Factors Associated with Dissatisfaction in Medical Care Quality among Older Medicare Beneficiaries Suffering from Mental Illness.

Approximately 25% of US older adults live with a mental health disorder. The mental health needs of this population are chiefly met by primary care providers. Primary care practices may have inadequate strategies to provide satisfactory care to mentally ill older adults. This study used Centers for Medicare and Medicaid Services data to identify factors, including racial/ethnic differences, associated with dissatisfaction with medical care quality among older adults diagnosed with a mental health disorder. Our findings suggest factors that can be addressed to improve satisfaction with medical care quality and potentially promote adherence and follow-up for mentally ill older adults.

Usability Evaluation of a Dashboard for Home Care Nurses.

The introduction of electronic health records has produced many challenges for clinicians. These include integrating technology into clinical workflow and fragmentation of relevant information across systems. Dashboards, which use visualized data to summarize key patient information, have the potential to address these issues. In this article, we outline a usability evaluation of a dashboard designed for home care nurses. An iterative design process was used, which consisted of (1) contextual inquiry (observation and interviews) with two home care nurses; (2) rapid feedback on paper prototypes of the dashboard (10 nurses); and (3) usability evaluation of the final dashboard prototype (20 nurses). Usability methods and assessments included observation of nurses interacting with the dashboard, the system usability scale, and the Questionnaire for User Interaction Satisfaction short form. The dashboard prototype was deemed to have high usability (mean system usability scale, 73.2 [SD, 18.8]) and was positively evaluated by nurse users. It is important to ensure that technology solutions such as the one proposed in this article are designed with clinical users in mind, to meet their information needs. The design elements of the dashboard outlined in this article could be translated to other electronic health records used in home care settings.

A multi-level usability evaluation of mobile health applications: A case study.

OBJECTIVE: To report a methodological approach for the development of a usable mHealth application (app). MATERIALS AND METHODS: This work was guided by a 3-level stratified view of health information technology (IT) usability evaluation framework. We first describe a number of methodologies for operationalizing each level of the framework. Following the description of each methodology, we present a case study which illustrates the use of our preferred methodologies for the development of a mHealth app. At level 1 (user-task), we applied a card sorting technique to guide the information architecture of a mobile HIV symptom self-management app, entitled mVIP. At level 2 (user-task-system), we conducted a usability evaluation of mVIP in a laboratory setting through end-user usability testing and heuristic evaluation with informatics experts. At level 3 (user-task-system-environment), usability of mVIP was evaluated in a real-world setting following the use of the app during a 3-month trial. RESULTS: The 3-level usability evaluation guided our work exploring in-depth interactions between the user, task, system, and environment. Integral to the findings from the 3-level usability evaluation, we iteratively refined the app's content, functionality, and interface to meet the needs of our intended end-users. DISCUSSION AND CONCLUSION: The stratified view of the health IT usability evaluation framework is a useful methodological approach for the design, development, and evaluation of mHealth apps. The methodological recommendations for using the theoretical framework can inform future usability studies of mHealth apps.

Relationships Among DNP and PhD Students After Implementing a Doctoral Student Organization.

BACKGROUND: Early career contact, between clinically focused DNP and research-focused PhD nursing students, may encourage desirable intradisciplinary synergies. AIM: The aim of the study was to assess relationships among DNP and PhD nursing students after initiating a doctoral student organization. METHOD: An online survey assessed student interaction pre- and post-doctoral student organization implementation. Analysis consisted of paired t-test, social network analysis, and content analysis methods. RESULTS: Response rates were 72 percent (n = 86) and 60 percent (n = 72) before and after implementation. Network density and centralization increased by 17 percent and 3 percent, respectively; intradisciplinary ties increased by 39 percent. The average student had approximately two new relationships; clique membership increased by 60 percent. Narrative responses corroborated network measurements. CONCLUSION: We documented additional integration and organized communication among students after this strategy to increase collaboration. Educators preparing nurses to work across research and practice may consider network analysis methods to evaluate their efforts.

The Public Health Workforce Taxonomy: Revisions and Recommendations for Implementation.

