Nakela Cook, MD, MPH

2003-2004

Chief of Staff, National Health, Lung and Blood Institute/ National Institutes of Health, Bethesda, MD

Dr. Nakela Cook is the chief of staff in the Immediate Office of the Director (IOD) of the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health (NIH).  Dr. Cook provides institutional leadership to support the NHLBI Director, serves as his liaison to senior officials within and outside of the Institute, and provides oversight to the support operations of the IOD. Additionally, she provides institutional leadership to catalyze multi-disciplinary activities initiated by the NHLBI director. As such, she provides direct leadership for the strategic direction of the women’s health research agenda at NHLBI and serves as a spokesperson related to the health of women for the Institute.

Prior to her appointment as chief of staff, Dr. Cook served as a medical officer in the Clinical Applications and Prevention Branch in the Division of Cardiovascular Sciences at the NHLBI. Her work in the Division involved outcomes research, epidemiology, and clinical trials. Dr. Cook’s research portfolio includes comparative effectiveness research, cardiovascular imaging, racial/ethnic and sex/gender disparities in cardiovascular disease, and cardiovascular health services research.

Dr. Cook is board certified in cardiology. She received a Bachelor of Science degree in materials science and engineering from the University of Alabama at Birmingham, a Doctor of Medicine from Harvard Medical School, and clinical training in primary care/internal medicine and cardiology at Massachusetts General Hospital (MGH). Dr. Cook completed a fellowship in Health Services Research at the Harvard School of Public Health. She is also an alumnus of the Commonwealth Fund/Harvard University Fellowship in Minority Health Policy and completed her Masters of Public Health with a concentration in health care policy as part of this fellowship.

2011

2010

2009

2007

2006

Access to Specialty Care and Medical Services in the Community Health Center Population

Background:

Despite improvements in the overall health of the U.S. population, medically underserved populations and areas still exist. These populations experience higher rates of morbidity and mortality and are often uninsured, ethnic or racial minorities, lower income or geographically isolated.  Community health centers were first funded by the federal government in the mid-1960’s with a mission to provide primary and preventive health care for individuals in rural and urban medically underserved communities. Community health centers equalize access to primary care regardless of insurance status, but do not address the disparities in accessing secondary level care. The existence of barriers to access of specialty care and services for minority and uninsured populations may contribute significantly to disparities in health and health outcomes overall for the medically underserved. In the current US health system, disparate health outcomes between the medically underserved and the mainstream result in part from tiered levels of care based upon insurance status and accessibility to needed specialized services

More recently the safety net of community health centers has been explored. Research has identified that capacity for the uninsured is inadequate outside of health centers with strained specialty services, pharmaceutical services, dental care, and behavioral health care.1 Directors in ten sampled states reported that when patients at community health centers need care not provided on site, including specialty services and diagnostic procedures, cost is a main barrier to access specialty referrals.2 Even surveyed providers at academic health centers report access to specialty care very difficult for uninsured patients relative to those privately insured.3 This project evaluates access to specialty care and medical services with the following aims:

  •     Assess whether access to specialty medical care and laboratory/diagnostic procedures differs according to patients’ insurance status, and if so, identify potential barriers.
  •     Assess whether specialty medical care and laboratory/diagnostic procedures differ according to the proportion of minority patients served by community health centers.

Methods:

Sample Executive Directors and Medical Directors at Community Health Centers across the nation were surveyed regarding access to specialty services. The data collection protocol consisted of an initial mailing to 1802 potential respondents followed by the mailing of reminder cards two weeks after initial mailing. A second mailing was sent to non-respondents.

Survey Development The survey instrument is a compilation of original and adapted items based upon discussions with key informants and literature review. Survey domains include health center characteristics, referral access, barriers to referral, and strategies to improve referral success by insurance status.

Statistical Analysis Preliminary analysis of 179 Executive Director surveys was performed. Descriptive statistics were used to describe the extent to which community health centers are experiencing problems with access to specialty referrals and laboratory and diagnostic procedures and to evaluate the ability to obtain needed referrals and specialty care according to insurance status. Bivariate tests were used to compare whether access to such services varies by insurance type.

Results:

Preliminary analysis of reports from Executive Directors at 179 community health centers revealed that the need for medically necessary referral does not differ by insurance status. However, obtaining referral to specialty services differs by insurance with uninsured patients attaining referral a lower percentage of the time. Executive Directors reported that barriers limit access to specialty care and medical services a greater extent of the time for uninsured patients compared to private patients. Executive Directors revealed that the creation or improvement of locally integrated referral networks as well as mandates for specialists to expand charity provision were strategies they thought would improve access to specialty services. Lastly Executive Directors’ perceptions of the quality of specialty services varies by insurance with uninsured patients having a lower perceived degree of quality.

Conclusion:

Access to specialty care and medical services is a problem with greater perceived barriers for uninsured patients, and patients with Medicaid, relative to privately insured patients, despite equivalent need for medically necessary referrals.

Faculty Preceptors:

Magda Peck, ScD, Executive Director, CityMatCH
Paul Wise, MD, MPH, Co-Chief, Division of Social Medicine and Health Inequalities, Brigham and Women’s Hospital

References:

    Felt-Lisk S, McHugh M, Howell E. Monitoring local safety-net providers: Do they have adequate capacity? Health Affairs 2002; 21(5):277-283.
    Gusmano MK, Fairbrother G, Park H. Exploring the limits of the safety net: Community health   centers and care for the uninsured. Health Affairs 2002; 21(6): 188-194.
    Weissman J, Moy E, Campbell E, et al. Limits to the safety net: Teaching hospital faculty report on their patients’ access to care. Health Affairs 2003; 22(6): 156-166.