The Patient-Centered Medical Home (PCMH) is a new model for primary care delivery intended to improve the care experience for both patients and providers, improve the health of populations, and reduce health care costs. Adopting the PCMH model into practice requires considerable investment of time and resources which often act as barriers for many small primary care practices; especially in rural areas. Few studies have examined performance of the PCMH model in rural clinics that have successfully implemented the model. It is important to obtain a comprehensive understanding of how context from the surrounding environment relates to implementation and performance of the model and whether there are differences between rural and urban primary care clinics. This study used a sequential explanatory mixed methods approach to assess differences in performance of the Patient Aligned Care Team (PACT) model between rural and urban primary care clinics within the Veterans Health Administration (VHA). Generalized Estimating Equations with repeated measures were used to estimate associations between rurality and five process-oriented endpoints among a national sample of 891 VHA primary care clinics. Results indicate that, after adjusting for patient characteristics and clinic structural capacity, clinics located in large rural or small/isolated rural areas demonstrated difficulty with enhancing access through use of non-traditional encounters (i.e. telephone visits, group visits, or secured messaging) and facilitating care coordination through post-discharge follow-up compared to urban clinics. Findings also suggest that rural clinics were more likely to struggle to meet system-wide performance standards for these same two PACT-related processes than their urban counterparts. A multiple-case study of five VHA primary care clinics was conducted to obtain a contextual understanding of the relationships between rurality and performance of PACT processes from the perspective of primary care staff engaged in PACT implementation. A comparison of the experiences of staff across the five cases revealed cross-cutting themes that are important to understanding the implementation and performance of PACT-related processes within these clinics. These themes included: both rural and urban clinics experience distance-related barriers; patient preferences and behavior impact performance of PACT-related processes; and primary care clinics experience frequent change. Findings from this qualitative assessment highlight the importance of understanding the unique context and circumstances experienced by each clinic and how they relate to performance and implementation of the PACT model. Insights gained through the qualitative assessment revealed that performance of PACT is influenced by complex relationships with both internal and external context. Combination of both quantitative and qualitative methods provided a more comprehensive understanding of these relationships beyond what could have been learned from a solitary assessment of standardized metrics by gaining additional context directly from the voices of those engaged in PACT care delivery. Identifying differences in PACT performance between rural and urban clinics calls attention to the possibility of unique advantages and challenges for PACTs delivering care to rural patients which need further exploration. Findings from this study contribute to the current understanding of PCMH implementation in rural settings by moving beyond the barriers related to structural capacity to performance of processes aligned with PCMH principles. More widespread implementation of PCMH will require additional attention to the complex relationships between the PCMH and surrounding context in order for primary care practices to successfully implement the model.

Thesis (Ph.D. (Nursing))--North-West University, Potchefstroom Campus, 2006.

