Leading a Healthcare Organization During a Period of Social Change: A Qualitative Study of Chief Executive Officers.

BACKGROUND: In recent years, organizational leaders have faced growing pressure to respond to social and political issues. Although previous research has examined the experiences of corporate CEOs engaging in these issues, less is known about the perspectives of healthcare leaders. OBJECTIVE: To explore the experiences of healthcare CEOs engaging in health-related social and political issues, with a specific focus on systemic racism and abortion policy. DESIGN: Qualitative study using semi-structured interviews from February to July 2023. PARTICIPANTS: CEOs of US-based hospitals or health systems. APPROACH: One-on-one interviews which were audio recorded, professionally transcribed, and analyzed using thematic analysis. KEY RESULTS: This study included 25 CEOs of US-based hospitals or health systems. Almost half were between ages 60 and 69 (12 [48%]), 19 identified as male (76%), and 20 identified as White (80%). Approximately half self-identified as Democrats (13 [55%]). Most hospitals and health systems were private non-profits (15 [60%]). The interviews organized around four domains: (1) Perspectives on their Role, (2) Factors Impacting Engagement, (3) Improving Engagement, and (4) Experiences Responding to Recent Polarizing Events. Within these four domains, nine themes emerged. CEOs described increasing pressure to engage and had mixed feelings about their role. They identified personal, organizational, and political factors that affect their engagement. CEOs identified strategies to measure the success of their engagement and also reflected on their experiences speaking out about systemic racism and abortion legislation. CONCLUSIONS: In this qualitative study, healthcare CEOs described mixed perspectives on their role engaging in social and political issues and identified several factors impacting engagement. CEOs cited few strategies to measure the success of their engagement. Given that healthcare leaders are increasingly asked to address policy debates, more work is needed to examine the role and impact of healthcare CEOs engaging in health-related social and political issues.

How Penn Medicine Is Advancing Care Delivery to Meet More Patients' Needs.

SUMMARY: The University of Pennsylvania Health System was founded in 1993 as one of the nation's first integrated academic medical centers. Over the past 29 years, Penn Medicine has systematically built a care delivery system based on three core values: innovation, integration, and impact. The operating strategy is designed to meet the patient's needs in a traditional brick-and-mortar hospital as well as in an increasingly virtual world. Today's patient is demanding an omnichannel experience with superior outcomes. Although long discussed in healthcare, such a comprehensive, seamless patient experience is only possible when all four channels of care delivery-hospital, ambulatory, home, and virtual-are sustainably integrated to improve the health of the population through digital innovation and analytics.The COVID-19 pandemic forced healthcare systems around the world to pour resources into telemedicine and other telehealth tools. This shift is fueling a dramatic shift from a piecemeal digital strategy to a comprehensive approach to the digital world where increased communication among clinicians, caregivers, and patients can lead to improved outcomes at a lower cost.In this article, we present an illustrative case study focusing on two of four channels of care: the Pavilion at the Hospital of the University of Pennsylvania, where the latest in digital innovation has been built into the walls of our most ambitious capital project to date, and Penn Medicine at Home, which provides home care services, home infusion, and hospice care to patients throughout the region. The new $1.6 billion Pavilion and its technological updates have been seamlessly woven into the longstanding Penn Medicine at Home program. As a system, we did this by learning from both the victories and the setbacks to design for a future of healthcare we could once only imagine.

Service Utilization Before and After Self-Direction: A Quasi-experimental Difference-in-Differences Analysis of Utah's Mental Health Access to Recovery Program.

Mental health self-direction involves participant control of an individualized budget to support recovery and wellness goals. This quasi-experimental study examined whether self-direction is associated with changes in service utilization. The study involved 2 years of administrative data for 94 self-directing participants and a matched comparison group of 529 non-participants with similar observed characteristics. Difference-in-differences were examined using four regression models predicting changes in four service utilization categories. Self-directing participants had greater increases in outpatient and rehabilitation services than the non-self-directing group, controlling for relevant covariates. There were no between-group differences in residential and emergency service utilization.

Self-Direction of Home and Community-Based Services in the Time of COVID-19.

