlated with an estimate of 69.7

million children in the U.S. in 1980. Researchers found

24
that 13.6% (SE 1.3) did not have health care insurance and
37.5% (SE 2.9) had no regular provider. While the
researchers found no causal relationship to regular care and
reported insurance coverage, they did find that those
children with a regular source of care have lower average
charges per visit; $31.68 for those with a regular provider
compared to $40.68 for those with episodic care (had no
regular source of care) (p.502). The increased cost of
those with non-primary care providers was in part due to
disproportionate use of expensive ER visits and other
hospital based services. Large differences in care were
found according to race or ethnicity as well. During a one
year period approximately one third of African Americans and
Hispanic children did not see any type of provider, compared
to 21% of Caucasian children who did see a provider.

Virji (1990) found that patients from lower
socioeconomic environments, particularly single mothers, had
negative attitudes toward making appointments. The
recommendation from the study was to have a mixed open
access and appointment system to better serve that patient
need. This would allow for spontaneity in visiting the
clinic, a behavior that group continued to value. The
clinic's innovation allowed for a change in type of health
care obtained, but change in the behavior of seeking
immediate care was not accomplished. Primary care clinics
are more desirable than government clinics and emergency

departments because in the government clinics and EDs,

25
patients usually face long waiting lines and discontinuity
of care. According to Aday and Anderson (1984), these
patients are less likely to seek preventative care and will
seek episodic care for illness. Along with these barriers
associated with emergency departments and government
agencies, personal or cultural feelings and attitudes about
healthcare may cause barriers that influence behaviors in
seeking healthcare.

Barriers to healthcare are often related to
misunderstanding cultural beliefs of Native American
patients. Kutenai (1996) believed that primary care NPs and
physicians can make a difference in whether or not Native
Americans take the antibiotic that they are prescribed, or
refuse to take medicine due to the provider's poor
understanding of the patient's cultural beliefs. Kutenai
stated that Native Americans have traditional ways of
healing using herbs, sweat lodges, and prayer. Primary care
physicians and NPs can learn Native ways by communicating
with patients over time, learning their beliefs and values
regarding treatments that are prescribed. In contrast, a
poorly conducted discharge by the ED or fast-track staff may
lead toI“non-compliance”, a term used too frequently by
persons who do not understand cultural needs.

Care and consideration of outcomes is an important part
of primary care. Jackson (1993) reported the case of a
Vietnamese toddler who was treated with moxibustion, a form

of Asian treatment for illness, which involves burning

26

mugwort leaves over skin acupuncture points. The burns were
noted by ED staff when the child was admitted for pneumonia.
The child's mother was educated on American treatment of
pneumonia, primary care follow-up was established, and
maintained by the child's parents. Western medicine was
applied by providing knowledge of new treatments for
pneumonia, while validating previous beliefs, and the
persuasion to make the change was put forth by the nurses,
physicians, and social services. The parents made the
decision to change and adopted the new form of treatment.
New treatment was implemented, and confirmation of the
change for the good was established when the child recovered
from the pneumonia. 1

The primary care provider can view cultures
holistically in order to discover methods to interact in
health and illness care. Leininger (1991) addressed
cultural values such as kinship, social factors,
socioeconomic status, educational background, religious and
philosophical factors. These factors are important in
explaining the role primary care has in providing optimum
care over episodic care. Leininger also stated that
“Culture care was conceptualized and transformed into a
nursing perspective to develop a body of new or distinct
knowledge in nursing" (p.24) .

Many patients may not find in an urgent care walk-in
clinic or fast track ED, a culturally sensitive environment.

Abdullah (1995) found that too often the health needs of

27

patients with diverse cultural backgrounds are not always
completely met due to partially recognized problems. For
example, Mexican American migrants may prefer to come to the
emergency department for acute care needs that are not an
emergency. The IOM (1993) reported that a study of
migrants' health care needs and found that knowing about the
existence of the migrant health center as well as of the
area in which it was located was a factor in increasing that
population's ability to access care. Of those migrants who
were recent immigrants, 45% had no knowledge of the migrant
health center, compared to only 10.4% of the long-term
migrants. Fifty-one percent of the recent-immigrants had
not seen a physician in the past year (p.208). Those who
were not aware of the migrant clinics tended to seek
episodic care or no care at all.
Methods Used to Promote Education About Primary Care

There are various methods of educating the public about
primary care and each method appeals to different
populations. Some cultural norms do not value primary care,
especially in some lower socioeconomic groups, or in others
where there are barriers to accessing primary care. Rogers
(1995) states, “Norms are the established behavior patterns
for the members of a social system? (p.26). With norms and
behavior patterns it is often difficult to persuade
individuals to change beliefs and to reach them with

education.

