Background: The Program of All-inclusive Care for the Elderly (PACE) is a program of care that enrolls nursing home eligible and offers them community-based long-term services and supports (LTSS). Many PACE enrollees are “dual eligibles” (DEs) meaning they qualify for Medicare and Medicaid services. Dental care is a unique feature of PACE among LTSS, as many LTSS do not include dental care, even though this population has difficulty in accessing these services. However, little is known about the delivery of dental care at PACE and how dental care and oral health promotion and prevention is being integrated into PACE. Thus, the purpose of this study is to describe the delivery and integration of dental care at PACE. Methods: Based on ten preliminary interviews and the PACE manual from the Centers for Medicare and Medicaid Services (CMS), a 56-question survey was developed to describe the delivery and integration of dental care at PACE across the country. In addition, the survey asked programs to rank their focus among five specialties (dentistry, mental health, optometry, audiology, podiatry), to determine if a program’s focus on dental care would influence the delivery and integration of dental services at PACE, and if this would lead the program to have a very high percentage of new and continuous enrollees with regular dental examinations. A publicly available contact list was obtained from CMS and the survey was distributed to all 124 PACE programs via email. Results: Respondents in this study represented 35 programs (28.2%) in 23 states (74.2%). Most programs had no limits for dental care, minimal waitlists, and provide most dental services without exclusions. This is evident by the 51.4% of programs that have no dental budget, 100% of programs providing preventive and basic restorative dental care, and nearly 100% offering advanced restorative services. Many programs also did not have a waitlist for non-emergent dental care. Few programs include a dentist in the routine operations of the PACE program, as evidenced by few programs having dentists conduct the dental assessment for the initial comprehensive assessment or having a dental director. A statistically significant association with a high percentage of reported utilization of dental examinations was detected with programs having a system for quality assurance for dental care (t=0.358, p=0.024), a protocol for a dental cleaning every 6-12 months (t=0.595, p<0.001), mandating a comprehensive dental examination (t=0.390, p=0.007), and providing preventive dental services onsite with built-in equipment (t=0.454, p=0.001). No factors were statistically associated with the focus ranking for dentistry among the other specialties. Conclusion: This study suggests that compared to nursing homes, PACE enrollees may have greater ability to receive dental care without limitations of the state adult Medicaid dental benefit. Dentistry also appears to be a high focus for some PACE programs. This study has begun to identify structures that support positive outcomes that can be used to develop best practices and guidelines for the delivery of dental care in PACE and other LTSS. Future studies are needed to better understand barriers and facilitators to the delivery of dental care and other specialty services.

Objective: To understand the association between dental insurance coverage and dental care utilization in Iowa children. Methods: The 2010 Iowa Child and Family Household Health Survey (IHHS) data was used to assess the association between dental insurance coverage and dental care utilization in Iowa children. Andersen’s model of health services utilization was used as a framework for determining the predictors of dental care utilization. Chi-square test was used for determining bivariate associations and Logistic regression analysis was used to determine factors associated with dental care utilization. Results: The results from the multivariable logistic regression model indicate that children with private dental insurance (p<0.001) and 4-9 years of age (p=0.005) were more likely to have a dental visit. Additionally, respondents who were always able to get dental appointments for their child (p<0.001), had a regular source of dental care for the child (p<0.001) and perceived dental need for their child (p<0.001), were more likely to report having a dental check-up for their child in the past 12 months. Conclusion: Dental insurance was significantly associated with having a dental visit in the past year in Iowa children 4-17 years of age. Some of the other predictors of dental care utilization were: having a regular source of dental care for the child, ease of getting dental appointment for the child, younger child’s age and having perceived dental need for the child.

In order to facilitate effective tobacco cessation services within dental school clinics, it is necessary to understand the perceived barriers encountered by dental students while providing these services. The aim of this study was to identify which factors fourth year dental students perceive to be associated with barriers to providing tobacco intervention services. A written survey was developed and completed by the incoming fourth year dental students at the University of Iowa College of Dentistry in 2008. The survey assessed the perceived barriers to providing tobacco intervention services and related factors. Descriptive, bivariate and logistic regression analyses were conducted. The response rate was 97 percent. Some of the most frequently reported barriers included: patient's resistance to tobacco intervention services (96%), inadequate time available for tobacco intervention services (96%) and forgetting to give tobacco intervention advice (91%). The following variables were significantly (p<0.05) related to greater perceived barriers in providing tobacco intervention services: lower "adequacy of tobacco intervention curriculum coverage of specific topics covered over the previous three years" and "perceived importance of incorporating objective structured clinical examination teaching method for learning tobacco intervention." Students could benefit from additional didactic training and enhanced clinical experience in order to facilitate effective intervention services in the dental school.

