Proposed population-based intervention for low income in Har…

Introduction

Despite advancements in both medical technology and service delivery within the U.S.,

many communities continue to have difficulty accessing healthcare services. For individuals who

live below the poverty line, financial burdens, lack of transportation, and limited access to

primary care often lead to delayed treatments and the development of preventable health

conditions. These barriers can be seen on a community level, where there are numerous factors

relating to the social environment that impact the overall health outcomes of individuals. Nurses

involved with population health and community-based practice must understand how social

determinants impact access to care for those they serve. This paper will explore low-income

adults residing within the region of Harris County, Texas, with an emphasis placed upon

identifying limited access to healthcare as a significant social determinant affecting overall

health status. The goal of this paper is to assess the needs of the surrounding communities while

providing evidence-based recommendations for an intervention to increase access to healthcare

services.

Description of Location and Subpopulation

Harris County, Texas, contains an estimated population of approximately 5,009,302

individuals. Approximately 50.4% of individuals living in Harris County identify as female,

whereas approximately 49.6% of individuals living in Harris County identify as male. These

numbers suggest that Harris County has a balanced ratio of males to females. (U.S. Census

Bureau, 2024). The racial/ethnic breakdown of Harris County consists of approximately 43.0%

Hispanic/Latino, 19.2% Black/African American, 36.4% White/Caucasian, 7.4% Asian, and a

smaller percentage of individuals identified as the other racial categories. The above statistics

demonstrate that there is a large amount of racial/ethnic diversity within Harris County (U.S

Census Bureau, 2023).3

For the purpose of this assessment, low-income adults are defined as individuals 18-64

living at or below 200% of the federal poverty level (FPL) (U.S Census Bureau, 2020).

The socioeconomic condition in Harris County demonstrates that about 16% to 18% of

Harris County’s population falls below the federal poverty threshold; this is much higher

amongst people of the Hispanic and Black ethnicities and those making under $25,000 yearly

(U.S. Census Bureau, 2023). Therefore, such socioeconomic challenges also create barriers for

these individuals, and combined with their overall lack of access to preventative health services,

will create barriers for healthy living today and in the future. The median income for households

in the county is around $63,022. In regard to education in Harris County, many of those with

higher educational attainment tend to show socioeconomic vulnerabilities. For example, 23.7%

of adults have a high school diploma or lower, which relates directly to having lower health

literacy, decreased work opportunities, and long-term health outcomes (Texas Community

Health News, 2024).

Crime and safety are major worries; approximately one-third of people living there said

they are victims of either being targeted because of their ethnicity/race, sex/gender, or another

form of discrimination that affects them mentally (e.g., by being treated differently). Domestic

violence was reported by over half of those victims (Rice University report titled: “Crime and

Victimization in Harris County: An Assessment”, 2024). There are additional issues associated

with living in these areas (i.e., challenges to healthy living due to the local community

environment), food insecurity affects approximately thirty-nine percent of Harris County

households, more than double the national rate of 14% (Kinder Institute for Urban Research,

2025) and some demographic groups, especially racially/ethnically disadvantaged households,4

have a higher prevalence of these challenges (i.e., food insecurity). Many poor neighborhoods

today not only face food shortages because they do not have enough grocery stores to meet their

needs, but they are classified as food deserts, which means they have high use of convenience

stores or places selling fast food as their primary source of food. This contributes to increased

risk for obesity and poor nutrition (Kinderd Institute for Urban Research, 2025). Harris County

reports a violent crime rate of approximately 547 incidents per 100,000 residents, which is higher

than the national average and disproportionately affects low-income and racially marginalized

communities.

One of the health outcome indicators that illustrates health inequities in Harris County is

obesity. Approximately 47.7% of adults ages 45-64 in Harris County are considered obese, and

adults who earn less than $25,000 a year are almost twice as likely to be obese as adults who

earn a higher income. (Understanding Houston, 2023). These collective indicators demonstrate

that low-income adults (especially those earning less than $25,000) in Harris County are faced

with several social and structural barriers that adversely affect their access to healthcare, their

economic stability, and their overall health outcomes.