28

Television and radio are effective methods to educate
the public. Television spots may attract the attention of
viewers, but these are costly and usually require funding
from a lucrative group. Persons who live in poverty may not
have access to a television. According to Lorig (1992),
many media approaches such as interactive TV or VCR programs
are not reaching rural and semi-rural environments. These
are difficult to engineer and are very costly. Thus, large
segments of the population may be denied educational
programs. Lorig stated that.“the simplest and most often
used solution to this problem is the use of printed
materials" (p.40).

Radio is another medium that reaches many persons
during their day in the car, work, home, or leisure time.
Radio is also expensive and not a means to reach some of the
population who are seeking healthcare. Socially
disadvantaged individuals may find newspapers difficult to
read. Therefore, public education on the advantages of
primary care, descriptions of what primary care is, who
provides it, and how to access those caregivers can be
difficult to bring to certain cultures and individuals.

With this in mind, the educational brochure, as a method to
provide education, has an advantage over other forms of
communication.

Brochures and other printed teaching materials can be
beneficial for review of educational sessions with the PCP

and patients can enjoy reviewing the material at their

29
leisure. Redman (1993) stated that “Printed teaching
materials can be described as a frozen language that is
selective in its description of reality” (p.140). Redman
added that printed material encourages limited feedback, but
the material is always available and readers can control the
speed at which they read and comprehend. Redman also noted
that certain types of education seems to demand written
expression, i.e., a complex sequence of thoughts,
definitions, or qualifications.

Redman offered comparisons of various readers'
abilities to absorb written text, in particular, the novice
reader. “Novices take advantage of the text's stability to
slow the rate of information processing; as a result they
are able to review the material? (p.141).

Price and Everett (1996) described a process for
developing a pamphlet specifically designed for low
socioeconomic and less well educated persons. When
developing materials for populations with limited education,
the writer must frequently evaluate the pamphlet to reduce
the number of barriers to comprehension and make the
material more interesting to read. A person's reading
ability is a combination of motivation and skill, and if the
content is too difficult to read, the motivation to read the
material will be lost. Price and Everett provide the
following guidelines for less well educated readers (p.163):
1) Use one or two syllable words whenever possible; 2) Keep

sentences concise; 3) Present one idea (innovation) at a

30
time; 4) Define and uSe phonetic pronunciation for difficult
words; 5) Use simple fonts: avoid all capitals, but use bold
print and italics; 6) Use illustrations and cartoons,
photos, and diagrams for ease of reading and appeal.

PCPs utilize pamphlets and brochures to educate on
various healthcare topics. Shires et al. (1987) stated that
educational brochures have two roles in primary care
practice. First, books and pamphlets provide:“food for
thought? and often motivate patients to seek more
information. The authors also stated that there is some
limited potential for health education during the “downtime”
when the patient, family and/or escorts are waiting for
service. Placing pamphlets or brochures in the waiting
rooms provides reading material to meet this education
potential. This may also indicate to the patients and
significant others that the provider extends a primary care
relationship to them.

Television, home videos and other methods of education
are available today but many educators overlook the brochure
as an easy method to educate patients and families. Haggard
(1989) noted that with today's technology and education of
the media, some people tend to ignore the simple handout.
But in education as an art, simpler is often the better way
to reach out to patients. The author relates a study of one
hospital that believed that a newer, sleeker video approach
would be the best presentation of their material. They

conducted a market survey to determine whether the written

31
patient education materials could be supplemented by the
addition of a similar videotape. The survey indicated that
90% of the respondents preferred a brochure alone.
Respondents also said it was helpful with home care to have
the brochure to read and re-read at their convenience. Only
1% said they wanted the videotape either instead of, or in
addition to, the brochure (p.84).

