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"We have to respect that option": The abortion aversion complex in safety-net healthcare organizations. Soc Sci Med 2021; 291:114468. [PMID: 34757239 DOI: 10.1016/j.socscimed.2021.114468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 09/18/2021] [Accepted: 10/07/2021] [Indexed: 11/21/2022]
Abstract
In July 2019, the Trump administration began implementing its domestic gag rule to ban discussion of abortion in pregnancy options counseling and ensure physical separation of contraceptive and abortion services at clinical sites funded by the federal government's Title X Family Planning program. In this paper, we examine how organizational policy utilization correlated with organization-level protocols for discussing abortion in options counseling interactions while the domestic gag rule policy was under legal contest. From April 2018 to July 2019, we conducted in-depth interviews with 50 administrators in charge of setting clinical protocols regarding options counseling after a positive pregnancy test at 20 Title X-covered and 14 non-Title X-covered safety-net healthcare organizations in Ohio. We found that organizational characteristics and Title X policy utilization did not explain the heterogeneity in approaches to abortion referral that administrators reported. Administrators from 2 of 20 organizations covered by Title X policy requirements pre-emptively restricted discussion of abortion in their facilities in advance of policy enactment. Meanwhile, administrators from 10 of 14 non-Title X-covered organizations did not restrict discussion of abortion. Our analysis demonstrates how safety-net healthcare organizations' response to federal policy is shaped by administrators' institutional entrepreneurship within the abortion aversion complex: a pattern of policy miscomprehension and endorsed abortion stigma that facilitates the structural stigmatization of abortion within safety-net healthcare organizations. We conclude that current efforts to reverse the domestic gag rule will fail unless local abortion aversion complexes are targeted with intervention.
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Choi S, Weech-Maldonado R, Powers T. The context, strategy and performance of the American safety net primary care providers: a systematic review. J Health Organ Manag 2020; 22:529-550. [PMID: 32681633 DOI: 10.1108/jhom-11-2019-0319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The objective of this research is to synthesize evidence on the relationship between context, strategies and performance in the context of federally qualified health centers (FQHCs), a core safety net health services provider in the United States. The research also identifies prior approaches to measure contextual factors, FQHC strategy and performance. Gaps in the research are identified, and directions for future research are provided. DESIGN/METHODOLOGY/APPROACH A systematic review of peer-reviewed journal articles published between the years 1997 and 2017 was conducted using a bibliographic search of PubMed, Business Source Premier and ABI/Inform databases. FINDINGS 28 studies were selected for the analysis. Results supported associations among contextual factors (organizational and environmental) and FQHC strategy and FQHC performance. The research also indicates that previous research was primarily emphasized on clinical performance with less focus on other types of FQHC performance. In addition, there exists a wide variability in terms of measuring context, FQHC strategy and performance. ORIGINALITY/VALUE Operating in resource-scarce and highly constraining environments, FQHCs have demonstrated the ability to stay innovative and competent as serving often unhealthier and costlier patient populations. To date, there has been no study that reviewed the relationships between context, FQHC strategy and FQHC performance. In addition, there is an absence of consensus on how context, FQHC strategy and FQHC performance are measured. This study is the first that examined context-strategy-performance relationships in the context of FQHCs.
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Affiliation(s)
- Seongwon Choi
- Department of Health Care Administration, Trinity University, San Antonio, Texas, USA
| | - Robert Weech-Maldonado
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas Powers
- Department of Marketing, Industrial Distribution and Economics, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Wright B, Martin GP. Mission, margin, and the role of consumer governance in decision-making at community health centers. J Health Care Poor Underserved 2016; 25:930-47. [PMID: 24858895 DOI: 10.1353/hpu.2014.0107] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE We explore the role of consumer trustees in decision-making as community health centers (CHCs) work to navigate the tension between pursuing their mission to provide primary care to all regardless of ability to pay and maintaining their limited finances. METHODS We interviewed 30 trustees from 16 CHCs in 14 different states, asking extensively about decision-making processes at their CHC related to services and finances, as well as perceived advantages and disadvantages of consumer governance. RESULTS Respondents described mission-dominant, margin-dominant, and balanced decision-making philosophies, and different decision-making pathways for service provision and finances. Consumer trustees were lauded for their role in informing the board of service quality and community needs, but criticized for being professionally unskilled and exhibiting a lack of objective decision-making. CONCLUSIONS While CHC boards do play a role in navigating the tension between mission and margin, executive directors and staff appear to be more influential.