Disparities exist between low-income adults in Harris County in terms of the health and

nutrition indicators described above. Approximately 14% of adults aged 18-64 years have

diabetes; over 32% of adults aged 18-64 years have hypertension; nearly 48% of adults aged 45-

64 are considered obese. The prevalence of these health conditions is substantially higher among

adults with a gross income of $25,000. As a result, access to preventive and primary healthcare

services is restricted due to both distance and cost of accessing healthcare services

(Understanding Houston, 2023; County Health Rankings & Roadmaps, 2023).

Subpopulation Impact of Limited Access to Healthcare

Biggest Contributor to Morbidity and Mortality5

The leading cause of preventable morbidity in low-income adults in Harris County is

limited access to healthcare, where patients who do not have health insurance go to the

emergency room at almost double the frequency of those with health insurance, and also have

substantially less access to preventative and chronic disease management services. (Harris Health

System Community Health Needs Assessment, 2023). In Harris County, residents who are low-

income encounter many obstacles to getting the basic health care services they need, which are

causing higher levels of illness and death in this area. Some examples of these complicated

factors impacting those who suffer from chronic illnesses are their lack of insurance and the

unavailability of primary care physicians in Harris County. Diabetes is present in approximately

14% of the adults living in Harris County. In comparison, hypertension affects more than 32% of

adults, and the proportions of both of these chronic conditions are much higher among adults

living at or below 200% of the federal poverty level (County Health Rankings & Roadmaps,

2023). Therefore, individuals who have these chronic illnesses may not have sufficient medical

care to help prevent the occurrence of complications from these diseases that could have been

prevented. This data shows that having limited access to basic healthcare services within Harris

County can create too many emergency room visits that could have been prevented with proper

medical attention. In addition, it can make it harder for people with chronic illnesses to get the

care they need, which can lead to an early death and/or affect their overall quality of life in the

long run (Texas DSHS, 2023; CDC, 2023).

In Harris County, cardiovascular disease and diabetes are the two leading causes of

premature death for those 40 years and older who fall below the poverty line. According to local

mortality reports, heart disease is to blame for about 22% of all county deaths, while around the

same rate of deaths due to complications of diabetes occurs compared to Texas and national6

death rates (Texas DSHS, 2023; CDC, 2023). The combination of delayed diagnosis and a

disjointed healthcare system (poor access to treatment) increases the chance of developing more

advanced stages of an illness when diagnosed, thereby increasing the potential for being

hospitalized and dying prematurely. State and national mortality data indicate that preventable

and treatable conditions are much higher among the uninsured than those with insurance, and

continue to evidence a greater relative mortality burden among people below the poverty line

(CDC, 2023).

Controversial Community Health Concern

One currently very hotly debated area of community health in Harris County concerns the

inappropriate use of the emergency department for health-related problems that do not require an

emergency response. Multiple reports by both public health officials and the health care system

provide documentation that supports this concern. On average, during the year preceding the

COVID-19 pandemic, adults in Harris County who did not have health insurance utilized the

emergency department at nearly double the rate of those with health insurance (Harris Health

System Community Health Needs Assessment, 2023). The result of the overuse of emergency

departments is an overall increase in the number of patients seen within the emergency

department, resulting in longer wait times for treatment and strain on hospital resources to

accommodate the high number of patients, particularly due to the lack of availability of

affordable primary care services for individuals without health insurance. Because of these

issues, there are growing concerns regarding health equity and the long-term viability of the

health care systemin both local and statewide communitiesdue to the continued

inappropriate utilization of the emergency department.

Community Health Concerns7

Individuals in the community have expressed having difficulty obtaining timely care,

long waiting periods for appointments, and limited help in navigating the health care system,

such as making appointments and understanding benefits. Similar access issues have been

identified in low-income families in other areas where poverty and social justice issues prevent

people from receiving adequate health care (Tiruneh et al., 2023). Individuals experiencing

diabetes complications and hypertension are commonly hospitalised, and their hospitalisations

could often be prevented. The increased quality of life and financial burden to both the individual

and the health care system are decreased when people cannot access adequate care. In addition to

financial burdens, inadequate access to care contributes to decreased productivity and higher

levels of stress. An improvement in access will improve both the individual and the system.

