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Class of 2017 Abstract / Objectives: To assess access to and quality of primary health care services by individuals receiving meals at a food bank in a rural location using the Primary Care Assessment Tool- Short Form (PCAT-S). Also, to investigate whether individuals with a mental health condition at a rural community food bank receive different care compared to those without a mental health condition. Methods: The PCAT-S, a survey developed by John Hopkins University, was administered to evaluate care at first contact, ongoing care, coordination of care, and comprehensiveness of care. Demographics data (age, gender, health conditions, insurance status, etc.) was also collected. Results: The majority of our participants surveyed lived within an urban zip code (84.8%), had government insurance (81.4%), were male (61.9%), or were Native American (45%). The groups with the highest mean PCAT-S scores were participants with diabetes (mean score= 96.8), participants with no insurance (94.63), and participants who were female (91). The patient populations with the lowest scores were those with less than a high school education (63.11) with serious mental illness (64), or who had bipolar disorder (69). Groups with higher mean PCAT-S scores indicated more involvement with a primary care provider or overall better care within that section of the PCAT-S. Conclusions: Participants with a mental health condition may be receiving less healthcare than those without a mental health condition, especially in the coordination of care between healthcare services, as indicated by lower mean PCAT-S scores. Those living in a rural community, among our population, do not appear to be receiving less healthcare than those in an urban setting.

As the population ages, providing health services for the growing number of older people will become an increasingly difficult problem. In countries where the health services are provided by the government, these problems are involved with complicated issues of finance and ethics. This is the case of the National Health Service, the government institution providing health care for the citizens of the United Kingdom. Knowing what social factors influence health care usage can be a link to match usage and funding. Literature has shown that health care utilization can be predicted by social factors, as well as the medical model, and from this orientation social variables were drawn from the 1994 General Household Survey. Social factors were analyzed to determine relationships that exist between certain types of health care use and these factors. Age, sex, and class, the three main factors shown in literature to affect usage, were then analyzed to determine if services are allocated on the basis of these factors or the basis of need from illness and disability. Results of the study show that of the predisposing variables, age, sex, and class, are associated with most types of health care use. From the enabling variables, both source of income and visits from friends and relatives are associated with most types of health care. Of the illness determinants, disability, limiting illness, restricted activity days and eyesight difficulty were all related to health care use. When intervening control variables were introduced, the intervening control variables of difficulty with activities of daily living and difficulty with instrumental activities of daily living had an explanatory effect on the use of home help, district nursing, consultations with a general practitioner at home, consultations with a general practitioner at a surgery or health clinic, and inpatient stays. These services were offered more according to need than the factors of age, sex, and class.

Recent federal legislation has incentivized hospitals to focus on quality of patient care. A primary metric of care quality is patient readmissions. Many methods exist to statistically identify patients most likely to require hospital readmission. Correct identification of high-risk patients allows hospitals to intelligently utilize limited resources in mitigating hospital readmissions. However, these methods have seen little practical adoption in the clinical setting. This research attempts to identify the many open research questions that have impeded widespread adoption of predictive hospital readmission systems. Current systems often rely on structured data extracted from health records systems. This data can be expensive and time consuming to extract. Unstructured clinical notes are agnostic to the underlying records system and would decouple the predictive analytics system from the underlying records system. However, additional concerns in clinical natural language processing must be addressed before such a system can be implemented. Current systems often perform poorly using standard statistical measures. Misclassification cost of patient readmissions has yet to be addressed and there currently exists a gap between current readmission system evaluation metrics and those most appropriate in the clinical setting. Additionally, data availability for localized model creation has yet to be addressed by the research community. Large research hospitals may have sufficient data to build models, but many others do not. Simply combining data from many hospitals often results in a model which performs worse than using data from a single hospital. Current systems often produce a binary readmission classification. However, patients are often readmitted for differing reasons than index admission. There exists little research into predicting primary cause of readmission. Furthermore, co-occurring evidence discovery of clinical terms with primary diagnosis has seen only simplistic methods applied. This research addresses these concerns to increase adoption of predictive hospital readmission systems. / Includes bibliography. / Dissertation (Ph.D.)--Florida Atlantic University, 2017. / FAU Electronic Theses and Dissertations Collection