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Li S, Dor A, Pines JM, Zocchi MS, Hsia RY. The Relationship of Financial Pressures and Community Characteristics to Closure of Private Safety Net Clinics. Med Care Res Rev 2015; 73:590-605. [PMID: 26712803 DOI: 10.1177/1077558715622897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 11/25/2015] [Indexed: 11/17/2022]
Abstract
In order to better understand what threatens vulnerable populations' access to primary care, it is important to understand the factors associated with closing safety net clinics. This article examines how a clinic's financial position, productivity, and community characteristics are associated with its risk of closure. We examine patterns of closures among private-run primary care clinics (PCCs) in California between 2006 and 2012. We use a discrete-time proportional hazard model to assess relative hazard ratios of covariates, and a random-effect hazard model to adjust for unobserved heterogeneity among PCCs. We find that lower net income from patient care, smaller amount of government grants, and lower productivity were associated with significantly higher risk of PCC closure. We also find that federally qualified health centers and nonfederally qualified health centers generally faced the same risk factors of closure. These results underscore the critical role of financial incentives in the long-term viability of safety net clinics.
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Affiliation(s)
- Suhui Li
- George Washington University, Washington, DC, USA
| | - Avi Dor
- George Washington University, Washington, DC, USA
| | | | | | - Renee Y Hsia
- University of California, San Francisco, CA, USA
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Luo H, Sotnikov S, Winterbauer N. Provision of Personal Healthcare Services by Local Health Departments: 2008-2013. Am J Prev Med 2015; 49:380-6. [PMID: 25997902 PMCID: PMC4831056 DOI: 10.1016/j.amepre.2015.01.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 01/30/2015] [Accepted: 01/30/2015] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The scope of local health department (LHD) involvement in providing personal healthcare services versus population-based services has been debated for decades. A 2012 IOM report suggests that LHDs should gradually withdraw from providing personal healthcare services. The purpose of this study is to assess the level of LHD involvement in provision of personal healthcare services during 2008-2013 and examine the association between provision of personal healthcare services and per capita public health expenditures. METHODS Data are from the 2013 survey of LHDs and Area Health Resource Files. The number, ratio, and share of revenue from personal healthcare services were estimated. Both linear and panel fixed effects models were used to examine the association between provision of personal healthcare services and per capita public health expenditures. Data were analyzed in 2014. RESULTS The mean number of personal healthcare services provided by LHDs did not change significantly in 2008-2013. Overall, personal services constituted 28% of total service items. The share of revenue from personal services increased from 16.8% in 2008 to 20.3% in 2013. Results from the fixed effect panel models show a positive association between personal healthcare services' share of revenue and per capita expenditures (b=0.57, p<0.001). CONCLUSIONS A lower share of revenue from personal healthcare services is associated with lower per capita expenditures. LHDs, especially those serving <25,000 people, are highly dependent on personal healthcare revenue to sustain per capita expenditures. LHDs may need to consider strategies to replace lost revenue from discontinuing provision of personal healthcare services.
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Affiliation(s)
- Huabin Luo
- Department of Public Health, Brody School of Medicine, East Carolina University, Greenville, North Carolina.
| | - Sergey Sotnikov
- Office for State, Tribal, Local and Territorial Support, CDC, Atlanta, Georgia
| | - Nancy Winterbauer
- Department of Public Health, Brody School of Medicine, East Carolina University, Greenville, North Carolina
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White K, Hopkins K, Aiken ARA, Stevenson A, Hubert C, Grossman D, Potter JE. The impact of reproductive health legislation on family planning clinic services in Texas. Am J Public Health 2015; 105:851-8. [PMID: 25790404 DOI: 10.2105/ajph.2014.302515] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We examined the impact of legislation in Texas that dramatically cut and restricted participation in the state's family planning program in 2011 using surveys and interviews with leaders at organizations that received family planning funding. Overall, 25% of family planning clinics in Texas closed. In 2011, 71% of organizations widely offered long-acting reversible contraception; in 2012-2013, only 46% did so. Organizations served 54% fewer clients than they had in the previous period. Specialized family planning providers, which were the targets of the legislation, experienced the largest reductions in services, but other agencies were also adversely affected. The Texas experience provides valuable insight into the potential effects that legislation proposed in other states may have on low-income women's access to family planning services.
