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Domain 1: Access


Timeliness of Care


Quick start protocols for contraception initiation:

refers to the initiation of contraception on the day of the visit.

Third next available appointment:

refers to the average length of time in days between the day a patient makes a request for an appointment and the third next available appointment. The third next available appointment is used rather than the next available appointment because it is a more sensitive reflection of true appointment availability.


  • Reduce unnecessary barriers and facilitate same-day access to and successful use of contraceptives.
    • For example, do not require a negative chlamydia test result prior to inserting an IUD or a Pap test/pelvic exam in asymptomatic women wanting oral contraceptives.
    • Follow the Centers for Disease Control and Prevention’s (CDC) U.S. Selected Practice Recommendations (US SPR) for Contraceptive Use to determine the appropriate initiation and use of specific contraceptive methods.1
    • Use the “quick start” method to provide patients with protection from unplanned pregnancy faster and more reliably.2
  • Develop written policies that include directions for phone staff to ask patients if they need a same-day appointment.
    • Establish a process to schedule these appointments as requested.
    • Ensure clinic workflows accommodate appointments for patients with urgent needs, including double booking as needed.
    • Consider maintaining at least 10% of the average number of daily appointments unfilled at the start of the business day based on an audit of a representative sample.3,4
  • Assess and understand the patterns of both demand (i.e., daily number of patient requests for appointments) and supply (i.e., clinical resources/members of care team available to the clinic) in clinical practice.
    • Adjust supply based on fluctuations in demand.
    • Use team members to expand access by having them provide all intake and education. Use medical providers only as needed for top-of-license work.
    • The Institute for Healthcare Improvement (IHI) measures access to care as the average length of time in days between the day a patient makes a request for an appointment and the actual appointment.5
  • See Domain 2. Service Provision: Component 2.6: Contraceptive Supplies, for information on stocking birth control methods on-site.


1. U.S. Selected Practice Recommendations (SPR) for Contraceptive Use, 2013: http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usspr.htm

2. Association of Reproductive Health Professionals, Quick Reference Guide for Clinicians, Choosing a Birth Control Method: https://www.arhp.org/Publications-and-Resources/Quick-Reference-Guide-for-Clinicians/choosing/Initiation-Hormonal-Contraceptives

3. Providing Quality Family Planning Services (QFP), Recommendations of CDC and U.S. Office of Population Affairs, 2014, page 26: http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf

4. Oregon’s Patient-Centered Primary Care Home Program, 2014 Recognition Criteria; Technical Specifications and Reporting Guide, page 26: http://www.oregon.gov/oha/pcpch/Documents/ TA-Guide.pdf

5. Institute for Healthcare Improvement (IHI): http://www.ihi.org/resources/Pages/Measures/ThirdNextAvailableAppointment.aspx




  • Consider using non-financial techniques to maximize fee collection and minimize barriers to patients.
    • Examples include focusing staff efforts on properly assigning patients for a sliding fee and other reimbursement programs, designing procedures to collect at the time of the service, and forgoing use of mailed statements and collection agencies for sliding fee patients
  • Contract with local Coordinated Care Organizations (CCOs) to maximize Medicaid billing and reimbursement capabilities.
  • Request that uninsured patients make some payment on day of visit, but do not deny access to care.
  • If located along state borders, consider enrolling in the other state’s Medicaid program.1
    • For Medicaid beneficiaries in underserved areas of the state, this increases patient access to providers.1
  • Develop a policy and system to identify and enroll patients who are eligible for a sliding fee scale discount.
    • To appropriately apply the discount, perform a cost analysis/assessment to determine the cost of providing services.
  • Hire dedicated outreach and enrollment assistance staff to seek out and engage uninsured individuals and assist them with enrolling in health care coverage.2
  • Consider finding outside grants and resources or internal mechanisms to ensure all women get the contraceptives they need at each visit.3


