The researcher examined the experiences of three directors of child care centers that had been accredited by the National Association for the Education of Young Children (NAEYC) and six directors of child care centers that had not yet reached accreditation status. The nature and meaning of these experiences was explored through interviews with each of the directors individually, and then with each mentor and her two protégés. The purpose of this study was to understand how a mentoring program promotes change in child care programs and how that change impacts the quality of care, if, in fact, it does. Using the constant comparative method, three major findings emerged. The first finding was the critical issue of identifying, screening, and selecting protégés to participate in the Director's Mentoring Project (DMP). Factors that result in protégés remaining in the program include self-selection, having previously met or heard of the mentors themselves, awareness of accreditation standards and procedures, and knowledge of and concern about quality care for young children. The second and third findings were intertwined. They had to do with the models of mentoring used and the nature of the relationship between the mentors and protégés. The mentors and the protégés utilized a model of mentoring that was based on their understanding that the primary goal of the DMP was to either gain NAEYC-accreditation status for the center itself or to provide professional and personal support to the protégé directors. While all the mentors began the program with accreditation as their primary goal, those who developed a close and empathic relationship with their protégés came to believe that support of the directors was primary. The former utilized a more goal-oriented model of mentoring; the latter utilized a more affective model of mentoring. The nature of the mentor-protégé relationship formed a continuum from instrumental to personal and developmental. Where the mentors and protégées fell on the continuum paralleled their understanding of the purpose of the project and the model of mentoring that was adopted.

Background: In health care services, equity is the delivery of similar care for similar needs (horizontal equity), and the delivery of more care for higher needs (vertical equity). This study assessed the extent to which primary care provision is equitable across gender, age and socioeconomic groups, and whether any observed disparity is associated with the type of primary care remuneration model to which a family practice belongs. Remuneration models include Fee For Service in which the physician is paid for each encounter, Salary where payment is fixed for the number of hours worked, and Capitation where payment is tied to the number of patients under the care of the provider, and very little or no additional compensation is provided for each patient encounter. // Methods: This thesis used data from a cross sectional study of 5,361 patients receiving care from practices (n) in which primary care providers were remunerated by Fee For Service (35), Salary (35), or Capitation (68). Multi-level linear or logistic regressions were used to assess the impact of gender, age and socioeconomic strata on quality of care. The quality of health service delivery and health promotion were assessed through surveys based on the Primary Care Assessment Tool (n=5,111). The quality of preventive care (n=4,108) and chronic disease management (n-514) were evaluated through chart abstraction using the Canadian recommendations for care as the standard. The analyses were conducted stratified by remuneration model to allow the impact of the model on the extent of disparity in quality of care between social strata to be assessed. // Results: Men and women reported similar quality of health service delivery. Women were significantly more likely to be up to date on their preventive care, but adherence to recommended guidelines for chronic disease management was better for men in the Fee For Service practices. Older individuals reported better health service delivery than younger ones. The quality of chronic disease management was also age dependent with better care delivered to individuals ages 60-69. Individuals of low income and education had better accessibility than those not disadvantaged in the Salaried model and Fee For Service, but not Capitation model. Despite their higher health risks, these individuals were not more likely to receive healthy lifestyle counseling. // Conclusions: Significant inequalities in the care of patients were found across social strata. In some cases, these inequalities are deemed appropriate; a justifiable response to differing health care needs. In other cases, they are deemed inappropriate and representing inequities in the delivery of care. Some of the observed disparities were present in one remuneration model but not others, suggesting that the payment approach may be contributing to these differences. The results raise the concern that the capitation remuneration structure may compromise accessibility.

This study examined the potential impact on processes of care and patient outcomes upon exposure of supportive and concurrent care provided by primary care providers (PCPs) to their hospitalized patients. A secondary objective was to describe the PCPs who conduct these services, and the patients who receive them. There was a marked, observable trend that PCP visits to their hospitalized patients is on the decline (dropped 10% between 2003 and 2009). The patients who received in-hospital visits from their PCPs had more disease burden and were hospitalized longer than the control group. Patients who received and in-hospital visit from their PCP were more likely to receive home care services and PCP visits post-discharge [adjusted OR 1.20 (95% CI 1.12-1.28)]. They were also less likely to experience the composite outcome of death, hospital readmission, or emergency department visit [aOR 0.95 (95% CI 0.91-0.98)].

