The hospital industry is now in a major transitional phase which is substantially changing its operational values and organizational forms. This transition was triggered primarily by a crisis brought on by rapidly escalating costs. Many forces centering on the cost containment theme are now forging new political and economic operating rules for health care providers. Collectively these forces are bringing about decisive changes in the quality, quantity and structure of health care delivery systems. The result has been the emergence of a new pattern of hospital organization and administration, described here as the <i>business model hospital</i>. This model is driven by incentives and performance criteria wholly different from those of traditional community hospitals. This research describes this new political economy of health care and identifies, via analysis of field interviews, the crucial issues faced by hospital administrators today and specific actions they are taking to adapt to their new environment. The emergence of the business model hospital has many positive attributes but could have adverse consequences for the broader public interest. Emerging public policy issues are discussed and recommendations are made as to how public policy makers may deal with these issues. These recommendations focus on retaining the major benefits of the business hospital model while preserving useful aspects of the community hospital framework. / Ph. D.

Vulnerable populations comprise a growing number of people living with HIV/AIDS and are at increased risk for poorer health outcomes. The purpose of this research was to approximate the effect of the Ryan White CARE Act on the health status of people living with HIV/AIDS who were receiving medical care in the United States. The vulnerable populations model was utilized to identify appropriate variables for analysis as well as to provide a sequencing for the testing of models. Data analyzed in this study came from the 1996 Baseline Survey of the HIV Cost and Services Utilization Study (HCSUS), a cooperative study between RAND and the Agency for Health Care Policy and Research (now known as the Agency for Health Care Quality and Research). Three analyses sequences, using different dependent variables, to estimate health status were conducted. In the first analysis, health status was measured by CD-4 count and stage of illness. In the second analysis, only CD-4 counts were used for health status. In the final analysis, health status was estimated based on AIDS diagnosis. Each of the three analyses included the same independent variables: race, gender, education, sexual orientation, income, insurance status, region of the country, receipt of case management, perceived health, and level of antiviral therapy. The three analyses suggested similar results. Specifically, that African Americans and women had better health status as compared to whites and men, respectively. Additionally, insurance, case management, and antiviral therapy were associated with poorer health status. Factors such as education, income, and region of the country yielded inconsistent results between models. To better understand the effect of the Ryan White CARE Act on health outcomes for people living with HIV/AIDS, future research should consider inclusion of a variable that more directly measures the CARE Act, such as payer source for medical care.

The purpose of this dissertation was to identify the components of women's domestic health work in networks surrounding poor Mexican American and Anglo households and compare women's experiences as domestic health workers. Women representing 10 Mexican American households and 10 Anglo households and their surrounding domestic networks were recruited for this study. Criteria for participation included the presence of at least one child in the household $\le$5 years of age and household income at or below the federally-defined weighted poverty threshold. Sources included, first, 66 interviews with women (n = 26) residing in the study households. Second, women kept 3-week daily health diaries on behalf of all household members. And third, women participated in an inventory of household medications. The study employed several analytic methods, including descriptive statistical analyses, phenomenological insight, taxonomic analyses of women's knowledge structures, life history analysis, thematic analysis, and narrative analyses. The results of the study emphasized several points, including the: (a) gendered but hotly contested nature of domestic responsibility for health, with responsibility negotiated between men and women in households, and disputed between households and social service agencies; (b) significant role played by women's informal networks in defining and evaluating the enactment of maternal responsibility; (c) workings of women's coalitions and cooperatives that protect women's threatened interests and redistribute resources among women; (d) influences governing the transmission of child health and illness knowledge and skills across generations of women; (e) double-edged nature of self-medication that appears as both a source of female autonomy and expertise, yet paradoxically and simultaneously can act as an inappropriate, self-palliating balm for the hurt incurred from inadequate accessibility to quality professional health care for poor women and children; and (f) cross-cutting influences of ethnicity and historical situation in each of the above domains. Women pieced together resources from their cultural background, femaleness, and sometimes their poverty; all these factors also entailed contradictory disadvantages in the production of household health. The health and social policy implications of this study were described in detail in the dissertation, as were the women's own visions for an approximation of utopia.