During the COVID-19 pandemic, nursing homes and assisted living facilities have accounted for over 20% of all infections, adult day care and other congregate sites have closed, and traditional home care agencies are facing staff shortages. In this environment, self-direction of home and community-based services, where the participant can hire their own staff and manage a budget that can be used for a broad range of goods and services including home modifications and assistive devices, is seen as a promising intervention. Using self-direction participants can minimize the number of people who enter their homes and pay close family and friends who were already providing many hours of informal care, and now may be unemployed. The Center for Medicare and Medicaid Services is encouraging this approach. This commentary presents information on how states have responded using the new CMS Toolkit by expanding who can be a paid caregiver, increasing budgets and broadening the kinds of items that can be purchased with budgets to include items like personal protective equipment and supports for telehealth. This Commentary concludes with policy and research questions regarding how the delivery of long-term services and supports (LTSS) may change as the world returns to"normal".

Online Ratings of the Patient Experience: Emergency Departments Versus Urgent Care Centers.

STUDY OBJECTIVE: Individuals increasingly use online rating platforms to rate and review hospitals. We seek to describe and compare publicly available online review content and ratings of emergency departments (EDs) and urgent care centers. METHODS: We analyzed Yelp reviews of EDs and urgent care centers to identify topics most correlated with 1- and 5-star ratings. Latent Dirichlet Allocation, a method of identifying groups of co-occurring words in narrative text, was used to identify and label 25 topics across 1- and 5-star reviews of urgent care centers and EDs. Differential Language Analysis was then used to measure the correlation of these topics with 1- and 5-star reviews for urgent care centers and EDs. RESULTS: We analyzed 100,949 Yelp reviews, 16,447 from 1,566 EDs and 84,502 from 5,601 urgent care centers. There were significantly more 5-star urgent care center reviews (n=43,487; 51%) than 5-star ED reviews (n=4,437; 27%). Themes associated with 5-star reviews among EDs and urgent care centers were similar for comfort, professionalism, facilities, pediatric care, and staff interactions. Themes associated with 1-star reviews among EDs and urgent care centers were similar for communication, telephone experience, waiting, billing, pain management, and diagnostic testing. Themes unique to 5-star ED reviews included bedside manner, care for family members, and access. Themes unique to 5-star urgent care center reviews were based on recommendation and prescription refills. Themes unique to 1-star ED reviews were service and speed of care. Themes unique to 1-star urgent care center reviews were lack of confidence and reception experience. CONCLUSION: Understanding drivers for high and low online ratings and what patients value in their ED and urgent care center experiences offers insights for health systems and providers to improve acute care delivery. Patients' perspectives may become increasingly important as they seek care in the expanding urgent care markets.

Difference Between Users and Nonusers of a Patient Portal in Health Behaviors and Outcomes: Retrospective Cohort Study.

BACKGROUND: Patient portals are frequently used in modern health care systems as an engagement and communication tool. An increased focus on the potential value of these communication channels to improve health outcomes is warranted. OBJECTIVE: This paper aimed to quantify the impact of portal use on patients' preventive health behavior and chronic health outcomes. METHODS: We conducted a retrospective, observational cohort study of 10,000 patients aged 50 years or older who were treated at the University of Pennsylvania Health System (UPHS) from September 1, 2014, to October 31, 2016. The data were sourced from the UPHS electronic health records. We investigated the association between patient portal use and patients' preventive health behaviors or chronic health outcomes, controlling for confounders using a novel cardinality matching approach based on propensity scoring and a subsequent bootstrapping method to estimate the variance of association estimates. RESULTS: Patient-level characteristics differed substantially between portal users, comprising approximately 59.32% (5932/10000) of the cohort, and nonusers. On average, users were more likely to be younger (63.46 years for users vs 66.08 years for nonusers), white (72.77% [4317/5932] for users vs 52.58% [2139/4068] for nonusers), have commercial insurance (60.99% [3618/5932] for users vs 40.12% [1632/4068] for nonusers), and have higher annual incomes (US $74,172/year for users vs US $62,940/year for nonusers). Even after adjusting for these potential confounders, patient portal use had a positive and clinically meaningful impact on patients' preventive health behaviors but not on chronic health outcomes. CONCLUSIONS: This paper contributes to the understanding of the impact of patient portal use on health outcomes and is the first study to identify a meaningful subgroup of patients' health behaviors that improved with portal use. These findings may encourage providers to promote portal use to improve patients' preventive health behaviors.