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Affiliation(s)
- Kari White
- Kari White is with the Department of Health Care Organization & Policy, University of Alabama, Birmingham. At the time of the study, Kristine Hopkins, Abigail R. A. Aiken, Amanda Stevenson, Celia Hubert, and Joseph E. Potter were with the Population Research Center, University of Texas, Austin. Daniel Grossman is with Ibis Reproductive Health, Oakland, CA
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Variation in Local Health Department Primary Care Services as a Function of Health Center Availability. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2015; 21:E1-9. [DOI: 10.1097/phh.0000000000000112] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Wright B, Ricketts TC. When patients govern: federal grant funding and uncompensated care at federally qualified health centers. J Health Care Poor Underserved 2014; 24:954-67. [PMID: 23728059 DOI: 10.1353/hpu.2013.0068] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine if the proportion of consumers on federally qualified health center (FQHC) governing boards is associated with their use of federal grant funds to provide uncompensated care. METHODS Using FQHC data from the Uniform Data System, county-level data from the Area Resource File and governing board data from FQHC grant applications, the uncompensated care an FQHC provides relative to the amount of its federal funding is modeled as a function of board and executive committee composition using fixed-effects regression with FQHC and county-level controls. RESULTS Consumer governance does not predict how much uncompensated care an FQHC provides relative to the size of its federal grant. Rather, the proportion of an FQHC's patient-mix that is uninsured drives uncompensated care provision. CONCLUSIONS Aside from a small executive committee effect, consumer governance does not influence FQHCs' provision of uncompensated care. More work is needed to understand the role of consumer governance.
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Affiliation(s)
- Brad Wright
- Center for Gerontology and Healthcare Research, Brown University, Providence, RI 02912, USA.
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The impact of the great recession on community-based mental health organizations: an analysis of top managers' perceptions of the economic downturn's effects and adaptive strategies used to manage the consequences in Ohio. Community Ment Health J 2014; 50:258-69. [PMID: 23408296 DOI: 10.1007/s10597-013-9603-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 02/02/2013] [Indexed: 10/27/2022]
Abstract
The Great Recession of 2007-2009 adversely affected the financial stability of the community-based mental health infrastructure in Ohio. This paper presents survey results of the type of adaptive strategies used by Ohio community-based mental health organizations to manage the consequences of the economic downturn. Results were aggregated into geographical classifications of rural, mid-sized urban, and urban. Across all groups, respondents perceived, to varying degrees, that the Great Recession posed a threat to their organization's survival. Urban organizations were more likely to implement adaptive strategies to expand operations while rural and midsized urban organizations implemented strategies to enhance internal efficiencies.
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Hsuan C, Rodriguez HP. The adoption and discontinuation of clinical services by local health departments. Am J Public Health 2013; 104:124-33. [PMID: 24228663 DOI: 10.2105/ajph.2013.301426] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We identified factors associated with local health department (LHD) adoption and discontinuation of clinical services. METHODS We used multivariate regression with 1997 and 2008 LHD survey and area resource data to examine factors associated with LHDs maintaining or offering more clinical services (adopter) versus offering fewer services (discontinuer) over time and with the number of clinical services discontinued among discontinuers. RESULTS Few LHDs (22.2%) were adopters. The LHDs were more likely to be adopters if operating in jurisdictions with local boards of health and not in health professional shortage areas, and if experiencing larger percentage increase in non-White population and Medicaid managed care penetration. Discontinuer LHDs eliminated more clinical services in jurisdictions that decreased core public health activities' scope over time, increased community partners' involvement in these activities, had larger increases in Medicaid managed care penetration, and had lower LHD expenditures per capita over time. CONCLUSIONS Most LHDs are discontinuing clinical services over time. Those that cover a wide range of core public health functions are less likely to discontinue services when residents lack care access. Thus, the impact of discontinuation on population health may be mitigated.
