Scholars have called for contextual based explorations of factors impacting implementation of integrated health care (IHC), yet IHC researchers agree that a paucity of research remains. (Kirschbaum, Rask, Brennan, Phelan, & Fortner, 2012; Miller, Kessler, Peek, & Kallenberg, 2011). Even less is known about the process of behavioral and physical health care integration in student health centers on university campuses (Alschuler et al., 2008). The purpose of this study was to address specific gaps in the literature of contextualized processes of integration (Kwan & Nease, 2013; Xyrichis & Lowton, 2008) by examining clinician, support staff, and administrator experiences with the process of integration at a student health center and to identify how values, principles, and attitudes impact this process. The results of a qualitative analysis of nine focus groups show the complexity associated with the process of integration as well as the factors impacting implementation at a university health center. Grounded theory methodology was used to analyze the data in three steps: (a) open-coding, (b) axial coding, and (c) selective coding (Corbin & Strauss, 2015). The analysis revealed three axial level categories comprised of 16 open-coding level categories and subcategories. A grounded theory model was developed and depicts how the various phenomena revealed at the axial level were interrelated in the early stages of the Student Health Center’s integration efforts.The conclusions of this study revealed that this organization’s integration was characterized by a collection of interacting Individual-Level, Organization-Level, and Communication variables, including barriers and facilitators of integration, which impact the process of integration. At the center of the theoretical structure was a co-constructed base of knowledge and attitudes from which staff approached and understood integrationa Shared Construct Representing Integration. However, since staff were at the beginning of the process of integration, the form of this construct had not yet come into focus. Therefore, the model is depicted as a “snapshot” in time. These conclusions have many implications for Administrators of student health centers who are considering integration. Prior to embarking on the integration process, interested parties are encouraged to seriously consider the many variables, processes, and strategies identified in this study.

Across the UK the integration of historically divergent specialities of genitourinary medicine (GUM) and well-woman/family planning (WW/FP) has emerged as a modern approach to sexual and reproductive health care provision. Integration’s most visible form is the ‘one-stop shop’ (OSS), where a full range of services are brought together under one roof and wherein care is provided by comprehensively trained practitioners. To date, there exists only limited insights into stakeholder experiences of integrated clinics. Conducting ethnographically-informed research at one such purpose-built OSS over a 9 month period (2013-2014), I sought to redress this gap in knowledge. Accompanying 29 attendees along their journey through the clinic, my research offers a detailed examination of the extent to which experience is shaped by integration. Drawing upon literature at the confluence of medical sociology, social geography, and anthropology, including Gesler’s (1992) ‘geographic metaphor’ of the ‘therapeutic landscape’, the thesis puts forward two key arguments. First, I suggest that participants often reconstructed the clinic as aligned to their presenting need, for example, a ‘GUM clinic’, or a ‘family planning’ service. This finding, teased out over the course of the thesis, destabilises assumptions present in previous studies that integration be inevitably deterministic in shaping attendees’ experiences. Second, the thesis contributes to a gaps in literature relating to Gesler’s (1992) ‘therapeutic landscapes’ in three key ways. The first contribution is to show how affective landscapes matter, are significant, in the formation of experience in a novel setting – a transient, ‘walk-in’ clinic. The findings, further, point to the elevated import of the physical and symbolic landscapes in the case of the OSS - a place where there is little opportunity to cultivate therapeutic social relationships. Finally, the thesis speaks to the ways in which the affective landscapes of the clinic work to challenge, confirm or reshape attendees’ preconceptions and expectations of sexual health services. Together, these findings contribute to pre-existing accounts of the experience of integrated services by asking us to consider the influence of forces other than the integrated status of service delivery on attendee experiences of such sites. I argue that place should not be conceived as immutable but, rather, is subject to individual interpretations that are, themselves, the product of both situated and external contexts.