Typescript (photocopy). / Digitized by Kansas Correctional Industries

Healthcare associated infections (HAI) continue to be a significant patient safety problem. Researchers have found that nurses; perception of organizational climate is associated with patient outcomes. However, given the increased prevalence of HAI, an examination of multiple organizational factors within the healthcare organization particularly amongst infection prevention and control staff is warranted. The purpose of this study was to gain a knowledge base on the issue of HAI in acute care hospitals and the role organizational climate plays in improving clinician;s performance and ultimately decreasing HAI rates. Guided by the integrative model of organizational climate and safety conceptual framework the specific aims were to: 1) systematically review published evidence examining relationships between organizational climate, adherence to infection prevention and control processes and HAI rates in hospital settings; 2) assess the psychometric properties of an organizational climate measure, the Leading a Culture of Quality (LCQ) scale, in a national sample of Infection Preventionists (IPs); and 3) identify setting characteristics that predict a more positive perception of organizational climate by the IP and measured by the LCQ revised, using a national sample. Ten studies, mostly cross sectional design, were included in the systematic review. There was evidence that positive perceptions of organizational climate as perceived by nurses and/or an intervention aimed at improving organizational climate are associated with decreased HAI rates and adherence to evidence based guidelines. The exploratory factor analysis on the LCQ identified a four factor solution explaining 59.65% of the total variance. The Cronbach's alpha of the new subscales ranged from .74 to .90 and .93 for the final composite LCQ, the LCQ revised. The subscales are: Psychological Safety, Organizational Leadership and Work Environment, HAI Prevention/Communication and Vision/Perspective of Organization. In a sample of 1,013 IPs, relationships were found between the structural characteristics examined and organizational climate. IPs who worked in hospitals that share or pool infection prevention resources with a larger facility perceived the climate more positively among 2 subscales (Psychological Safety β = 0.113, p-value = 0.006; HAI Prevention/Communication β = 0.129, p-value = 0.005) and the overall climate (β = 0.085, p-value = 0.027). IPs in hospitals with an Infection Control Director position in the Infection Control department perceived the organizational climate more positively among 3 subscales (Psychological Safety β = 0.120, p-value = 0.005; Organizational Leadership β = 0.198, p-value = 0.000; HAI Prevention/Communication β = 0.159 , p-value = 0.001) and the overall climate (β = 0.152, p-value = 0.000). IPs working in hospitals located in a rural area as compared to urban perceived organizational climate more negatively on all 4 subscales (Psychological Safety β = -0.123, p-value = 0.001; Organizational Leadership and Work Environment β = -0.099, p-value = 0.029; HAI Prevention/Communication β = -0.168, p-value = 0.002; Vision/Perspective of Organization β = -0.179, p-value = 0.000) and the overall climate (β = -0.124, p-value = 0.001). Also, IPs working in hospitals located in a suburban area as compared to urban perceived organizational climate more negatively among HAI Prevention/Communication (β = -0.111, p-value = 0.039). These findings suggest the need for additional support and organizational resources for the infection prevention and control department. As the issue of patient safety continues to progress, particularly around HAI, concerns of how to improve organizational systems to enable implementation and adherence to safety processes should be a priority on the research agenda. This is the first study to evaluate associations between structural characteristics of the hospital setting and organizational climate via the IP perspective using a large national sample. Future research should focus on other structural variables such as IP staffing. Also, further analyses on organizational climate and outcomes such as clinician adherence to evidence based practices and HAI rates should be conducted.

During eight turbulent years in the World War I era, policy makers, soldiers, and veterans laid the groundwork for the extension of government sponsored medical care to millions of former service members. In the process, they built a pillar of the American welfare state. Legislation and rehabilitation plans formulated shortly after the U.S. entered the Great War aimed to minimize the government's long-term obligations to veterans, but within less than a decade, those who had served gained conditional access to their own direct assistance agency and a national system of hospitals. This dissertation explains why that drastic transition occurred, and how one group of citizens won the right to obtain publicly funded health services. The story of wartime health policies has a variety of larger implications. It shows how veterans' welfare shifted from centering on pension and domicile care programs rooted in the nineteenth century to the provision of access to direct medical services; how rehabilitation and citizenship rights were conceived of and perceived at the dusk of the Progressive Era; how race, class, and gender shaped the health-related experiences of soldiers, veterans, and caregivers; how shifting ideals about hospitals and medical care influenced policy; and how interest groups capitalized on the tense political and social climate to bring about change. On a general level, an examination of the roots of a nationwide veterans' hospital system demonstrates how privileges were won in the twentieth century United States. It reveals a moment of state expansion, but it also illustrates the wider tendency of the U.S. government to award entitlements selectively. Given those factors, the policies that paved the way for the advent of a veterans' medical system deserve to be considered - alongside later federal assistance programs such as Social Security, Medicare, and Medicaid - as foundational in the development and shape of the American welfare state.