Haggard (1989) also related the advantages health care
providers may realize in writing their own educational
material. Those advantages are that the provider will have
the ability to: 1) Target questions frequently asked by
patients; 2) Highlight special interests or attributes of
primary care; ad 3) Clarify difficult concepts using
approaches that have worked for that provider in the past.

Studies conducted to evaluate patient knowledge on self
care have demonstrated that educational booklets have an
advantage over oral instructions alone. Maggs et al. (1996)
conducted a single-blind randomized controlled trial on the
effect on knowledge base of arthritis self-care utilizing an
educational booklet for patients with chronic arthritis.

The authors learned that a booklet was found to be more
useful in gaining knowledge about arthritis when used alone,
or in addition to individualized instruction, compared to
group education only. All of the three groups involved in
the study had a similar knowledge base about arthritis self-
care prior to the study. The researchers learned that in

the three groups of 50 person studied over a six week

 

32

period, knowledge base increased significantly (o<0.0001) in
those given the booklet, and those with the booklet and oral
instruction (o<o.001). But for the oral instruction alone
group the increase in knowledge was not significant (as).
The mean knowledge increase score was slightly higher in the
booklet and individual instruction group. A Mann-Whitney U-
test was used to test the statistical differences between
ratio values, using SPSS PC equipment (p.776).
Limitations of the Review of the Literature

Most of the literature regarding the access of primary
care is focused on barrier issues, especially financial
barriers. There is minimal primary care literature
regarding education programs for patients that focuses on
the benefits of primary care. There is a paucity of
brochures or handbooks for the public other than the

materials sent by government or private insurance companies.

CHAPTER IV
METHODS
Overview

The brochure focusing on primary care (Addendum A) was
developed to aid the health care provider to educate the
lower socioeconomic populations of the Grand Traverse region
about primary care. The brochure is a tool that will
promote and enhance discussion about primary care with
patients. It was designed for the lower socioeconomic
patient population to provide an overview of the benefits of
seeking non-emergent and health maintenance care by a
primary care provider. The verbiage and format was designed
to facilitate ease in reading and comprehension of the
material. The brochure will be evaluated by primary care
providers for content, clarity and ease of comprehension
before it is distributed to patients.

The cover of the triple-fold brochure is colorful to
attract the reader's attention and will be titled, “Ezimsry
Carsi_flo_ooro_bost_for_yonf. The title was chosen in an
attempt to reinforce the attributes of primary care (as
stated in the review of literature) over episodic care.
There is an illustrated representation of a provider and
family on the cover. This illustration was selected because

the provider depicted in the illustration is a person of

33

34
color, thus providing ethnic-sensitive validation to the
culturally diverse population. The provider is surrounded
by a family thus implying family centered care.

The left section of the inner portion of the brochure
is titled” ”What is Primary Care?” This section defines
primary care succinctly, according to the Michigan Primary
Care Association (refer to p.12 in the concept section).
The inner section is titled" “Why is Primary Care the best
care?" ‘This section addresses, in simple terminology, the
attributes of primary care, accessibility, continuity,
longitudinality, and cost effectiveness. The inner right
section is titled, “Who are Primary Care Providers?” The
providers, are noted by Starfield (1992), to be physicians
(MD/DO), nurse practitioners (NP), and physician assistants
(PA) (p.146). These providers are listed and there is a
brief explanation of the functions of NPs and PAs. A
stethoscope illustration is located on the bottom of this
section to signify a professional diagnostic tool associated
with healthcare. It was also selected to add color and
interest for the reader. The left side on the back of the
brochure is titled; “When do I see my Primary Care Provider?
A list of minor injuries, medical problems, according to
Parker (1984), and health maintenance services are listed
as: Flu, coughs, and colds, rashes, abdominal discomfort,
small cuts and burns, mental problems, infections, minor
injuries, routine examinations, immunizations, health

maintenance, and chronic health problems.

35

An illustration of an ambulance will precede the
section titled: “When do I go to the Emergency Room?”
Problems that require emergent care, according to Parker
(1984), are listed as: severe breathing problems, fainting,
unconsciousness, or confusion, chest pain, severe bleeding,
burns, or broken bones, and rashes that cause swollen lips
and tongue.

