The Michelle P. Waiver (MPW) is the primary means of health insurance for more than 10,000 people in the state of Kentucky. The waiver is especially popular among families with young children with disabilities because it is robust in its benefit offerings and also one of the few Medicaid resources that does not include parental income as a qualifying factor in eligibility. Through the waiver, children receive a medical card as well as additional coverage for medical expenses that fall beyond the scope of traditional health insurance. For these young children to gain access to the comprehensive offerings of the MPW, their parents must apply for the waiver, negotiate the terms of service, and make critical health care decisions on their behalf, or at least until they reach adulthood—although this responsibility often extends throughout the child’s life. The present study builds upon recent research on parental uncertainty in caregiving for children with complex care needs. By combining two ecological approaches to health communication research, Brashers’s (2001) uncertainty management theory (UMT) and Ball-Rokeach, Kim, and Matai’s (2001) communication infrastructure theory (CIT), my aim in this dissertation was to explain how meso-level (e.g., community organization) interactions influenced parental caregivers’ experiences of uncertainty. I collected data through narrative interviews with 31 parents of children who are currently receiving services through the MPW and analyzed them using narrative thematic analysis. The analysis focused on the community-level communication that contributes to parent caregivers’ ability to successfully access and negotiate care within the MPW system. Findings show that parents experience unique personal, social, and medical uncertainties related to the MPW. In addition, the findings demonstrate that MPW-related uncertainty and decision making are managed with a variety of strategies aimed to decrease, increase, or maintain desired levels of uncertainty. Finally, findings showcase how one’s connectedness to community storytelling at the meso level, particularly within online communities and disability network communities supports their adaptive management of MPW-related uncertainty. This project contributes to the health communication literature theoretically by (a) expanding the conceptualization of the uncertainty in illness framework to include the means of health care (i.e., Medicaid) as a consequential element of an individual’s illness experience, (b) identifying two additional strategies of uncertainty management (i.e. advocacy and vigilance), and by (c) extending existing notions of residency, connectedness, and belongingness within the CIT framework to include membership in online and disability-specific networks. Practically, this project offers important insights that can guide future research exploring the role of meso-level communication in parent caregivers’ management of waiver-based care, such as in identifying the need for a systematic communication process that introduces potentially eligible families to the MPW.

California’s elderly population over age 85 is estimated to grow 361% by the year 2050. Many of these elders are frail and highly dependent on caregivers making them more likely to need nursing home care. A 1998 United States Government Accountability Office report identified poor quality of care in California nursing homes. This report spurred multiple Assembly Bills in California designed to increase nursing home nurse staffing, change the state’s Medi-Cal reimbursement methodology, or both. The legislation culminated in Assembly Bill (AB) 1629, signed into law in September 2004, which included the Long-Term Care Reimbursement Act. This legislation changed the state’s Medi-Cal reimbursement from a prospective, flat rate to a prospective, cost-based methodology and was designed in part to increase nursing home nurse staffing. It is estimated that this methodology change moved California from the bottom 10% of Medicaid nursing home reimbursement rates nationwide to the top 25%. This study analyzed the effect of AB 1629 on a panel of 567 free-standing nursing homes that were in continuous operation between the years 2002 – 2007. Resource Dependence Theory was used to construct the conceptual framework. Ordinary least squares (OLS) and first differencing with instrumental variable estimation procedures were used to test five hypotheses concerning Medi-Cal resource dependence, bed size, competition (including assisted living facilities and home health agencies), resource munificence, and slack resources. Both a 15 and 25 mile fixed radius were used as alternative market definitions instead of counties. The OLS results supported that case-mix adjusted licensed vocational nurse (LVN) and total nurse staffing hours per resident day increased overall. Nursing homes with the highest Medi-Cal dependence increased only increased NA staffing more than nursing homes with the lowest Medi-Cal dependence post AB 1629. The fixed effects with instrumental variable estimation procedure provided marginal support that nursing homes with more home health agency competition, in a 15 mile market, had higher LVN staffing. This estimation procedure also supported that nursing homes with more slack resources (post AB 1629) increased nurse aide and total nurse staffing while nursing homes located in markets with a greater percentage of residents over the age of 85 had more nurse aide staffing.