The process for the incorporation, integration or collaboration of traditional healers into the National Health Care Delivery System of South Africa was marred by an array of mixed attitudes from all the parties concerned, namely traditional healers, patients, biomedical personnel, and the policy makers. The variety of approaches for inclusion of the traditional healers into the National Health Care System of South Africa was a further indication of the complexity of the situation. The possibility of functioning together between traditional healers and biomedical personnel existed before 1990 when the two groups met in Johannesburg in 1986 to discuss ways by which functioning together can be established. A series of meetings and discussions followed after which came the promulgation of the Chiropractors Homeopaths and Allied Health Services Professionals Act of 1996, which gives traditional healers their due recognition but does not include them as part of health care providers. The process of functioning together is a recommendation made by the World Health Organization and the most used terms for this functioning together is, incorporation, integration and collaboration. The process of incorporation can be realised by ensuring that both biomedical personnel and traditional healers remain autonomous, not controlling each other, respecting the existence of one another, as well as each other's own methods of healing. Integration was another method whereby the two health care systems can function together, even though integration differs in context from incorporation. Integration means that the traditional healers will have to function within the health care system under the directions of the biomedical personnel, whereby the patient receives a combination of both treatment methods depending on the problem or diagnosis. The third modality of getting the two health care systems to function together could be by collaboration. Collaboration was seen as a two sided effort whereby the healing methods of one are brought to fore and the most effective one is chosen to cure the patient's identified problem at that time. For the process of functioning together to be meaningful, it was necessary to get the government to review licensing the traditional healer's practices, so as to identify the healing techniques that are of value and use these to treat the patients. It was not really possible to clearly separate the three approaches because they all addressed the issue of having the two health care systems function together to increase health care services and fulfil the patients' health needs. For the purpose of this research the word incorporation was used. In South Africa the traditional healer is identified as the health care choice of 80-9036 of the black population. If this large number of black people uses traditional healing, then it becomes necessary to investigate the manner in which the traditional healer can be utilized effectively in the National Health Care Delivery System of South Africa to render the services that the patient needs for his/her health needs. It is for this reason that the researcher aimed at investigating the existing models of incorporation of traditional healers, the perceptions and attitudes of the traditional healers, biomedical personnel, patients and the policy makers regarding incorporation, their views on how this incorporation should be achieved, as well as how the incorporation of traditional healers into the National Health Care Delivery System of South Africa could be realised. A qualitative research design and theory generating approach was followed, and the research was conducted in two stages. In stage one qualitative research, participants were traditional healers, biomedical personnel, patients and policy makers, selected by means of non-probable purposive voluntary sampling. Data was collected by means of conducting semi-structured interviews with all the participants in the three identified provinces of South Africa. Field notes were recorded after each interview session. Data analysis was achieved by open coding. A co-coder and the researcher analysed the data independently after which consensus discussions took place to finalise the analysed data. Ethical principles were applied according to the guidelines of the Democratic Nurses Organisation of South Africa and the Department of Health. The second stage which was a theory generation approach, was used to formulate a model for the incorporation of the traditional healers into the National Health Care Delivery System of South African. / Thesis (Ph.D. (Nursing))--North-West University, Potchefstroom Campus, 2006

The process for the incorporation, integration or collaboration of traditional healers into the National Health Care Delivery System of South Africa was marred by an array of mixed attitudes from all the parties concerned, namely traditional healers, patients, biomedical personnel, and the policy makers. The variety of approaches for inclusion of the traditional healers into the National Health Care System of South Africa was a further indication of the complexity of the situation. The possibility of functioning together between traditional healers and biomedical personnel existed before 1990 when the two groups met in Johannesburg in 1986 to discuss ways by which functioning together can be established. A series of meetings and discussions followed after which came the promulgation of the Chiropractors Homeopaths and Allied Health Services Professionals Act of 1996, which gives traditional healers their due recognition but does not include them as part of health care providers. The process of functioning together is a recommendation made by the World Health Organization and the most used terms for this functioning together is, incorporation, integration and collaboration. The process of incorporation can be realised by ensuring that both biomedical personnel and traditional healers remain autonomous, not controlling each other, respecting the existence of one another, as well as each other's own methods of healing. Integration was another method whereby the two health care systems can function together, even though integration differs in context from incorporation. Integration means that the traditional healers will have to function within the health care system under the directions of the biomedical personnel, whereby the patient receives a combination of both treatment methods depending on the problem or diagnosis. The third modality of getting the two health care systems to function together could be by collaboration. Collaboration was seen as a two sided effort whereby the healing methods of one are brought to fore and the most effective one is chosen to cure the patient's identified problem at that time. For the process of functioning together to be meaningful, it was necessary to get the government to review licensing the traditional healer's practices, so as to identify the healing techniques that are of value and use these to treat the patients. It was not really possible to clearly separate the three approaches because they all addressed the issue of having the two health care systems function together to increase health care services and fulfil the patients' health needs. For the purpose of this research the word incorporation was used. In South Africa the traditional healer is identified as the health care choice of 80-9036 of the black population. If this large number of black people uses traditional healing, then it becomes necessary to investigate the manner in which the traditional healer can be utilized effectively in the National Health Care Delivery System of South Africa to render the services that the patient needs for his/her health needs. It is for this reason that the researcher aimed at investigating the existing models of incorporation of traditional healers, the perceptions and attitudes of the traditional healers, biomedical personnel, patients and the policy makers regarding incorporation, their views on how this incorporation should be achieved, as well as how the incorporation of traditional healers into the National Health Care Delivery System of South Africa could be realised. A qualitative research design and theory generating approach was followed, and the research was conducted in two stages. In stage one qualitative research, participants were traditional healers, biomedical personnel, patients and policy makers, selected by means of non-probable purposive voluntary sampling. Data was collected by means of conducting semi-structured interviews with all the participants in the three identified provinces of South Africa. Field notes were recorded after each interview session. Data analysis was achieved by open coding. A co-coder and the researcher analysed the data independently after which consensus discussions took place to finalise the analysed data. Ethical principles were applied according to the guidelines of the Democratic Nurses Organisation of South Africa and the Department of Health. The second stage which was a theory generation approach, was used to formulate a model for the incorporation of the traditional healers into the National Health Care Delivery System of South African. / Thesis (Ph.D. (Nursing))--North-West University, Potchefstroom Campus, 2006

