HLTH 4343 Module 3 Access to Care Analysis Example

A Five-Month Wait for the Endocrinologist: Access Barriers for Adults With Diabetes at a Community Health Center Network in Imperial County, Mapped With the Levesque Framework

Student Name

American College of Education

HLTH4343: Health and Wellness Across Populations

Module 3 Assignment

Instructor Name

October 19, 2026

Access as a Process

Access to care is often measured with a single number, such as the share of people with insurance, but patients experience it as a series of steps. Levesque et al. (2013) describe access as the opportunity to identify health care needs, to seek services, to reach them, to obtain or use them, and to have the need actually fulfilled. Their framework pairs five dimensions of services, approachability, acceptability, availability and accommodation, affordability and appropriateness, with five corresponding abilities of people: the ability in the patients themselves: perceiving that care is needed, seeking it out, physically getting there, paying for it and taking part in it. Access happens where the two meet.

I use this framework to examine access for adults with diabetes at a four-clinic community health center network, a composite, in Imperial County, California, the population profiled in Module 1. The county's context is well documented: 22.2% of adults aged 18 to 64 lack health insurance and 15.5% of adults say transportation problems have kept them from care or other daily needs (Centers for Disease Control and Prevention [CDC], 2025). The network's own data, reviewed with the clinical director, add detail on how those barriers play out.

Perceiving and Seeking Care

The first steps are knowing that care is needed and deciding to seek it. The network's data suggest many patients enter late. Of adults newly diagnosed with diabetes at the network last year, 38% had a first hemoglobin A1c of 9% or higher, a level suggesting that diabetes had gone undetected or untreated for some time. Patients describe reasons that match the framework's early dimensions. Some did not know that symptoms such as fatigue or frequent urination could signal diabetes. Others avoided clinics because of cost or because they did not know the health centers serve people regardless of insurance or immigration status, which is a matter of approachability: the network had never advertised that fact in Spanish-language media.

Acceptability also plays a part. Patients who have had experiences of being rushed or spoken to only in English may not return, and several told front desk staff that they preferred to wait until a trip to Mexicali, where they could see a physician who spoke their language and pay in cash.

Reaching and Obtaining Care

Reaching care requires transportation and hours that fit patients' lives. The network's clinics are open from eight to five on weekdays, which collides with agricultural work that starts before dawn and runs through the afternoon during harvest. Missed appointment rates for patients with diabetes rise from about 14% in winter to 23% in the peak harvest months, according to the network's scheduling data. For the 15.5% of county adults without reliable transportation, a clinic twenty miles away may be unreachable without a ride from family.

Obtaining specialty care is the hardest step. The network refers patients with complicated diabetes to endocrinologists in San Diego, about two hours away, and last year a patient's first endocrinology visit typically came five months after the referral. Many patients never went; of 112 endocrinology referrals, the network could confirm that 51 resulted in a visit. Retinal screening for diabetic eye disease faces a similar gap, since the county has few eye specialists, and the network's records show a retinal exam within twelve months for only about half of its patients with diabetes.

Paying for and Engaging With Care

Affordability shapes whether patients can continue care after the first visit. Health centers charge uninsured patients on a sliding fee scale, but costs outside the visit, such as glucose testing supplies, insulin and specialist bills, can be prohibitive. The network's pharmacy staff report that uninsured patients often ration test strips. Many uninsured adults in the county may qualify for Medi-Cal, but eligibility rules for some immigrant adults have changed in recent state budgets, and enrollment requires paperwork that many find confusing or fear. Staff who help with applications need to check the current rules for each case rather than rely on what was true a year ago.

Engagement, the last step, requires care that patients can understand and act on. A treatment plan explained in English to a patient who reads Spanish is available care that the patient cannot use. The network employs bilingual clinicians, but printed education materials are uneven, and diabetes education classes are offered only once a month, in the morning, at one site.

What the Network Can Change

The framework's value is that it directs each response to a specific dimension. For approachability, the network should run a Spanish-language radio and social media campaign stating that its centers serve everyone regardless of insurance or immigration status, and should offer free A1c screening at community events. For availability and accommodation, it should open one clinic on Saturday mornings and until seven in the evening two days a week during harvest months, and schedule diabetes visits outside the hottest hours of the day. For reaching care, it should add a transportation benefit through a rideshare contract for patients with diabetes who have missed two appointments.

For specialty access, the network should introduce electronic consultations, or e-consults, in which a primary care clinician sends a structured question to a specialist through a shared record and receives written advice without a face-to-face visit. Vimalananda et al. (2015), reviewing 27 articles, found that e-consults provide timely access to specialty input, are feasible in a variety of settings and are well received by primary care clinicians, though they noted that more rigorous studies are needed on their effect on costs and clinical outcomes. For the many referrals that seek advice on medication adjustment, an e-consult could replace a five-month wait with a reply in days, reserving in-person visits for patients who truly need them. For affordability, a full-time enrollment specialist should help uninsured patients apply for Medi-Cal. For engagement, diabetes education should be offered in Spanish at two sites, in the evening and on Saturdays.

Measuring Access

The network will measure access at each step rather than with a single figure. The measures are the share of new diabetes diagnoses with a first A1c of 9% or higher, as a sign of earlier detection; missed appointment rates by season; the share of specialty questions resolved by e-consult and the median time to specialist advice; the proportion of patients with diabetes whose retinal exam is current; and the number of uninsured patients enrolled in coverage. Each will be reported quarterly and, where the data allow, separately by preferred language, so that improvements for English speakers do not hide gaps for Spanish speakers. A change that shortens the specialist wait but leaves the harvest-season no-show rate untouched would tell the network that its hours, not its referrals, are the next barrier to address.

References

Centers for Disease Control and Prevention. (2025). PLACES: Local data for better health, county data 2025 release [Data set]. https://data.cdc.gov/

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

Vimalananda, V. G., Gupte, G., Seraj, S. M., Orlander, J., Berlowitz, D., Fincke, B. G., & Simon, S. R. (2015). Electronic consultations (e-consults) to improve access to specialty care: A systematic review and narrative synthesis. Journal of Telemedicine and Telecare, 21(6), 323-330. https://doi.org/10.1177/1357633X15582108