In 2010 Medicaid financed approximately 48% of all births in the United States and nearly 30% of all births in Virginia. Due to strict state-specific eligibility criteria, many low-income women qualify for Medicaid coverage exclusively as a result of pregnancy status. As the nation moves forward with the Patient Protection and Affordable Care Act (PPACA), state-elected Medicaid expansion has the potential to expand services to women of reproductive age that would precede pregnancy events and offer continuous access to care postpartum. Despite this potential influx of newly insured women, little is known about how this population may make decisions regarding reproductive healthcare services and if these selections influence process and outcome measures. This study examines two research aims that provide insight into these knowledge gaps. First, utility theory and discrete choice modeling is used to examine clinic and patient level factors associated with clinic type choice. Specifically, this study examines the role of high risk pregnancy status and travel distance to clinic as associated with clinic selection. Second, Donabedian’s Structure, Process, Outcome framework provides a conceptual lens to examine if clinic selection is associated with maternal and infant measures. The linear probability model and logistic regression models are employed to examine two process measures, including prenatal care inadequacy and postpartum visit nonattendance, and three outcome measures including maternal long acting reversible contraceptive method (LARC) use and infant birthweight and gestational age. Results examining clinic type selection reveal significant associations between independent and dependent variables. Women experiencing a high risk pregnancy are significantly more likely to select a hospital based clinic for care, compared to women experiencing a normal risk pregnancy. However, when specifically examining women experiencing their first pregnancy, this association is no longer significant. Additionally, as distance to clinic type increase, women are significantly less likely to select that clinic type for prenatal care. Clinic selection was found to be significantly associated with maternal measures, but not significantly associated with infant outcomes. Selecting a public health department or Federally Qualified Health Center for prenatal care services was associated with a significant decrease in inadequate prenatal care, postpartum visit nonattendance, and non-LARC use compared to a private physician office. Clinic type selection, however, was not found to be significantly associated with infant outcomes including preterm birth and low birthweight babies. Results from Research Aim 1 have a variety of implications for clinic and public policy and offer guidance for future research. Clinics that seek to provide care to pregnant Medicaid beneficiaries should examine local residential patterns of current and potential future pregnant Medicaid recipients and consider how these might affect decisions about future clinic locations. Results suggest that women are more likely to attend clinic types closer to their area of residence, and this close proximity may have additional implications beyond shorter travel time to clinic including the minimization of transportation and childcare issues. Results from Research Aim 2 analyses offer a variety of public policy implications and guidance for future research. This research provides evidence that public health facilities including public health departments and FQHCs have improved prenatal care adequacy and postpartum visit attendance compared to private physician offices, providing evidence that public funding should continue for these facility types. As the United States moves forward with PPACA, healthcare organization administration should turn to the public facilities in their communities to learn how to manage and improve the health of these patient populations and ultimately aim to improve access and quality care among the nation’s most vulnerable populations.

This document is a review of literature on needs assessments and the benefits of conducting one. Communicare is a mental health agency that serves the Lincoln Trail Region. Currently, most of the revenue from their children programs comes from Medicaid, which is a fee-for-services payer source. The Kentucky Medicaid Program is in the process of contracting with managed care organizations to oversee services that have been paid directly from Kentucky Medicaid. With these changes, mental health organizations must identify specific community service needs as well as expanding revenue sources. Applying for grants is one way mental health agencies can expand revenue sources. Communicare has identified the KY SEED grant that focuses on prevention and providing services to early childhood programs as a potential funding source. A needs assessment was conducted to gather information on children services implemented by Communicare. It was conducted in order to assess current programs and seek out potential areas of future program growth. The needs assessment further sought to identify gaps in services for the early childhood programs and assist in the grant application process. A review of existing data on children’s services offered at Communicare, including a satisfaction survey and a System of Care Assessment Report, was conducted as part of the needs assessment. A Community Forum with community partners from the Lincoln Trail region was held to gather additional data for the needs assessment.