The back side of the brochure has a section for address
and phone numbers of the PCP, the emergency department and
ambulance. The illustration of a cheerful appearing family
is centered on this section and it depicts primary care as
family centered care. The simple illustration is the type
suggested by Price and Everett (1996) as noted in the review
of literature. A space is provided above the illustration
for the business card or stamp of the PCP. Below the
illustration is a section stating, “for appointments call".
The PCP telephone number can be printed there. “We are
available 24 hours a day by calling” is next and is for the
PCPs phone number, which is provided for patient access to a
provider (or on-call PCP). Following that section is a
section titled, “If you have to go to the Emergency Room,
calls” This is to assist the patient to phone for triage
advice if he/she perceives the problem to be severe (see
list). The last section is “If you need an ambulance,
callf’911.

This brochure will be available as a pilot educational

tool in four selected areas: Two primary care clinics,

 

36
Partners in Family Practice in Traverse City, and The
Medicine Lodge at Peshawbestown, the Native American clinic
at the reservation; Munson Medcare Community Health Care
(walk-in); and the Emergency department at Munson Medical
Center. The facilities involved with the pilot educational
brochure will evaluate the tool and provide feedback prior
to utilizing the brochure for their socioeconomically
underserved patient population. These facilities were
selected for reasons of convenience and this author's
familiarity with the clinic staff. The Medicine Lodge was
also chosen for reasons of concentrated ethnic (Native
American) population base.

The evaluation (Addendum B) will consist of 8 questions
that are designed on a Likert Scale as follows: 1=strongly
disagree; 2=disagree; 3=no opinion; 4=agree; and 5=strongly
agree. The questions are: 1) The brochure has sufficient
content to describe primary care; 2) The definition of
primary care provider: DO/MD; NP and PA is clear; 3) The
definition of primary care is clear and concise; 4) The
definition of conditions requiring emergent care is clear
and concise; 5) Examples of illness and injury that can be
treated by a primary care provider are clear; 6) The
brochure is written for ease of comprehension by lower
socioeconomic or persons with a limited education; 7) The
brochure is colorful, attractive and neat; and 8) I would
use the brochure in my practice. Room for comment is

provided at the bottom of each question.

37

A week before the brochures are distributed a letter
will be sent to the providers participating in the survey.
The letter will describe the questionnaire, brochure, and
purpose for the study. Questionnaires will be hand-
delivered to providers in the facilities stated and will be
collected three weeks later. After the questionnaires are
collected they will be evaluated and the brochure may be
modified in accordance with feedback from the participating
providers.

The primary care education brochure, designed for this
project, can be reviewed with applicable patients before
they leave their provider's office. This is a time for the
provider to answer questions and clarify points of the
brochure. The health care provider, through education, can
influence patients and families by helping them accept the
innovation of primary care and thus assist them in accessing
primary care.

In summary, the brochure is an educational tool
utilized to educate the lower socioeconomic population about
the attributes of primary care, identify the providers of
primary care, and to assist them to make decisions about

emergent and non-emergent care needs.

CHAPTER V
IMPLICATIONS FOR ADVANCED PRACTICE NURSING
Overview
The primary care brochure has a focus on APN by briefly
defining the role of the nurse practitioner (NP). It is
important for individuals to be acquainted with the role
that NPs play in primary care. Pearson (1995) cited a draft
of the Clinton healthcare reform plan that included NPs as
one of the important primary care providers. Pearson also
noted that primary care physicians have come to recognize
the need for the addition of NPs to their practices. This
need is related to overwhelming volumes of lower
socioeconomic patients requiring primary care and the
concurrent, significant reduction in reimbursement for care
of these patients. Patients from lower socioeconomic
groups, often require more education and follow-up than do
other patients. Bernard (1994) stated that NPs serve the
healthcare needs of rural populations and those in less
desirable locations, such as inner cities. As stated in
Nursing's Agenda for Healthcare Reform (1994), nurses have
improved access to care in a wide variety of non-geographic
settings that are underserved by physicians. These areas
include nursing homes, adult foster care homes, homeless

shelters, the prison system, as well as many other sites.

38

39
Nurse Practitioners continue to help fill the need for
primary care to those patients that do not have access to
physicians or patients who prefer NPs for primary care.

