Abstract

Vulnerability is the increased susceptibility for poor medical, mental, and oral health outcomes. Vulnerable individuals and populations often have a greater risk for poor health outcomes than the general population because of the interplay of disparate healthcare access; healthcare quality; and genetic, personal, behavioral, environmental, socioeconomic, and community risk factors. All of these factors can operate at the individual, family, community, and population levels.

Traditionally, healthcare providers have considered biomedical conditions as primary determinants of poor health. Since poor health along one dimension can be compounded by poor health along others, health needs are considerably greater for those with multiple health problems than for those with single health problems. Likewise, when non-biomedical health determinants converge in an individual, vulnerability may dramatically increase.

As our population, society, and environment change, so does the constellation of vulnerability factors that healthcare providers must be competent to address. The U.S. population has also significantly changed over recent years, including dramatic increases in racial and ethnic minorities and new immigrant groups, many of whom are non-English-speaking and with differing cultural beliefs; children living in poverty; and individuals who have no healthcare insurance or who are underinsured.

The Nation’s 100 million persons from racial and ethnic minority groups are a critical vulnerable population. Persons from minority groups have well-documented barriers to essential healthcare services and suffer a great burden of preventable disease. These individuals must be the focus of healthcare, educational, and research initiatives to reduce unacceptable disparities. In particular, healthcare providers must develop the knowledge, skills, and competencies necessary to address this large vulnerable population. These goals are important in all programs that train medical and dental providers, but they are a special focus of programs for primary care physicians, physician assistants, and dentists who assume an even greater role in the care of vulnerable populations.

However, there are other groups of vulnerable populations who have, to date, been overlooked in discussions about patients with special needs and greater risks of adverse outcomes. Advancements in medical technology and specific treatment interventions, for example, have significantly increased longevity for many persons with developmental disabilities. As a result, there is a growing population of adult patients with developmental and intellectual disabilities who are unable to find appropriate health and dental care providers experienced in caring for their special healthcare needs. Persons with intellectual and developmental disabilities are an emerging vulnerable population, as are prisoners and survivors of terrorism, war, and natural disasters. These groups must be added to the list of those with traditional risk factors, such as homelessness, substance abuse, mental illness, poverty, and poor access to healthcare.

Clinicians must develop an expanded set of clinical skills in order to address the complex problems of vulnerable patients. They must learn to identify factors that contribute to vulnerability and to work with patients and communities to bolster factors that promote good health. This work requires clinicians to be able to perform effectively across lines of difference in culture, class, race, and ethnicity, as well as with persons with intellectual and physical disabilities.

The Advisory Committee on Training in Primary Care Medicine and Dentistry (ACTPCMD) commissioned six experts to provide a detailed written description of vulnerability and vulnerable populations and the challenges facing an evolving healthcare system attempting to remedy identified disparities. These six papers, found in Appendices A through F of this report, highlight a multi-factorial approach to defining vulnerable populations and individuals in the United States. At the same time, the papers provide a guide for interdisciplinary workforce approaches and clinical innovations and training competencies through Title VII, section 747 programs directed toward this ever-changing epidemiology among the Nation’s citizens.

The U.S. Department of Health and Human Services should promote educational programs for primary care dentists, physicians, and physician assistants that contribute to the development of these competencies and clinical innovations in caring for vulnerable -populations.

Conclusion

Vulnerability is the increased susceptibility for poor medical, mental, and oral health outcomes that is influenced by conditions such as disparate healthcare access; healthcare quality; and genetic, personal, behavioral, environmental, socioeconomic, and community risk factors. Current educational training available in the Nation’s medical and dental schools and residency programs does not adequately train students to be competent to provide comprehensive and preventive healthcare for the Nation’s most vulnerable populations. Title VII, section 747 programs are uniquely positioned to provide the leadership to change a healthcare system that has often neglected its most vulnerable citizens. Adoption of the recommendations in this report will significantly expand healthcare services to all vulnerable individuals, including those with special health needs.

Recommendations

Consistent with its stated purpose:

To educate and train physicians, pediatric and general dentists, and physician assistants to enhance the quality, capacity, and diversity of the Nation’s primary care workforce, giving special consideration to the healthcare needs of underserved populations and other high-risk groups.

The Advisory Committee on Training in Primary Care Medicine and Dentistry (ACTPCMD) recommends the following:

1. To prepare future primary healthcare providers with the training to meet the emerging challenges to the health of the public, the Title VII, section 747 grant program requires reauthorization and an appropriation at a minimum level of $215 -million.
2. The Title VII, section 747 grant program should address the identified curricular and clinical instruction inadequacies relating to the management of vulnerable and high-risk individuals in the Nation’s medical and dental predoctoral and postgraduate training programs.
3. In order to address health disparities as outlined in Healthy People 2010, the recruitment, education, and training of a larger and more diverse primary care workforce of physicians, physician assistants, and pediatric and general dentists are necessary to address the Nation’s critical healthcare needs, specifically those of vulnerable individuals and populations.
4. The Title VII, section 747 grant program should encourage the educational accreditation, licensure, and certification organizations for physicians, physician assistants, and general and pediatric dentists to mandate policies and procedures that ensure that the healthcare workforce is prepared to provide competent care to vulnerable individuals and populations.
5. The Title VII, section 747 grant program should review and expand the definition of underserved and high-risk populations to include all aspects of vulnerability. Title VII, section 747 proposals that address primary care education and training to serve vulnerable populations should be prioritized. The Title VII, section 747 grant program should encourage programs to provide their trainees with the means to know the basic demographics about their patient populations and to understand the implications for the care of those patients.