Patterns and trends in local health departments' efforts to promote access to care in local communities throughout the United States: The contributions of governance structures.

Public health agencies like local health departments (LHDs) play an important role in addressing healthcare access disparities and service delivery gaps in local communities throughout the United States. Previous research has provided important snapshots into specific access issues confronted by LHDs; however, the literature lacks a more comprehensive view of LHDs' efforts to ensure broad access to care, how these have evolved over time more recently, and whether certain types of LHDs governance structures are more likely to engage in activities to ensure access to care. The purpose of this study was to address these gaps in the literature by exploring the prevalence of different activities to ensure access to care, describing how the prevalence of these activities have evolved over time, and examining whether the prevalence of these activities varied as a function of different governance structures. Using pooled, cross-sectional survey data from four waves of a survey (2009, 2013, 2016, 2019) of LHDs in the United States, the univariate and bivariate analysis revealed that, over time, LHDs have generally increased their efforts to assess gaps in access to healthcare services and across all healthcare categories (i.e., medical, dental, behavioural health) but especially for behavioural health. Poisson regression models showed that LHDs with a more decentralised decision-making structure were associated with more activities to ensure access to care, as compared to more centralised structures. Collectively, our findings indicate that despite growth in the number and percentage of LHDs assessing and addressing gaps in services, opportunities still exist to enhance access to healthcare services in local communities, particularly in the areas of dental and behavioural health. Our findings also suggest that stakeholders interested in improving LHDs' efforts to ensure access to care in local communities may want to pay close attention to governance features of LHDs.

Association between the number of adopted implementation strategies and contextual determinants: a mixed-methods study.

BACKGROUND: The successful implementation of evidence-based innovations to improve healthcare delivery often requires a well-planned strategy to support their use. With a greater recognition of the importance of an implementation process, researchers have turned their attention to implementation strategies and their customization to target specific organizational barriers and facilitators. Further, there is a paucity of empirical evidence demonstrating the link between implementation determinants and the number of selected implementation strategies. The purpose of this mixed methods analysis is to examine how formatively assessed barriers and facilitators to implementation relate to the number and type of implementation strategies adopted to address context-specific factors. METHODS: A mixed methods evaluation that included 15 rheumatology clinics throughout the United States that were planning for implementation of an evidence-based shared decision-making aid for patients with lupus. Quantitative data consisted of a count of the number of implementation strategies used by a clinic. Qualitative data collection was guided by the Consolidated Framework for Implementation Research (CFIR) and relied upon semi-structured interviews with 90 clinic members between November 2018 and August 2019. RESULTS: Using the CFIR, we found that local clinic factors (Inner Setting Domain) resulted in different perceptions about Planning and Executing the DA (Process Domain); these domains were most likely to distinguish between the number and type of implementation strategies adopted by the clinics. In contrast, Intervention characteristics, Individual Characteristics, and the Outer Setting did not differentiate between the groups with different numbers of implementation strategies. The number and type of chosen strategies were not those associated with the context-specific factors. CONCLUSIONS: Findings show that, despite recognition of the value of customizing implementation strategies for the contexts in which they are applied, they are too often chosen in a manner that fail to adequately reflect the diverse settings that may present unique factors associated with implementation. Our findings also highlight the importance of the inner context - both in terms of structural characteristics and existing work processes - as a driving factor for why some organizations select different numbers and types of implementation strategies.

Community social capital or health needs: What is driving hospital-community partnerships to address social determinants of health?