Public health workforce size and composition have been difficult to accurately determine because of the wide variety of methods used to define job title terms, occupational categories, and worker characteristics. In 2014, a preliminary consensus-based public health workforce taxonomy was published to standardize the manner in which workforce data are collected and analyzed by outlining uniform categories and terms. We summarize development of the taxonomy's 2017 iteration and provide guidelines for its implementation in public health workforce development efforts. To validate its utility, the 2014 taxonomy was pilot tested through quantitative and qualitative methods to determine whether further refinements were necessary. Pilot test findings were synthesized, themed by axis, and presented for review to an 11-member working group drawn from the community of experts in public health workforce development who refined the taxonomy content and structure through a consensus process. The 2017 public health workforce taxonomy consists of 287 specific classifications organized along 12 axes, intended for producing standardized descriptions of the public health workforce. The revised taxonomy provides enhanced clarity and inclusiveness for workforce characterization and will aid public health workforce researchers and workforce planning decision makers in gathering comparable, standardized data to accurately describe the public health workforce.

An Efficient Nurse Practitioner-Led Community-Based Service Model for Delivering Coordinated Care to Persons With Serious Mental Illness at Risk for Homelessness [Formula: see text].

BACKGROUND: Access to mental health care is a struggle for those with serious mental illness (SMI). About 25% of homeless suffer from SMI, compared with 4.2% of the general population. OBJECTIVE: From 2003 to 2012, St. Paul's Center (SPC) operated a unique model to provide quality care to the homeless and those at risk for homelessness, incarceration, and unnecessary hospitalization because of SMI. Data were available for analysis for the years 2008 to 2010. DESIGN: The SPC was developed, managed, and staffed by board-certified psychiatric/mental health nurse practitioners, offering comprehensive mental health services and coordinated interventions. RESULTS: All clients were housed and none incarcerated. From 2008 to 2010, only 3% of clients were hospitalized, compared with 7.5% of adults with SMI. Clinical, academic, and community partnerships increased value, but Medicaid reimbursement was not available. CONCLUSION: Mental health provisions in the recently passed 21st Century Cures Act support community mental health specialty treatment. The SPC provides a template for similar nurse practitioner-led models.

Self-reported Preparedness to Respond to Mass Fatality Incidents in 38 State Health Departments.

CONTEXT: Public health departments play an important role in the preparation and response to mass fatality incidents (MFIs). OBJECTIVE: To describe MFI response capabilities of US state health departments. DESIGN: The data are part of a multisector cross-sectional study aimed at 5 sectors that comprise the US mass fatality infrastructure. Data were collected over a 6-week period via a self-administered, anonymous Web-based survey. SETTING: In 2014, a link to the survey was distributed via e-mail to health departments in 50 states and the District of Columbia. PARTICIPANTS: State health department representatives responsible for their state's MFI plans. MEASURES: Preparedness was assessed using 3 newly developed metrics: organizational capabilities (n = 19 items); operational capabilities (n = 19 items); and resource-sharing capabilities (n = 13 items). RESULTS: Response rate was 75% (n = 38). Among 38 responses, 37 rated their workplace moderately or well prepared; 45% reported MFI training, but only 30% reported training on MFI with hazardous contaminants; 58% estimated high levels of staff willingness to respond, but that dropped to 40% if MFIs involved hazardous contaminants; and 84% reported a need for more training. On average, 76% of operational capabilities were present. Resource sharing was most prevalent with state Office of Emergency Management but less evident with faith-based organizations and agencies within the medical examiner sector. CONCLUSION: Overall response capability was adequate, with gaps found in capabilities where public health shares responsibility with other sectors. Collaborative training with other sectors is critical to ensure optimal response to future MFIs, but recent funding cuts in public health preparedness may adversely impact this critical preparedness element. In order for the sector to effectively meet its public health MFI responsibilities as delineated in the National Response Framework, resources to support training and other elements of preparedness must be maintained.

Assuring a strong foundation for our nation's public health systems.

BACKGROUND: A strong public health infrastructure is necessary to assure that every community is capable of carrying out core public health functions (assessment of population health, assurance of accessible and equitable health resources, and development of policies to address population health) to create healthy conditions. Yet, due to budget cuts and inconsistent approaches to base funding, communities are losing critical prevention and health promotion services and staff that deliver them. PURPOSE: This article describes key components of and current threats to our public health infrastructure and suggests actions necessary to strengthen public health systems and improve population health. DISCUSSION: National nursing and public health organizations have a duty to advocate for policies supporting strong prevention systems, which are crucial for well-functioning health care systems and are fundamental goals of the nursing profession. CONCLUSION: We propose strengthening alliances between nursing organizations and public health systems to assure that promises of a reformed health system are achieved.

Innovative use of the integrative review to evaluate evidence of technology transformation in healthcare.

