Thesis advisor: Sara Moorman / Studies show that family caregivers are at high risk for morbidity and mortality due to high strain and low efficacy. Dementia caregivers experience a particular type of strain because of the long term nature of the disease. Caregiver studies and intervention programs aim to lower strain and improve perceived efficacy, but they do not often look at these outcomes over time and how they may change throughout the prognosis. This thesis aims to analyze caregiver outcomes in relation to the duration of caregiving, individual characteristics, and type of diagnosis. By using linear regressions and hierarchical linear modeling, I find that caregiver outcomes do not change over time for the average caregiver but vary significantly among individuals. This emphasizes that caregiver strain and efficacy are not solely guided by caregiving tasks. Understanding relationships, perception of one's role, and the ability to adapt to changes are crucial to effective and sustained caregiving. / Thesis (BA) — Boston College, 2019. / Submitted to: Boston College. College of Arts and Sciences. / Discipline: Departmental Honors. / Discipline: Sociology.

Purpose: The purpose of this inquiry was to explore how nurses envision and benefit from restorative built environments in acute care hospitals. Background: The Covid-19 pandemic has resulted in alarming rates of occupational stress and attrition in front-line clinicians, which has made inquiry into how to promote well-being in nurses particularly timely, and salient. Much of the existing design literature is functionalist in tenor, foregrounding how to improve the efficiency and productivity of staff. Provided this, little is known about how nurses experience hospital environments and what restorative features they imagine within these spaces to attenuate stress. This insight is necessary for an improved articulation of supportive and restorative architectural affordances. Methods: Informed by interpretive description, a qualitative study using photo-elicitation was employed to solicit the experiences of 4 frontline registered nurses working in acute care hospitals in Canada. Data was triangulated from three sources; (1) Photographs; (2) Narrative notes; (3) Semi-structured interviews. Results: Iterative and thematic analysis revealed that nurses recognize the power of good design to promote staff retention and promote well-being, although participants largely regard their present work environments as pathogenic and perpetuating harm. Nurses visually and narratively envisioned enriched environments through the use of adaptable space, visual and associative references to nature, a creative atmosphere, inclusive spaces, a civic presence, and the provision of spaces to enable rituals of (self)care. Conclusions: Nurses have considerable tacit and embodied knowledge which can improve the hospital built environment, but further research is needed to capture and solicit these holistic experiences.

America’s poor face many obstacles including health disparities and limited access to affordable primary healthcare services. This study focuses on treatment seeking and knowledge of the Patient Protection and Affordable Care Act among the working poor in Tupelo, Mississippi, where research was conducted in 2014. The working poor cannot afford medical insurance even with government subsidies but earn too much money to qualify for Medicaid, leaving them with few options. Strategies to manage acute and chronic illnesses include frequenting organizations that attempt to fill the gaps in healthcare. This thesis presents a cultural model of health-seeking among the working poor as they attempt to navigate the changing healthcare marketplace. Research indicates that the working poor are largely uninformed and unable to utilize ObamaCare and are still relying on safety net providers.