Social determinants of health (SDOH) are strongly linked to individual and population health outcomes. Hospitals and health systems are in a unique position to initiate or partner on community-wide efforts address SDOH. However, such efforts typically require collaboration with other healthcare and local community organizations since SDOH affect more than just medical care. Despite studies that have identified specific organizational and environmental factors associated with hospital-community partnerships, the role of social capital and community health needs as drivers of such partnerships remains unexplored. This study examines whether hospital partnerships with community organizations in the United States are driven predominantly by community social capital or the prevailing health needs of the community, and whether these drivers are similar for overall partnerships as well as for partnerships with individual organizations. We use 2020 data from the American Hospital Association, US County Health Rankings, and Social Capital Project and employ ordinary least-squares (OLS) regression and logit models to assess the relationship between social capital, community health needs and hospital-community partnerships to address SDOH. Our results indicate that for community social capital was significantly and positively associated with total hospital partnerships (ß = 0.05, p = 0.01). We also found that community social capital was significantly more likely to be associated with hospitals' partnerships with local/state public health agencies, schools, law enforcement agencies, other healthcare providers, and organizations that assist with food insecurity. On the other hand, community health needs were not associated with total partnerships and had limited associations with hospital partnerships with individual organizations. Overall, this research suggests that social capital is a critical determinant of hospital partnerships with community organizations, and hospitals may seek partnerships with organizations that allow them to address community health issues outside of their own expertise since such partnerships and collaborative efforts can help address SDOH and manage population health.

Service Profiles in Substance Use Disorder Treatment: Are Treatment Facilities Consistent In Service Mix and Service Offerings?

OBJECTIVE: Substance use disorder (SUD) treatment facilities are the specialty treatment settings for individuals with SUDs and offer a variety of services for their treatment and long-term management. Despite the recommendations from evidence-based practice guidelines, individual facilities differ in terms of the number and type of services offered, resulting in gaps in service availability. The purpose of this study was to examine whether systematic differences exist among SUD treatment facilities based on the facility's service mix. METHOD: Publicly available data on SUD treatment facilities within the United States were obtained from the National Survey of Substance Abuse Treatment Services (N-SSATS) for 2015-2018. Latent class analysis was used to identify the presence of different service profiles (i.e., classes of facilities) based on service mix and bivariate analysis to determine organizational characteristics associated with each profile. RESULTS: SUD treatment facilities systematically differ in service mix, and we identified three distinct service profiles--broad, high-prevalence; narrow, nonmedical; and broad, intermediate-prevalence. The distribution of facilities across the three profiles varied considerably, with a majority (90%) of facilities belonging to the broad, high-prevalence service profile, whereas 9.5% belonged to the narrow, nonmedical profile and the remainder (<1% of all facilities) to the broad, intermediate-prevalence service profile. CONCLUSIONS: The three service profiles and the distribution of facilities within each profile identified in this study highlight challenges and opportunities for practitioners and policymakers. The findings also suggest several avenues for future research in the area of policy, organizational strategy, and service delivery within SUD treatment.

Estimating the differences in Caesarean section (C-section) rates between public and privately insured mothers in Florida: A decomposition approach.

BACKGROUND: Caesarean section (C-sections) is a medically critical and often life-saving procedure for prevention of childbirth complications. However, there are reports of its overuse, especially in women covered by private insurance as compared to public insurance. This study evaluates the difference in C-Section rates among nulliparous women in Florida hospitals across insurance groups and quantifies the contribution of maternal and hospital factors in explaining the difference in rates. METHODS: We used Florida's inpatient data provided by the Florida Agency for HealthCare Administration (FLAHCA) and focused on low-risk births that occurred between January 1, 2010, and September 30, 2015. A Fairlie decomposition method was performed on cross-sectional data to decompose the difference in C-Section rates between insurance groups into the proportion explained versus unexplained by the differences in observable maternal and hospital factors. RESULTS: Of the 386,612 NTSV low-risk births, 72,984 were delivered via C-Section (18.87%). Higher prevalence of C-section at maternal level was associated with diabetes, hypertension, and the expectant mother being over 35 years old. Higher prevalence of C-section at the hospital level was associated with lower occupancy rate, presence of neonatal ICU (NICU) unit and higher obstetrics care level in the hospital. Private insurance coverage in expectant mothers is associated with C-section rates that were 4.4 percentage points higher as compared to that of public insurance. Just over 33.7% of the 4.4 percentage point difference in C-section rates between the two insurance groups can be accounted for by maternal and hospital factors. CONCLUSIONS: The study identifies that the prevalence of C-sections in expectant mothers covered by private insurance is higher compared to mothers covered by public insurance. Although, majority of the difference in C-Section rates across insurance groups remains unexplained (around 66.3%), the main contributor that explains the other 33.7% is advancing maternal age and socioeconomic status of the expectant mother. Further investigation to explore additional factors that explain the difference needs to be done if United States wants to target specific policies to lower overall C-Section rate.