Healthcare is in a period significant transformational activity through the accelerated adoption of healthcare technologies, new reimbursement systems that emphasize shared savings and care coordination, and the common place use of mobile technologies by patients, providers, and others. The complexity of healthcare creates barriers to transformational activity and has the potential to inhibit the desired paths toward change envisioned by policymakers. Methods for understanding how change is occurring within this complex environment are important to the evaluation of delivery system reform and the role of technology in healthcare transformation. This study examines the use on an integrative review methodology to evaluate the healthcare literature for evidence of technology transformation in healthcare. The methodology integrates the evaluation of a broad set of literature with an established evaluative framework to develop a more complete understanding of a particular topic. We applied this methodology and the framework of punctuated equilibrium (PEq) to the analysis of the healthcare literature from 2004 to 2012 for evidence of technology transformation, a time during which technology was at the forefront of healthcare policy. The analysis demonstrated that the established PEq framework applied to the literature showed considerable potential for evaluating the progress of policies that encourage healthcare transformation. Significant inhibitors to change were identified through the integrative review and categorized into ten themes that describe the resistant structure of healthcare delivery: variations in the environment; market complexity; regulations; flawed risks and rewards; change theories; barriers; ethical considerations; competition and sustainability; environmental elements, and internal elements. We hypothesize that the resistant nature of the healthcare system described by this study creates barriers to the direct consumer involvement and engagement necessary for transformational change. Future policies should be directed at removing these barriers by demanding and emphasizing open technologies and unrestricted access to data versus as currently prescribed by technology vendors, practitioners, and policies that perpetuate market equilibrium.

Associating co-authorship patterns with publications in high-impact journals.

OBJECTIVES: To develop a method for investigating co-authorship patterns and author team characteristics associated with the publications in high-impact journals through the integration of public MEDLINE data and institutional scientific profile data. METHODS: For all current researchers at Columbia University Medical Center, we extracted their publications from MEDLINE authored between years 2007 and 2011 and associated journal impact factors, along with author academic ranks and departmental affiliations obtained from Columbia University Scientific Profiles (CUSP). Chi-square tests were performed on co-authorship patterns, with Bonferroni correction for multiple comparisons, to identify team composition characteristics associated with publication impact factors. We also developed co-authorship networks for the 25 most prolific departments between years 2002 and 2011 and counted the internal and external authors, inter-connectivity, and centrality of each department. RESULTS: Papers with at least one author from a basic science department are significantly more likely to appear in high-impact journals than papers authored by those from clinical departments alone. Inclusion of at least one professor on the author list is strongly associated with publication in high-impact journals, as is inclusion of at least one research scientist. Departmental and disciplinary differences in the ratios of within- to outside-department collaboration and overall network cohesion are also observed. CONCLUSIONS: Enrichment of co-authorship patterns with author scientific profiles helps uncover associations between author team characteristics and appearance in high-impact journals. These results may offer implications for mentoring junior biomedical researchers to publish on high-impact journals, as well as for evaluating academic progress across disciplines in modern academic medical centers.

Mass fatality preparedness among medical examiners/coroners in the United States: a cross-sectional study.

BACKGROUND: In the United States (US), Medical Examiners and Coroners (ME/Cs) have the legal authority for the management of mass fatality incidents (MFI). Yet, preparedness and operational capabilities in this sector remain largely unknown. The purpose of this study was twofold; first, to identify appropriate measures of preparedness, and second, to assess preparedness levels and factors significantly associated with preparedness. METHODS: Three separate checklists were developed to measure different aspects of preparedness: MFI Plan Elements, Operational Capabilities, and Pre-existing Resource Networks. Using a cross-sectional study design, data on these and other variables of interest were collected in 2014 from a national convenience sample of ME/C using an internet-based, anonymous survey. Preparedness levels were determined and compared across Federal Regions and in relation to the number of Presidential Disaster Declarations, also by Federal Region. Bivariate logistic and multivariable models estimated the associations between organizational characteristics and relative preparedness. RESULTS: A large proportion (42%) of respondents reported that less than 25 additional fatalities over a 48-hour period would exceed their response capacities. The preparedness constructs measured three related, yet distinct, aspects of preparedness, with scores highly variable and generally suboptimal. Median scores for the three preparedness measures also varied across Federal Regions and as compared to the number of Presidential Declared Disasters, also by Federal Region. Capacity was especially limited for activating missing persons call centers, launching public communications, especially via social media, and identifying temporary interment sites. The provision of staff training was the only factor studied that was significantly (positively) associated (p < .05) with all three preparedness measures. Although ME/Cs ranked local partners, such as Offices of Emergency Management, first responders, and funeral homes, as the most important sources of assistance, a sizeable proportion (72%) expected federal assistance. CONCLUSIONS: The three measures of MFI preparedness allowed for a broad and comprehensive assessment of preparedness. In the future, these measures can serve as useful benchmarks or criteria for assessing ME/Cs preparedness. The study findings suggest multiple opportunities for improvement, including the development and implementation of national strategies to ensure uniform standards for MFI management across all jurisdictions.