This thesis presents a challenge to policy initiatives that presume that patient-centered care will reduce racial disparities in health. Data from the Medical Expenditure Panel Survey were used to test patient assessment of provider behavior defined as patient-centered care according to the National Health Disparities Report of the Agency for Healthcare Research and Quality of the Department of Health and Human Services. Results indicated patient-centered care improves self-rated health status, but blacks still report worse health status than whites experiencing comparable patient-centered care. Further, black-white differences in patient-centered care had no affect on health status. Rival theories of black-white differences in health, including social class and health literacy, provided better explanations of disparities than assessment of provider behaviors. These findings suggest that policies designed to financially incentivize patient-centered care practices by providers should be considered with caution. While patient-centered care is better quality care, financial incentives could have a negative effect on minority health if providers are deterred from practices that serve disproportionate numbers of poor and less literate patients and their families. Measurement of the concept of patient-centered care in future health disparities research was also discussed.

Patient outcomes are influenced by the quality of care that the workforce renders. The registered nurse, as designated process-owner of the “Back to basics” quality improvement (QI) initiative, plays a vital role, being responsible for providing compassionate patient-centred care to alleviate suffering and restore health. The aim of the study was to gain an in-depth understanding of how nurses perceive their roles, responsibilities and challenges in delivering basic nursing care, linked to the organisational “Back to basics” QI initiative. A qualitative study with an explorative descriptive contextual design was utilised. Registered nurses with a direct patient care involvement in the general nursing discipline of a private hospital group participated in focus-group interviews. Data were analysed using Creswell’s data-analysis cycle. Findings were that patient care coordination involves an assessment-delegation-supervision triad. However, meeting stakeholder expectations, management and administrative responsibilities, remove the registered nurse from direct patient care. Time constraints affect physical bedside availability to model the exemplary knowledge, skills and attitudes underlying quality basic nursing care delivery. Reduced opportunities to model quality basic nursing care at the bedside affect patients’ care expectations, resulting in complaints related to basic nursing care omissions. Participants felt that they needed more clarification on the “Back to basics” QI initiative, and more in-service training. The many broad-ranging recommendations include in-service training that empowers registered nurses with the competencies to deal with role and task balance in the face of the diverse and complex demands of the modern healthcare arena. / Health Studies / M.A. (Health Studies)

The purpose of this phenomenological study was to describe the lived experiences of African American women with secondary infertility, defined as an inability to conceive or carry a baby to term after a previous conception. Research on secondary infertility has ignored the prevalence of the condition in African American women. The implications of secondary infertility in African American women have immediate and far-reaching health and psychosocial consequences. African American women rely on interconnectedness and social networks; therefore, social networks and social support served as the key concepts underwriting the study's conceptual framework. Social networks and social support underscore the connection between those needing and those rendering support during stressful life events. The study consisted of 10 African American women ages 18-75 years old, who met the inclusion criteria for the study. Participants completed screening questions, a brief demographic questionnaire, and an interview. Their experiences were captured through first person accounts during one-to-one semi-structured interviews developed through pilot testing. Qualitative analysis yielded four themes: (a) defining family and adjusting to the change in definition of a family; (b) experiences with secondary infertility; (c) psychosocial stressors and supports from friends and family; and (d) treatment and intervention. This research promotes social change by informing clinical practice through access to culturally competent resources, increased responsiveness and policy development promoting timely access to care.

