Thesis (M.S)--State University of New York at Binghamton, Decker School of Nursing, 2007. / Includes bibliographical references.

Thesis (D.P.H.)--University of Michigan.

Dissertation (D.P.H.)--University of Michigan.

The health care industry is undergoing significant change, particularly with the passage of the Patient Protection and Affordable Care Act in March of 2010. Using the Rokeach Value survey, the value priorities of the insured and uninsured respondents were assessed. The value priorities were also evaluated for the demographics of gender, ethnicity, education, income, and age group. The terminal value of health was culled out as a moderator variable relative to its influence in the decision to seek health care coverage. The most significant contribution of this study reveals an increased understanding of consumer value preferences and demographics and their influence on health care coverage choices. In turn, it advances personal value theory in a health care context and its implications to behavior and decision-making. The results establish the role of health as a significant moderator variable in the decision process. These findings reveal a multitude of insights, not only for the academic researcher, but for practitioners and policymakers alike who are commissioned to execute the new health care reform bill over the next several years. As health care reform is implemented over the next several years, a combination of legislative and market-based solutions will be necessary to curtail the rising number of the uninsured, and ensure there are parity, equity, and morality in the distribution of health care for all Americans.

Access to primary health care services is a significant issue for many communities seeking to improve the health of their populations. This single case study describes the 12-year journey of 2 adjoining rural counties in 2 states towards meeting the primary and specialty care needs of the uninsured and underinsured population. Data were triangulated using historical documents, first-person interviews, and health utilization data. The community leadership moved through various models including a free clinic and a university-sponsored health center before finally establishing a federally qualified health center, which now serves 40,000 citizens in these counties. The site is now hosting new programs funded by research grants in alliance with area universities. Success is contributed to an unwavering desire to provide a medical home for the underinsured and underinsured, a shared vision, recognition that continued success was dependent on a funding source, recognition that practices and processes must be in place to assist with navigation for those in need of services to seek care at the appropriate venue, and a belief that the infrastructure built to provide care was sustainable. All participants recognized the importance of funding for sustainability. Positive social change has occurred from the emergence of a multidisciplinary center to serve the community's uninsured and underinsured, thus improving access to care, management of chronic conditions, and access to behavioral health professionals. Findings from this study may inform other communities faced with similar problems and can inform legislators of the importance of federally qualified health centers in the provision of health care to vulnerable populations.

Affordable Care Act (ACA) was passed and implemented to expand insurance coverage, reduce health care cost, and improve the quality of care. The purpose of this dissertation study was to investigate whether the ACA insurance expansion correlates with the number of visits made to emergency departments (EDs). The quasi-experimental design interrupted time series was utilized in the analysis. The ED visits were compared using MANOVA to determine the relationship between ED visits and ACA and canonical correlation analysis to assess the strength of the relationship and the extent to which independent variables could predict the dependent variable. The hypothesis was that the ACA will reduce the uninsured, increase the insured, and reduce the ED visits. The relationship between number of ED visits and the ACA will present whether the uninsured patients contributed significantly to the ED overcrowding. Analysis of secondary data from four EDs (H1, H2, H3, and H4) in the Chicago area showed that 484,742 visits were made, and 2,801 were excluded due to unknown payer type. Medicaid patients recorded the largest number of visits (181,226) while the uninsured patients recorded the least number of visits (56,572). The ED visits decreased by 6% from 2012 to 2013 (pre-ACA) and increased by 4% from 2013 to 2105 (post-ACA). The ACA implementation increased the people with insurance who visited the EDs by 11%. The results demonstrated a strong relationship between ACA and ED visits. The correlation of the variables (hospital and year) and ED visits demonstrated that the hospital could explain 97% of the Medicaid visits and 87% of uninsured while the year could predict 82.6% of the uninsured visits and 52.5% of Medicaid visits.

No description available.

