The coronavirus pandemic exposed the systemic issues faced by nursing homes with a higher percentage of Medicaid residents. By using the Brown University's Long-Term Care focus facility-level data and the Centers for Medicare and Medicaid Services data, the study examines the association between the nursing home and resident characteristics with Covid-19 cases in high-Medicaid nursing homes. Fifty-eight facilities in Florida were identified as having residents whose primary support was Medicaid. The findings from the study suggest a higher proportion of Medicaid residents, for-profit status, and chain affiliation status, were associated with a higher prevalence of Covid-19 cases among nursing home residents. Further research on related health policies is necessary to resolve the current disparities in nursing home care serving a higher proportion of Medicaid residents.

The opioid epidemic impacts all levels of society, yet discernible disparities exist concerning opioid use disorder (OUD) prevalence and access to treatment, including medications for opioid use disorder (MOUDs). Specifically, adults involved in the justice system face a disproportionate burden of OUD and are more likely to go untreated. Insurance coverage plays a critical role in facilitating healthcare access, including OUD treatment. Under the Affordable Care Act, select states elected to expand their Medicaid coverage to more low-income individuals. Additionally, some incarcerated individuals are affected by the "inmate exclusion" law which bars Medicaid from covering healthcare for those in correctional facilities. Some states automatically terminate Medicaid eligibility upon incarceration, while others choose to suspend. Although research indicates that Medicaid expansion correlates with increased insurance coverage and MOUD access and utilization within the general population, the effects on justice-involved individuals remain inadequately understood. To address these gaps, this dissertation examines the effects of state policies expanding access to Medicaid coverage on outcomes for individuals with OUD referred to treatment by the justice system using a quasi-experimental, difference-in-difference framework and data from the Treatment Episode Dataset-Admissions (TEDS-A) from 2006-2019. More specifically, we estimated the effects of Medicaid expansion on insurance coverage at admission (i.e., Medicaid, private, uninsured, or other) and planned utilization of MOUD for all justice referrals and the effects of suspension and Medicaid expansion on outcomes for individuals referred from prison or probation/parole since suspension policies should only affect recently incarcerated individuals. We found that Medicaid coverage increased while uninsurance decreased, and planned utilization of MOUD improved by 133%. Moreover, in expansion states, Medicaid coverage and planned utilization of MOUD increased. For the prison and parole/probation subpopulation, we found that Medicaid expansion improved Medicaid coverage and planned utilization of MOUD, but that Medicaid suspension was not associated with either outcome.

Chronic kidney disease (CKD) is a condition that requires access to renal replacement therapies (RRTs) to enable patients to live. The use of such therapies has been continuously researched due to the high cost to payers and their patients. This dissertation aimed to analyze the incidence, prevalence, and mortality of renal replacement therapies in patients with end-stage renal disease (ESRD), and document cost trends and analyze possible inequalities in access to these therapies. Based on an integrated health risk management (IHRM) model, this study examined patient characteristics associated with renal replacement therapies in ESRD patients through a pooled cross-sectional study based on USRDS (United States Renal Data System), and examined information related to costs and utilization of health services one year after the initiation of dialysis through a retrospective cohort study. Findings suggest that morbidity and mortality measures of renal replacement therapies continue to increase from 2001 to 2018, and costs continue to decrease from 2014 to 2017 in the United States. In-center hemodialysis (ICHD) (196.2 cases per 100,000 inhabitants) continues to be the most prevalent RRT utilized over home hemodialysis (HHD) (4.4 cases per 100,000 inhabitants) and peritoneal dialysis (PD) (24.7 cases per 100,000 inhabitants). The cost for ICHD (306,705,989 million dollars) is significantly higher than HHD (234,559,170 million dollars) and PD (5,360,136 million dollars). White patients have a 25% lower probability of accessing in-center hemodialysis compared to patients of other races. Hispanic patients were also found to be 31% more likely to access in-center hemodialysis compared to non-Hispanic patients, which would indicate potential inequities in access to these alternative RRTs. Study findings provide critical data to inform decision-makers on the use of HHD, PD, and ICHD among ESRD patients in the US and increase awareness of PD and HHD to reduce long-term costs to the healthcare system.

