Assessment of Health Care Safety Net Capacity: A Scoping Review of Methodologies

Introduction: Millions of Americans depend on a loosely organized and variable safety net health care institutions and providers, which is described as fragile, strained for resources, and vulnerable to shifting social, political, and economic forces. A call to action has been made by many to increase and improve efforts to monitor the structure, capacity, and stability of the safety net. Efforts to do so have been short lived, fragmented, and inconsistent. This task falls within the responsibilities of public health agencies.Objective: This scoping review aims to identify focused assessments of health care safety net capacity in order to inventory and qualitatively map the indicators and metrics used to assess capacity, and the methodologies or primary sources used to obtain relevant data. Its findings inform recommendations for public health officials, researchers and other stakeholders interested in assessing safety net capacity, or furthering research on this topic.Methods: A search of PubMed, Scopus, and Web of Science was conducted to identify English-language articles published between 2000 and 2018. Digital Commons and select government websites were searched to identify relevant unpublished literature. Eligible studies included descriptive reports and focused inquiries assessing the safety net including its capacity; and cohort, cross-sectional, and before-after studies that assessed measures of capacity as independent or dependent variables. Data was extracted from the selected articles to include the indicators used to assess capacity, the metrics used, and the data collection methodologies. The indicators used in the selected studies were grouped into categories to produce a consistent nomenclature, and a potential framework for future assessments of capacity.iiResults: Thirty-one articles were included. Three were comprehensive assessments of community safety nets; the rest were focused on specific facilities, providers, or services within the safety net. Indicators of capacity used were grouped into 12 categories: Workforce, Infrastructure, Range of Services, Specialist Availability, Primary Care Availability, Medicaid Participation and Indigent Care, Health Information Technology Capacity, Enabling Services, Organizational Capacity, Sentinel Events, Disaster Preparedness, and General Capacity. A wide range of metrics were used to assess these indicators. Both primary and secondary data were frequently used, but they were infrequently used in conjunction. Surveys, key informant interviews, and site visits were the most frequently used strategies for collecting primary data. The Uniform Data System, Medicare/Medicaid claims data, administrative data, and the AMA Masterfile were the most frequently used sources of secondary data.Discussion and Conclusion: Efforts to monitor the safety net continue to be urgently needed. Examples of safety net capacity assessments are limited in number and scope, and are often difficult to locate. This report proposes recommendations for public health organizations, policy makers, and academics to better enable safety net capacity assessment and research through increased investment, improved data collection and reporting guidelines, inclusion of focused safety net assessment in Community Health Assessments, and the development of a national repository of similar documents.Master of Public Healt