Recent changes in health care policy, which mandate the monitoring of illness symptoms and improving the satisfaction of medical patients, may shed light on possible points of intervention to improve patient-centered outcomes. Health-related quality of life (HRQL), or one’s appraisal of their mental and physical functioning, is a frequently-used metric relevant to improved health care outcomes. HRQL may be impacted by multiple inter- and intra-personal factors, whether an adaptive (e.g., social problem solving ability) or maladaptive effect (e.g., thwarted interpersonal needs, depression). We examined the association between social problem solving ability and mental and physical HRQL, and the potential mediating roles of thwarted interpersonal needs and depressive symptoms. Participants (N=223) were middle-aged and recruited from a primary care clinic. Our hypotheses that thwarted interpersonal needs and depressive symptoms would sequentially mediate the association between independent scales of social problem solving (negative problem orientation, positive problem orientation, rational problem solving, impulsive/careless style, avoidant style) and HRQL (mental and physical), were largely supported. Our findings highlight the importance of social problem solving ability as a potential point of intervention to improve mood, interpersonal functioning, and mental and physical health in an integrated care setting. Strategies such as Social Problem Solving Therapy might be particularly effective in bolstering social problem solving, with consequent beneficial effects on interpersonal functioning and mood, thereby improving overall health-related quality of life.

The purpose of this study was to determine whether a coordinated and comprehensive system of care for the uninsured changed the behavior of the uninsured by decreasing non-urgent utilization of the emergency departments within a large, urban county. The literature on emergency department trends and interventions designed to decrease "inappropriate" or non-urgent use of the emergency departments was reviewed and links to relevant theoretical concepts were identified. Utilization data from six emergency departments and six federally qualified health centers were evaluated. Secondary data over a three-year time period were abstracted from patient and organizational records at the hospitals and federally qualified health centers. The utilization data from the emergency departments and health centers were compared. The analysis revealed a significant change in the number of non-urgent visits by self-pay patients at the emergency departments when the health centers expanded. A 32.2 percent decrease in utilization of the emergency departments by self-pay patients was found. Non-parametric tests demonstrated significant differences in the population seen at the emergency departments and the clinics over the three-year study period. Regression analysis demonstrated a statistically significant decrease in non-urgent, self-pay visits at the emergency departments as a result of the increase in self-pay visits at the federally qualified health centers. Further analysis includes forecasting the impact of future federally qualified health centers on emergency department utilization. Recommendations for future research include evaluation of the increased numbers of non-urgent transports from the local emergency medical system by self-pay patients as well as the design of a pilot study to look at the effectiveness of transporting these patients to the federally qualified health centers for care instead of to the local emergency departments.

In 2001, The Institute of Medicine published its recommendations for bringing high quality care to all people of the United Sates. That solution involved fulfilling criteria expressed in the acronym, STEEEP. Care must be: Safe, Timely, Effective, Efficient, Equitable and Patient Centered (Institute of Medicine 2001). While improvements were made in terms of infant mortality, longevity, and deaths amenable to quality care, healthcare in the United States has remained fragmented with much work yet to be done. This leaves many uninsured individuals without access to affordable healthcare. Despite the implementation of policies such as the Affordable Care Act and the American Rescue Plan, which have expanded Medicaid and given access to many, it still falls short. Approximately 24.9 million people remain uninsured. The rising costs of healthcare in the U.S. have led to both insured and uninsured patients being exposed to medical debt, lower health status, and limited access to care. Safety net clinics, such as free clinics, have become essential for many uninsured individuals who rely on them to receive medical care. Free clinics are an example of safety nets that give medical access to the uninsured. These clinics have positive results on health outcomes and help to lower healthcare expenditures, particularly in emergency room visits. Studies have shown that uninsured individuals are more likely to use emergency services, which results in higher healthcare costs. Free clinics provide preventative care and early interventions that can help prevent costly emergency visits and hospitalizations. Moreover, free clinics serve as a place for volunteers to grow their skills and become better providers of medicine. Volunteers include physicians, nurses, medical students, and other healthcare professionals who dedicate their time and expertise to help those in need. Volunteers at free clinics are provided with a unique opportunity to enhance their skills by working with a diverse patient population that often has complex medical conditions. Free clinics are essential safety nets that provide medical access to the uninsured and underserved communities. Without these clinics, many uninsured individuals would be left without access to care, leading to poor health outcomes and higher healthcare costs. The importance of free clinics cannot be overstated, and unless there is a change in the current healthcare system, free clinics should be given the place they deserve, including more volunteer and funding support. As the U.S. healthcare system continues to evolve, it is critical to recognize the value of free clinics and the role they play in ensuring access to care for all individuals, regardless of their insurance status.