The present study is a retrospective cohort analysis which sought to examine adherence to medications used in managing painful diabetic peripheral neuropathy (PDPN) and to determine their association with oral antidiabetic (OAD) medication adherence using the Texas Medicaid prescription claims database. The study objectives were to: 1) provide a description of PDPN and OAD medication use among the study subjects; 2) determine if PDPN medication adherence differs among individual PDPN agents (i.e., tricyclic antidepressants, gabapentin, pregabalin and duloxetine); 3) determine if pre-index OAD and post-index OAD medication adherence differs among mono, dual, and triple OAD therapies; and 4) determine if PDPN medication adherence is related to post-index OAD medication adherence while controlling for covariates. Study participants were adult (≥18 years) Medicaid beneficiaries prescribed OAD and PDPN medications. The index date was the first PDPN prescription. Data were extracted from June 1, 2003 to October 31, 2009 and prescription claims were analyzed over an 18-month study period (i.e., 6 months pre-index and 12 months post index period). Medication possession ratio (MPR) was used as a proxy measure of medication adherence. An MPR less than 80 percent was regarded as being non-adherent to prescribed medication, while an MPR greater than or equal to 80 percent was regarded as being adherent to prescribed medication. Objective 1 was addressed using descriptive statistics (i.e., mean, standard deviation, frequency). Univariate analysis (ANOVA) was employed to address Objectives 2 and 3. Multivariate analyses (i.e., multiple linear regression and logistic regression) were conducted to address Objective 4. For the logistic regression MPR was dichotomized at the cut-off value of 80 percent. A total of 4,277 patients met the study’s inclusion criteria. The overall mean MPR (±SD) for PDPN medications was 75.4 percent (±23.9). Mean MPR (±SD) was highest for duloxetine (85.6% ±18.2) and was lowest for pregabalin (69.4% ±24.9). Mean MPR differed significantly among individual PDPN medications (p<0.0001). The overall mean MPR (±SD) for OAD medications in the pre and post-index period was 73.0 percent (±24.3) and 64.5 percent (±25.6) respectively. In both pre and post-index periods, mean MPR differed significantly among mono, dual, and triple OAD therapies (p<0.0001). In the pre-index period, mean MPR (±SD) was highest for monotherapy users (75.4% ±24.7) and was lowest for triple therapy users (63.9% ±22.9). Similarly, mean MPR (±SD) was highest for monotherapy users (69.0% ±26.1) and was lowest for triple therapy users (52.9% ±21.8) in the post-index period. After controlling for the covariates, PDPN adherence (i.e., MPR) was statistically significant (p<0.0001) and positively related to post-index OAD adherence (i.e., MPR). PDPN patients who were non-adherent (i.e., MPR<80%) to their PDPN medications (or neuropathic pain medications), compared to those who were adherent (MPR≥80%), were significantly less likely to be adherent to their OAD medications [Odds Ratio (OR) = 0.626, 95% CI=0.545-0.719]. In addition, post-index OAD adherence (i.e., MPR) did not differ significantly (p>0.05) when pregabalin, duloxetine and gabapentin users were individually compared to tricyclic antidepressants users. In conclusion, PDPN patients who were adherent (i.e., MPR≥80%) to their PDPN medications, compared to those who were not adherent (i.e., MPR<80%), were more adherent to their OAD medications. Also, adherence to OAD medications was independent of the type of PDPN medication used. PDPN patients need to be educated regularly that neuropathic pain medications only relieve the pain associated with the neuropathy but achieving adequate glycemic control remains the only established approach for slowing down the progression of the neuropathy and other complications associated with the diabetes. / text

In this comparative policy development analysis, I utilize path-dependence theory and presidential records to analyze President Lyndon Johnson's success in passing Medicare and Medicaid and President Bill Clinton's failure to pass national health care reform. Findings support four major themes from the Johnson administration: 1) President Johnson had a keen understanding of the importance of language in framing debate; 2) He placed control of the legislative process in the hands of a small, select group of seasoned political operatives and career policymaking professionals; 3) He paid considerable attention to the details of negotiations and the policy consequences; and 4) He had a highly developed sense of the political and legislative processes involved in passing major legislation. The case study of the Clinton administration reveals five major themes: 1) There is a lack of evidence that President Clinton remained actively engaged throughout the policy development and legislative processes, instead choosing to delegate the process to the First Lady; 2) There was a naiveté on the part of the Clintons and many administration staff members with regard to the legal and political ramifications of their decisions; 3) The Clintons tried to make the plan fully their own, sharing little credit for its development with Congress; 4) Their attempts to incorporate existing corporate health care delivery structures with their vision for universal coverage proved unworkable; and 5) The extended time from task force launch to bill delivery gave opponents ample time to marshal their opposition forces. I conclude that in developing health care legislation, Johnson had the advantages of: 1) a small group of key policymakers; 2) multiple, simultaneous legislative initiatives which diffused the attention of a more limited media; and, 3) national crises which promoted an environment conducive to sweeping policy change. I suggest that major, national health care reform will not occur until: 1) an economic or geopolitical crisis sets the stage for change; 2) business interests and progressive interests find common ground; and, 3) Americans achieve a new cultural understanding of universal health care as both economically just and economically necessary. / text