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Affiliation(s)
- Charleen Hsuan
- Both authors are with the Department of Health Policy and Management, University of California Los Angeles Fielding School of Public Health, Los Angeles
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Mathis A, Barnes PA, Shah GH. Assessing gaps in the maternal and child health safety net. Popul Health Manag 2013; 16:270-5. [PMID: 23437869 DOI: 10.1089/pop.2012.0026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The Patient Protection and Affordable Care Act of 2010 proposed sweeping changes to health insurance and health care delivery systems. As a result, local health departments, community health centers, and other safety net providers are expected to play a role in providing access to care for millions of individuals. This study examines the availability of population-based services by local health departments and community health centers in the Midwest/Great Lakes region. For this study, the authors used secondary data on location of community health centers collected by the Health Resources and Services Administration and local health department services delivery from the 2008 National Profile of Local Health Departments. To simultaneously examine the geospatial patterns of service delivery and location of community health centers, the geographic information system shape files of local health department jurisdictions were used to examine prenatal care services. Additionally, the effect of service availability was examined by analyzing the rate of low birth weight births within the service areas of these facilities. Results show large variation in the distribution of community health centers. Additionally, the analysis of local health department services shows that prenatal care services are not available in every jurisdiction. Furthermore, the rates of low birth weight births in these areas are significantly higher than in areas where prenatal care is available. Future studies are needed to examine the relationship between safety net providers as well as their role in improving population health.
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Affiliation(s)
- Arlesia Mathis
- Institute of Public Health, Florida A&M University, Tallahassee, Florida 32307, USA.
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Ndumele CD, Baer HJ, Shaykevich S, Lipsitz SR, Hicks LS. Cardiovascular disease and risk in primary care settings in the United States. Am J Cardiol 2012; 109:521-6. [PMID: 22112741 DOI: 10.1016/j.amjcard.2011.09.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 09/29/2011] [Accepted: 09/29/2011] [Indexed: 10/15/2022]
Abstract
Primary care site may play an important role in cardiovascular disease prevalence; however, the distribution of risk factors and outcomes across care sites is not known. In this study, a cross-sectional analysis of 21,778 adult participants from the National Health and Nutrition Examination Survey (NHANES; 1999 to 2008) using multivariate logistic regression was conducted to assess the relation between site of usual care and disease prevalence. Patients' self-reported histories of several chronic conditions (hypertension, diabetes, and hypercholesterolemia), awareness of chronic conditions, and associated cardiovascular events (angina, coronary heart disease, cardiovascular disease, myocardial infarction, and stroke) were examined. After adjustment for demographic and health care utilization characteristics, there were no significant differences in the prevalence of diabetes or hypercholesterolemia among patients receiving usual care at private doctors' offices, hospital outpatient clinics, community-based clinics, and emergency rooms (ER). However, participants without usual sources of care and those receiving usual care at ERs had significantly lower awareness of their chronic conditions than participants at other sites. The odds of having a history of each of the adverse cardiovascular events ranged from 2.21 to 4.18 times higher for patients receiving usual care at ERs relative to private doctors' offices. In conclusion, participants who report using ERs as their usual sites of care are disproportionately more likely to have histories of poor cardiovascular outcomes and are more likely to be unaware of having hypertension or hypercholesterolemia. As health care reform takes place and millions more begin seeking care, it is imperative to ensure access to longitudinal care sites designed for continuous disease management.