  1. Families USA Policy Brief: Interstate Medicaid Billing Problems: Helping Medicaid Beneficiaries Who Get Care Out of State: http://familiesusa.org/product/interstate-medicaid-billing-problems-helping-medicaid-beneficiaries-who-get-care-out-state
  2. Enroll America, Best Practices in Outreach and Enrollment for Health Centers: http://www.nhchc.org/wp-content/uploads/2011/09/Enroll-America-best-prac-outreach-enroll-for-health-centers-Sept-2012.pdf
  3. Patient-assistance program for purchasing Skyla and Mirena IUDs, ARCH Foundation: http://www.archpatientassistance.com


Special Populations/Diversity


Special populations:

in this document, refers to those who are vulnerable, experience unequal access to health care and/or who experience the burden or risk of health disparities due in part to race, ethnicity, culture, socioeconomic status, geography, gender, age, disability status, risk status related to sex and gender, and other factors.

Transgender or Trans:

umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth. (Note: Transgender is correctly used as an adjective, not a noun, thus “transgender people” is appropriate but “transgenders” is often viewed as disrespectful.)


term used by some individuals who identify as neither entirely male nor entirely female. Also termed gender-queer.


The impact of culture on access to and quality of care is particularly important to address in health care. As Oregon’s population of diverse racial and ethnic communities and linguistic groups continues to increase, patients and providers bring with them individual, learned patterns of language and culture. All of these patterns affect the health care experience.

  • Develop a plan to implement the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care.1
  • Provide ADA training for all clinic staff; assess clinic facility and services for ADA compliance; ensure physical access to medical care for people with mobility disabilities, and ensure effective communication for people who are deaf or have hearing loss.2
  • Use images, written materials and signs that can be easily understood by the diversity of patients served by the clinic and are reflective of the patient population.1
  • Provide ongoing in-service training on ways to meet the unique needs of the populations served.3
  • Ensure that all clinicians are aware that individuals with same-sex partners may not identify as gay/lesbian, particularly teenagers and young adults. Avoid making assumptions based on identity.5
  • Training on transgender health issues and availability of clinical resources should be provided to all clinic staff and providers, including front desk staff, and should be integrated into the standard hiring and on-boarding process for all employees.6-9
  • Ensure intake forms include a way to document patient’s preferred name and gender pronoun.
    • Institute procedures to ensure that patients preferred name is used by all clinic staff at every visit, regardless of whether the patient’s preferred name is identical to the patient’s name as listed in the electronic health record system.6, 9
  • Assess the limitations of the clinic’s electronic health record system in providing trans care and ensure the patient is advised in advance of potential obstacles. Examples include:
    • Challenges that may arise with any gendered forms of care (such as Pap smears, mammograms, prostate exams, Plan B, etc.)
    • Rejection of coding if the gender associated with the service is incongruent with the gender on record.
  • Policies should either define all bathrooms as gender-neutral or specifically state that patients may choose the women’s or men’s rooms according to their own preference.6, 9
  • Prioritize the recruitment of staff who reflect the patient population and possess skills to effectively interact with diverse patients.
    • Specify key characteristics such as training in cultural competency, experience providing services to diverse and underserved populations, and demographics similar to patients served.3
  • Hire individuals for entry-level positions (community health workers, medical assistants) with backgrounds closely matching those of patients, close community ties, firsthand knowledge of cultural practices relevant to sexual health, and the ability to speak more than one language.3
  • Conduct a community needs assessment or partner with the local Public Health Authority and/or CCO to do so. Gather input from an advisory board, including CCO Community Advisory Committee. Create and/or strengthen relationships with the community, patients and their families.3 Create new partnerships and programming as needed in response to these findings.
  • Conduct outreach activities to underserved communities such as holding town hall meetings and community health fairs, and establishing community advisory panels.
  • Use a system to collect distinct racial categories in demographic data, such as REAL+D race, ethnicity and language (REAL) and disability (+D).4