The United States is in the midst of an opioid crisis. Fortunately, effective treatments for opioid use disorder exist (OUD); however, they are underutilized. Medications for opioid use disorder (MOUDs) decrease death by 50 %. These MOUDs are particularly relevant in the criminal justice population given that this population has a higher OUD disease burden but is less likely than the general population to receive this life-saving treatment. Research has identified negative attitudes toward MOUDs among corrections staff as a barrier to utilizing MOUDs. This thesis examines the relationships between community correction staff familiarity with methadone, one type of MOUD, and their opinions toward methadone using extant data from the Criminal Justice Drug Abuse Treatment Studies 2 (CJ-DATS 2) series. These data were collected between 2010-2012. The study was guided by the Knowledge-Attitude Behavior (KAB) model. The data are described using descriptive statistics, and I estimate logistic regressions to examine the relationship between respondent familiarity with methadone and their attitude toward methadone while controlling for other covariates. With a sample of 167 corrections employees, I found that corrections staff who agreed or strongly agreed with the statement that they were familiar with methadone had more positive methadone attitudes. Future research should examine the relationship between familiarity/knowledge, attitudes, and behaviors in other criminal justice settings and for other MOUDs (i.e., buprenorphine and naltrexone).

Annually, hypertension is responsible for over 10 million deaths. During the span of a decade, low-middle income countries (LMICs) have experienced the most negative change in progress towards decreasing hypertension prevalence. It is estimated that 46% of the adult population in Sub-Saharan Africa (SSA) is hypertensive. When looking at solutions to address hypertension management in SSA, finding effective medication adherence interventions is the way forward. The purpose of this study was to promote the implementation of evidence-based interventions for successful treatment and improved life quality of hypertensive adults in Sub-Saharan Africa, with the input of healthcare stakeholders. The specific aims were to: 1) determine what interventions for antihypertension medication adherence have been successfully implemented in SSA and assess their implementation outcomes, and 2) conduct a focus group with health practitioners to evaluate what interventions and implementation practices were supported. The methods used to complete this study were a systematic review and focus group sessions. The systematic review was able to identify measurable implementation outcomes for the evidence based interventions found in the literature. The implementation outcomes identified in each of the included studies were categorized according to definitions derived from Proctor, et al.’s Outcomes for Implementation Research and Gyamfi, et al.’s Assessment of Descriptors of Scalability. The systematic review findings revealed that to establish antihypertensive medication adherence in SSA, the appropriateness of an intervention and the inclusion of health education are essential. Additionally, in order to have successful implementation of an intervention, stakeholders need to commit to addressing systematic challenges emphasized in the literature. The focus group sessions helped to identify tangible actions that can be implemented in order to improve antihypertensive medication adherence in the region. Thematic analysis was used to organize themes found across the focus group transcriptions. During the focus group sessions, health practitioners addressed the practicality of implementing evidence-based interventions found in the literature within their communities. The focus group findings reveal key recommendations including increasing government participation and addressing barriers to implementation. Overall, the data gathered across the studies shows that implementation is not easy to achieve. In addressing antihypertensive medication adherence, stakeholders must take into consideration how healthcare systems function as a whole. Although international and national guidelines provide excellent guidance for implementing evidence-based care, adjustments are needed in order to address population needs and scale interventions.

This qualitative phenomenological study examined central Florida's nursing home administrators' knowledge and perception of cultural competence and how they perceive that their knowledge and perceptions impact residents, families, and healthcare. The theoretical framework for this study was explained through Campinha-Bacote's interdisciplinary model of The Process of Cultural Competence in the Delivery of Healthcare Services. The theoretical framework was used to guide research questions, and individual interview questions to obtain nursing home administrator's knowledge and perception of cultural competence. The study explored the level of cultural competence reported by nursing home administrators, their individual perception of cultural competence, their degree of confidence in cultural competence, and how nursing home administrators describe their proficiencies and skills in cultural competence. Interviews with six nursing home administrators included licensed nursing home administrators (NHA) and assistant nursing home administrators, and the director of nursing (DON). The findings identified and analyzed the diverse levels of nursing home administrator's knowledge and perception of cultural competence. Some participants demonstrated difficulty expressing their knowledge and perception of cultural competence. Findings indicate that various factors influenced participants' overall degree of confidence in their knowledge and perception of cultural competence. Nursing home administrators also had a difficult time articulating particular skills that demonstrate their ability to adapt to the diverse residents in their facilities, and how they promote cultural competence in their nursing home facilities. This study identified the need for additional research and continuing education about cultural competence in healthcare.