Unmet needs in self-directed HCBS programs.

Unmet need for long-term services and supports has been linked to a variety of harmful health outcomes. One suggested strategy for ameliorating unmet need is to give participants control of a budget and let them construct individualized plans. The evaluation of the Cash and Counseling controlled experiment (CCDE) documented a marked reduction in unmet need when compared to traditional agency-based solutions, but it also showed significant unmet needs remained. This paper reanalyzes 76 case studies from the CCDE to, for the first time gain an understanding of what those unmet needs are, who sees them, and what participants, caregivers and support brokers think might reduce this problem. Using a collective or multiple case study approach to understand this phenomenon, unmet needs were sorted into five categories using real life experiences of respondents. Unmet needs for assistance in managing the employer and budget tasks of self-direction were also captured.This paper discusses situations where the clinician researchers documented needs that were not expressed by the care recipients and provides a picture of where and why unmet needs remain.The paper concludes with strategies for reducing unmet needs and training future social workers.

The times they are a-changing: Self-directed long-term services and supports and gerontological social work.

The Partnerships for Person-Centered (PC) and Participant-Directed (PD) Long-Term Services and Supports (LTSS) Project (Partnerships Project) was a three-year effort funded by the New York Community Trust to develop and implement social work curriculum that would better prepare students for the changing practice demands of the aging and disability services network for self-directed LTSS (SD-LTSS). This article first describes the growth of SD-LTSS and the need for trained social workers on this service delivery model. The paper then describes the Partnerships Project that involved schools of social work along and aging and disability network organization partners in nine states. This description includes the major activities of the project including the creation of SD-LTSS competencies for social work education, the infusion of these competencies in beginning and advanced social work classes, and student assessment of their attainment of these competencies. This article then discusses the challenges to institutionalizing such curricular changes within social work programs and the need for a national strategy to train social workers for the demands of SD-LTSS.

The Tasks and Characteristics of Supportive Support Brokers.

In the United States, under the Cash and Counseling or budget authority model of self-directed personal assistance where the participant manages his or her own services and supports, the Support Broker role was established to assist and coach the participant. The support broker role grew out of a person-centered planning process where focus groups and surveys helped ascertain what potential participants wanted to help them establish a self-directed alternative. But, despite this role being described in policy guidance from the Center for Medicare and Medicaid, little research has been conducted examining the functions, activities and usefulness of this position. This study draws on 76 ethnographic case studies with early Cash and Counseling participants, examines what participants and their caregivers actually saw the support broker doing, and looks at what the participants found helpful and less than helpful. Participants and family caregivers saw support broker duties as falling into four areas: Coaching, Problem Solving, Advocacy and Monitoring. Equally important was how the support broker performed these duties. Key aspects of quality included: Familiarity, Supportive Relationship, Proactive Engagement, Responsiveness, Knowledge and Cultural Friendliness. These findings can provide the basis for establishing quality indicators for self-direction.

"It's Changed Everything": Voices of Veterans in the Veteran-Directed Home and Community Based Services Program.

The purpose of this study was to understand the value and impact of the Veteran-Directed Home and Community Based Services program (VD-HCBS) on Veterans' lives in their own voices. Focus groups and individual interviews by telephone were conducted to elicit participant perspectives on what was most meaningful, and what difference VD-HCBS made in their lives. Transcripts were analyzed using content analysis. The sample included 21 Veterans, with a mean age of 66±14, enrolled in VD-HCBS an average of 20.8 months. All were at risk of institutional placement based on their level of disability. Five major categories captured the information provided by participants: What a Difference Choice Makes; I'm a Person!; It's a Home-Saver; Coming Back to Life; and Keeping Me Healthy & Safe. Participants described the program as life changing. This study is the first time that Veterans themselves have identified the ways in which VD-HCBS impacted their lives, uncovering the mechanisms underlying positive outcomes. These categories revealed new ways of understanding VD-HCBS as an innovative approach to meeting the person-centered needs of Veterans wishing to remain at home, while experiencing quality care and leading meaningful lives, areas identified as priorities for improving long term services and supports.

