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Emergency rooms often are used for extremely ill patients, but they also are used and overused for non-urgent acute-care needs, especially in the urban setting where patients might not have access to primary care services. While U.S. legislation has aimed to reduce emergency-room usage for non-emergency needs, the emergency room continues to be an essential support in low-income and urban neighborhoods. Specifically, North Philadelphia residents rely on and use the emergency room for reliable care. The central premise of this thesis is that we should shift from working to curtail emergency room usage, and therefore costs, to fundamentally re-redefining the nature and identity of emergency rooms. / Urban Bioethics

The increased out-of-pocket payments required from today’s insurance plan designs is leading to the advent of patients acting more like regular consumers. They are shopping for the best value for their personal spending on healthcare services. This is leading to an increased use of less hospital and health system centric delivery sites. Enabled by the availability of information on the internet, more patients are using alternative settings such as urgent care centers, retail clinics, etc. Specifically, patients are opting for Urgent Care Centers (UCC) in lieu of the hospital emergency room (ER), principally due to higher out-of-pocket costs for unscheduled care but also a desire for a better overall service experience with amenities and a service orientation towards the consumer/patient. This shift in patient behavior raises questions as to how UCCs compare to ERs. To better understand this, two studies were conducted: the first examining the relative patient experience at UCCs versus ERs, and the second examining the effect of UCC visits on overall cost of service. To better understand the patient experience in UCCs compared to ERs, a quantitative analysis of reviews posted on Yelp for hospital emergency room and urgent care center was conducted. UCCs received significantly higher Yelp ratings than emergency rooms. Machine learning was used to determine which topics in Yelp reviews were most closely correlated with 5-star and 1-star ratings. 16,447 ER Yelp reviews were analyzed from 1,566 hospitals, and 84,502 reviews from 5,601 UCCs. There were more 5-star UCC reviews (n=43,487, 51%, p<0.05) compared to 5-star ER reviews (n=4,437, 27%, p<0.05). The study determined that 5-star reviews for ERs tend to focus on clinical care while UCC reviews focused on convenience. Online patient reviews provide an understanding of what patient’s value in their unscheduled care experience offering insights for health systems and providers in planning the future care delivery systems. To determine if urgent care centers are a less-costly substitute service to hospital-based emergency rooms or a complementary, cost-amplifying service, a second study was completed. The study compared the pre- and post-period spending differences, for selected low-acuity patient conditions, between patients who started their treatment at an urgent care center versus starting at an emergency room using difference-in-differences analysis. The study methodology was based on a sample University of Pennsylvania Health System employees and their dependents seen at an urgent care facility or in the emergency room between 2012-2017 with a primary diagnosis among 15 most common low-acuity conditions seen in those settings. The sample included 3,055 episodes with initial index visits in urgent care and 3,650 initial index visits in a hospital emergency room. Patients who visited the ER spent $1,323 (p < 0.0001) more than those who visited urgent care centers within 30 days following the visit, and $2,152 (p < 0.0001) more within 6 months following the visit. Visiting the emergency room corresponded to a 68.0% greater change in pre- to post-index period cost when evaluating the first 30 days and 40.0% comparing costs over 6 months. Thus, this study demonstrated the significant cost advantage of urgent care centers for treating selected conditions as compared to a hospital emergency rooms when the unit of analysis is total health care spending at 30-day and 6 months. / Business Administration/Interdisciplinary

Thesis advisor: Thomas M. Crea / The United States is home to over 44 million immigrants, giving it the largest foreign-born population in the world, a number which is projected to roughly double by 2065. Among foreign-born individuals, significant disparities have been uncovered in health care utilization compared to their U.S.-born peers. A growing body of research has recognized the need to assess the institutional and systemic barriers to health care access contributing to this disparity, and how those barriers may be effectively mitigated. My investigation of this topic was based in California and consisted of two analytic components. The first was a quantitative assessment of barriers to health care access and how those barriers were uniquely experienced by subgroups of participants. Utilizing data from the 2015-2019 California Health Interview Survey data collection cycles, latent class analysis was used to investigate unique patterns of barrier endorsement based on participant immigration status, race or ethnicity, and the interaction between the two. Three distinct classes were identified with a low-, moderate-, and high-risk of endorsing multiple barriers to health care access. The hypotheses that legal status, race or ethnicity, and the interaction between the two were partially supported. The second component of this study was a critical policy analysis of California’s SB 54, a package of legislation which aimed to foster trust in public institutions and increase use of health care by limiting the ability of local law enforcement to act on behalf of federal immigration authorities. This analysis determined that county-level implementation was inconsistent, and those differences were associated with mixed success in decreasing immigration contact and increasing service utilization. These findings are leveraged to identify policy and programmatic recommendations that may improve delivery and facilitate increased ability to safely seek high-quality care for medically underserved populations. / Thesis (PhD) — Boston College, 2024. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

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Thesis (M.A. (Clinical Psychology)) -- University of Limpopo, 2020 / The integration of mental health care (MHC) into primary health care (PHC) has been identified as a practical intervention to: increase accessibility to mental health care; reduce stigma and discrimination against people living with mental illnesses; improve the management of chronic mental illness; and, to reduce the burden of comorbidity of mental illnesses with other chronic illnesses. In the South African context, integrating MHC into PHC also seeks to respond to numerous legislative reforms, with the aim of providing comprehensive health care, particularly to previously disadvantaged populations. The aim of the present study was to explore the perceptions of facility managers in the Tshwane District (Gauteng Province) towards the integration of mental health into PHC. Fifteen participants from the Tshwane district facilities participated in the study. The participants were selected through a non-probability purposive sampling method. Data was collected through in-depth interviews using a semi-structured questionnaire, and analysed using the thematic coding approach. Significant findings suggested that the major hindrances to the realisation of the policy objectives may be due to: the lack of rehabilitation and psychotherapeutic services; insufficient skill and knowledge of mental health on the part of staff; insufficient or unsuitable practice space in the facilities; and, poor cooperation between South African Police Services, Emergency Medical Services and Primary Health Care. Inter-facility communication, district implementation support and policy knowledge has notably increased over the years and were deemed to be amongst the biggest enablers.