Racial and ethnic disparities in health care continue to be problematic in the United States. Although many Americans experience the negative effects associated with health disparities (e.g., negative perceptions of care, lack of access to care, and poorer health outcomes), health disparities have been shown to be increasingly problematic for many members of African American populations. In addition, cultural mistrust of providers and health care systems have also been shown to impact perceptions of care and utilization of health care services. Recent literature suggests that integrated health care could be a possible solution to improving care, although a gap in the research currently exists regarding how members of African American populations view integrated health care. The current study was designed to fill this gap. In order to achieve this goal, the current project consisted of two studies. The purpose of Study 1 was to develop an instrument to measure attitudes toward integrated health care among African Americans. The purpose of Study 2 was to validate the integrated health care measure and to test gender as a potential moderator of the effects of cultural mistrust on attitudes toward integrated health care for a sample of African American adults. Through Exploratory Factor Analysis in Study 1, eigenvalues, scree plots, factor loadings, and orthogonal rotations were examined to identify the underlying factors and overall reliability of the Patient Attitudes Toward Integrated Health Care scale. Results from Study 1 indicated that this scale was reliable and valid among the current sample of American adults. Study 2 used Confirmatory Factor Analysis to examine the validity of the Patient Attitudes Toward Integrated Health Care scale. The results of the CFA confirmed that the Patient Attitudes Toward Integrated Health Care scale was reliable and valid among the current sample. Study 2 also used moderated regression analysis to test the hypothesis that gender would moderate the relationship between cultural mistrust and attitudes toward integrated health care. Results from the regression analysis showed that gender did not significantly moderate the effects of cultural mistrust on attitudes toward integrated health care. However, results suggested that gender significantly influenced attitudes toward integrated health care. The findings further suggested that cultural mistrust and attitudes toward seeking psychological help to be significant predictors of attitudes toward integrated health care. Although the original hypothesis was not supported in the current study, these results provide useful insight into predictors of attitudes toward integrated health care among African Americans. These results can be used to assist in improving integrated health care systems to better meet the needs of this population.

No description available.

The Affordable Care Act of 2010 proposed a new integrated care model for individuals with chronic mental illness and multiple medical comorbidities by using Behavioral Health Homes (BHH). The purpose of this doctoral project was to evaluate the effectiveness of the BHH in reducing emergency department (ED) use in the community mental health outpatient setting. Guided by the American Association for Critical Care Nurses synergy model for patient care a cross-sectional, post-test only with comparison group quasi-experimental research design was used. A de-identified data set of 68 patient records in the BHH group and 73 patient records in non-BHH as a control group were analyzed using logistic regression. The analysis revealed that participants in the BHH were statistically less likely to visit the ED. Sensitivity was 16.2%, specificity was 95.2%, positive predictive value was 54.5%, and negative predictive value was 76.2%. The Homer-Lemeshow and omnibus test of model coefficients showed the model was a good fit (p=.726, p=.007). Participants in BHH were .225 less likely to visit the ED. For every year of reduction in age, the odds of visiting the ED increased by a factor of 1.0. Females had a 1.8 higher odds of visiting the ED than males. This study provides evidence for the effectiveness of the BHH in reducing visits to the ED. Standard measures to track ED use in BHH are essential to understanding reasons for ED use and reducing nonurgent use. The BHH has the potential to transform health care delivery toward an all-inclusive model of care. Providers can utilize the findings of this project to promote social change by targeting patients with serious mental illness and reducing health disparities by emphasizing preventive care and eliminating barriers to care.

The objective of this dissertation is to describe a systematic approach to effectively treat common mental health disorders, which involves integrating care managers and mental health specialists into the primary care treatment team. Despite an extensive body of evidence demonstrating the effectiveness of collaborative care, implementation in various “real world” settings presents a number of barriers. Successful clinical trials have failed to result in widespread changes in practice. Gaps in the literature persist as to what the clinical, organizational and financial barriers to integration are. As a result, dissemination of the model lags far behind. This dissertation sought to contribute new information to the literature on integrated health care by examining various elements of dissemination efforts. The first article examined the experience among a group of health care providers in Texas who were attempting to integrate physical and behavioral health care. This article identified the barriers that they have encountered in addition to the strategies they have used to integrate mental and physical health services, and to determine whether the strategies reflect an evidence-based model of care delivery. In addition, the perceived clinical, organizational and financial barriers to integration were evaluated. The second article for this dissertation examined quantitative clinical outcomes of an integrated health care program in a community-based clinic with a low-income, uninsured population of Hispanics, a portion of which were Spanish-speaking. A socio-culturally adapted model for the provision of comprehensive health services may have a significant impact on the health and mental health outcomes of minority, non-English speaking populations. The third article offers an in-depth case study of an interdisciplinary collaborative care treatment team. Understanding the details of program implementation and the elements of the model that community based providers found useful, and those they found challenging, has implications for widespread implementation efforts. This qualitative article offered an analysis of how the treatment team organized itself to perform as a coordinated, high functioning effort that fit well with the needs of patients, and had each professional doing what they do best. / text