According to Giger and Davidhizar (1991), nurses today
have different cultural insights into humanity and have a
deeper appreciation for human life and values than do other
providers. Nurses are developing a sensitivity for
different clinical approaches with respect to their
patient's cultural and emotional needs and multivariate
lifestyles. Nurse Practitioners have the ability to meet
educational needs of various patient populations.

Nurse Practitioners in primary care practice have many
opportunities to assist patients to choose primary care over
episodic care. Nurse Practitioners function as sonoators.
Nurse practitioners (NPs) in particular, are educators who
can be the change agents who introduce the innovation of
primary care to the public. One of the domains of the NP,
according to Benner (1984), is the Teaching-Coaching
Function. Nurse Practitioners are educated to assess and
interpret a patient's readiness to learn, preferred methods
of learning, and make culturally avoided aspects of an
illness approachable and understandable. Nurse
Practitioners explain benefits of having longitudinal,
comprehensive, coordinated, cost effective, and accessible
healthcare. This can be accomplished by teaching patients
and families, utilizing the brochure, addressing the

community, church groups, or by using the media. Nurse

40
Practitioners can educate individuals about the importance
of healthcare maintenance, screening and continuity of care.
Focus can be made on education of patients and families in
regard to when they need to seek immediate treatment for
emergent problems and which problems can wait for an
appointment with the primary care provider. Patients are
more likely to adopt this behavior if NPs make their
practice more accessible. One way this is accomplished by
leaving openings in the schedule for drop-ins.

Nurse Practitioners serve as consultants for patients
and families who have medical or emotional concerns. An
individual may need a brief phone conversation with the NP
to alleviate fears and concerns or the problem may require
an office visit. In either case, NPs can set aside a block
of unscheduled time to address these patients or they may be
scheduled for an appointment. As stated in the review of
literature, it is often the lower socioeconomic populations
or minority patients who seek immediate care for their
problems. This response by the NP may again reinforce their
decision to adopt primary care instead of episodic care.

NPs role of adzooafio enables patients to make healthcare
decisions by transferring responsibility for these decisions
to the patients. This role is accomplished by keeping
patients informed and directing the healthcare back to them
for self-care, when possible. Nurse Practitioners can
assist patients to obtain Medicaid or other general

assistance for health care reimbursement, and obtain cost-

41
free medication samples and supplies from pharmaceutical
companies. This will enable patients to continue self care
regimens.

Nurse Practitioners are excellent oiinioians, who
address healthcare concerns and can formulate a plan of care
for acute and chronic illness in a timely manner to promote
a feeling of care and concern that patients expect.
Patients will hold the belief that they are a partner in
their health and illness care, and this may deter their
visits for episodic care.

Nurse Practitioners are assossors who identify and
diagnose health problems and outline a plan for their
patient population. This is an especially integral role
when caring for minorities and others who are
socioeconomically challenged. Native Americans, according
to Kutenai (1996), are often reluctant to admit they are
taking Native remedies along with conventional medicine, or
may not admit they do not understand what the provider is
treating. Careful assessment of cultural views and
relationships is essential to reinforcing continuity of care
by the primary care provider. Nurse Practitioners must
frequently assess the compatibility and social
characteristics of a patient before implementing an
innovation.

Nurse Practitioners serve as a ohsngs_ogont when
demonstrating the primary care brochure, thus using Rogers'

(1995) model to introduce and persuade the individual and/or

42
family to adopt primary health care instead of episodic
care. The NP, as change agent, will provide optimum health
and illness care, and assist the patient to change poor
health behaviors. This is especially needed in the lower
socioeconomic culture when morbidity and mortality are
higher than in the middle and upper classes, as shown by the
literature review.

Nurse Practitioners can provide more culturally
sensitive care if they research cultural behaviors and
beliefs of Native American, Mexican American, and Asian
patients and families. If a Native American grandmother is
burning sweetgrass and sage to cure her hypertension, the NP
attempts to understand these ways and address a healthcare
plan for hypertension that is compatible with the patient's
beliefs. She/he can provide data to the patient which
demonstrates the relative advantage of the plan.

Nurse Practitioners serve as ooiisborators who work
with other members of the healthcare team to plan a
patient's care, including the available resources for the
patients after regular primary care hours. This is to give
a sense of direction and security to patients so they don't
feel abandoned when the NPs office is closed. The NP can
use the primary care brochure to outline what is a true
emergency to assist the patient to make a good decision. If

they are in doubt they can phone the emergency department

for assistance in making a decision.

