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The theoretical framework guiding this research is an adaptation of the Gelberg-Andersen Behavioral Model for Vulnerable Populations (Gelberg-Andersen model) developed from the Andersen Behavioral Model of Health Services Use (Andersen model).^84,85 The Gelberg-Andersen model examines which factors affect a vulnerable population’s utilization of health care services, personal health practices, and predictors of health outcomes.⁸⁴ The Gelberg-Andersen model incorporates predisposing, enabling, and need factors, from both traditional and vulnerable domains, to predict health behaviors and health outcomes.⁸⁴

The initial Andersen model was developed to predict or explain people’s use of health care services as a function of their predisposition to use services, factors that enable or are a barrier to use, and their need for care.⁸⁵ Predisposing characteristics include demographics, social

structure, and health beliefs.⁸⁵ Social structure may include the person’s ability to cope with problems, their status in the community, their physical environment, their education level or ethnicity.⁸⁵ Another predisposing characteristic is health beliefs, which are defined as the

“attitudes, values, or knowledge that people have about health and health services that might influence their subsequent perceptions of need and use of health services.”⁸⁵ Enabling factors are regarded from both a community and personal perspective.⁸⁵ Examples of community enabling resources are the types of medical providers in the community and organizations that provide care.⁸⁵ Personal enabling resources include factors which affect the ability to use the health care services in the community, such as income level or health insurance status.⁸⁵ Need is another variable which predicts health services use from two perspectives, perceived and evaluated.⁸⁵

Perceived need involves people’s views of how they evaluate their own health and functional state and when they feel that they need to use health care services.⁸⁵ Evaluated need involves a health care professional’s judgment on a person’s health status and when care or treatment is necessary.⁸⁵

Further revisions of the Andersen model included health care system variables such as policy, resources, and their organization as predictors of a people’s use of health care services.⁸⁵

Additional factors included type of services, site of service, purpose of the service, and consumer satisfaction. In addition, primary determinants of health behavior, health behaviors, and health outcomes were included.⁸⁵ The health behavior domain included personal health practices (e.g.

diet, exercise, self-care behaviors) and use of health services.⁸⁵ Health outcomes included perceived health status, evaluated health status, and consumer satisfaction.⁸⁵ This version recognized that changes in health behaviors and improvement in health are key outcomes and goals of health services utilization.⁸⁴

The addition of the vulnerable domains in the Gelberg-Andersen revision of the model gives a focus to social structure and enabling resources that are applicable to a vulnerable population, such as the impoverished and elderly.⁸⁴ These vulnerable characteristics, such as public benefits, transportation, and telephone access, are included as they may effect a person’s access or ability to use health care services and their health.⁸⁴ The Gelberg-Andersen model was originally applied to research in homeless patients,⁸⁴ but has been used in other studies examining cancer screening in Mexican-American women, health services utilization in homeless adults with

hepatitis B and C, self-reported depression among Hispanics and African-Americans, and access to vision care in a diverse low-income population.^86-89 The Gelberg-Anderson model, with the addition of vulnerable domains, is a good fit for this study with a focus in low-income, older adults. Table 7 provides a summary of studies which used multivariable analyses to examine predictors of older adult ED use. The predictors are categorized by predisposing, enabling, and need factors. Need factors, such as number of comorbidities or previous hospital or ED use, were the most common predictors in studies examining older adult ED use.16,18,19,21,32

Table 7. Predisposing, enabling, and need factors of older adult ED use Reference

Study Population and

Sample Size Study Design

Factors^a Outcome

Variable

Predisposing Enabling Need

McCusker et al., 2000³²

1,122 ED patients ≥ 65 years with ED visits during the daytime hours on weekdays, during a three month period in 1996 Inclusion criteria: non-critical medical status, orientation to time and place or informant

 Limited activities before ED visit

 Needed assistance before ED visit

 Reduced function

 Increased

 Hearing impairment

 Visual impairment

 Memory impairment

 Depressed

 Limited activities before ED visit

 Needed assistance before ED visit

 Reduced function

 Increased

 Hearing impairment

 Visual impairment

 Memory impairment

 Bereavement

Shah et al, 2001²¹

9,784 community-dwelling Medicare beneficiaries ≥ 66 years in 1993 Excluded: 65 year old persons due to need to have previous years information

 Trouble obtaining care

 Delay care due to cost

 Lacking usual source of care

 Self-reported health poor-very good compared to excellent*

 ADL deficiencies*

 Charlson Comorbidity Index score > 0*

Presence or absence of at least one ED claim

Hastings et al., 2007¹⁸

942 veterans ≥ 65 years old discharged home from Durham VA Medical Center between July 1- September 30, 2003 and followed in VA primary care

Excluded: Patients admitted to the hospital or having missing data

 Hospitalization within past 6 months*

 Number of medications

Adverse events Medicare beneficiaries ≥ 65 years with at least 1 outpatient ED visit between January 2000-September 2002

Excluded: Residents of long-term care facilities, those enrolled in a Medicare HMO

 Hospitalization in past 6 months*

 Hearing difficulty

Time to first

 Vision difficulty*

 Number of Instrumental Activities of Daily Living (IADL) deficiencies*

 Hospitalization in the past 6 months*

Hastings et al., 2008¹⁹

1,662 community dwelling older adults ≥ 65 years in a 5 county area in North

Carolina

Included: Patients remaining in the study at time of final interview with data on past 12 months of ED use (self-report and hospitalization

 Hospitalized within the past year*

 Good, fair, or poor self-rated health compared to excellent*

 Mobility disability or IADL disability

 Hospitalized within the past year*

 Good, fair, or poor self-rated health compared to excellent*

 Mobility disability, IADL disability, or

a * = statistically significant predictor; Bold font indicates vulnerable domain.