This retrospective study examined records of 230 low-income elderly and disabled individuals enrolled in the Georgia Community Care Services Program (CCSP) which provides home health services in the client’s home rather than a nursing facility (NF). This study sought to determine if any common characteristics exist in program enrollees who enter a NF within one year of enrollment. Common factors found could be used to identify those who are at the highest risk for entering an NF. This knowledge could lead to reduced costs for the State of Georgia and better service for CCSP enrollees. Findings associated with NF entry include: age, Medicaid status, and monthly income. Further study is recommended to determine which common factors could be developed into a screening tool used to identify individuals at highest risk for NF entry. Specific care plans could then be developed to avoid or delay NF admission for CCSP enrollees.

Thesis (Ph.D. in Nursing) -- University of Colorado at Denver and Health Sciences Center, 2006. / Typescript. Includes bibliographical references (leaves 188-199). Free to UCDHSC affiliates. Online version available via ProQuest Digital Dissertations;

Thesis (M.P.A.)--Kutztown University of Pennsylvania, 1999. / Source: Masters Abstracts International, Volume: 45-06, page: 2928. Typescript. Abstract precedes thesis as preliminary leaves iii-iv. Includes bibliographical references 122-127.

Avoidable use of the Emergency Departments (EDs) constitutes a significant public health problem, which has health, economic and ethical implications. The factors that affect avoidable use of the EDs are complex and poorly understood. The goal of this dissertation was to examine the role of medical home in avoidable pediatric ED visits, assess the impact of Medicaid policy on ED visits for dental problems and assess the factors affecting follow-up dental care after a dental ED visit. Iowa Household Health Survey data was used for the first study, which included a sample of families with at least one child residing in Iowa. It was found that 68% of parents who took their child to an ED in the previous year thought the ED visit could have been avoided if primary care was available to them. Having a medical home was not found to be associated with pediatric ED visits; however, food insecurity was significantly associated. Parents of children with public insurance, those who were not referred by a healthcare provider and those who reported difficulty in getting routine care appointments were more likely to report an avoidable ED visit by their child. The second study examined a policy change in California where Medicaid eliminated its comprehensive adult dental coverage on July 1, 2009. State Emergency Department Database were obtained from Agency for Healthcare Research and Quality for California for 2006 through 2011. Interrupted time series, a quasi-experimental approach of was used to examine the impact of the policy change on rate of dental ED visits by Medicaid enrolled adults. Segmented linear regression revealed that policy change led to an immediate significant increase in the rate of dental ED visits. The policy had a differential impact on various subgroups based on age, race-ethnicity and residential location. The annual costs associated with dental ED visits made by Medicaid adults also increase 68%. Survival analytic approach was used in the final study to examine the patterns of dental care following a dental ED visit by Medicaid enrolled adults in Iowa. Medicaid claims and enrollment data were used to identify adults with an index dental ED visit in 2011, and then each subject was followed for up to 6 months. About 52% of all adults who satisfied the study inclusion criteria, had a follow up dental visit within 6 months of the index dental ED visit. Cox regression model revealed that adults who had visited a dentist in the year prior to the ED visit had greater hazards of having an early dental follow up after the ED visit. Having repeated dental ED visits was found to have a dose-response relationship to follow-up time to dentist visit, with those having 1 repeat ED visit having 53% hazards and those with 2 or more repeat ED visits having 34% hazards of having a follow-up dentist visit, compared to those with no repeat ED visits. Collectively, the results from this dissertation provide important insights in understanding the complex problem of avoidable ED visits. Factors such as food insecurity and medical home need to be further investigated in their association with avoidable ED visits. State Medicaid policy plays an important role and limiting Medicaid adult dental coverage may lead to an increased reliance of the affected population on EDs for dental care. However, EDs do not provide any definitive dental care, and our results indicate that almost half of the adults with dental ED visit do not have a follow-up dentist visit in the next 6 months.