43

Finally, NPs serve as a ro1o_modoi whose behavior is
worthy of emulation by patients and other healthcare
members. Nurse Practitioners use the combined roles of
advance practice nursing to enable the patient, family, or
social system to adopt the innovation of primary care and
implement that behavior for long term optimum healthcare
delivery. The primary care brochure may serve to reinforce
the role of NPs in primary care and to confirm the
innovation for those who adopt primary care for a lifetime.

A Website is an excellent and expedient method of
distributing the primary care brochure for downloading and
utilization by other health care providers. Information
printed in the brochure can be individualized for primary
care clinics across the United States and possibly other
countries. Horton (1994) stated that web sites are
beneficial for retrieving documents because less time is
spent searching for information, and that information such
as the brochure, can be easily accessed by providers.

A research question that may be generated from this
scholarly project is: “Does this primary care brochure
promote a change in behavior of the lower socioeconomic
population of the Grand Traverse Area, who presently seek
non-emergent care in emergency departments and urgent care
centers, to instead seek primary care?" Nursing research
can demonstrate whether or not a behavioral change occurs in
this population toward maintaining a primary care

relationship with their providers.

44

Summary and Implications of This Study: Potential
Contributions

The onrooso of this scholarly project was to develop an
educational tool to assist the primary care provider to
educate the lower socioeconomic population of the Grand
Traverse area and surrounding counties about primary care.
The decision to educate this population about primary care
was founded on reviewing literature on the patterns they
have of seeking episodic care in emergency departments and
walk-in clinics. Barriers to access of primary care were
addressed, according to Melnyk (1990), as intrinsic and
extrinsic. Intrinsic barriers were noted as: the
inconvenience of seeking healthcare, previous adverse
healthcare experiences, or cultural, religious, or social
issues. Extrinsic barrier Melnyk stated are, for example:
lack of providers, transportation, or financial concerns.

The oonoootooi_mooo1 for this project was based on
Rogers' Innovation-Decision Process Model (1995) in order to
apply this concept in the decision-making process of the
lower socioeconomic population after education about primary
care. The outcome after education about primary care can be
a change toward adopting primary care instead of episodic
care. The Innovation-Decision Process Model was adapted to:
review previous practices of seeking healthcare, review
needs or problems of episodic care, assess innovativeness to

change the behavior of seeking episodic care, and assess

45
norms of the social/cultural systems that apply to beliefs
about seeking healthcare.

The communication channels for this process are:
knowledge, persuasion, decision to change, implementation of
the change, and confirmation of the change to adopt primary
care (p.14).

Imoismontotion_of_tho_oroioot. An educational brochure
was developed for this project that is to be utilized by the
primary care provider to educate the described population
about the attributes of primary care compared to episodic
care. The brochure was selected after researching
literature on various educational methodologies. Brochures
were found to be a valid and useful method for educating the
lower socioeconomic populations and the general population
as well. The primary care brochure is a tri-fold brochure
that provides a definition of primary care, describes the
attributes of primary care, identifies the providers of
primary care (DO/MD, NP, and PA). The brochure lists non-
emergent health concerns that may be treated by a primary
care provider. The brochure also explains which concerns
require emergency department intervention. Sections are
provided by a listing of phone numbers and addresses for
accessing a primary care provider. Guidelines for
developing brochure information to lower socioeconomic
patient populations are outlined by Haggard (1989). An
evaluation tool and methodology was developed to evaluate

the brochure for use in the primary care setting. The

46

brochures may be duplicated for educational use by any
healthcare provider and can be reproduced in Spanish for the
migrant population. A Website can be utilized to download
the brochure for use by healthcare providers across the
United States and in other countries.
Recommendation for Nurse Practitioners

The primary care brochure can be a tool for NPs to
educate lower socioeconomic populations about primary care.
Nurse Practitioners, as stated by Barnard (1994), serve the
healthcare needs of rural populations. Nurse Practitioners
also provide culturally sensitive care as described by
Kutenai (1996). The multifaceted roles of the NP as
educator, consultant, advocate, assessor, role model,
collaborator, change agent and clinician, provide patients
with an optimum quality primary care provider. Nurse
Practitioners use the roles of the advanced practice nurse
to enable the patient, family, or social system to adopt

primary care for accessible, longitudinal, and cost-

effective healthcare.