References to accountability are common throughout public administration literature. However, a clear model to assess accountability in government programs is not fully developed. This research fills this gap and provides policymakers with a tool they can use to assess accountability in both public and contracted programs and enables them to make more informed contracting-out decisions. In addition, the Integrated Accountability Framework introduced in this research will serve as a guideline for how public administrators can improve accountability in the programs they administer and oversee. For the public and private health care programs analyzed in this study, the findings indicate that the publicly delivered programs provided more accountability to the vulnerable populations served than the contracted-out health care programs. / by Thomas W. Cleare. / Thesis (Ph.D.)--Florida Atlantic University, 2011. / Includes bibliography. / Electronic reproduction. Boca Raton, Fla., 2011. Mode of access: World Wide Web.

Purpose: The purpose of this research was to develop quality and efficiency improvements in the health care administration system of Mauritius. The aim of the study is to describe how the health care services of Mauritius could be improved based on the results obtained during this investigation. Methodology: The health care executives, board members, search firm executives, and health administration managers, as well as several patients, were selected by stratified sampling 1802 participants (quantitative) and by purposive sampling method nine focus groups of nine participants each (qualitative). The population for the qualitative research was comprised of patients and health care professionals selected by the purposive sampling technique. The population was comprised of patients and health care professionals for quantitative phase selected by stratified and the health care professionals for qualitative part selected through purposive sampling technique. Findings: The participants showed a preference for Patients’ Satisfactions, ISO Quality Standards Compliance, workforce efficiency, infrastructure fitness, and adaptability principally experience a better quality of care. Moreover, there was no statistical difference between financial cost and quality of health care was depicted. The outcome of the study: A common aspect, recognised empirically, is the approach regarding enhanced external pressure on the healthcare administrators in their work. Higher administration decisions, patient pressure and judgments made by policymakers have impacted and established the choices prepared by health care managers regarding where to concentrate attempts of growth. In the context of practical implications, health care administrators must properly make new management control systems so that they help healthcare systems in their work. Implications for the healthcare leader’s perceptions are that knowledge from the environment is normally complicated and not easy to define and also transmitted from particular stakeholders. / Health Studies / D. Litt. et Phil. (Health Studies)

The study of policy implementation has recently garnered research and federal attention highlighting the importance of implementation in achieving desired policy and program outcomes (Durlak & DuPre, 2008; Meyers, Durlak & Wandersman, 2012; National Institutes of Health, 2013). Psychology is one discipline that is well poised to guide the study of policy implementation as it can inform the creation, development, and outcomes associated with the introduction of a policy (Esses & Dovidio, 2011; Fischhoff, 1990). Given that batterer intervention programs (BIPs) have been developed to prevent future intimate partner violence (IPV) and improve victim safety, ensuring these programs have successfully implemented state standards for practice is immensely important. Despite the widespread use of state standards to guide BIP practices (Maiuro & Eberle, 2008), only one study (Boal, 2010) has assessed the extent to which BIPs comply with standards and no research has evaluated program responses to standards or the process by which implementation occurs. Given this, the current study focused on four areas of inquiry: (1) program compliance with state standards; (2) current and former BIP representatives' response to standards, including the social psychological constructs of actual control, perceived control, retrospective accounts of attitude change, absoluteness, and legitimacy; (3) program compliance as it relates to these responses; and (4) the process of implementing standards. In order to address these topics, key program representatives were assessed using a sequential mixed-methods design, which consisted of a preliminary quantitative phase (i.e., Phase One) (n = 35, response rate = 74%) and principal qualitative phase (i.e., Phase Two) (current providers: n = 13, response rate = 87%; former providers: n = 5, response rate = 100%) (Morgan, 1998). Findings from Phase One indicate that programs complied with 75% of the assessed components of standards. Phase Two findings suggest that participants primarily voiced experiences with the standards consistent with a lack of actual control, perceived control, and legitimacy. Contrary to hypotheses a statistically reliable difference in actual control, perceived control, and legitimacy were not detected across high and low compliance participants. Participants retrospectively described responses to the standards consistent with changing and maintaining negative attitudes towards the standards (31% and 31% respectively) and as hypothesized, those who shifted negative initial attitudes to be positive (i.e., a proxy for rationalization) were primarily from high compliance programs (75%) and those who maintained negative attitudes (i.e., a proxy for reactance) were all from low compliance programs (100%). While participants generally perceived the standards as primarily absolute, this construct did not differentiate those who changed and maintained negative attitudes as predicted. Participants' utilized diverse strategies to implement the standards and have changed or attempted to change many program characteristics to better comply with state standards. Participants have experienced diverse enablers to compliance (e.g., positive community collaborations; participation in the research process) and barriers to compliance (e.g., negative or lack of community collaborations; challenges understanding the standards) while attempting to implement standards. Suggestions to better facilitate compliance aligned with the enablers and barriers and centered on the need for positive information-sharing relationships among providers. Finally, former providers tended to disagree that the standards were the primary reason for program closure. Together, these findings provide valuable insight into the manifestation of common social psychological constructs during the policy implementation process, as well as information regarding the logistics of implementation. The information gathered in this study can be applied to better understand the role of actual control, perceived control, retrospective accounts of attitude change, absoluteness, and legitimacy, as they are experienced in the real world in relation to an actual policy. This extends the study of these constructs out of a laboratory and experimental context and suggests aspects of these constructs that may be relevant in applied settings. Further, data regarding the policy implementation process is useful to inform policymakers about the diverse steps that can be taken to assist implementation efforts and increase compliance.