Emergency Room Visits and Hospital Admissions

Members of this subpopulation utilize emergency care as a primary service for hospital

admissions or emergency room visits for conditions that can be treated with outpatient care (e.g.,

uncontrolled diabetes, hypertensive crises, asthma exacerbations, infections) as well as for

complications resulting from either delayed diagnosis or treatment (e.g., preventable

hospitalizations for chronic health problems), with these numbers being larger among low-

income individuals compared to those with higher incomes. Data collected at the state level

validate the claim that low-income individuals in Texas have limited access to outpatient care

and that lack of outpatient care (i.e., regular healthcare visits) contributes to increased usage of

emergency rooms and hospitalization. Costs associated with emergency room visits and

hospitalizations place additional burdens on both the patient and provider, and essentially lead to

overcrowding within hospitals.8

Impact on Quality of life

Those residents of Harris County who lack regular access to healthcare endure an inferior

quality of life as a result of their inability to manage conditions that (commonly) lead to chronic

illness, as well as the burden of financial strain and/or being unable to take preventive measures.

In the county, almost forty percent of low-income families report food insecurity, which has been

shown to have strong negative associations with worse health outcomes, more overall stress, and

a lower functional status (The Kinder Institute for Urban Research, 2025). Chronic illness

management barriers, coupled with the added financial anxiety associated with accessing

medical care, result in decreased capacity of these individuals to hold jobs and perform

engagements with health-promoting activities, thus continuing the cycle of poor health and social

and economic disadvantage within a community.

Social Determinant of Health: Limited Access to Healthcare

The lack of access to healthcare is a key social determinant of poor health for adults

living on low incomes in Harris County, as high costs, limited insurance coverage, and not

having enough primary care providers lead to delays in accessing health services. Because of the

lack of regular primary care, people will often put off seeking care, resulting in an increase in the

severity of their health problem(s). This has been shown by numerous research studies that

looked at the relationship between social needs and health care service utilisation. Due to the

lack of access to primary care, many people end up in an emergency room for conditions that are

preventable if they were able to have regular access to a primary care doctor and/or other types

of providers. Furthermore, untreated chronic conditions can result in increased rates of morbidity

and mortality within this population. Therefore, addressing barriers to access to health care is

essential for improving the overall health of populations in Harris County.9

The community health issues related to inadequate access to care have been found

through the repeated use of emergency departments, the prevalence of uncontrolled chronic

conditions, and the financial burdens of high costs associated with health care.

Available Community Resources

Several community resources are available to assist lower-income adults in Harris

County, Texas. Federally Qualified Health Centres serve individuals without insurance or who

are under-insured by providing Primary Care Services on a sliding fee scale. Federally Qualified

Health Centres provide preventive care, chronic disease management, and referral to specialty

services, resulting in a decrease in avoidable emergency department visits (Fiori et al., 2023).

Other than Federally Qualified Health Centres, the Harris Health System also provides

healthcare to low-income county residents through the Financial Assistance and Gold Card

programs, which enable low-income county residents to have access to Primary Care, Speciality

Care, and Hospital Services through the Harris Health System, even if they do not meet the

traditional eligibility criteria for health insurance coverage. Medicaid also assists low-income

adults by covering essential healthcare services to those who meet the eligibility criteria.

Collectively, these community and systemic resources provide assistance to provide healthcare to

lower-income adults; however, there are still gaps in access to healthcare.

Needed Resources

The people of Harris County need more assistance to increase their healthcare options.

These services include increased Care Coordination opportunities to help the people who use

them find out about their insurance policies and make appointments and referrals to other

providers (State of the Health System Report 2014). The evidence from community health

worker programs indicates that People who are supported through navigation services can access10

medical care and coordinate with their healthcare providers (Fiori et al., 2024). Providers of

medical services in Harris County must offer more flexible hours of service as well as develop

mobile service opportunities to allow greater access to those individuals with non-traditional

work hours. The lack of sufficient transportation assistance for residents continues to restrict the

ability of those individuals to access their medical care. All of the items mentioned above are

necessary to ensure that residents of Harris County have the ability to access medical services to

reduce the number of avoidable conditions resulting from a lack of access.