This study examined the potential impact on processes of care and patient outcomes upon exposure of supportive and concurrent care provided by primary care providers (PCPs) to their hospitalized patients. A secondary objective was to describe the PCPs who conduct these services, and the patients who receive them. There was a marked, observable trend that PCP visits to their hospitalized patients is on the decline (dropped 10% between 2003 and 2009). The patients who received in-hospital visits from their PCPs had more disease burden and were hospitalized longer than the control group. Patients who received and in-hospital visit from their PCP were more likely to receive home care services and PCP visits post-discharge [adjusted OR 1.20 (95% CI 1.12-1.28)]. They were also less likely to experience the composite outcome of death, hospital readmission, or emergency department visit [aOR 0.95 (95% CI 0.91-0.98)].

Families who are dissatisfied with the nursing home care of their family member may supplement their care by hiring a private companion. Families who have the financial resources pay for extra care, while families who cannot afford a private companion receive the current standard of care. Anecdotal evidence suggests that private companion use has increased over time. However, there is no research that examines private companions. The goal of this mixed methods study was to provide empirical evidence about who private companions are, what they do, and why they are needed. Andersen and Newman’s Health Service Utilization Model was used to understand private companion use. This study used both survey research and grounded theory. A mailed survey was completed by 280 of 432 family members of nursing home residents in a Toronto nursing home, yielding a response rate of 65 percent. Grounded theory principles were used to conduct interviews with 10 family members to understand why private companions were hired. Almost two-thirds of nursing home residents had a private companion. Family members reported that they paid about $475 per week for private companions who provided about 40 hours of care per week. Private companions were mostly women and immigrants. Private companions performed many activities including assisting with activities of daily living, toileting, feeding, escorting to activities, and providing social support. In the survey, family members reported hiring a private companion for reasons related to families’ needs (e.g. quality of care concerns), residents’ needs (e.g. deteriorating health); and staff recommendations. The family members reiterated these reasons in the interviews. Quality of care was the overarching theme that captured the reason for private companion use, which encompassed the following themes: inadequate staffing, unmet residents’ needs, overburdened family members, and suboptimal nursing home environment. The qualitative data emphasized the importance of building relationships with nursing home residents. The predictors of private companion use in the multivariate analysis were longer duration of nursing home stay, higher resident dependency, and family members’ concerns with quality of care. This research is among the first to study private companions, and has implications for research, policy, and practice.

Families who are dissatisfied with the nursing home care of their family member may supplement their care by hiring a private companion. Families who have the financial resources pay for extra care, while families who cannot afford a private companion receive the current standard of care. Anecdotal evidence suggests that private companion use has increased over time. However, there is no research that examines private companions. The goal of this mixed methods study was to provide empirical evidence about who private companions are, what they do, and why they are needed. Andersen and Newman’s Health Service Utilization Model was used to understand private companion use. This study used both survey research and grounded theory. A mailed survey was completed by 280 of 432 family members of nursing home residents in a Toronto nursing home, yielding a response rate of 65 percent. Grounded theory principles were used to conduct interviews with 10 family members to understand why private companions were hired. Almost two-thirds of nursing home residents had a private companion. Family members reported that they paid about $475 per week for private companions who provided about 40 hours of care per week. Private companions were mostly women and immigrants. Private companions performed many activities including assisting with activities of daily living, toileting, feeding, escorting to activities, and providing social support. In the survey, family members reported hiring a private companion for reasons related to families’ needs (e.g. quality of care concerns), residents’ needs (e.g. deteriorating health); and staff recommendations. The family members reiterated these reasons in the interviews. Quality of care was the overarching theme that captured the reason for private companion use, which encompassed the following themes: inadequate staffing, unmet residents’ needs, overburdened family members, and suboptimal nursing home environment. The qualitative data emphasized the importance of building relationships with nursing home residents. The predictors of private companion use in the multivariate analysis were longer duration of nursing home stay, higher resident dependency, and family members’ concerns with quality of care. This research is among the first to study private companions, and has implications for research, policy, and practice.