The primary purpose for this study was to investigate small businesses organizational support and interest in health promotion. The research question for this study was, "Are small businesses actively involved with the organizational support of health promotion programs?"A survey was distributed via mail to small businesses in the Lynchburg, Virginia area, with a follow up three weeks later because an appropriate number of surveys had not been returned. The results of this study have provided insight into the current status of worksite wellness programs of businesses with fewer than 250 employees.Small businesses do actively support healthy food and smoking policies at the worksite. Some small businesses provided activities to measure employee health risks. The main issue small businesses deal with are safety/accident prevention. Other health topics are not prevalent in small businesses. Small businesses that had a health promotion program in place offered more programs and awareness materials than those who did not and are actively involved in the organizational support of health promotion programs. / Fisher Institute for Wellness

The purpose of this study is to evaluate financial and clinical data of patients within a selected DRG. The data obtained from such analysis will be used to design a system whereby clinical pharmacists may improve the hospital's reimbursement potential. Based upon Upton's proposed plan, this study is designed to evaluate all DRGs in a community hospital in an attempt to focus on those DRGs which represent the greatest financial pressure to the pharmacy department and, therefore, to the institution. Clinical and financial data of patients within the expensive DRG, will be collected from their medical and financial records for subsequent statistical analysis with special consideration to pharmacy charges. The ultimate objective of this study, though, is to provide a list of measures or parameters that may affect the patient's hospital charges. Using these parameters, the clinical pharmacists will be able to intensify their monitoring of patients with high pharmacy charges in an attempt to reduce their impact on patients' charges. This study was designed to review and analyze DRGs at St. Joseph's Hospital, in Stockton, Californias. The main objective was to determine the relationship between clinical and financial data for patients within a DRG. The second objective was to identify patient-specific information that may reflect high pharmacy charges and the need for clinical pharmacy intervention. The third objective was to propose criteria that may predict which patients need to be monitored in an attempt to control pharmacy charges within a selected DRG category.

Indiana University-Purdue University Indianapolis (IUPUI) / A significant body of literature has accumulated in the last decade that provides evidence of the growing health care disparities among racial and ethnic groups in the United States. The literature suggests that Black adults share a disproportionate burden in death, disability, and disease. In 2002, the Institute of Medicine report, Unequal Treatment, showed that racial-ethnic disparities in health cannot be entirely attributed to problems of health care access, clinical performance, or patients’ personal characteristics. Many studies have shown that institutional and individual level discrimination that Blacks face in the health care system impacts their health status. This study used secondary data analysis to examine how primary care experience impacts self-reported health status and health care utilization among Black adults. Data were from the Medical Expenditure Panel Survey (MEPS) implemented by the Agency for Healthcare Research and Quality (AHRQ). Specifically, MEPS Panel 10 (2005-2006) and Panel 11 (2006-2007) data were used in the analyses. The final sample comprised of N=15,295 respondents ages 18 and over. Logistic regression analyses were carried out using Stata Statistical Software, version 11. The study results reflect the disparities among Blacks and Whites on self-reported health and health care utilization. Blacks were 15% less likely to report good health status compared to Whites and had 0.11 less expected office-based doctor visits. Respondents who had better primary care experience had 0.05 times higher expected office-based doctor visits than respondents who did not have good primary care experience. Health care Social Workers should advocate for structural changes in health policy that will take into account the historical marginalization and contemporary inequities that continue to encompass the lives of many Black Americans.

Spinal cord injury is one of the most catastrophic events that may befall a human being. As greater numbers of disabled young adults survive for longer periods, the need for long-term care at home increases. However, self-satisfaction and perceived quality of their care at home are thus important of study. The study had two purposes which included: (1) to describe what factors influence self-satisfaction and perceived quality of care provided for individuals who have had spinal cord injury, and (2) to generate the Learned Response Model that describes the relationships among factors essential for self-satisfaction and perceived quality of care provided for persons with spinal cord injury in the home. A correlation design with a causal modeling methodology was used. Eighty spinal cord injured persons were obtained from six rehabilitation sites in Arizona. Six instruments were utilized to collect data: (1) Knowledge of Disability Questionnaire (KDQ), (2) Stressful Life Events Questionnaire (SLEQ), (3) Activities of Daily Living Scale (ADLS), (4) Involvement of Significant Others Questionnaire (ISOQ), (5) Self-Satisfaction Questionnaire (SSQ), and (6) Perceived Quality of Care Scale (PQCS). Data analysis included use of descriptive statistics to summarize the sample in terms of demographic variables and theoretical and empirical model testing using multiple regression techniques and residual analysis. The study findings indicated that stressful life events was found to have direct negative impact upon perceived quality of care. Activities of daily living and involvement of significant others were found to be moderators relative to self-satisfaction. These variables also interacted together relative to self-satisfaction and perceived quality of care. Involvement of significant others was found to have a significant, but weak, moderation effect relative to the relationship of stressful life events with perceived quality of care.