LI ST OF REFERENCES

LIST OF REFERENCES

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Aday, L. & Anderson, R. (1984). The National profile
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Iournal_cf_2ublic_Health1_14. 1331- 1337

Advanced Practice Nurses: An innovation for primary
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Baranski, M. & Westover, G. (1993). Retrospective

“fast track” study results. Munson Medical Center, Traverse
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Barnard K., Croenwith, L., Doughty, S., Hall, B.,
Harkness, G., Korthan, M., Lamendoal, F., Porkorney, B., &
Walker. M- (1994)- Nnrs1ns1_A_social_pelic¥_statement.
(draft), Kansas City, MO: American Nurses Association.

Butler, J., Winter, W., Singer, J., & Wenger, M.
(1985). Medical care use and expenditure among children and
youth in the United States: Analysis of a National

probability sample. Podiatrios+_1§(4), 495-507.

Calking, J. (1984). A model for advanced nursing
practice. The_IDurnal_of_Nursing_Administration1_1A(1). 27.

Davis, K. (1991). Inequality and access to health
care. The_Millbank_Memorial_Eund_Qnarterl¥+_§2(2). 259-

Giger, J. & Davidhizar, R. (1991). Tronsoultnral
nnrsing1_Assessment_and_interxention- St. Louis, Baltimore:
Mosby Year Book.

Greene, J. (1996). ERs adapt to era of HMOs. Modozn
Hooithooro. January 29, p.38.

Haggard, A. (1989). Handbook of Patient Education.
Royal Turnbridge Wells, Rockville, MD: Aspen Publications.

47

48

Hastings, K. (1995). Health care reform. We need it,
but do we have the National will to shape our future? Tho
NRZ§£_EIEQLiLiQn§I+_ZQ(91), 52- 57.

Horton, W. (1994). Designing and writing on-line
documents: Hypermedia for self-supporting products, (2nd
Ed.)., New York: John Wiley and Sons, Inc.

Hulen, D. & Beeler, L. (1995). TennCare: The impact of
state health care reform on emergency patients and

caregivers. The_Journal_Qf_Emergencx_Nurs1nsi_21I4). 282-
286.

Institute of Medicine. (1993). (Millman Ed.) Aoooss
toD_Health_sare_1n_America. Washington DC: National Academy
Press.

Jackson, L. (1993). Understanding, eliciting, and
negotiating clients' Multicultural Health Beliefs. Nozso
Practitioner1_1§(4). 43.

Kasper, J. (1987). Importance of type of usual source
of care for children's physician access and expenditures.
Medical_9arei_25(5), 386- 398-

Kelly, K. (1994). Cost containment in the Emergency
Department. Shifting the cost of caring for patients with
nonemergency conditions from crowded emergency departments

to primary care settings. 1ournal_of_Emergenc¥_Nursino
29(6). 54-

Kleinman, J., Gold, N., & Makuc, D. (1980). Use of
ambulatory medical care by the poor; another look of equity.
Medical_Care(XIX). 1011- 1021..

Kutenai, K. (1996). A Native-American nurse's view.
Adyanced_Eractice_Nurs1ng_QuarterlY+_2(2), 59-61.

Leininger, M. (1991). Culture care diversity and
universality: A theory for nursing. New York: National
League Nursing Press.

Lcrig. K. (1992). Eat1ent_Education1_A_nractical
aooroooh. St. Louis, Baltimore: Mosby Book Co., p.40.

Maggs, F., Jubb, R., & Kemm, J. (1996). Single-blind
randomized controlled trial of an educational booklet for
patients with chronic arthritis. British_lournal_of
Bheumatolss¥1_1§(8). 775- 777

Melnyk, K. (1990). Barriers to care: Operationalizing
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49

Mezy, M., & McGovern, D. (1993). Nursssi_Nnrso
' ' ° ' , (2nd Ed.).
New York: Springer Publishing Co.

Michigan Primary Care Association. (1989). A blueprint
for primary health care communities building a healthy
foundation. Executive Summary, p. 149.

