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.

Family and friends provide substantial daily assistance to older adults with disabilities, but little is known about how that caregiving impacts the health of older adults. Using survey data on a nationally-representative sample of older adults and their caregivers, matched with Medicare claims, I explored several aspects of the relationship between caregiving and the health of older adults receiving care. I relied largely on Andersen’s behavioral model, which describes health services use as a product of predisposing, enabling, and need characteristics. I found that 33%-37% of older adults with unmet care needs at one point in time still have them one year later. I also found frequent change in the composition of older adults’ networks of caregivers. Having a formal caregiver was associated with lower odds of unmet care needs for women; conversely, men receiving care from a spouse had three times lower odds of unmet care needs than those receiving care from a non-spousal caregiver. Some caregivers use services such as respite care, training, and support groups, but some caregivers lack access to desired services. I found that caregivers reporting unmet service need were more likely to be Black and Hispanic, while service use was higher among caregivers providing help on a regular schedule. Care-recipient health and function was associated with both service use and unmet service need, but available measures of local caregiver service supply were not. Older adults frequently seek care in emergency departments (EDs), but this care may not always be necessary or desirable. I hypothesized, but did not find, that caregiver service use was associated with care-recipient ED use. Instead, chronic health conditions and other need factors were the strongest predictors of ED use. I found that care-recipients of male caregivers had lower rates of ED utilization for reasons that were urgent and not preventable. I also found that care-recipients of adult children had lower rates of non-urgent ED utilization than care-recipients of more distantly-related or unrelated caregivers. These findings suggest that unmet care needs might be reduced by improving access to formal care for older women with functional limitations and monitoring unmarried older men. In addition, improving service access for Black and Hispanic caregivers, and for caregivers who provide unscheduled care, could reduce caregivers’ unmet service need. Finally, targeting training and support services to male spousal caregivers could improve access both to needed daily care and to emergency care. Future research should focus on replicating these analyses after more data become available and on developing alternate measures of caregiver service supply.

In this thesis I am concerned to examine the management behaviours and predilections of managers across the two settings of health and theatre considered to be divergent. To do this I explore and map methods, similarities and differences managers employ to ???manage??? workers across the industries. I also deconstruct creativity and its manifestations in both managerial behaviours and environmental contexts and map the complexity issues that managers face in different settings. Further, I explore the extent to which management activity is contextual to the identity of participant organisational aims and processes and examine the level of calculated chaos experienced by managers across the settings. Central to this approach is the utilisation of multi-method design incorporating interview, micro-ethnography, auto-ethnography and a RAND expert panel to assist with interpretation of the results. Core findings include high degrees of similarity in the roles and functions and support systems utilised by managers across the settings despite substantial differences in environmental contexts and organisational aims and processes. Differences were identified in the areas of: levels of chaos, interactions, purposes, and environmental characteristics. To account for these differences I apprehended seven metafactors grounded in the data sets. These seven metafactors can be found in each setting but emerge in different ways. The metafactors that I apprehend are order versus disorder; creativity; experimentation and change; risk; reflection; trust and respect; and time and pressure. While I discuss these seven metafactors as separate factors in reality they are fundamentally inter-related. Suggestions for future research are included.

