Health Policy & Management Theses and Dissertations

Permanent URI for this collectionhttp://hdl.handle.net/1903/7127

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End date: 2019Subject: search.filters.subject.Health care management

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    The Impact of International Accreditation on The Quality of Health Services at King Fahd University Hospital, Saudi Arabia: A Mixed Methods Approach
    (2019) AL Shawan, Deema Saad; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    The Joint Commission International Accreditation (JCIA) is perceived worldwide as the symbol of exceptional quality of care. Despite the popularity of international accreditation, evidence of its effectiveness on improving health care quality is inconclusive. This dissertation research utilized a Convergent parallel mixed method framework to evaluate the impact of the JCIA process on quality and to identify the factors that influence the effectiveness of this process at King Fahd Hospital of the University in Khobar, Saudi Arabia. An interrupted time series analysis was conducted to assess the changes in a total of 12 quality outcomes pre and post accreditation. Furthermore, a qualitative approach was used to investigate the attitudes and perceptions of 31 health providers towards this process and the factors that influence its success. The quantitative results suggested that the JCIA had a positive impact on 9 out of 12 outcomes. The improved quality outcomes included: the average length of stay, the percentage of hand hygiene compliance, the rate of nosocomial infections, the percentage of radiology reporting outliers, the rate of pressure ulcers, the percentage of the correct identification of patients prior to medication administration, the percentage of critical lab reporting within 30 minutes, and the bed occupancy rate. The outcomes that did not improve were the rate of patients leaving the ER without being seen, the percentage of OR cancelations on the day of the or and the rate of patient falls. The qualitative analysis suggested that the JCIA was perceived positively by all participants. Some of the perceived advantages of international accreditation included the transformation of the organizational culture to a culture that promotes continuous quality improvement, standardization, and the reduced paperwork in some departments. The participants’ responses also indicated that there were many factors that influence the success of the process. Examples of the factors identified in the study include the increased workload and the providers’ resistance to participate in the JCIA process. In conclusion, international accreditation seemed to have a positive impact on quality outcomes and was received positively by providers. Nevertheless, the factors that hindered the JCIA process need to be addressed by the hospital’s leadership to ensure more efficient quality improvement efforts during future accreditation cycles.
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    Connecting the Dots Across the Care Continuum: Addressing Behavioral Health in ACO Networks
    (2019) Anderson, Andrew; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    Accountable Care Organizations (ACOs) represent a shift from traditional fee-for-service payment systems that reward volume to payment models that reward providers for value (e.g. quality improvement and cost reduction). Hospitals that lead or participate in ACOs have the potential to work with other providers to bridge the gap between traditional medical and behavioral health services. The goal of this dissertation was to examine the structures, processes, and outcomes of care for hospitals that lead or participate in ACO networks. The overarching hypothesis was that ACO-affiliated hospitals provide better behavioral health care due to increased care coordination and increased connections to behavioral health providers. This dissertation had three aims: 1) compare the implementation of care coordination strategies between ACO affiliated hospitals and unaffiliated hospitals and examine whether the implementation of care coordination strategies varies by hospital payment model types; 2) compare the use of care coordination strategies between ACO-affiliated hospitals with and without in-network behavioral health providers; and 3) compare rates of follow-up after a hospitalization for mental illness between ACO-affiliated and unaffiliated hospitals. These aims build on each other to illustrate how hospitals that participate in ACOs are improving care coordination and the provision of behavioral health services. There were several meaningful findings. ACO-affiliated hospitals were more likely to use care coordination strategies compared to unaffiliated hospitals. Participation in global capitation and shared savings models was associated with greater use of care coordination strategies. Nearly two-thirds of ACO-affiliated hospitals did not have in-network behavioral health providers. ACO-affiliated hospitals had a significantly higher average unadjusted rates of follow-up after a hospitalization for mental illness at 7 days and 30 days post-discharge compared to unaffiliated hospitals. Hospitals are important components of the care continuum and will play a critical role in improving outcomes for patients with behavioral health conditions. Policy makers should include behavioral health related performance measures tied to performance-based payment arrangements in ACO programs. ACOs can be used as way to bridge behavioral, clinical, and social services to address the unique needs of individuals with behavioral health conditions.