Proposed Evidence-Based Intervention

To remedy the lack of access to Healthcare faced by low-income adults, the development

of a Nurse-led Community Health Worker Care Navigation program is being initiated. The

married inclusion of Community Health Workers as part of an overall problem-solving model is

the most comprehensive method to effectively assess Social Needs, while also providing ongoing

assistance with Social Needs and care navigation processes to their members. The data support

the assertion that Community Health Workers positively influence success through increased

access to community resources and decreased barriers to care, with more significant benefits to

underrepresented populations (Fioris et al., 2024). The Nurse will maintain oversight of the

screening process, while also coordinating referrals to both medical and Social Services.

Community Health Workers will assist the members in relation to appointment scheduling,

insurance registration/ enrollment, and linking members to community resources associated with

their needs. The Coordinated Community Care Model provides both clinical support and support

to meet the social requirements for members of these communities. By implementing this model,

we will begin to address the long-standing access issues that many individuals experience when

seeking Healthcare.11

Evidence supports this proposed method for applying Social Needs Screening processes

+ Navigation Services together. This is demonstrated by Systematic reviews showing that post-

program follow-up and coordination ultimately reduce utilisation of Emergency Room services

while increasing patient engagement through their respective Primary Care provider (Yan et al.,

2022). By placing services in proximity to Community members and supplying personalised

assistance, this methodology addresses many of the barriers, including Transportation and The

Complexity of navigating the Health Care System. For instance, monthly visits to communities

identified as having the greatest need, by Mobile Units supporting Registered Nurses (RN’s) and

Community Health Workers (CHWs), would allow for screening for Social Needs and

establishing Referrals for community services. These continual interactions would foster

consistency in the delivery of Care, leading to long-term Health Management. Evidence also

exists to demonstrate the Sustainability of such interventions, by Successful Integration into the

Current Health Systems (Fiori et al., 2024). The proposed method aligns Nursing professionals’

roles within Population Health and Care Coordination.

Conclusion

Harris County’s low-income adults are at a significant disadvantage when it comes to

accessing healthcare. They encounter barriers to being able to receive care, thus preventing them

from having a higher quality of life due to their illnesses that could have been prevented. The

limited access to care for low-income adults is due to financial, structural, and environmental

barriers; thus, these barriers represent a significant social determinant of health. The current

resources that exist do provide some assistance, but they do not adequately meet the needs of all

low-income individuals in Harris County. A nurse-led community health worker navigation

program would be an evidence-based solution and practical strategy to improve access for low-12

income residents of Harris County and improve coordination of care for this underserved

population. The nurse-led community health worker navigation program would provide a holistic

approach to both social and clinical needs, thereby reducing health disparities and improving

overall population health. Community-based strategies, such as this one, require the involvement

of nurses to lead and implement such programs

References

Fiori, K. P., Levano, S., Haughton, J., Whiskey-LaLanne, R., Telzak, A., Hemen Muleta, V., K.,

Chambers, E. C., & Racine, A. (2024). Advancing social care integration in health

systems with community health workers: an implementation evaluation based in the

Bronx, New York. BMC Primary Care, 25(1). https://doi.org/10.1186/s12875-024-

02376-7

Misganaw Guadie Tiruneh, Eneyew Talie Fenta, Destaw Endeshaw, Habitu Birhan Eshetu,

Ousman Adal, Abiyu Abadi Tareke, Kebede, N., Amare Mebrat Delie, Eyob Ketema

Bogale, & Tadele Fentabel Anagaw. (2024). Six in ten female youths in low-income East

African countries had problems in accessing health care: a multilevel analysis of recent

demographic and health surveys from 20162021. BMC Health Services Research, 24(1).

https://doi.org/10.1186/s12913-024-10934-z

Yan, A. F., Chen, Z., Wang, Y., Campbell, J. A., Xue, Q.-L., Williams, M. Y., Weinhardt, L. S.,

& Egede, L. E. (2022). Effectiveness of Social Needs Screening and Interventions in

Clinical Settings on Utilisation, Cost, and Clinical Outcomes: A Systematic Review.

Health Equity, 6(1), 454475. https://doi.org/10.1089/heq.2022.0010