  1. The National Standards for Culturally and Linguistic Appropriate Services (CLAS) in Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice issued by the HHS Office of Minority Health: https://www.thinkculturalhealth.hhs.gov
  2. Information and Technical Assistance on the Americans with Disabilities Act: http://www.ada.gov/ada_intro.htm
  3. Assuring Healthcare Equity, A Healthcare Equity Blueprint: http://www.ihi.org/resources/Pages/Tools/HealthcareEquityBlueprint.aspx
  4. Oregon Health Authority, Office of Equity and Inclusion, Division 70, Race, Ethnicity, Language, and Disability Demographic Data Collection Standards: http://www.oregon.gov/oha/OEI/Policies/Race-Ethnicity-Language-Disability-Data-Collection-Standards.pdf
  5. Reproductive Health Access Project: Contraceptive Care for LGBT Patients: http://www.reproductiveaccess.org/resource/contraceptive-pearl-contraceptive-care-for-lgbt-patients
  6. Center of Excellence for Transgender Health: http://www.transhealth.ucsf.edu
  7. OHSU Transgender Health Program: http://www.ohsu.edu/xd/health/services/transgender-health
  8. Gay, Lesbian, Bisexual, and Transgender Health Access Project, Community Standards of Practice for Provision of Quality Health Care Services for Gay, Lesbian, Bisexual and Transgendered Clients: http://www.glbthealth.org/documents/SOP.pdf
  9. Gay and Lesbian Medical Association, Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients: http://www.glma.org/_data/n_0001/resources/live/Welcoming%20Environment.pdf


Language/Health Literacy/ Communication


Limited English proficiency (LEP):

refers to individuals who are unable to communicate effectively in English because their primary language is not English.

Health literacy:

defined by the HHS National Institutes of Health as the degree to which individuals have the capacity to obtain, process and understand basic health information and services they need to make appropriate health decisions. Patients with limited English proficiency (LEP) and/or limited health literacy are less able to access health care services, understand health-related information and follow health care instructions. Limited English proficiency and poor health literacy are associated with poor health outcomes and higher health care costs. Clinicians and patients need to be able to understand each other. If patients with limited English proficiency lack access to language assistance services, they will have a difficult time understanding the care they receive and will be less satisfied with services

Universal precautions for health literacy:

steps that practices take when they assume that all patients may have difficulty comprehending health information and accessing health services. Health literacy universal precautions are aimed at:

  • Simplifying communication with all patients and making sure they understand information, to minimize the risk of miscommunication.
  • Making the office environment and health care system easier to navigate.
  • Supporting patients’ efforts to improve their health.4
Non-written formats:

verbal formats and graphic formats such as visual brochures, videos, infographics, and graphic demonstrations.


  • Use the Ten Attributes of a Health Literate Organization to guide thinking/implementation.1
  • Offer language assistance to patients who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.2
  • Use “I Speak” cards with patients who do not speak enough English to respond to questions about language preference, to identify the language they speak.3
  • Display interpretive services posters in waiting and reception areas to make patients aware that free interpreter services are available.2
  • Ask all new patients what language they prefer to speak and read, and if they would like an interpreter. Record patients’ language assistance needs in the medical record.3,4
  • Practice universal precautions for health literacy.3,4
  • Assess whether patient materials are easy to read and understand.3,4,5
  • Assess and meet the direct language needs of patients during visits by using clinicians who speak the same language, providing in-person interpretation by trained language interpreters and using visual aids.2


  1. Institute of Medicine’s Ten Attributes of Health Literate Health Care Organizations: http://www.ahealthyunderstanding.org/Portals/0/Documents1/IOM_Ten_Attributes_HL_Paper.pdf
  2. Oregon Office of Equity and Inclusion: http://www.oregon.gov/oha/oei/Pages/hci-resources.aspx
  3. Providing Quality Family Planning Services (QFP), Recommendations of CDC and U.S. Office of Population Affairs, 2014, page 48: http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf
  4. Agency for Health and Research Quality (AHRQ) Health Literacy Universal Precautions Toolkit, Second Edition, January 2015: http://www.ahrq.gov/professionals/quality-patient-safety/qualityresources/tools/literacy-toolkit
  5. CMS Toolkit for Making Written Material Clear and Effective: https://www.cms.gov/Outreach-and-Education/Outreach/WrittenMaterialsToolkit/index.html