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    Health Policy, Care Coordination, and Racial and Ethnic Disparities Among US Adults Aged 18-64 with Serious Psychological Distress
    (2019) Novak, Priscilla; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    About one in five Americans have a mental health condition, and in any given year, 3-5% of the population experiences serious psychological distress (SPD). The goal of this dissertation is to examine the impact of health policy on racial and ethnic disparities among people experiencing SPD. The literature review in my dissertation details evidence on systemic racial and ethnic differences in access, quality, and care coordination. I develop a causal theory examining the reasons why the problem of SPD and racial and ethnic health disparities exist and specific evidence that illuminates how the problems come into existence. Using National Health Interview Survey data from 2011-2016, access to care among Non-Hispanic (NH) Whites, NH Blacks and Hispanics with SPD is examined. Findings suggest that in comparison to NH Whites, NH Blacks and Hispanics experienced greater gains in health care access following the Affordable Care Act (ACA). Next, using data from the 2015 and 2016 Medical Expenditure Panel Survey, differences in racial and ethnic minorities being served by usual sources of care with care coordination services is examined. Findings suggest that in comparison with NH Whites with SPD, Hispanics with SPD had lower odds of being seen at a Patient Centered Medical Home (OR 0.55, (p <0.05)). Hispanics had higher odds (1.29 (p <0.03)) of being seen at a practice that used case managers; and Non-Hispanic Blacks with SPD had higher odds (3.25 (p< 0.001)) of being seen at a practice that used care managers. Given that people with diabetes experiences mental health conditions occur at about twice the rate of the general population, this dissertation examined the quality of care provided to people with doctor-diagnosed diabetes and SPD using data from the Medical Expenditure Panel Survey. Findings suggest that between 2012 and 2016, racial and ethnic disparities in the receipt of glycated hemoglobin (HbA1c) testing improved but were not eliminated. Results suggest that increased health insurance coverage alone does not eliminate health disparities, and work remains to be done to ensure that all Americans benefit from high-quality, evidence-based care.
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    PREVENTIVE CARE UTILIZATION AND ITS IMPACT ON POTENTIALLY PREVENTABLE HOSPITALIZATIONS: IMPLICATIONS OF MEDICAID COST-SHARING, MEDICAID EXPANSION, AND THE AFFORDABLE CARE ACT FOR VULNERABLE POPULATIONS
    (2017) Bloodworth, Robin; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    About half of Americans have at least one chronic disease, and chronic diseases account for nearly 90% of healthcare expenditures in the US. Primary care can reduce potentially preventable hospitalizations and overall costs of chronic diseases. However, only about 3% of US healthcare spending is on prevention. Racial/ethnic disparities and income disparities have been well documented in the use of primary care. The ACA expanded insurance coverage for millions of Americans and included a mandate that all insurance plans must cover recommended preventive services at no cost to the patient. Literature shows the ACA resulted in an increase in access to care, but results on utilization rates of primary care post-ACA are mixed. Using nationally representative data sets from 2009-2015, I examined the utilization rates of preventive services among vulnerable populations after the full implementation of the ACA, and how Medicaid state policy and expansion under the ACA affected the utilization of preventive services among vulnerable populations. Next, using the Maryland Medical Care Database from 2012-2014, I examined how continuity of primary care affects the odds of having any hospitalization as well as potentially preventable hospitalizations. I found that the ACA was associated with an increase in preventive services recommended yearly, and the ACA was not associated with disparities in preventive service utilization among vulnerable populations. Additionally, I found that state Medicaid policies on preventive services were associated with increased utilization of flu shot, but Medicaid expansion was not associated with increased utilization of preventive services or many changes in disparities in preventive service utilization among vulnerable populations. Finally, I found that primary care, especially ongoing primary care, was strongly associated with a decrease in the odds of having any hospitalization and potentially preventable hospitalizations. Results suggest that increased access alone will not increase utilization rates and reduce health disparities, but rather, a focus on education of what coverage options are available through the ACA, the importance of ongoing primary care, and how to navigate the healthcare system once insured could increase utilization of preventive care, especially in vulnerable populations.
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    Inpatient Mortality in Emergency Care: Is Competition Always Good?
    (2014) Kwok, Veronica; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    The objective of this study was to measure the association between regional competition and emergency care outcomes. Competition was measured using the Herfindahl-Hirschman Index for three hospital referral regions in Maryland. Preliminary regression analysis using a logistic binary model showed that higher competition was associated with lower odds of mortality. Further investigation suggested that competition could be endogenous. Further regression analysis using an instrumental variable of hospital system affiliation and two-stage least squares estimation showed that lower competition was associated with lower odds of mortality for sepsis and trauma (OR = 0.7, p-value <0.001, OR = 0.5, p-value <0.001, respectively). Future investigation perhaps on a national level could help identify a stronger, more uniform association between competition and emergency care outcomes including large scale events, and as such provide policy guidance for quality of emergency care.
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    EXPANDING THE CONCEPTUAL FRAMEWORK OF HEALTH LITERACY TO IMPROVE LONG-TERM SERVICES AND SUPPORTS
    (2013) Ruben, Kathleen Ann; Simon-Rusinowitz, Lori; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    Low health literacy is a significant and growing public health problem. It is estimated that 90 million individuals in the U.S. have low health literacy, which is associated with poor health outcomes. Individuals with low health literacy skills may not be able to obtain health information, communicate with health care providers, or make optimal health care decisions. People from all backgrounds can have low health literacy levels, however, the rates are higher in certain groups such as older adults, Medicaid beneficiaries, and minority populations. Due to our rapidly aging and increasingly diverse U.S. population, the problems associated with low health literacy may increase over the next few decades. Studies have examined the relationship between an individual's health literacy level and their own health outcomes. However, few have focused on how the health literacy level of others, such as caregivers and health care professionals, impacts the health outcomes of care recipients. It is important to understand this relationship in terms of elders who depend on others, such as caregivers and family members, for their care. This series of three studies addresses this critical gap in health literacy research. The first two studies examine the need for a health literacy component of a training program for care teams for individuals with dementia in participant-directed programs. The first is an ethnographic pilot study of caregivers in West Virginia's Personal Options Program, and the second is a mixed- methods study of "Decision-Making Partner" preparedness in Arkansas' IndependentChoices Program. The third study examines the effect of the emergency department referral process on repeated utilization of community health centers by low-income, uninsured adults and Medicaid Beneficiaries, as well as the role of Patient Navigators as mediators within the framework of health literacy. This research provides evidence that the health literacy level of others, including caregivers, decision-making partners, and health care providers significantly impacts the ability of older adults to access health services and supports, communicate with healthcare providers, navigate the healthcare system, and manage chronic diseases. Therefore, addressing health literacy is essential for increasing health-related knowledge, improving health outcomes, and decreasing health disparities in long-term care.