A partir da implantação do SUS, o setor saúde vem se expandindo no país tanto em volume de atendimentos quanto em aumento de gastos que são decorrentes de diversos fatores como complexidade das doenças, introdução de novas tecnologias e outros. Dentre os desafios para os gestores do SUS, o financiamento e a conciliação do desejo e a necessidade do usuário com os recursos disponíveis têm se constituído em preocupações permanentes. Conhecer a variação interna de preços é aspecto importante para o planejamento e acompanhamento das contas de qualquer empresa, dentre elas, os hospitais que enfrentam aumento de gastos e de custos tanto pelo crescimento de demanda quanto pela incorporação necessária de tecnologias, além das tendências do mercado. Então, diante da necessidade do HCFMRP-USP ter um indicador para acompanhar a evolução dos preços de materiais de consumo e medicamentos e compará-los com a realidade de mercado e, também formar séries históricas para compor bancos de dados que servirão de ferramenta de gestão financeira e orçamentária foi proposto este estudo, cujos resultados e fórmulas apresentadas poderão servir de base para que outras instituições obtenham os seus índices internos de variação de preços. Objetivos: Apresentar os índices de variação de preços do HCFMRP-USP (IVPH), ano 2013, geral para materiais de consumo e medicamentos; específico para materiais de consumo e específico para medicamentos. Método: Para o IVPH foi definido o Índice de Paasche como o mais adequado para o perfil de consumo do Hospital por ser este o índice que considera a ponderação feita em função dos preços e quantidades do período de referência. Para o cálculo, foi definida a cesta de consumo considerando 40% do gasto financeiro em 2012 o que representou 13% dos itens e também pelos itens que tiveram consumo regular, ou seja, em todos os meses de janeiro a dezembro de 2013. Os preços utilizados foram os últimos pagos no período. Resultados: os IVPHs gerais foram 6,74% para materiais e medicamentos; 6,97% para materiais de consumo e 6,73% para medicamentos. Comprar bem, a preços praticados no mercado é aplicar bem os recursos disponíveis. Recursos financeiros bem gerenciados podem gerar mais cobertura e mais qualidade para o sistema de saúde e o IVPH é uma das ferramentas que contribui para este gerenciamento. / Since the implementation of Unified Health System, named Sistema Único de Saúde (SUS), in Brazil, the health care system has been expanding in the country in volume of healthcare actions andin increase of expenses due to several factors such as the complexity of the diseases, introduction of new technologies and others. Among the challenges for managers of the SUS, reconciling funding and the desires and needs of the users with available resources have been permanent concerns. Knowing the internal price variation is an important aspect for planning and monitoring of any company accounts, among them, hospitals facing increased expenses and costs by both demand growth and the incorporation of required technologies and market trends. Therefore the need for Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo - HCFMRP-USP to have an indicator to monitor the progress of consumables and medicines prices and compare them with the market reality and also form historical series to form databases that will serve as a management tool for financial and budget decisions. Such data may also serve as a basis for other institutions to obtain their internal rates of price change. Objectives: To present the variation rates of HCFMRP- USP prices (IVPH), 2013, in general for both consumables and medicines and specific rates for consumables and drugs. Method: For the IVPH was defined the Paasche index as the most suitable for the consumption profile of the Hospital because this is the index that considers the weighting made according to the prices and quantities variation of the reference period. To calculate the consumption basket the items considered were the ones that made up 40% of the financial expenditure in 2012, which represented 13% of all items and had regular consumption that is, items that had consumption in every month from January to December 2013. Prices used were the last paid in the period. Results: The general IVPH\'s were 6.74% for materials and medicines; 6.97% for consumables and 6.73% for medicines. Buying well, at market prices means applying the available resources adequately. The well done management of the financial resources can generate more coverage and best quality for the health system and the IVPH is one of the tools that contribute to this management.