The purposes of this study were (1) to identify the factors present in negligence suits found in case law involving prehospital care providers and (2) based on those factors, to develop a typology of causation of legal actions that could be used by postsecondary educators to emphasize specific areas in the initial training and continuing education of EMTs and paramedics. An additional purpose was to provide data which could be used to develop standards and protocols for quality assurance programs. / Using traditional legal research methods, 182 state and federal cases were identified. It was found that lawsuits involving prehospital care providers and systems have been increasing. A marked increase since 1981 was noted. / Elements of alleged negligence were identified, coded, and ultimately used to develop a typology of causation. The four major categories of causation were, in decreasing order of frequency, (1) treatment and care issues; (2) ambulance accidents; (3) dispatch and transport issues; and (4) other issues, such as training, staffing, and administration. Although alleged treatment and care negligence was the most frequent category, it involved a myriad of types of patient scenarios. On the other hand, the number one most frequent single cause of alleged negligence was ambulance accidents. / Implications of the typology for postsecondary educators, administrators, policy makers, and others were discussed. It was suggested that the typology be used to emphasize and/or alter certain aspects of educational curricula, such as driving skills, assessment skills, spinal immobilization, and others. / Legal precedents set down by the courts were dissected in order to view trends. Precedents, such as, immunity issues, emergency vehicle status, guest statutes, common carrier status, constitutional issues, and duty of care were discussed. The similarities and differences found in case law regarding these precedents were also evaluated. / Source: Dissertation Abstracts International, Volume: 53-03, Section: B, page: 1275. / Major Professor: Louis Bender. / Thesis (Ed.D.)--The Florida State University, 1992.

Context: Self-learning (i.e., students learning independently) and clinical simulation are essential components in contemporary health professions education (HPE). Self-learning is discussed often, yet the concept is seldom the target of rigorous study. Likewise, simulation modalities are abundant, though educational theory that guides their use in HPE remains elusive. Objectives: This dissertation investigates the effects of directed self-guided learning (DSGL) on novice health professions students’ skill acquisition, retention, and transfer in the context of simulation-based education. The objective is to explore how the combination of external direction and student self-guidance influences: students’ cognitive and metacognitive processes, students’ interactions with the learning environment and available resources, and how students learn in different DSGL contexts. Methods: Three research studies used randomized, controlled experimental designs to address five hypotheses. All studies included a performance assessment one-week after the initial practice session that evaluated skill retention and/or skill transfer. Data analysis employed univariate and multivariate analyses of variance and correlational techniques. Results: Regarding students’ cognitive and metacognitive processes, the data show a relation between DSGL and goal-setting. The results suggest that self-guided students benefit when they are directed to set goals related to performance processes, rather than performance outcomes. Regarding the learning environment, when students are directed to practice on simulators that increase progressively in fidelity (i.e., realism) they self-guide their advancement between those simulators effectively and display successful skill transfer. Finally, self-guided students that controlled their learning progression and learning sequence selected the theoretically most appropriate practice schedule (i.e., progressive learning). Students in this latter group seemed able, surprisingly, to direct their own self-guidance. Conclusions: This dissertation adds support to the hypothesis that self-guided students benefit due to their autonomy in controlling practice conditions to meet their own learning needs. Thus, the question of whether or not DSGL is effective, becomes how best to augment the DSGL experience. The instructional design of elements such as goals lists and task structuring (e.g., progressive increases in simulator fidelity) represent techniques that an educator can use to fulfill the role of director in a student’s SGL.

Context: Self-learning (i.e., students learning independently) and clinical simulation are essential components in contemporary health professions education (HPE). Self-learning is discussed often, yet the concept is seldom the target of rigorous study. Likewise, simulation modalities are abundant, though educational theory that guides their use in HPE remains elusive. Objectives: This dissertation investigates the effects of directed self-guided learning (DSGL) on novice health professions students’ skill acquisition, retention, and transfer in the context of simulation-based education. The objective is to explore how the combination of external direction and student self-guidance influences: students’ cognitive and metacognitive processes, students’ interactions with the learning environment and available resources, and how students learn in different DSGL contexts. Methods: Three research studies used randomized, controlled experimental designs to address five hypotheses. All studies included a performance assessment one-week after the initial practice session that evaluated skill retention and/or skill transfer. Data analysis employed univariate and multivariate analyses of variance and correlational techniques. Results: Regarding students’ cognitive and metacognitive processes, the data show a relation between DSGL and goal-setting. The results suggest that self-guided students benefit when they are directed to set goals related to performance processes, rather than performance outcomes. Regarding the learning environment, when students are directed to practice on simulators that increase progressively in fidelity (i.e., realism) they self-guide their advancement between those simulators effectively and display successful skill transfer. Finally, self-guided students that controlled their learning progression and learning sequence selected the theoretically most appropriate practice schedule (i.e., progressive learning). Students in this latter group seemed able, surprisingly, to direct their own self-guidance. Conclusions: This dissertation adds support to the hypothesis that self-guided students benefit due to their autonomy in controlling practice conditions to meet their own learning needs. Thus, the question of whether or not DSGL is effective, becomes how best to augment the DSGL experience. The instructional design of elements such as goals lists and task structuring (e.g., progressive increases in simulator fidelity) represent techniques that an educator can use to fulfill the role of director in a student’s SGL.