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    RACIAL AND ETHNIC DIFFERENCES IN ACCESSING TIMELY CANCER SCREENING AND TREATMENT SERVICES: A QUANTITATIVE ANALYSIS
    (2013) King, Christopher Jerome; Thomas, Stephen B.; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    This research is organized into three integrated studies that explored differences in screening and treatment services across the cancer care continuum by race and ethnicity. The Andersen Behavioral Model of Health Services Use and the Five Dimensions of Access were used as conceptual frameworks. In the first study (Chapter 2), data from the Medical Expenditure Panel Survey were used to examine breast and cervical cancer screening rates before and during the Great Recession (2007-2009). The interaction terms of recession and race and ethnicity were controlled to examine whether minorities exhibited different utilization patterns under economic shock compared to Whites. In Chapter 3, data from the National Health Interview Survey (NHIS) from 2006-2010 were used to identify adult cancer survivors and adults without a history of cancer. Multivariate logistic regressions were applied to examine the prevalence of cost, organizational and transportation barriers between survivors and the general population. The likelihood of experiencing barriers was explored by race and ethnicity. In Chapter 4, differences in the likelihood of experiencing access barriers among survivors by race and ethnicity was explored. Data were merged from the 2000-2011 (NHIS) to identify adult cancer survivors who reported cost, organizational and transportation barriers. Logistic regressions were applied to determine the likelihood of reporting each type of barrier, while controlling for demographic and socioeconomic variables. The Fairlie decomposition technique was applied to identify contributing factors that explained differences in accessing care based by race and ethnicity. Overall, results of the investigations demonstrate that: (1) breast and cervical screening rates declined most among White women during the recession period, while rates increased among Hispanic women during the same period; (2) minority cancer survivors were significantly more likely to experience access-to-care barriers than Whites; and (3) insurance, comorbidity, perceived health and nativity were leading factors that contributed to racial and ethnic differences in timely receipt of cancer screening and treatment services. As provisions of the Affordable Care Act take effect, findings provide insight into practices, policies, and future research that will help achieve Healthy People 2020 screening objectives and reduce racial and ethnic disparities in accessing timely cancer care.
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    PERCEPTION OF PATIENT-PROVIDER COMMUNICATION AND ITS ASSOCIATION WITH HEALTH SERVICES UTILIZATION
    (2012) Villani, Jennifer; Mortensen, Karoline; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    The Patient Protection and Affordable Care Act of 2010 has generated an unprecedented emphasis on patient satisfaction and patient-centered care. This dissertation is composed of a series of papers on how patients perceive the quality of care delivered by their healthcare providers and its relationship to their usage of health services. The main hypothesis is that higher perceived quality of care is associated with more effective use of health services. The studies use nationally representative data from the Medical Expenditure Panel Survey (MEPS) with the research grounded in Andersen's Behavioral Model of Health Services Use. In the first study, I explore whether differences in satisfaction between English- and Spanish-speaking Hispanics can be explained by acculturation and concordance with their providers with regard to race, ethnicity, gender, and language. I use the econometric Blinder-Oaxaca decomposition method to quantify the contributions of each measured characteristic for explaining disparities in patient satisfaction. In the second study, I examine whether a lack of patient-centeredness and poor access to a regular provider are associated with greater nonemergent emergency department (ED) utilization. I employ a hurdle model to account for the two-part decision making process of whether to use the ED and how often to use the ED for nonemergent purposes. In the third study, I investigate the relationship between patient-centered care and receipt of six recommended clinical preventive services including screening for breast cancer, cervical cancer, colorectal cancer, high cholesterol, hypertension, and vaccination against influenza. I use multivariate logistic regression models to determine the probability of compliance with national prevention guidelines. The results reveal the importance of how patients perceive interpersonal communication with their healthcare providers. In the first study, acculturation is implicated as a major contributor to differences in patient satisfaction with communication. Furthermore, the results from the second study indicate language concordance between patients and providers is related to less nonemergent ED use. Findings from the third study suggest a pattern of greater compliance with clinical preventive service recommendations when patients perceive receiving patient-centered care from their providers. Implications for policy and practice are presented.