The recent trend toward patients participating in their own healthcare has opened up numerous opportunities for computing research. This dissertation focuses on how technology can foster this participation, through user interfaces to effectively communicate personal health status and care progress to hospital patients. I first characterize the design space for electronic information communication to patients through field studies conducted in multiple hospital settings. These studies utilize a combination of survey instruments, and low- and high-fidelity prototypes, including a document-editing prototype through which users can view and manage clinical data to automatically associate it with progress notes. The prototype, activeNotes, includes the first known techniques supporting clinical information requests directly within a document editor. A usage study with ICU physicians at New York-Presbyterian Hospital (NYP) substantiated our design and revealed how electronic information related to patient status and care progress is derived from a typical Electronic Health Record system. Insights gained from this study informed following studies to understand how to design abstracted, plain-language views suitable for patients. We gauged both patient and physician responses to information display prototypes deployed in patient rooms for a formative study exploring their design. Following my reports on this study, I discuss the design, development and pilot evaluations of a prototype Personal Health Record application providing live, abstracted clinical information for patients at NYP. The portal, evaluated by cardiothoracic surgery patients, is the first of its kind to allow patients to capture and monitor live data related to their care. Patient use of the portal influenced the subsequent design of tools to support users in making sense of online medication information. These tools, designed with nurses and pharmacists and evaluated by cardiothoracic surgery patients at NYP, were developed using topic modeling approaches and text analysis techniques. Embodied in a prototype called Remedy, they enable rapid filtering and comparison of medication-related search results, based on a number of website features and content topics. I conclude by discussing how findings from this series of studies can help shape the ongoing design and development of patient-centered technology.

The major objective of this research was to investigate factors involved in discharge planning for terminal patients and their families where alternatives exist--home vs. institution. This was an exploratory-descriptive survey, utilizing questionnaires and telephone interviews. The respondents were 86 trained social workers from acute care hospitals and hospice units within hospitals. Data collected were analyzed quantitatively and qualitatively. The social workers who responded came from hospitals within one state, and from hospices across the country. Sampling was a two-stage process, with hospitals and hospices selected in the first stage, and social workers in the second. The major research aims were: (1) Identify the parameters of discharge plans for terminal patients, including those factors already suggested in the literature as being involved in discharge planning. (2) Specify the relative importance among factors that social workers consider in their formulation of discharge plans for terminal patients. (3) Compare differences in worker reactions to discharge planning as between the hospital and hospice settings. Most social workers felt terminal patients needed nursing services upon discharge, and doctors and nurses were important team members in discharge planning. Hospice workers were more likely than hospital workers to take patients' needs and home conditions into account. Hospice workers recognized patients' spiritual needs and considered religious personnel to be significant team members. Hospital workers saw their patients as more helpful, while hospice workers perceived their patients to be more accepting of prognosis. Although most social workers felt patients and families needed counseling around death and dying, hospice workers especially noted the need for bereavement counseling. They were more likely than hospital workers to consider the family attitude of leaving the decision of disposition to the patient. All hospice workers and many hospital workers had personal experience with family and terminal illness. Most workers preferred sending patients home to die, rather than to an institution. Plans to send patients home generated workers' feelings of competence and empathy toward their work, while plans to send patients to institutions provoked feelings of sadness, guilt, and frustration. Generally, workers believed patients were aware of their prognosis, despite their feelings that the patients were not formally told by their physicians. Principal factors influencing discharge planning were found to be the family's desire to have the patient home, financial conditions, and the patient's desire to go home.

The three papers in this dissertation apply quasi-experimental and experimental methods for causal inference to the fields of health and development economics. The first paper exploits a plausibly exogenous reduction in the supply of health care in New York City caused by an historic storm to separately identify the impacts of health care access, weather shocks, and their interaction on chronic conditions. The second paper investigates how formal credit, informal risk sharing, and insurance interact. I exploit a natural experiment wherein tens of thousands of microfinance borrowers across rural Haiti received a quasi-random value of insurance benefit in the aftermath of catastrophic hurricanes. I show that subsequent demand for credit is increasing in the value of insurance, that insurance has decreasing marginal effects on the demand for credit, and that formal insurance increases the fungibility of the informal social ties underpinning risk sharing arrangements. Additionally, I present evidence suggestive of collusion in peer-based claims processing as a function of informal financial proximity. Finally, the third paper reports results from a cluster-randomized trial in rural Haiti that I led. It provides the first causal evidence that delivering basic health goods through microfinance institutions, which offer a platform that reaches 200 million rural poor households globally, is clinically effective.