Background: Most treatment for people with arthritis occurs at the primary care level yet many studies have documented the need for improved arthritis management in this environment. The dissemination of clinical practice guidelines (CPGs) has been suggested as one method for improving care delivery. Getting a Grip on Arthritis, a theory and evidence-based educational program was developed to disseminate arthritis best practices based on published CPGs for the management of osteoarthritis (OA) and rheumatoid arthritis (RA). Primary care organizations were invited to enroll providers in an inter-professional workshop. Six months of reinforcement activities were offered following the workshop to support the delivery of arthritis care in their communities. Purpose: This study was designed to determine which organizational and individual level characteristics contributed to improved provider use of arthritis best practices six months following the workshops. Methods: The ACREU Primary Care Survey was completed by workshop participants at baseline and six months following the workshops in order to evaluate their use of arthritis best practices. This survey measured providers’ responses to open-ended questions that asked how they would manage the individual patients described in three hypothetical case scenarios. One point was given for each recorded best practice and totaled for each case scenario, with the highest possible score being eight for the late RA case and moderate knee OA case, and seven for the early RA case. Requests for reinforcement activities were tracked by study staff during the six months following the workshops. A practice profile was also completed by each organization. Analysis: Two models of knowledge utilization (KU) were constructed for testing. For Model 1, two-level hierarchical linear modeling (HLM) was used to determine the direct effects of provider and organizational level variables on intended use of arthritis best practices six months post-workshops, while controlling for clustering within organizations. In model 2, logistic regression was used to determine the influence of organization level factors on one specific best practice, that is, dissemination of patient educational materials during the six months following the workshop. Results: 275 providers from 131 organizations completed both baseline and six month follow-up surveys. For Model 1, total best practice scores for all three case scenarios were predicted by the discipline of the provider, the model of care in which they worked and baseline best practice scores (P<0.05). Controlling for these variables, baseline confidence in managing arthritis also predicted the six month follow-up scores for moderate knee OA (P=0.05) and baseline satisfaction with ability to manage arthritis predicted the follow-up scores for late RA (P=0.04). For Model 2, the estimated probability of disseminating patient educational materials was >82% for community health centres, primary care networks and regionally funded models of care compared to 30% for the federally funded model of care (P<0.01), and was 88% for organizations that sent multidisciplinary team members to the workshops, compared to 70% for those that did not send such a team (P=0.07). Conclusions: Use of arthritis best practices may be influenced by provider characteristics (discipline, satisfaction and confidence in managing arthritis), the model of care in which they work and the team learning experience. These results have implications for the training and education of health professionals and the design of models of care to enhance arthritis care delivery.

Background: Most treatment for people with arthritis occurs at the primary care level yet many studies have documented the need for improved arthritis management in this environment. The dissemination of clinical practice guidelines (CPGs) has been suggested as one method for improving care delivery. Getting a Grip on Arthritis, a theory and evidence-based educational program was developed to disseminate arthritis best practices based on published CPGs for the management of osteoarthritis (OA) and rheumatoid arthritis (RA). Primary care organizations were invited to enroll providers in an inter-professional workshop. Six months of reinforcement activities were offered following the workshop to support the delivery of arthritis care in their communities. Purpose: This study was designed to determine which organizational and individual level characteristics contributed to improved provider use of arthritis best practices six months following the workshops. Methods: The ACREU Primary Care Survey was completed by workshop participants at baseline and six months following the workshops in order to evaluate their use of arthritis best practices. This survey measured providers’ responses to open-ended questions that asked how they would manage the individual patients described in three hypothetical case scenarios. One point was given for each recorded best practice and totaled for each case scenario, with the highest possible score being eight for the late RA case and moderate knee OA case, and seven for the early RA case. Requests for reinforcement activities were tracked by study staff during the six months following the workshops. A practice profile was also completed by each organization. Analysis: Two models of knowledge utilization (KU) were constructed for testing. For Model 1, two-level hierarchical linear modeling (HLM) was used to determine the direct effects of provider and organizational level variables on intended use of arthritis best practices six months post-workshops, while controlling for clustering within organizations. In model 2, logistic regression was used to determine the influence of organization level factors on one specific best practice, that is, dissemination of patient educational materials during the six months following the workshop. Results: 275 providers from 131 organizations completed both baseline and six month follow-up surveys. For Model 1, total best practice scores for all three case scenarios were predicted by the discipline of the provider, the model of care in which they worked and baseline best practice scores (P<0.05). Controlling for these variables, baseline confidence in managing arthritis also predicted the six month follow-up scores for moderate knee OA (P=0.05) and baseline satisfaction with ability to manage arthritis predicted the follow-up scores for late RA (P=0.04). For Model 2, the estimated probability of disseminating patient educational materials was >82% for community health centres, primary care networks and regionally funded models of care compared to 30% for the federally funded model of care (P<0.01), and was 88% for organizations that sent multidisciplinary team members to the workshops, compared to 70% for those that did not send such a team (P=0.07). Conclusions: Use of arthritis best practices may be influenced by provider characteristics (discipline, satisfaction and confidence in managing arthritis), the model of care in which they work and the team learning experience. These results have implications for the training and education of health professionals and the design of models of care to enhance arthritis care delivery.