DM is a serious and complex public health problem in the U.S. The CDC (2013) estimated that 25.8 million people, or 8.3% of the U.S. population, were suffering from DM in 2011. DM can significantly affect patient’s quality of life. Additionally, DM places a significant economic burden on the U.S. healthcare system. Over the past two decades, DMPs have emerged as a promising intervention to improve health outcomes for patients suffering from chronic conditions, such as DM, and to bend the cost curve. DMP’s aim is to improve communication and follow-up so that patients can better manage their chronic condition(s) to avoid costly hospital stays and emergency room visits (Fireman, Bartlett, & Selby, 2004). The Georgia region of Kaiser Permanente (KPGA) is a fully integrated health system that serves 260,000 members at 28 medical offices along with two specialty offices in the metropolitan Atlanta area. The Center for Care Partnership, the population care division of KPGA, administers a chronic disease management program (DMP), Healthy Solutions (HS). HS exists to improve and maintain the health of chronically ill KPGA members, including patients diagnosed with diabetes mellitus (DM), by providing health coaches via telephone who counsel members on their specific chronic disease and aid members in starting or maintaining a physician approved self-care management plan. In order to determine the impact HS has on KPGA members with DM, an evaluation plan was created to evaluate the impact HS has on members’ glycated hemoglobin (A1C), blood pressure, and emergency department (ED) utilization. This capstone thoroughly details the proposed evaluation plan created for HS by using Robert Milstein and Scott Wetterhall’s six-step framework for program evaluation. Additionally, further evaluation questions are suggested and discussed in order to provide a more complete picture of program performance to stakeholders.

Abstract EXPLORING SUBSTANCE USE DISORDERS COMMUNITY OUTPATIENT COUNSELORS’ EXPERIENCES TREATING CLIENTS WITH CO-OCCURRING MEDICAL CONDITIONS. AN INTERPRETATIVE PHENOMENOLOGICAL ANALYSIS Lauretta Anne Cathers, Ph.D. A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University. Virginia Commonwealth University, 2013 Major Director: Amy Armstrong, PhD, Chair, Rehabilitation Counseling The Interpretative Phenomenological Analysis study presents the findings from a qualitative study examining substance use disorders (SUD) community outpatient treatment counselors’ experiences treating clients with co-occurring medical conditions. Interviews from five SUD community outpatient treatment counselors resulted in four emerging super-ordinate themes. The findings illustrate the relationships between SUDs, medical conditions and other predisposing, enabling and need factors. In order to assist clients in focusing on therapy, counselors work to identify resources to treat the basic needs of the clients, including medical care. Challenges included limited resources, complex system processes, and client fear and apathy. In addition, various unique challenges related to medical conditions treated by potentially habit forming medications and traumatic brain injury were identified. Counselors discussed how their roles and responsibilities have expanded to include case management and additional responsibility for the overall well-being of the clients they serve. They encouraged SUD educators to include more education on counselor self-care, trauma, pain conditions and the assessment process. Implications from the study highlight the need for integrated behavioral and physical health care.