Introduction: Management of complex systems is facilitated through effective information systems that provide real-time data to decision makers. For example, instrument panels in airplanes ensure that pilots have well-designed feedback concerning the status of mission-critical variables. Problem: While pilots have dashboards for feedback and communication, healthcare executives may be unaware of effective use of evidence-based guidelines within their healthcare system. Purpose: The first objective of this research was to design and implement an automated intranet dashboard reporting performance measures for a geographically dispersed health system. The second objective was to describe how this dashboard might increase cooperation and coordination for individuals and organizations involved with healthcare delivery. Design: This research was exploratory in nature, employing descriptive research approaches. A convenience sample of healthcare executives completed a baseline survey at the start of the study assessing levels of communication and cooperation. After three months of exposure to the dashboard, participants were asked to complete a follow-up survey. All visits to the dashboard were recorded in a web server log file. Semistructured qualitative exit interviews were also conducted to explore reactions to the dashboard, experiences with receiving outcome reports, and barriers to communicating and coordinating with counterparts. Results: Descriptive analysis of paired survey scores found substantial increases on a number of survey items, suggesting that the dashboard contributes toward increased communication and coordination for healthcare executives. This finding is balanced by the limited rigor in the research design and an analysis of the web server log file, which found few visitations to the dashboard by research participants. Qualitative data analysis suggests that current reporting mechanisms are suboptimal for healthcare executives and that one solution is the use of dashboards. Conclusion: This study resulted in a number of important discoveries and avenues for further research. A more rigorous research design is needed to explore the role of intranet dashboards in healthcare settings. / Graduation date: 2004

Thesis (Ph.D.)--University of Wollongong, 2009. / Typescript. Includes bibliographical references: p. 235-248.

Thesis (master's)--Universität Hannover, 1999? / Includes bibliographical references (p. 175-189).

Sub-Saharan Africa has the highest number of people living with HIV and AIDS in the world. Several studies that were carried out suggest that there is a negative impact of HIV and AIDS on the health sector. This impacts directly on health care providers as they are the first point of contact for ill people. This study seeks to explore the impact of HIV and AIDS on health care provision looking at the perception of health care providers. Qualitative methods were used for collecting data from the health care providers. Two focus group discussions were conducted and ten in-depth interviews were conducted in three health care facilities in Lesotho. Audio tapes were used to record the interviews and thematic analysis was utilized to analyse the data. The results showed that the workload has increased due the increased number of people who seek health care services. There is also a shortage of staff in facilities which leads to health workers having to work extra hours. The study further indicated that there is lack of knowledge among health care providers regarding the management of HIV and AIDS. Consequently, the health care providers fear the risk of contracting HIV from their patients. In addition, the results revealed that the poor infrastructure at the facilities hinder health care providers from performing their duties effectively. The other concern was the lack of support structures from the management. Furthermore, stigma and discrimination emerged as the major problems for providers as work and home. As a result, the health care providers are stressed and suffered from burnout. There is a need for further research on the impact of HIV and AIDS on health providers. Government should take more responsibility for encouraging students to enroll at health training institutes. The curriculum should include an emphasis on HIV and AIDS and workshops on HIV and AIDS should be held. / Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2010.

In this thesis I am concerned to examine the management behaviours and predilections of managers across the two settings of health and theatre considered to be divergent. To do this I explore and map methods, similarities and differences managers employ to ???manage??? workers across the industries. I also deconstruct creativity and its manifestations in both managerial behaviours and environmental contexts and map the complexity issues that managers face in different settings. Further, I explore the extent to which management activity is contextual to the identity of participant organisational aims and processes and examine the level of calculated chaos experienced by managers across the settings. Central to this approach is the utilisation of multi-method design incorporating interview, micro-ethnography, auto-ethnography and a RAND expert panel to assist with interpretation of the results. Core findings include high degrees of similarity in the roles and functions and support systems utilised by managers across the settings despite substantial differences in environmental contexts and organisational aims and processes. Differences were identified in the areas of: levels of chaos, interactions, purposes, and environmental characteristics. To account for these differences I apprehended seven metafactors grounded in the data sets. These seven metafactors can be found in each setting but emerge in different ways. The metafactors that I apprehend are order versus disorder; creativity; experimentation and change; risk; reflection; trust and respect; and time and pressure. While I discuss these seven metafactors as separate factors in reality they are fundamentally inter-related. Suggestions for future research are included.

Thesis (Ph.D.) -- McMaster University, 1998. / Includes bibliographical references (leaves 143-147). Also available via World Wide Web.

Thesis (Ph.D.)--University of Wollongong, 2006. / Typescript. Includes bibliographical references: leaf 343-380.