<p>Background: College settings are likely environments for Black women to contract STIs (including HIV) or experience unintentional/unwanted pregnancies. Effective prevention strategies for this population include dialogue and activities that focus on gender, maturity, cultural barriers, personal strength, and information needs. However, technological advancements (including virtual reality) and innovation are limited in prevention efforts. </p><p> Methods: Four 90-minute focus group sessions were conducted in a convenience sample of Black college females (ages 18 years or older) and a research-intensive public institution in the southeast. A series of surveys were distributed during each audio-recorded focus group session. A mixed-method approach to data analysis was based on applications of the Health Belief Model constructs to three principal research questions: (1) Q1: How do Black college females perceive the importance of sexual risk topics? (2) What are the experiences and attitudes of Black college females regarding the use of VR for education and training versus video game entertainment (i.e. &ldquo;gaming)? and (3) Among Black college females, what sexual risk topics are considered most relevant to a VR education and training platform? </p><p> Results: Each of four study cohorts enrolled between 2-6 participants each (n=15). Participant ages ranged from 18-48 (x&macr;=28.6, &sigma;=9.2) years within age groups of 18&ndash;24 years (60%, n=9), 25&ndash;34 years (26.7%, n=4), and 35 years or above (13.3%, n=2). The majority of participants (86.7%, n=13) were enrolled as full-time students, and resided in various off-campus locations (73.3%; n=11). Assessments of sexual risk topic importance were reported based on aggregated Survey 1 Lickert scale values. The majority of participants equally viewed the topics of HIV and STI status as important, mostly important, or very important. Other notable concerns include sex with drug/alcohol use, risk of intimate partner violence, and sexual communication (e.g. partners and peers. Despite the lack of formal virtual reality knowledge, the majority of participants reported experience with VF technology via &ldquo;gaming&rdquo; (e.g. <i>SIMS</i>). They also concluded that a virtual reality platform for sexual health education and training should involve comprehensive approaches to HIV/STI and unintentional pregnancy via use of barrier methods, including birth control, as well as facilitation of sexual communication. </p><p> Discussion: This research represents a unique approach to the identification of sexual health risk importance for HIV/STI transmission, as well as unintentional pregnancy, in Black college females. Although a successful demonstration of feasibility, this research is formative in nature&mdash;results should be interpreted as preliminary. However, methods and concepts presented in this thesis hold the potential for scientific contribution in prevention research, clinical practice, and other fields of study. </p>

The healthcare marketplace is rapidly changing how we finance medical education, how we train physicians, and the interrelationships within an academic institution. This case study examined the historical development of the Department of Family and Community Medicine and the impact of growing financial constraints on the training of medical students and residents, the clinical practice, faculty workload, and departmental organization. The theoretical frameworks of resource dependence, culture, and professionalization theory were employed to understand how different groups within the context of an academic health center co-exist to meet the core missions of teaching, research, and service. Data collection was conducted over a two-year period and utilized the triangulation of interviews, document analysis, and participant observation methods. The study's findings indicated that the Department of Family and Community Medicine continually faced the challenge of being a primary care department in an academic medical culture that placed more emphasis on specialized care and specialty departments. Over a period of time, the Department went from a profit-center to a cost-center where faculty's ability to teach and conduct research revolved around the success or failure of the clinical care enterprise. Faculty productivity was increasingly emphasized and its definition was dependent on the healthcare marketplace and the availability of resources. The competitive health care market encroached on faculty workload and manifested itself in part through the loss of a major patient care contract, the receivership of the Department, and the splitting of the Department and its resources. During the period of time analyzed, the department was in a no-win situation because the success of the department was determined by more powerful coalitions that had decision making ability and controlled the necessary resources. The department's power lay in the provision of teaching resources and its alignment with the state's goal of training primary care physicians to work in rural and underserved communities. Conflict arose as departments tried to defend and protect their declining resources and jurisdictions. The study findings emphasized the importance of understanding departmental jurisdictions and how resource allocation decisions are made in the context of the academic setting and culture.