The fragmented approaches to delivering health care services in the United States, along with the associated structural inefficiencies and unsustainable increases in health care costs affecting all payers, compel the need for reform. Various federal and state-level delivery system reform models have emerged in response. The Medical Home (MH) is one of such reform models. In 2004 a national initiative entitled "The Future for Family Medicine Project" identified the lack of emphasis on comprehensive primary care, especially for chronic care patients, and proposed the introduction of MHs to improve comprehensive primary care delivery for every patient. Oregon's MH variant, the Patient-Centered Primary Care Home (PCPCH), was introduced in 2009 as part of a state-wide health reform initiative ushered in by the passage of House Bill 2009 to promote the Triple Aim. Since 2011, over 600 primary care clinics have been recognized as PCPCHs. Proponents of the model argued that it will help improve comprehensive primary care services upstream and reduce inappropriate utilization of Emergency Department (ED) and Inpatient (IP) care and expenditures downstream. Evidence on the model's application to reduce ED and IP utilization and expenditures have so far been mixed. Based on growing interests in the effects of the model's application to provide care for different types of patients, this research was designed to evaluate the policy effects of the application of PCPCHs, with a focus on PCPCHs that treat greater proportions of chronic care patients, to answer the following questions: (1) What is the average chronic disease burden of PCPCHs, and how does their average chronic disease burden compare to the communities PCPCHs are in pre-post PCPCH recognition? (2) How do primary care expenditures change based on the chronic disease burden of PCPCHs? (3) Do PCPCHs that engage more high chronic disease burden patients have more reductions in ED and IP expenditures? For this research, a chronic disease burden measure was developed from 10 markers of chronic conditions. This measure was then used to stratify PCPCH clinics and their comparators into high and low chronic disease burden clinics. The research was designed as a natural experiment, utilizing difference-in-difference methods to measure outcome differences pre-post PCPCH policy implementation and comparing outcome differences between PCPCHs and their control groups. The unit of analysis was PCPCH clinics. The theoretical perspectives that informed this research were Risk Selection and Complex Adaptive Systems (CAS). Data from Oregon's All Payer All Claims (APAC) data system, which included 16 quarters of claims and eligibility data from fourth quarter 2010 to third quarter 2014, as well as PCPCH attestation data on 525 clinics were utilized for this research. The results suggest that the chronic disease burden for PCPCHs was significantly lower than their comparator groups before clinics recognition as PCPCHs, but the chronic disease burden did not change after clinics recognition as PCPCHs. Average primary care expenditures did not change after PCPCH recognition. Average ED and average IP expenditures for high chronic disease burden PCPCHs did not change but rather decreased significantly for low chronic disease burden PCPCHs. The results imply that the distribution of chronic disease burden in PCPCHs is important and related to ED and IP expenditures, but in a different direction than expected. The results also suggest that focusing on low chronic disease burden patients in PCPCHs could help reduce ED and IP expenditures in the short and medium terms. Policies to engage a broader mix of chronic disease burden patients in PCPCHs could help increase savings from ED and IP utilization. The results also suggest the need for more research to improve current understanding of how PCPCHs are impacting health care trajectories in the current delivery system environment.

The study evaluates the effectiveness of a pregnancy intervention model (PIM) developed to improve first trimester prenatal care utilization in a population of 2,694 low-income Medicaid women. Engagement in prenatal care is critical before prenatal care can occur. Early initiation of prenatal care is important for low income pregnant women at risk for poor birth outcomes and the Medicaid managed care organizations that enroll them. Once identified and enrolled the health plan utilization medical management staff assessed these women for a myriad of high risk and socially detrimental behaviors in order to facilitate, in a sensitive manner, their access to drug treatment or any needed service. Interventions included a real time identification, reporting, incentive model using medical informatics to supplement existing clinical based assessment of high risk pregnant women and nursing care coordination that included outreach, enrollment assistance, support services, interagency coordination, home visits, transportation and medical home assignment. A difference was found in the utilization of first trimester prenatal care visits for all women who conceived after the intervention compared to those who conceived prior to the intervention date. A difference was also noted in the "no prenatal care" category due a decrease in the number of women who did not receive prenatal care. PIM appears to be a cost effective, simple solution to a real world problem. / Graduation date: 2005

Thesis (Ph. D.)--University of Hawaii at Manoa, 2004. / Includes bibliographical references (leaves 538-584). / Also available by subscription via World Wide Web / xvii, 584 leaves, bound 29 cm