Dissertations / Theses on the topic 'Of Health Management and Policy'

Background: Throughout the twentieth century, Brazil developed a Social Health Insurance, providing coverage to formal workers and their dependents. In 1988, the country implemented a health reform adopting a National Health Service model, based on three core principles, universal coverage, open-ended benefit package and striving for health equity. During this transition, formal workers recomposed their privileged access to healthcare through private health insurance, resulting in a two-tier system represented by those with dual coverage—public and private—and those who must rely exclusively on the public insurance. Private health insurance coverage has a positive correlation with income, however, between 1998 and 2008 private coverage expanded vigorously among the poor, while remained stable among the rich. The health equity literature in Brazil consistently reports the presence of relevant inequalities in utilization of health services favoring privately insured individuals. A gap in this literature, however, is to determine whether inequalities in utilization of health services remain among insured individuals, i.e., does private insurance improve access regardless of individuals’ income?

Methods: The study relies on Andersen’s behavioral model as a theoretical framework to analyze data from two rounds (1998 & 2008) of a national household survey, assessing levels of utilization of fourteen dependent variables across income quintiles and calculating concentration indexes as summary measures of inequality. Dependent variable distributions across income are standardized by need using the indirect method. Concentration curves compare the evolution of inequality during that time. Curve dominance is formally tested between survey years. Decomposition analysis identifies the most relevant contributors to inequality. Physician services are analyzed as the probability of having a physician visit and the number of physician visits. Hospital services are analyzed as the number of hospital admissions, the probability of having a hospitalization, and the number of hospital days during the last hospitalization. The latter two variables are broken down according to their financing source, either public (SUS) or private insurance.

Results: Physician services present very low inequalities, although a statistically significant positive gradient persists in both survey rounds. Poor PHI beneficiaries have an advantage compared to national levels. SUS financed hospitalizations are a rare phenomenon among privately insured individual but strongly concentrated on the poor. Poor PHI beneficiaries utilize private hospital at lower levels than the rich. Compared at a national level, they are at a disadvantage. In 1998, this was not the case, suggesting that insurers may be developing mechanisms to deter hospital utilization among the poor. Premium value and income are the most relevant contributors to inequality in physician and hospital services.

Conclusions: The Brazilian government (ANS) needs to monitor utilization levels across income and develop policies to increase accountability of PHI products particularly preventing insurers from purposefully pushing their beneficiaries to use SUS hospitals. Greater availability on insurance policies segmented as ambulatory care only and inpatient services only would increase the range of options for consumers that could sort more adequate coverage according to their capacity to pay and healthcare needs.

Early public health efforts in the United States addressed social conditions that contributed to poor health, with public health workers playing a role in large scale societal reforms, such as passing housing and sanitation laws, which led to diminishing deaths from infectious diseases. As chronic diseases became leading causes of death, public health research and practice became more focused on individual behaviors, widely thought to be the primary cause of chronic diseases. However, health inequities along the lines of place, race, class, and other forms or marginalization are still prevalent. A substantial body of research illustrates how social, political, economic, and environmental factors affect multiple health outcomes, including chronic diseases, and contribute to health inequities.

In public health practice, some local health departments (LHDs) and organizations that support their work have called for broader public health interventions that address social policies that contribute to health inequities in addition to providing direct services to individuals. With continued research and support, the approximately 2,800 LHDs nationwide can play a central role in reducing health inequities. However, engaging in this complex work necessitates new approaches, skills, frameworks, and organizational infrastructures for LHDs. The recent foreclosure crisis, which stands to increase racial and health inequities, provides a lens to examine whether and how LHDs can move from a rhetorical commitment to addressing social determinants of health (SDH) into actual public health interventions that reduce health inequities.