Esta Pesquisa tem como objetivo investigar os sentidos construídos acerca da assistência prestada e recebida em Hospital Psiquiátrico e em Centro de Atenção Psicossocial, sob a ótica de usuários e profissionais de saúde deste último. Para tanto, adota a Estratégia Qualitativa de Pesquisa, dentro das perspectivas teóricas da pós-modernidade, do social construcionismo e da desinstitucionalização. Seus resultados foram ordenados sob dois eixos temáticos e respectivas categorias que emergiram da fala dos sujeitos. Seguindo a trajetória histórica da assistência em saúde mental, o primeiro eixo temático diz respeito à assistência em Hospital Psiquiátrico e, o segundo em serviço substitutivo do tipo CAPS. Em relação ao primeiro, na ótica dos usuários, este espaço assistencial é tido como aprisionamento, onde vêem perdida a sua autonomia e obrigados a seguir normas rígidas e repetitivas; espaço pobre em relações, afeto e escuta, mas rico em produção de violência. Para estes mesmos sujeitos, o CAPS surge como uma porta que se abre às relações, aos contratos, à convivência mais estreita e respeitosa, com possibilidades que podem ser ativadas para a maior compreensão da pessoa que vivencia o sofrimento psíquico e melhoria da assistência recebida. Entre os profissionais, apesar das experiências negativas no processo de formação em Hospital Psiquiátrico, há a defesa da sua manutenção para o atendimento do usuário em crise. Por outro lado, o CAPS, para a maioria destes profissionais, é uma nova e criativa experiência, com aprendizados e faltas sentidas que se traduzem ainda num processo incipiente, porém, em construção de uma nova prática em saúde mental. Ao final, é realizada uma análise das dimensões políticas, históricas e culturais locais que condicionam os sentidos produzidos acerca da assistência em saúde no serviço substitutivo em questão e, são apontados desafios a serem superados; responsabilidades a serem compartilhadas e, caminhos possíveis e necessários para a mudança paradigmática. / This research has the objective of investigating the senses constructed by users and professionals of health about the assistance given and received both in the Psychiatric Hospital and in a Center for Psycho-Social Attention (CAPS). It adopts the Qualitative Strategy of Research, under the theoretical perspectives of Postmodernity; Social-Constructionism and Des - institutionalization guidelines. Its results were organized in two themes and respective categories that emerged from the interviews. Following the historical trajectory of assistance in Mental Health, the first theme refers to the assistance in the Psychiatric Hospital and the second to the CAPS. In the perspective of the users, the Hospital is like a prision, where they lose their autonomy and follow rigid and repetitive norms; it is a space poor in relationships, affection and listening, but rich in violence. For the same subjects, the CAPS appears as a door that opens to relationships, contracts, and respectful acquaintanceship, with the possibility of better understanding of the person who suffers and improvement of the assistance. The professionals, in spite of negative experiences during their formation in the Hospital environment, defend its maintenance for the attendance of the user in crisis. On the other hand, the CAPS, for the majority of these professionals, is a new and creative experience. Although the learning and the achievements are still in an incipient process, they point to the construction of a new practice in Mental Health. The analysis of the categories covers political, historical and cultural aspects that condition the produced meanings concerning Mental Health assistance in open services. It also detects the challenges to be surpassed; responsibilities to be shared and the possible and necessary ways for a change of paradigm.

This thesis presents a challenge to policy initiatives that presume that patient-centered care will reduce racial disparities in health. Data from the Medical Expenditure Panel Survey were used to test patient assessment of provider behavior defined as patient-centered care according to the National Health Disparities Report of the Agency for Healthcare Research and Quality of the Department of Health and Human Services. Results indicated patient-centered care improves self-rated health status, but blacks still report worse health status than whites experiencing comparable patient-centered care. Further, black-white differences in patient-centered care had no affect on health status. Rival theories of black-white differences in health, including social class and health literacy, provided better explanations of disparities than assessment of provider behaviors. These findings suggest that policies designed to financially incentivize patient-centered care practices by providers should be considered with caution. While patient-centered care is better quality care, financial incentives could have a negative effect on minority health if providers are deterred from practices that serve disproportionate numbers of poor and less literate patients and their families. Measurement of the concept of patient-centered care in future health disparities research was also discussed.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.