Este trabalho teve como objetivo avaliar a integralidade no cuidado ao CCU em um município de grande porte populacional e com tecnologia de distinta complexidade disponível. Foi utilizada uma metodologia mista (quanti-quali). Para a abordagem quantitativa utilizou-se a base de dados secundários referentes à citologias e biópsias do sistema de informação municipal e regional. A análise e os testes estatísticos foram realizados pelo software PASW statistic 17.0. A abordagem qualitativa foi realizada por meio de entrevistas semi-estruturadas com usuárias, profissionais e representantes da gestão. Os dados qualitativos foram submetidos a uma análise de conteúdo realizada com o software NVivo 9.0. Na análise dos dados secundários, identificou-se que a cobertura de Papanicolau é insuficiente, sendo concentrada em mulheres mais jovens. As biópsias realizadas são equivalentes à quantidade de citologias alteradas. Os diagnósticos mais graves, tanto de citologias quanto de biópsias, prevalecem em mulheres com idade mais avançada. A abordagem qualitativa indica como potencialidades: o acolhimento, o acesso breve a serviços de média e alta complexidade, o papel ativo da gestão municipal de saúde e como fragilidades: a dificuldade para marcação das consultas na atenção básica, a falta de preparo dos profissionais para dar o diagnóstico, a contra referência tardia por parte do serviço terciário, o incentivo ao uso do Pronto-Atendimento e a formação focada na especialidade. Constata-se neste estudo que os principais gargalos para efetivação da integralidade no município investigado estão concentrados no primeiro nível de atenção à saúde / This study aimed to analyze the completeness in the Cervical Cancer care in a city with a large population and with enough technology health equipment available to the people. It was used a mixed methodology (quantitative and qualitative). For the quantitative approach it was used the database regarding cytology and biopsy exams registered in the city. The analysis and statistical tests were performed by the statistic software SPSS 17.0. A qualitative approach was performed through interviews with users, professionals and members of the health system. Qualitative data were submitted to content analysis performed by the software NVivo 9.0. In the analysis of the content, it was found that coverage of Pap test is insufficient and is concentrated in younger women. The biopsies are equivalent to the amount of the cytology with abnormal results. The severe diagnosis, from both cytology and biopsies, are prevalent in older women. A qualitative approach indicates potentialities: the good reception of the patient, the fast access from both medium and high complexity health services, the active role of municipal health. Weaknesses: the difficulty in scheduling an appointment with a doctor, lack of training to inform the patient about the diagnosis, the encouragement to use emergency care and the overspecialization of the health professionals. It appears from this study that the main gaps for having a complete integrate healthcare system in the investigated city are concentrated in the first level of health care

Este trabalho teve como objetivo avaliar a integralidade no cuidado ao CCU em um município de grande porte populacional e com tecnologia de distinta complexidade disponível. Foi utilizada uma metodologia mista (quanti-quali). Para a abordagem quantitativa utilizou-se a base de dados secundários referentes à citologias e biópsias do sistema de informação municipal e regional. A análise e os testes estatísticos foram realizados pelo software PASW statistic 17.0. A abordagem qualitativa foi realizada por meio de entrevistas semi-estruturadas com usuárias, profissionais e representantes da gestão. Os dados qualitativos foram submetidos a uma análise de conteúdo realizada com o software NVivo 9.0. Na análise dos dados secundários, identificou-se que a cobertura de Papanicolau é insuficiente, sendo concentrada em mulheres mais jovens. As biópsias realizadas são equivalentes à quantidade de citologias alteradas. Os diagnósticos mais graves, tanto de citologias quanto de biópsias, prevalecem em mulheres com idade mais avançada. A abordagem qualitativa indica como potencialidades: o acolhimento, o acesso breve a serviços de média e alta complexidade, o papel ativo da gestão municipal de saúde e como fragilidades: a dificuldade para marcação das consultas na atenção básica, a falta de preparo dos profissionais para dar o diagnóstico, a contra referência tardia por parte do serviço terciário, o incentivo ao uso do Pronto-Atendimento e a formação focada na especialidade. Constata-se neste estudo que os principais gargalos para efetivação da integralidade no município investigado estão concentrados no primeiro nível de atenção à saúde / This study aimed to analyze the completeness in the Cervical Cancer care in a city with a large population and with enough technology health equipment available to the people. It was used a mixed methodology (quantitative and qualitative). For the quantitative approach it was used the database regarding cytology and biopsy exams registered in the city. The analysis and statistical tests were performed by the statistic software SPSS 17.0. A qualitative approach was performed through interviews with users, professionals and members of the health system. Qualitative data were submitted to content analysis performed by the software NVivo 9.0. In the analysis of the content, it was found that coverage of Pap test is insufficient and is concentrated in younger women. The biopsies are equivalent to the amount of the cytology with abnormal results. The severe diagnosis, from both cytology and biopsies, are prevalent in older women. A qualitative approach indicates potentialities: the good reception of the patient, the fast access from both medium and high complexity health services, the active role of municipal health. Weaknesses: the difficulty in scheduling an appointment with a doctor, lack of training to inform the patient about the diagnosis, the encouragement to use emergency care and the overspecialization of the health professionals. It appears from this study that the main gaps for having a complete integrate healthcare system in the investigated city are concentrated in the first level of health care