Background and Objectives: High-cost health care users (HCU) represent a minority of patients who consume a large proportion of health care resources. Due to their high burden on the healthcare system and internal heterogeneity, a better understanding of various segments of the HCU population is needed. The general objective was to advance our understanding of incident senior HCUs in the Canadian context so that we can advise health policy makers on potential strategies to prevent seniors transitioning to HCU and to identify priorities for further investigation. Methods: A retrospective population-based matched cohort study was conducted using province-wide linked administrative data. The research employed a spectrum of advanced methods to accomplish the general objective, including the method of recycled predictions, random intercept two-part multi-level models, and stratified logistic regression. Results: Total costs attributable to incident senior HCU status accounted for almost one-tenth of the provincial healthcare budget, with prolonged hospitalizations making a major contribution. Unplanned first (index) hospitalizations (IHs) in the incident year were considerably more common among HCUs, with ten conditions accounting for one third of their total costs. A lower risk of IH among HCUs was associated with residence in long-term care (LTC), attachment to a primary care provider, and recent consultation by a geriatrician. Although there was little variation in costs incurred by Ontario seniors for healthcare services they receive, access to the healthcare services varied greatly. The traditional drivers of costs and mortality (e.g., age, sex, health status) played little role in driving the observed variation in HCUs’ outcomes. Conclusions: By answering research questions, this thesis advances our knowledge of the HCU population in Canada. Further exploration of the nature and quality of care that may be associated with HCU conversion and investigation of the regional variation in accessing specific healthcare services is warranted. / Thesis / Doctor of Philosophy (PhD) / A small group of patients that use the most of healthcare resources are called high-cost users (HCU). HCUs are often seniors. Policy makers need a better understanding of new senior HCUs to be able to prevent seniors from becoming HCU. This study used administrative data and advanced statistical methods. We found that almost one-tenth of the 2013 provincial healthcare budget was spent on new senior HCUs, mainly because of lengthy unplanned hospitalizations. Patients who lived in long-term care, had a primary care provider, or recently visited a geriatrician were less likely to have an unplanned hospitalization. Overall, healthcare costs were distributed equally to Ontario seniors, but access to healthcare services varied greatly. This variation could not be explained by differences in age, sex, or health status. This thesis advances our knowledge of HCUs in Canada. Additional research is needed into care associated with becoming HCU and provincial variation in accessing healthcare.

This research examines the healthcare services ecosystem and the impact and role service interventions made by providers and patients have on this ecosystem. Each area has an important role in contributing to the value and sustainability of the ecosystem. Healthcare, as a community service, requires a minimum of two counterparts: the providers and the customers, in this case the patients. Healthcare is a unique ecosystem because often the customers are not conscious of the interplay of the ecosystem but are reliant upon the system for their health and wellbeing. The first section of this dissertation examines the effects that occur in the healthcare ecosystem when part of the system experiences a disaster and the impact and role of other areas of the system in response to the disaster, particularly regarding the resilience. Similar to a biological ecosystem that is undergoing a flood, in the healthcare services ecosystem if too many patients present to the Emergency Department (ED) at the same time disaster level overcrowding will occur. We aim to measure the resilience of the healthcare ecosystem to this disaster level overcrowding. The second section of this dissertation examines how the components of the healthcare ecosystem maintain sustainability and usability. Healthcare professionals are assessed regarding their ability to maintain the healthcare ecosystem, with a specific focus on what occurs after patients are in the hospital system. To examine the ability of the healthcare professionals to maintain the ecosystem we analyze the usability and adaptability of the electronic health record and the professional's workflows to determine how they use this tool to sustain the healthcare ecosystem. The third section of this dissertation examines patient self-management and the influence this has on the healthcare ecosystem. Much of the management of health in patients, particularly those with chronic illnesses, occurs outside of the hospital, thus examining this aspect of self-care provides insight on the overall system. This research examines patients with a chronic illness and their use of online health communities, with a particular focus on their reciprocal behaviors and the impact this support system has on their overall health state. By examining these aspects of the healthcare services ecosystem, we can better improve our understanding of these phenomena. / Ph. D.

Whether it is offering services, delivering solutions or driving innovations, team work has been a hallmark of efficiency and effectiveness in various industries. The healthcare industry is not left out as its service delivery process involves numerous interfaces, information flows and patient hand-offs among professionals with different educational training, differing knowledge levels and possibly working from different locations as well. As healthcare delivery evolves to being more patient-centered, so does the team settings as well, becoming more collaborative. Such changes also translate into a need for support systems to evolve to be able to provide support for the extent of collaboration that would be needed. A framework is needed to guide in the development of such systems. However, due to the varying needs of patients, team types and make-up would generally differ, so we explored the different types of team settings studying what they entail based on their various degrees of collaboration. We therefore present in this thesis a model of team based concepts, an ontology formalizing the model, team based scenarios designed using the ontology and then application of the scenarios to test the ability of BPMN (Business Process Modeling Notation) to model healthcare teams.