Through this dissertation, I examine LHDs’ role in the foreclosure crisis through three related papers. My aim is provide insight into how LHDs responded to the deep and fundamental shifts in access to stable and quality housing and wealth created by the foreclosure crisis that disproportionately impacted African-American, Latino, and some Asian/Pacific Islander communities. Through all three papers, I incorporate a focus on challenges and approaches to addressing the racialized causes and outcomes of the foreclosure crisis. My overall aim is to help advance local public health practice within LHDs to more effectively target the causes of health inequities, including gaining a better understanding of LHD approaches and needs related to addressing SDH through local policy.

In the first paper, A National Survey on Local Health Department Engagement in Addressing the Foreclosure Crisis, I describe the results of a national survey on LHD engagement in the foreclosure crisis, which includes LHD approaches to addressing foreclosure and barriers to engagement. Responses followed a diffusion of innovation pattern, with innovator, early adopter, early majority, late majority, and lagging LHDs. Respondents expressed a high level of interest in adopting innovative approaches to addressing SDH and described a need for models of how other LHDs are preventing or mitigating the impacts of foreclosure, especially through local policies.

In the second paper, Adopting an Innovative Public Health Practice to Address Foreclosure: A Case Study of Alameda County Public Health Department , and the third paper, Policy Entrepreneurs, Agenda-Setting, and Communication: An Exploration of How a Local Health Department Engaged in Addressing the Foreclosure Crisis, I describe findings from qualitative interviews with current and former ACPHD staff and partners. In the second paper, I identify factors that 1) differentiate ACPHD’s innovative approach from traditional LHD activities; and, 2) contributed to ACPHD being an innovator among LHDs.

Finally, in the third paper, I focus on ACPHD’s role as a policy entrepreneur in agenda-setting, including their communication approach. While the second paper focuses on how ACPHD developed into an innovative LHD in the area of local housing policy, the 3rd paper focuses on how in this role, ACPHD interacted in the local policymaking process. This case study also examines how the role of policy entrepreneur can be shared across two organizations (ACPHD and Causa Justa::Just Cause) and provides another way to conceive of entrepreneurism.

Designed as a qualitative multiple-case evaluation, this study assessed the nature of policy congruence in health care organizations by evaluating the relationship of policy implementation strategies in these organizations with policy objectives contained in legislative enactments. The Program of All-Inclusive Care for the Elderly (PACE) was the conduit for this study, and research emphasis focused on how PACE programs attempt to implement policy objectives engrossed in the Patient Protection and Affordable Care Act of 2010 (ACA), even when not specifically required to do so. The problem identified has been that questions of policy consistency with the ACA continue to permeate the discussions surrounding PACE, and its utility as an alternative elder care initiative as contrasted against those concepts promoted in the ACA. The purpose of this research project was to advance theory and the application of theory in policy analysis. No review of PACE had been conducted through a theoretical perspective, and the theories of public choice and new institutionalism served as the theoretical framework which guided this study. Phone interviews of twelve PACE managers were conducted to ascertain organizational response to policies promoted in the ACA. Observational research was conducted at three PACE locations where high levels of policy congruence with the ACA were detected. This was complemented with public record document review which served to triangulate the research project. The study’s key finding is that uncertainty in markets where PACE is located has led most PACE programs to reflect characteristics of mimetic isomorphism. Furthermore, the ACA can be seen as subtly coercive in that regard, whereby PACE managers migrate PACE towards policies promoted in the ACA, and attempt to attain institutional legitimacy through mimetic behavior, which leads to more homogenous health care organizations. This study confirms the utility of public choice theory and new institutional theory in the investigation of public policy, and organizational strategies associated with public policy implementation. Evaluating PACE through public choice and new institutional theory expands the understanding of these theories, and their applicability and utility in evaluating the linkage between the policy theory, promulgation, and implementation processes, and thus, consequent effective governance strategies.

The Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct Community Health Needs Assessment (CHNA) every three years, formulate implementation strategies, and report yearly to the IRS and the public the progress of their work. The IRS CHNA incentivizes hospitals to provide programs responsive to community health needs. The purpose of this study was to examine the relationship between community benefit programs and prioritized community health needs in the context of a national IRS reporting requirement through analysis of published community benefit reports among North Carolina’s (NC) tax-exempt hospitals.

This study employed quantitative research that analyzed longitudinal and cross-sectional data; qualitative research that reviewed published documents; and mixed-methods research that analyzed the integrated quantitative and qualitative results. The findings indicate that performing IRS-mandated CHNA did not substantially increase the alignment of community benefit programs with prioritized community health needs but did clearly highlight those needs. NC tax-exempt hospitals continue to focus on providing patient care financial assistance than population health, a strategy misaligned with community health needs. Although the hospitals are beginning to address population health and access to care concerns, their dollar expenditures in these areas paled in comparison to patient care financial assistance. If the IRS’ purpose in mandating CHNA was to spur a shift in community benefit priorities toward population health needs and away from the traditional patient care financial assistance, then, the evidence from 4 years after the requirement’s implementation, indicates it is currently failing in North Carolina. As elucidated in the articles, their ingrained patient-level intervention perspective and desire to recover high unreimbursed costs or lost revenues for providing care to Medicare, Medicaid, and poor patients likely influence the hospitals’ community benefit programming to favor individual welfare over population health. Nevertheless, policymakers should continue to direct community benefit programs toward population health because it is a step in the right direction. Organizational change takes time and the desired results of policy interventions are usually incremental. Thus, conducting CHNA must remain a legal obligation by non-profit hospitals for maintaining their privileged tax status to facilitate organizational paradigm shift in community benefit programming toward population health programs or community building activities and away from individual welfare.

Pneumoconiosis is a chronic and slowly progressive parenchymal lung disease. Estimates suggest that about 68,000 ex-miners in Botswana will develop or have already developed pneumoconiosis. However, most of these cases do not know they have the disease because of the poor quality of care in primary healthcare settings and weak implementation of the Occupational Diseases in the Mines and Works (ODMW) Act.

This dissertation was a health service research framed from the systems approach using the chronic care model as a theoretical tool. The study employed a concurrent, convergent parallel mixed method research which combined quantitative and qualitative methods of inquiry. The quantitative arm of the study evaluated whether the Botswana primary care settings meet ‘reasonably good standards’ of the pneumoconiosis quality of care measured on the chronic care model. The chronic care model measures quality of care on a 0 to 11 scale, where “0” denotes lack of quality care and “11” stands for optimal quality of care. Reasonably good quality of care comprises scores between 6 and 8 on the scale. The qualitative arm of the study assessed the implementation of the ODMW Act in the Botswana primary healthcare settings. The study mixed quantitative and qualitative results at the interpretation stage to determine the extent to which quality of care for pneumoconiosis and the ODMW Act implementation promote equitable access to pneumoconiosis services among ex-miners in Botswana. (Abstract shortened by ProQuest.)

Purpose. The purpose of this phenomenological qualitative case study was to explore the experiences of advocates who represent organizations that engage in disability policy advocacy. The study investigated the strategies and activities used by disability rights advocates, including those used when advocating for deinstitutionalization of people with intellectual and developmental disabilities (I/DD), and the recommendations for advocates of the deinstitutionalization of individuals who live in large intermediate care facilities (ICFs).

Methodology. A phenomenological case study and semistructured interviews were used to explore the strategies and practices of organizations that engage in disability policy advocacy. The researcher used a purposeful sampling approach to interview 5 disability policy advocates with extensive experience for the study. Gen and Wright’s (2013) policy advocacy framework was used to guide the development of the interview questions and resulting themes that emerged from the interviews.

Findings. Advocacy organizations identified three main activities used when advocating for individuals with I/DD: coalition building, information campaigning, and engaging decision makers. When advocating for the deinstitutionalization of people with I/DD, their strategies included coalition building, information campaigning, and reform efforts. The advocates consistently recommended reform efforts, and to a lesser extent, coalition building as strategies and activities to expedite the deinstitutionalization of individuals who reside in large ICFs.