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Peltzer JN, Teel CS. The development of a comprehensive community health center in a rural community. Leadersh Health Serv (Bradf Engl) 2012. [DOI: 10.1108/17511871211198070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThis paper seeks to identify strategies that promote the development and sustainability of a successful comprehensive community health center located in a rural Mid‐western state.Design/methodology/approachThe authors used a qualitative case study methodology, using a purposive sample of 15 employees and board members of a rural community health center. Semi‐structured interviews were conducted, transcribed, and analyzed for common themes and sub‐themes that would describe the strategies used to develop and sustain the successful center.FindingsLeading with Consideration was identified as the dominant theme in the interviews, field notes and archival data. Four sub‐themes: Living the Mission, Fostering Individual Growth, Building a Community, and Encouraging Innovation, emerged from the narratives. Leadership was the most important theme that emerged from the data, resulting in a workforce culture that upholds the mission of the center, leadership that seeks to inspire the growth of both employees and clients. As a result, there is a sense of community and innovative health care endeavours that have created a sustainable holistic health care model.Research limitations/implicationsThe themes that emerged from the narratives of the participants may not be transferable to other community health centers. The case selected for this study was located in a rural, primarily Caucasian setting, so the findings may not be transferable to urban or more racially diverse settings.Practical implicationsTransformational leadership may be an important concept for safety net clinics to promote a positive work environment that continually addresses the important mission of the organization, promotes retention of staff, and promotes staff to provide quality, continuity of care to clients to promote their health. Within current safety net organizations, the findings from this research may affirm leaders' servant leadership styles and how they positively impact their organization. Healthy work environments guided by transformational leaders promote retention of quality health care professionals, who in turn, provide quality care in medically underserved communities.Originality/valueThis study is one of the first qualitative studies to describe concepts that support the development of a successful, sustainable community health center.
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Free Health Clinic Links College, Church, and Community. J Christ Nurs 2011; 28:88-91. [DOI: 10.1097/cnj.0b013e31820c2f5e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Weiner BJ, Amick HR, Lund JL, Lee SYD, Hoff TJ. Use of qualitative methods in published health services and management research: a 10-year review. Med Care Res Rev 2011; 68:3-33. [PMID: 20675353 PMCID: PMC3102584 DOI: 10.1177/1077558710372810] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the past 10 years, the field of health services and management research has seen renewed interest in the use of qualitative research methods. This article examines the volume and characteristics of qualitative research articles published in nine major health services and management journals between 1998 and 2008. Qualitative research articles comprise 9% of research articles published in these journals. Although the publication rate of qualitative research articles has not kept pace with that of quantitative research articles, citation analysis suggests that qualitative research articles contribute comparably to the field's knowledge base. A wide range of policy and management topics has been examined using qualitative methods. Case study designs, interviews, and documentary sources were the most frequently used methods. Half of qualitative research articles provided little or no detail about key aspects the study's methods. Implications are discussed and recommendations are offered for promoting the publication of qualitative research.
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Affiliation(s)
- Bryan J Weiner
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7411, USA.
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Bowser DM, Utz S, Glick D, Harmon R. A systematic review of the relationship of diabetes mellitus, depression, and missed appointments in a low-income uninsured population. Arch Psychiatr Nurs 2010; 24:317-29. [PMID: 20851323 DOI: 10.1016/j.apnu.2009.12.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2009] [Revised: 11/21/2009] [Accepted: 12/09/2009] [Indexed: 11/29/2022]
Abstract
The purpose of this systematic literature review was to determine the relationship between the diagnosis of diabetes and depression and missed appointments in a low-income, uninsured, racially heterogeneous, adult population. Research demonstrates that individuals with diabetes have an increased incidence of depression across socioeconomic and racial groups. Low-income individuals have an increased prevalence of depression. The cost and burden of diabetes are greatly increased among individuals with both diabetes and depression versus diabetes alone. The prevalence and effects of diabetes and depression in a low-income, uninsured, racially heterogeneous population have not been determined. Further research to explore the relationship of diabetes, depression, and missed appointments in this vulnerable population is needed before effective treatment models can be developed. Longitudinal studies are also needed to determine the cause and effect between diabetes and depression among all populations.
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Willging CE, Waitzkin H, Lamphere L. Transforming administrative and clinical practice in a public behavioral health system: an ethnographic assessment of the context of change. J Health Care Poor Underserved 2009; 20:866-83. [PMID: 19648713 DOI: 10.1353/hpu.0.0177] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In July 2005, New Mexico placed all publicly funded behavioral health services under the management of one private corporation. This reform emphasized the provision of evidence-based, culturally competent services. Methods. Participant observation and semi-structured interviews with 189 administrators, staff, and providers were carried out in 14 behavioral health safety-net institutions (SNIs) during the transition period. Results. New administrative requirements led to substantial paperwork demands, payment problems, and financial stress within SNIs. Personnel at the SNIs often lacked knowledge about and training in evidence-based practices and culturally competent care, and viewed the costs of delivering such services as prohibitive. Discussion. Policymakers must account for the challenges that SNIs face as the reform continues to unfold. The financial stability of SNIs is of critical importance. Efforts are needed to increase training and development opportunities in evidence-based care and cultural competency; SNIs typically lack resources to pursue these opportunities on their own.