Whether it is offering services, delivering solutions or driving innovations, team work has been a hallmark of efficiency and effectiveness in various industries. The healthcare industry is not left out as its service delivery process involves numerous interfaces, information flows and patient hand-offs among professionals with different educational training, differing knowledge levels and possibly working from different locations as well. As healthcare delivery evolves to being more patient-centered, so does the team settings as well, becoming more collaborative. Such changes also translate into a need for support systems to evolve to be able to provide support for the extent of collaboration that would be needed. A framework is needed to guide in the development of such systems. However, due to the varying needs of patients, team types and make-up would generally differ, so we explored the different types of team settings studying what they entail based on their various degrees of collaboration. We therefore present in this thesis a model of team based concepts, an ontology formalizing the model, team based scenarios designed using the ontology and then application of the scenarios to test the ability of BPMN (Business Process Modeling Notation) to model healthcare teams.

Whether it is offering services, delivering solutions or driving innovations, team work has been a hallmark of efficiency and effectiveness in various industries. The healthcare industry is not left out as its service delivery process involves numerous interfaces, information flows and patient hand-offs among professionals with different educational training, differing knowledge levels and possibly working from different locations as well. As healthcare delivery evolves to being more patient-centered, so does the team settings as well, becoming more collaborative. Such changes also translate into a need for support systems to evolve to be able to provide support for the extent of collaboration that would be needed. A framework is needed to guide in the development of such systems. However, due to the varying needs of patients, team types and make-up would generally differ, so we explored the different types of team settings studying what they entail based on their various degrees of collaboration. We therefore present in this thesis a model of team based concepts, an ontology formalizing the model, team based scenarios designed using the ontology and then application of the scenarios to test the ability of BPMN (Business Process Modeling Notation) to model healthcare teams.

Whether it is offering services, delivering solutions or driving innovations, team work has been a hallmark of efficiency and effectiveness in various industries. The healthcare industry is not left out as its service delivery process involves numerous interfaces, information flows and patient hand-offs among professionals with different educational training, differing knowledge levels and possibly working from different locations as well. As healthcare delivery evolves to being more patient-centered, so does the team settings as well, becoming more collaborative. Such changes also translate into a need for support systems to evolve to be able to provide support for the extent of collaboration that would be needed. A framework is needed to guide in the development of such systems. However, due to the varying needs of patients, team types and make-up would generally differ, so we explored the different types of team settings studying what they entail based on their various degrees of collaboration. We therefore present in this thesis a model of team based concepts, an ontology formalizing the model, team based scenarios designed using the ontology and then application of the scenarios to test the ability of BPMN (Business Process Modeling Notation) to model healthcare teams.

This research addresses the fluctuating demand and high variability in healthcare systems. These system’s variations need to be considered whilst at the same time making efficient use of the systems’ resources. Patient dependency fluctuation, which makes determining the level of adequate staffing highly complex, is among the variations addressed. Dealing with variability is found to be a key feature in the design, planning and evaluation of healthcare systems. Healthcare providers are facing increasing challenges resulting from an aging population, higher patient expectancies, a shortage of healthcare professionals, as well as increasing costs and reduced funding. Despite the accentuated need for effective healthcare systems and efficient use of resources, many healthcare organisations are inadequately designed and, moreover, poorly managed. Hospital systems consist of complex interrelations between relatively small units, each of which is sensitive to stochastic variations in demand. In addition to this aspect of the system view, a critical resource for the patients’ wellbeing and survival is the staffing level of nurses. This puts the planning and scheduling of human resources as one of the system’s foremost aims. Current tools for staffing and personnel planning in healthcare organisations do not take into consideration the workload variations that result from the variable nature of patient dependency levels. The work presents the empirical findings of a number of case studies conducted at a regional hospital in Sweden. Principles and practical suggestions for the robust system design of inpatient wards using Discrete Event Simulation (DES) have been identified. Although DES techniques have, in principle, all the features for modelling the variation and stochastic nature of systems, DES has not been previously used for workload studies of inpatient wards. The main contribution of this work is therefore how a combination of DES and the data of Patient Classification Systems (PCSs) can be used to model workload variations and, subsequently, plan the nurse staffing requirements in systems with high variability. The work presented gives step by step guidance in how the analysis and subsequent modelling of an inpatient ward should be carried out. It defines a novel modelling methodology for patient dependency variations and length of stay modelling of a patient’s dependency progression, including an adaptation to the ward’s discharge figures. The modelling approach opens a novel way of analysing and evaluating the system design of inpatient wards.