The influence of management and environment on local health department organizational structure and adaptation: a longitudinal network analysis.

OBJECTIVE: The nation's 2862 local health departments (LHDs) are the primary means for assuring public health services for all populations. The objective of this study is to assess the effect of organizational network analysis on management decisions in LHDs and to demonstrate the technique's ability to detect organizational adaptation over time. DESIGN AND SETTING: We conducted a longitudinal network analysis in a full-service LHD with 113 employees serving about 187,000 persons. Network survey data were collected from employees at 3 times: months 0, 8, and 34. At time 1 the initial analysis was presented to LHD managers as an intervention with information on evidence-based management strategies to address the findings. At times 2 and 3 interviews documented managers' decision making and events in the task environment. RESULTS: Response rates for the 3 network analyses were 90%, 97%, and 83%. Postintervention (time 2) results showed beneficial changes in network measures of communication and integration. Screening and case identification increased for chlamydia and for gonorrhea. Outbreak mitigation was accelerated by cross-divisional teaming. Network measurements at time 3 showed LHD adaptation to H1N1 and budget constraints with increased centralization. Task redundancy increased dramatically after National Incident Management System training. CONCLUSIONS: Organizational network analysis supports LHD management with empirical evidence that can be translated into strategic decisions about communication, allocation of resources, and addressing knowledge gaps. Specific population health outcomes were traced directly to management decisions based on network evidence. The technique can help managers improve how LHDs function as organizations and contribute to our understanding of public health systems.

Using social network analysis to examine collaborative relationships among PhD and DNP students and faculty in a research-intensive university school of nursing.

The nursing profession has seen a dramatic rise in the number of schools offering both DNP and PhD nursing programs. Information is limited on the impact of this parallel approach in doctoral education on the quality and scope of scholarly interactions or institutional culture.The authors studied collaboration characteristics across the DNP and PhD programs of a research-intensive university school of nursing, before and after programmatic enhancements. An IRB-approved online survey was delivered to faculty and students of both programs at baseline and one year after curricular changes. Response rates were 70% and 74%, respectively. The responses were analyzed by using social network analysis and descriptive statistics to characterize the number and strength of connections between and within student groups, and between students and faculty. At baseline, the flow of communication was centralized primarily through faculty. At Time 2, density of links between students increased and network centralization decreased, suggesting more distributed communication. This nonlinear quantitative approach may be a useful addition to the evaluation strategies for doctoral education initiatives.

Topology of local health officials' advice networks: mind the gaps.

OBJECTIVE: To determine how a health officials' advice network might contribute to a high-performing public health systems by facilitating diffusion of innovation and best practices. DESIGN: A secondary analysis of cross-sectional data obtained from the National Association of County and City Health Officials 2010 Profile of local health departments (LHDs) using network analysis. SETTING: The Profile survey is distributed biannually to all 2565 LHDs in the United States. In 2010, it included a network question: "In thinking about your peers who lead other local health departments in the U.S., list the five LHDs whose leaders you communicate with most frequently about administrative, professional, and leadership issues in public health." PARTICIPANTS: The network question was answered only by the top executive. The subjects are 1522 health officials who answered the network question plus 477 named as contacts (n = 1999). MAIN OUTCOME MEASURES: Measurements to assess network topology were density, centralization, transitivity, and reciprocity. At the node level, average centrality, clustering, effective network size, and clique count were measured. The convergence of iterated correlations algorithm was used to detect subgroups. RESULTS: : A sparsely connected core periphery network exhibited minimal evidence of unified communication. Mutually connected small groups tend to clump within state boundaries suggesting gaps in information flow. The pattern persisted at the regional level with an average health official having an effective network of only 2 others. CONCLUSIONS: Communication between peers may not be the primary way professional information diffuses among local health officials. National groups involved in performance improvement may wish to consider strategies to increase the diffusion of best practices and innovations through this network.

Clinical and Demographic Profiles of Home Care Patients With Alzheimer's Disease and Related Dementias: Implications for Information Transfer Across Care Settings.