Preparedness of representatives for people with dementia in a self-directed program.

Representatives enact their role as decision-making partners across the intersection of participant direction (PD) and dementia care. Self-rated preparedness for key dimensions of the role endorsed by a panel of experts in PD and dementia was assessed by telephone survey of 30 representatives of persons with dementia in a PD program. The sample (daughters 60%; Black 50%; rural 70%) was diverse in length of time in the role and additional responsibilities. They represented participants with moderate to advanced dementia and ≥ two additional chronic illnesses. Overall preparedness scores were in the pretty well to very well prepared range, with variation across dimensions and between individuals. Preparedness varied according to what has to be done day-to-day in dynamic or unpredictable situations, gauging decisional capacity, anticipating changing needs, ensuring safety, supporting a dementia-capable care team and negotiation. Stress was related to having a safety net of capable back-up supports and dementia care literacy. Areas of strength, individual variation and particular challenges along the trajectory of representing can guide development of support counselor interventions to provide representatives with tailored training and resources as they enable the benefits of PD for persons with dementia.

"I'm just trying to cope for both of us": Challenges and supports of family caregivers in participant-directed programs.

Recently, national attention has focused on the needs of family caregivers providing complex chronic care, noting the necessity to better understand the scope of challenges they encounter. Although a robust body of literature exists about the scope of family caregiving, little is known specifically about the experiences and perspectives of family caregivers who support participant directed (PD) participants, particularly across the caregiving trajectory. Therefore, the aim of this qualitative descriptive study was to describe what family caregivers of individuals with developmental disabilities, physical disabilities, aging, or chronic health conditions identify as the challenges they experience as complex, and their perceptions of the effectiveness and gaps in family support resources in PD. Semi-structured interviews were audio-recorded with a purposive sample of caregivers. Transcribed interviews were analyzed using conventional content analysis. Fifty-four caregivers of individuals with a range of disabilities participated (age 34-78, M 59.9 ± 8.8; male 19%; spouse 17%, parent 61%). Six categories emerged from the analysis: contextualizing complexity, complexity in transitions, coping with complexity: advocacy & isolation, supportive support, unsupportive support, and systems challenges. Caregivers emphasized the interplay between unpredictability, transitions, and complexity and the interaction between the person receiving support, the caregiver's own situation, and the environment. Findings highlight the need, and provide a guide, for family assessment and for tailoring interventions matched to the profiles and self-identified challenges of families living with disability. Social workers can learn what families see as complex and what support broker behaviors families find helpful, and which not.

Long-Term Experiences in Cash and Counseling for Young Adults with Intellectual Disabilities: Familial Programme Representative Descriptions.

BACKGROUND: Our aim was to explore previously unknown long-term outcomes of self-directed personal care services for young adults with intellectual disabilities and limitations in activities of daily living. MATERIALS AND METHODS: The present authors utilized participatory action research and qualitative content analysis in interviewing 11 unpaid familial programme representatives of young adults with intellectual disabilities, ages 23-34, who were eligible for income-based Medicaid and enrolled five or more years in a Cash and Counseling-based programme of self-direction in the United States. RESULTS: Young adults are represented as receiving services and supports in a supportive and stable environment, with previously identified short-term programme benefits evident over the long-term. Young adults are also transitioning to adulthood at home with their families as primary social support and caregivers, bridging a service gap. CONCLUSIONS: Our results show that self-direction helps meet these young adults' personal care and community engagement needs over time.

"It just took the pressure off": The voices of Veterans' family caregivers in a participant-directed program.

The Veteran-Directed Home and Community Based Services Program (VD-HCBS) operates using a participant-direction approach, allowing Veterans to self-direct services. Only a small body of literature has explored the impact of these programs on caregivers. This study aimed to explore the experiences of caregivers in VD-HCBS. Telephone focus groups and interviews were conducted with caregivers (n = 23; 52.2% spouses; 8.7% male). Conventional content analysis revealed five categories: Coming home and staying home; Taking the pressure off; Providing security; Giving us time as a couple; and Importance of choice. Stories highlighted sources of stress and mechanisms behind stress relief and support.