Millman. M. (1993). (Ed-I Access_to_2r1mer¥_sere_1n
Amorioo. National Academy of Sciences. Washington DC:

National Academy Press, p. 162-164.

Northwestern Michigan Council of Governments. (1994).
Population Characteristics. Demographic Profile of

Northwest lower Michigan. September, 1994 (includes U.S.
Census Bureau Reports), pp. 20-89.

Parker. J. (1984). Emergenc¥_Nurs1ns1_A_sn1de_to
oomorohsnsiyo_ooro. New York: J. Whiley & Sons, pp. 46-48.

Pearson, L. (1995). Annual update of how each state
stands on Legislative issues affecting advance nursing
practice. The_Nurse_2ractitioner1_zui1). 13.

Price, J. & Everett S. (1996). Developing cancer
pamphlets for economically disadvantaged African Americans.
‘ ° ' , 159-176.

Redman, B. (1993).
(7th ed.), New York: Mosby Year-book Inc., 140-177.

Rogers, E. (1995). D1ffusion.of_1nno1ations. (4th

ed.). Tokyo, London, The Free Press.

Shires, D., Hennen, B., & Rice, D. (1987). Family

- , (2nd
ed.). New York: McGraw-Hill.

Starfield. B. (1992). Er1marY_care1_Concent_exaluat19n
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Stevenson, L., Cody, D., Evans, K., Plumb, 8.,
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access to health care: Pediatric nurse practitioner in WIC-
based clinics for one stop health care. Journoi_of
'Eedidtzin_§anfii_§(4)i 158'172-

T.C. Community Survey. (1993). Preferences for Non-
Emergent Care. Northeast Research Co. September 1, 1993.

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Med121ne_lonrnali_1nl. 22-26.

50

Wasson, J., Sauvigne, A., Mogielnicki, R., Frey, W.,
Sox, C., Gaudette, C., & Rockwell, A. (1984). Continuity of
outpatient care in elderly men. A randomized trial.

MW, 2413- 17.

APPENDIX A

Primary Care Brochure

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APPENDIX B

Evaluation of the Primary Care Brochure

53

Primary Care Brochure

Jo Hendrix

5942 Marilyn Ct.
Traverse City. MI. 49684
April 30. 1998

Dear Healthcare Provider.

Thank you for agreeing to participate in the evaluation of a pilot brochure that will be
used as an educational tool to teach our lower socioecenomic population of patients about
primary care. The brochure is designed to facillitate conversation between you and your
patient regarding the benefits of seeking their primary care provider for health and illness
concerns. This educational process is intended to persuade patients to change the behavior
of seeking episodic care at the emergency department and urgent care centers.

On May 8. I will be providing you with a copy of the primary care brochure pilot tool
along with an attached cvalualion form. I will collect the evaluation forms 3 weeks after
that date I May 29). Il'you have any questions I can be reached at 616-943-3005.

Sincerely.

Jo Hendrix. RX. .\IS.\'

F”

54

Primary Care Brochure

E\-"ALUATION OF THE PRD IARY C ARE BROCHURE:
A pilot educational tool

Please answer the following questions by assigning each one number from 1 to 5. The
value for the numbers are as follows:

1=strongly disagree: 2tdisagree: 3=no opinion: 4=agree; and 52strongly agree

1. The brochure has sufficient content to describe primary care. 1 2 3 4 5
Comments:

2. The definition of primary care provider: DO..\ID: .\P and PA 1 2 3 4 5

is clear

C omments:

3. The definition of primary care is clear and concise. 1 2 3 4 5

Comments:

4. The definition of conditions requiring emergent care is clear 1 2 3 4 5
and concise.

Comments:

5. Examples of illness and injury that can be treated by a primary 1 2 3 4 5
care provider are clear.

Comments:

6. The brochure is written ior ease of comprehension by lower 1 2 3 4 5
socioeconomic or persons
with limited education.

Comments:

7. The brochure is colorlu1. attractive and neat. 1 2 3 4 5

Comments:

8. 1 would use the brochure in my practice. 1 2 3 4 5

Comments:

Name (optional)

 

Thank you for participating in this evaluation and agreeing to trial this educational tool. I
will collect them on May 16. 1998. Ifyou have questions. phone 943-3005.

.10 Hendrix. RN I\ISI\'

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