Home health care (HHC) clinicians serving individuals with Alzheimer's disease and related dementias (ADRD) do not always have information about the person's ADRD diagnosis, which may be used to improve the HHC plan of care. This retrospective cohort study examined characteristics of 56,652 HHC patients with varied documentation of ADRD diagnoses. Data included clinical assessments and Medicare claims for a 6-month look-back period and 4-year follow-up. Nearly half the sample had an ADRD diagnosis observed in the claims either prior to or following the HHC admission. Among those with a prior diagnosis, 63% did not have it documented on the HHC assessment; the diagnosis may not have been known to the HHC team or incorporated into the care plan. Patients with ADRD had heightened risk for adverse outcomes (e.g., urinary tract infection and aspiration pneumonia). Interoperable data across health care settings should include ADRD-specific elements about diagnoses, symptoms, and risk factors.

A comparative study of 11 local health department organizational networks.

CONTEXT: Although the nation's local health departments (LHDs) share a common mission, variability in administrative structures is a barrier to identifying common, optimal management strategies. There is a gap in understanding what unifying features LHDs share as organizations that could be leveraged systematically for achieving high performance. OBJECTIVE: To explore sources of commonality and variability in a range of LHDs by comparing intraorganizational networks. INTERVENTION: We used organizational network analysis to document relationships between employees, tasks, knowledge, and resources within LHDs, which may exist regardless of formal administrative structure. SETTING: A national sample of 11 LHDs from seven states that differed in size, geographic location, and governance. PARTICIPANTS: Relational network data were collected via an on-line survey of all employees in 11 LHDs. A total of 1062 out of 1239 employees responded (84% response rate). OUTCOME MEASURES: Network measurements were compared using coefficient of variation. Measurements were correlated with scores from the National Public Health Performance Assessment and with LHD demographics. Rankings of tasks, knowledge, and resources were correlated across pairs of LHDs. RESULTS: We found that 11 LHDs exhibited compound organizational structures in which centralized hierarchies were coupled with distributed networks at the point of service. Local health departments were distinguished from random networks by a pattern of high centralization and clustering. Network measurements were positively associated with performance for 3 of 10 essential services (r > 0.65). Patterns in the measurements suggest how LHDs adapt to the population served. CONCLUSIONS: Shared network patterns across LHDs suggest where common organizational management strategies are feasible. This evidence supports national efforts to promote uniform standards for service delivery to diverse populations.

Modernizing state public health enabling statutes to reflect the mission and essential services of public health.

It is unclear whether efforts of the past decade to modernize state public health statutes have succeeded in codifying into state law the currently understood mission and essential services of public health. Although many state health agencies may be operating in a manner consistent with these principles, their codification in state law is crucial for the sustainability of agency efforts in disease prevention and health promotion. This research examines the 50 state public health enabling statutes for their correspondence with the 6 mission statements and the 10 essential services of public health described in Public Health in America. This analysis finds that modernization efforts have not been universally effective in ensuring that the legislative basis of public health is commensurate with the accepted scope of authority necessary to support health agency performance. Given current imperatives for law modernization in public health, this analysis highlights the importance of model statutory language in facilitating the codification of the mission and essential services of public health in state law. As a result, this research provides the practice community with a research base to facilitate statutory reform and develops a framework for future scholarship on the role of law as a determinant of the public's health.

Examination of the relationship between public health statute modernization and local public health system performance.

OBJECTIVES: Wide variation in performance of public health (PH) systems, coupled with national interest in improving PH system quality, makes it a priority to identify factors associated with performance. One factor may be congruence between a state's PH enabling statutes and the obligations outlined in Public Health in America-the collaboratively developed framework that defines the mission and essential services (ESs) of PH. SUBJECTS: This research examined the relationship between (1) the degree to which language in a state's PH enabling statutes reflects PH's mission and ESs and (2) the performance of local public health systems in delivering ESs, measured by National Public Health Performance Standards scores in 207 local jurisdictions. METHODS: Binary logistic regression demonstrated that a high degree of congruence between statutory language and public health's mission increased the odds of above-average system performance for 5 of 10 ESs. RESULTS: High levels of congruence between statutory language and the ESs themselves increased odds of above-average system performance for 6 of 10 ESs. Results yielded modest odds ratios (<2.0). CONCLUSIONS: Limitations of the data make it impossible to draw firm conclusions; however, these modest results suggest that statutory language may account for little of the variation in local public health system performance.

Advocating for HIT That Captures Nursing Process.

Nurses can influence choices about EHR systems and their design.