Intraoperative Simulated Weightbearing Lateral Foot Imaging: The Clinical Utility and Ability to Predict Sagittal Plane Position of the First Ray in Lapidus Fusion.

The sagittal plane relationship of the first to second ray is a primary determinant of proper alignment in Lapidus midfoot fusion as assessed both clinically and on postoperative weightbearing lateral radiographs. The traditional approach to intraoperative fluoroscopic imaging allows for accurate assessment of fixation placement and intermetatarsal angle correction but only a crude evaluation of final sagittal plane alignment. Surgeons have used various methods in an attempt to load the foot during lateral imaging. This had led to inconsistent results and the potential for poor outcome. Skepticism exists regarding the ability of simulated weightbearing fluoroscopy to predict the final outcome, and evidence is lacking to support this practice. A prospective investigation was performed to assess the correlation of the first to second ray sagittal plane alignment as demonstrated on intraoperative simulated weightbearing lateral foot imaging studies and the 10-week postoperative lateral weightbearing radiograph. A consistent simulated weightbearing technique was used prospectively with 50 consecutive cases of Lapidus midfoot fusion with the goal of achieving parallel sagittal plane alignment of the first and second metatarsals with no divergence. Although 47 cases had no divergence and 3 had divergence with mild first ray elevatus, all 50 cases demonstrated a direct correlation between the intraoperative simulated and postoperative full weightbearing images. In conclusion, we believe the findings from our intraoperative imaging technique are a reliable predictor of first ray sagittal plane alignment in Lapidus midfoot fusion.

Incidence and Clinical Significance of Heterotopic Ossification After Partial Ray Resection.

Heterotopic bone growth is a common finding after partial foot amputation that can predispose to recurrent wounds, osteomyelitis, and reamputation. Heterotopic ossification is the formation of excessive mature lamellar bone in the soft tissues adjacent to bone that is exacerbated by trauma or surgical intervention. The relevance of heterotopic ossification is dependent on its anatomic location. Its occurrence as a sequela of partial foot amputation can lead to prominence on the plantar aspect of the foot that can predispose the patient to recurrent neuropathic ulceration or preclude appropriate wound healing. Reulceration puts the high-risk patient who has already undergone local amputation at greater risk of recurrent infection and further amputation. The present study aimed to assess the incidence and risk factors for heterotopic ossification to further evaluate its role in partial foot amputation. A retrospective analysis of 72 consecutive patients who had undergone partial metatarsal resection was performed, with 90% of the cohort having peripheral neuropathy and 88% diabetes mellitus. Our findings revealed a heterotopic ossification incidence of 75% diagnosed radiographically. The initial onset of heterotopic ossification was not appreciated >10 weeks postoperatively. Ten patients (18.5%) exhibited heterotopic ossification-associated ulceration. The incidence of heterotopic ossification was 30% less in patients with peripheral vascular disease. These results indicate that heterotopic ossification is a common sequela of partial ray resection in an already high-risk patient population. The perioperative use of pharmacologic or radiation prophylaxis in an attempt to minimize amputation-related morbidity should be considered.

The Long-Term Effects of Participant Direction of Supports and Services for People With Disabilities.

Numerous studies have demonstrated the short-term effectiveness of the Cash and Counseling model option of participant-directed home and community-based personal care service programs for Medicaideligible recipients with disabilities requiring long-term care. However, long-term experiences with participant-directed services have yet to be examined for these individuals. We addressed this gap in the literature through participatory action research and qualitative content analysis. Working together as coresearchers with members of the National Participant Network, a peer organization for people interested in or enrolled in participant-directed services, we interviewed 17 adults enrolled in one state's Cash and Counseling-based program. Participants' ages ranged from 40 to 83 years, had been enrolled for at least 5 years, and acted as their own representative within the program. Our major findings show (a) the program's flexibility allowed for adaptation to meet participants' changing needs over time and (b) that program attendants helped connect participants with community in multiple ways. In this article, we provide important policy and practice implications for participant-directed programs for people with disabilities.