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Grogan CM, Gusmano MK. Political strategies of safety-net providers in response to medicaid managed care reforms. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2009; 34:5-35. [PMID: 19234292 DOI: 10.1215/03616878-2008-990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Safety-net providers play a central role in the U.S. health care system because they provide the bulk of services to the poor and the uninsured. The health policy literature focuses a great deal on the capacity of these institutions to provide services and the forces that shape these institutions and the services they provide, yet little is made of safety-net providers' potential role as advocates for the poor and for disadvantaged groups. In this article, we draw on findings from a case study of Medicaid policy making in Connecticut to explore efforts by safety-net providers and other nonprofit organizations to advocate around health care policy for the poor. Our findings illustrate how the capacity of nonprofit advocates to represent the poor can be compromised when the rules of the game change and nonprofit providers are asked to compete with for-profit organizations. We find that under a change in the contracting regime--from collaboration to competition--nonprofit service providers may increase political activity to secure a favorable role under the new regime, but these efforts may compromise their ability to act as representatives of the poor.
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Willging CE, Waitzkin H, Nicdao E. Medicaid managed care for mental health services: the survival of safety net institutions in rural settings. QUALITATIVE HEALTH RESEARCH 2008; 18:1231-1246. [PMID: 18689536 DOI: 10.1177/1049732308321742] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Few accounts document the rural context of mental health safety net institutions (SNIs), especially as they respond to changing public policies. Embedded in wider processes of welfare state restructuring, privatization has transformed state Medicaid systems nationwide. We carried out an ethnographic study in two rural, culturally distinct regions of New Mexico to assess the effects of Medicaid managed care (MMC) and the implications for future reform. After 160 interviews and participant observation at SNIs, we analyzed data through iterative coding procedures. SNIs responded to MMC by nonparticipation, partnering, downsizing, and tapping into alternative funding sources. Numerous barriers impaired access under MMC: service fragmentation, transportation, lack of cultural and linguistic competency, Medicaid enrollment, stigma, and immigration status. By privatizing Medicaid and contracting with for-profit managed care organizations, the state placed additional responsibilities on "disciplined" providers and clients. Managed care models might compromise the rural mental health safety net unless the serious gaps and limitations are addressed in existing services and funding.
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Affiliation(s)
- Cathleen E Willging
- Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, Albuquerque, New Mexico, USA
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Waitzkin H, Schillaci M, Willging CE. Multimethod evaluation of health policy change: an application to Medicaid managed care in a rural state. Health Serv Res 2008; 43:1325-47. [PMID: 18384362 DOI: 10.1111/j.1475-6773.2008.00842.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To answer questions about the impacts of Medicaid managed care (MMC) at the individual, organizational/community, and population levels of analysis. DATA SOURCES/STUDY SETTING Multimethod approach to study MMC in New Mexico, a rural state with challenging access barriers. STUDY DESIGN Individual level: surveys to assess barriers to care, access, utilization, and satisfaction. Organizational/community level: ethnography to determine changes experienced by safety net institutions and local communities. Population level: analysis of secondary databases to examine trends in preventable adverse sentinel events. DATA COLLECTION/EXTRACTION METHODS SURVEY multivariate statistical methods, including factor analysis and logistic regression. Ethnography: iterative coding and triangulation to assess documents, field observations, and in-depth interviews. Secondary databases: plots of sentinel events over time. PRINCIPAL FINDINGS The survey component revealed no consistent changes after MMC, relatively favorable experiences for Medicaid patients, and persisting access barriers for the uninsured. In the ethnographic component, safety net institutions experienced increased workload and financial stress; mental health services declined sharply. Immunization rate, as an important sentinel event, deteriorated. CONCLUSIONS MMC exerted greater effects on safety net providers than on individuals and did not address problems of the uninsured. A multimethod approach can facilitate evaluation of change in health policy.
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Affiliation(s)
- Howard Waitzkin
- Department of Sociology, Family & Community Medicine, University of New Mexico, MSC 053080, 1070 Social Sciences Building, 1915 Roma NE, Room 1103, Albuquerque, NM 87131-0001, USA.