Conclusion. Reform efforts (pilots, demonstrations, litigation) are consistently recommended for future advocacy efforts in support of expediting the community transition of individuals who reside in large ICFs.

Recommendations. Future research should explore the activities of advocacy organizations for other populations or in other geographies. This research study has direct implications for individuals who reside in large ICFs and want to move to community living. This study adds to the practice of advocacy in that it will aid the development of future advocates through training targeting practices of successful, highly experienced advocates.

ISBN 978-91-982282-7-4

Healthcare quality measurement and care reimbursement have become a central focus for leaders and administrators of healthcare organizations. The provision of high-quality healthcare is contingent on the skills and abilities of leaders and clinical staff who support evidence-based clinical practice through implementation strategies. The problem defined in this qualitative exploratory multiple-case study was concerned with the frequency of unplanned hospital readmissions occurring in the state of Florida specifically, in healthcare facilities located in Broward, Miami-Dade, and Monroe Counties (tri-county area). Healthcare stakeholders working in organizations located in the tri-county area report hospital readmission rates of 23%, that resulted in higher financial penalties. The purpose of this qualitative exploratory multiple-case study was to explore the reasons for higher than expected unplanned hospital readmissions in healthcare facilities located in the tri-county area of south Florida to help hospital administrators to improve healthcare quality through reducing unplanned rehospitalizations. Thirteen participants contributed to this study: 4 (31%) healthcare leaders, 4 (31%) clinicians, and 5 (38%) registered nurses. Through the collective experiences of healthcare stakeholders, two primary and two secondary themes emerged to provide a clearer understanding of the contributing factors related to unplanned hospital readmissions. Four themes namely, education, population, and cultures and resources supported existing literature and provided new knowledge related to the importance of executive leader knowledge, nurse educational and skill levels, patient literacy and language, and cultural elements when applying evidence-based clinical practices in complex healthcare environments.

Today’s emerging patient centered health movement is focused not on a specific condition or demographic, but rather on shifting the balance of power and enabling access to information to drive decision-making in healthcare. This takes place through electronic health records as well as more generalized sources. The uptake of social media is contributing to an innovation in patient centered healthcare: information and support on a global scale is coming not only from the formal healthcare system, but also within online social networks. Today, through computer-mediated interactions, patients are not only seeking information, they are curating and sharing information. Subsequently, patients are also creating information, establishing a novel ecosystem of engagement that has the potential to disrupt the current healthcare system.

This dissertation explores an online health community, BCSM (which stands for “breast cancer social media”), established using Twitter, a largely public and searchable social media platform. Drawing primarily from social network theory, disruptive innovation, and ecological systems theory, this research identifies essential characteristics within the community that may inform future development and support for patient centered healthcare. To conduct this research, a blended approach of netnography – referring to the approach of ethnography applied to the study of online cultures and communities – and in-depth interviews with BCSM participants were employed.

Data collected via interviews and tweets using the hashtag #bcsm provide evidence of clinical support, emotional support, information sharing, and knowledge translation. Underpinning this activity is the opportunity to associate not only with peers, but also with individuals of varying roles (including patients, providers, advocates, researchers, and caregivers). As evidenced by the data collected, educational opportunities flow in both directions.

This work contributes to the larger corpus of health-related literature in the identification and naming of a significant community element that has seen little focused attention: cross-peer engagement, a term used to highlight the interaction amongst individuals of differing status, ability, or rank. This research also documents the formation of microspurs, defined as relationships that form as a result of community participation. These come in many forms and range from expanding a personal support network to participation in federal policy work. Findings suggest that the future of healthcare will not revolve around hospitals and bounded systems. Instead, patients will demand an expanded set of entry points for health information sharing, knowledge transfer, condition management, and general support.