Background: In health care services, equity is the delivery of similar care for similar needs (horizontal equity), and the delivery of more care for higher needs (vertical equity). This study assessed the extent to which primary care provision is equitable across gender, age and socioeconomic groups, and whether any observed disparity is associated with the type of primary care remuneration model to which a family practice belongs. Remuneration models include Fee For Service in which the physician is paid for each encounter, Salary where payment is fixed for the number of hours worked, and Capitation where payment is tied to the number of patients under the care of the provider, and very little or no additional compensation is provided for each patient encounter. // Methods: This thesis used data from a cross sectional study of 5,361 patients receiving care from practices (n) in which primary care providers were remunerated by Fee For Service (35), Salary (35), or Capitation (68). Multi-level linear or logistic regressions were used to assess the impact of gender, age and socioeconomic strata on quality of care. The quality of health service delivery and health promotion were assessed through surveys based on the Primary Care Assessment Tool (n=5,111). The quality of preventive care (n=4,108) and chronic disease management (n-514) were evaluated through chart abstraction using the Canadian recommendations for care as the standard. The analyses were conducted stratified by remuneration model to allow the impact of the model on the extent of disparity in quality of care between social strata to be assessed. // Results: Men and women reported similar quality of health service delivery. Women were significantly more likely to be up to date on their preventive care, but adherence to recommended guidelines for chronic disease management was better for men in the Fee For Service practices. Older individuals reported better health service delivery than younger ones. The quality of chronic disease management was also age dependent with better care delivered to individuals ages 60-69. Individuals of low income and education had better accessibility than those not disadvantaged in the Salaried model and Fee For Service, but not Capitation model. Despite their higher health risks, these individuals were not more likely to receive healthy lifestyle counseling. // Conclusions: Significant inequalities in the care of patients were found across social strata. In some cases, these inequalities are deemed appropriate; a justifiable response to differing health care needs. In other cases, they are deemed inappropriate and representing inequities in the delivery of care. Some of the observed disparities were present in one remuneration model but not others, suggesting that the payment approach may be contributing to these differences. The results raise the concern that the capitation remuneration structure may compromise accessibility.

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The researcher examined the experiences of three directors of child care centers that had been accredited by the National Association for the Education of Young Children (NAEYC) and six directors of child care centers that had not yet reached accreditation status. The nature and meaning of these experiences was explored through interviews with each of the directors individually, and then with each mentor and her two protégés. The purpose of this study was to understand how a mentoring program promotes change in child care programs and how that change impacts the quality of care, if, in fact, it does. Using the constant comparative method, three major findings emerged. The first finding was the critical issue of identifying, screening, and selecting protégés to participate in the Director's Mentoring Project (DMP). Factors that result in protégés remaining in the program include self-selection, having previously met or heard of the mentors themselves, awareness of accreditation standards and procedures, and knowledge of and concern about quality care for young children. The second and third findings were intertwined. They had to do with the models of mentoring used and the nature of the relationship between the mentors and protégés. The mentors and the protégés utilized a model of mentoring that was based on their understanding that the primary goal of the DMP was to either gain NAEYC-accreditation status for the center itself or to provide professional and personal support to the protégé directors. While all the mentors began the program with accreditation as their primary goal, those who developed a close and empathic relationship with their protégés came to believe that support of the directors was primary. The former utilized a more goal-oriented model of mentoring; the latter utilized a more affective model of mentoring. The nature of the mentor-protégé relationship formed a continuum from instrumental to personal and developmental. Where the mentors and protégées fell on the continuum paralleled their understanding of the purpose of the project and the model of mentoring that was adopted.

Background: There is little information on how the quality of oral health services in long-term care (LTC) facilities is conceptualized or assessed. Objectives: This study aims to develop a model for assessing the quality of oral healthcare services in LTC facilities. Methods: This study is divided into four main steps. Firstly, I examined literature for existing concepts relating to program evaluation and quality assessment in healthcare to build a theoretical framework appropriate to dental geriatrics. Secondly, I explored as an ethnographic case study a comprehensive oral healthcare program within a single administrative group of 5 LTC facilities in a large metropolis by interviewing 33 participants, including residents and their families, nursing staff, administrators and dental personnel. I also examined policy documents and made site visits to identify other attributes influencing the quality of the program. Thirdly, I drafted the assessment model combining a theoretical framework with empirical information from the case study. And lastly, I tested the feasibility and usability of the model in another dental geriatric program in northern British Columbia. I applied the assessment model by conducting 15 interviews with participants in the program, made site-visits to the 5 facilities, and reviewed documents on the development and operation of the program. Results: A combination of theory-based evaluation and quality assurance provided six sequential and iterative steps for quality assessment of oral health services in LTC. The empirical information supported the theoretical framework that a program of oral healthcare in a LTC context should be assessed for quality from multiple perspectives; it should be comprehensive; and it should include the three main attributes of quality - capacity, performance, and outcomes. Participants revealed 20 quality indicators along with suggested program objectives which encompass eight quality dimensions such as effectiveness, efficiency, and patient-centered. Conclusion: The model provides a unique system for assessing the quality of dental services in LTC facilities that seems to meet the needs of dental and non-dental personnel in LTC.