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Soto NI, Bazyler LR, O'Toole ML, Brownson CA, Pezzullo JC. Starting a diabetes self-management program in a free clinic. DIABETES EDUCATOR 2007; 33 Suppl 6:166S-171S. [PMID: 17620397 DOI: 10.1177/0145721707304966] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this project is to develop and implement a system of care for people with type 2 diabetes in a free clinic setting. METHODS This project was conducted in the Homestead/Florida City community at the Open Door Health Center (a free clinic for the uninsured poor). Through a grant from the Robert Wood Johnson Foundation Diabetes Initiative, organizational and programmatic changes were made to improve care for patients with type 2 diabetes. Program participation and clinical data, incorporation of healthy practices and programs in other community organizations, and the success of collaborations were evaluated to judge program success. RESULTS Critical factors for providing health care for persons with type 2 diabetes in a free clinic setting were identified. These included reviewing and organizing medical records of patients with diabetes, developing a system that made efficient use of limited staff resources, finding an educational approach appropriate for the population served (ie, Popular Education), involving patients in self-management support roles by providing them the opportunity and training to become peer mentors, and developing strong community partnerships to complement and reinforce self-management. CONCLUSION Creation of a successful system of care for patients with diabetes in a free clinic setting is possible through innovative collaboration and creative program design.
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Affiliation(s)
- Nilda I Soto
- The Open Door Health Center, Homestead, Florida (Dr Soto, Ms Bazyler)
| | - Laura R Bazyler
- The Open Door Health Center, Homestead, Florida (Dr Soto, Ms Bazyler)
| | - Mary L O'Toole
- National Program Office of the Robert Wood Johnson Foundation Diabetes Initiative, St Louis, Missouri (Dr O’Toole, Ms Brownson)
| | - Carol A Brownson
- National Program Office of the Robert Wood Johnson Foundation Diabetes Initiative, St Louis, Missouri (Dr O’Toole, Ms Brownson)
| | - John C Pezzullo
- Georgetown University, Washington, DC (Dr Pezzullo, retired)
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Slack KS, Holl JL, Yoo J, Amsden LB, Collins E, Bolger K. Welfare, Work, and Health Care Access Predictors of Low-Income Children's Physical Health Outcomes. CHILDREN AND YOUTH SERVICES REVIEW 2007; 29:782-801. [PMID: 25505809 PMCID: PMC4260331 DOI: 10.1016/j.childyouth.2006.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
This analysis examines whether young children's (N= 494) general physical health is associated with parental employment, welfare receipt, and health care access within a low-income population transitioning from welfare to work. A latent physical health measure derived from survey and medical chart data is used to capture children's poor health, and parental ratings of child health are used to identify excellent health. Controlling for a host of factors associated with children's health outcomes, results show that children of caregivers who are unemployed and off welfare have better health than children of caregivers who are working and off welfare. Children whose caregivers are unemployed and on welfare, or combining work and welfare, have health outcomes similar to children of caregivers who are working and off welfare. Health care access characteristics, such as gaps in health insurance coverage, source of primary care setting, and type of health insurance are associated with children's general physical health. Implications of these results for state TANF programs are discussed.
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Gollust SE, Jacobson PD. Privatization of public services: organizational reform efforts in public education and public health. Am J Public Health 2006; 96:1733-9. [PMID: 17008563 PMCID: PMC1586133 DOI: 10.2105/ajph.2005.068007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2005] [Indexed: 11/04/2022]
Abstract
The public health and the public education systems in the United States have encountered problems in quality of service, accountability, and availability of resources. Both systems are under pressure to adopt the general organizational reform of privatization. The debate over privatization in public education is contentious, but in public health, the shift of functions from the public to the private sector has been accepted with limited deliberation. We assess the benefits and concerns of privatization and suggest that shifting public health functions to the private sector raises questions about the values and mission of public health. Public health officials need to be more engaged in a public debate over the desirability of privatization as the future of public health.
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Affiliation(s)
- Sarah E Gollust
- Department of Health Management and Policy at the University of Michigan School of Public Health, Ann Arbor, MI 48109-2029, USA
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