Generation and Use of Evidence by Local Health Departments: The Role of Leader Attributes.

OBJECTIVE: The purpose of this study was to examine whether certain types of leaders were associated with the degree to which local health departments (LHDs) generate and use evidence to inform their service offering. DESIGN: Pooled, cross-sectional analysis using 4 waves (2010, 2013, 2016, and 2019) of the National Profiles of Local Health Departments sponsored by the National Association of County and City Health Officials (NACCHO). Univariate analysis was used to assess the extent to which LHDs were generating and using evidence to improve the health of their local communities and whether this changed over time. Multinomial logistic regression models were used to examine the relationships between LHD leader attributes and the extent to which LHDs were generating and using evidence. PARTICIPANTS: Between 1496 and 2087 (varied by survey round) LHDs from throughout the United States. MAIN OUTCOME MEASURES: Two outcome variables pertaining to the generation of evidence: (1) how recently an LHD completed a community health assessment and (2) how recently an LHD completed a community health improvement plan. A third outcome variable reflected how extensively an LHD used the Community Guide, a compendium of evidence-based findings. RESULTS: In 2010, 25.1% and 41.4% of all LHDs had not completed a community health assessment or a community health improvement plan, respectively; by 2019, those figures declined significantly to 14.6% and 24.7%. Similarly, in 2010, 61.7% of all LHDs were not using the Community Guide; by 2019, that percentage declined significantly to 42.5%. Multivariable analysis revealed that leader experience was a more robust correlate of evidence generation and use by LHDs than leader education. CONCLUSIONS: While LHDs' generation and use of evidence have grown over the past decade, there is room for improvement. Local health department leader attributes-education and experience-highlight targeted opportunities to fill gaps in the use of evidence-based public health practices.

Organizational context and the learning and change readiness climate for implementing an evidence-based shared decision-making aid in US rheumatology clinics.

PURPOSE: The purpose of this study was to examine the organizational context that may support learning and change readiness climates that previous research has found to be conducive to implementing evidence-based interventions. DESIGN/METHODOLOGY/APPROACH: An exploratory, mixed method evaluation that included 15 rheumatology clinics throughout the United States was performed. Quantitative data were collected using a web-based survey completed by 135 clinic members. Qualitative data were collected via semi-structured interviews with 88 clinic members. FINDINGS: In general, clinics reported strong, positive learning and change readiness climates. More complex organizations (e.g. multispecialty, academic medical centers) with rational/hierarchical cultures and members with longer tenure were associated with less supportive learning and change readiness climates. The authors' findings highlight opportunities for organizational leaders and evidence-based intervention sponsors to focus their attention and allocate resources to settings that may be most susceptible to implementation challenges. ORIGINALITY/VALUE: First, the authors address a deficit in previous research by describing both the level and strength of the learning and change readiness climates for implementing an evidence-based shared decision-making aid (SDMA) and examine how these vary as a function of the organizational context. Second, the study examines a broader set of factors to assess the organizational context (e.g. organizational culture, organizational structure, ownership) than previous research, which may be especially salient for shaping the climate in smaller specialty clinics like those we study. Third, the authors utilize a mixed methods analysis to provide greater insights into questions of how and why organizational factors such as size and structure may influence the learning and change readiness climate.

Perspectives on life following a traumatic spinal cord injury.

BACKGROUND: Persons living with traumatic Spinal Cord Injury (SCI) face challenges when returning to their communities. The Spain Rehabilitation Center at the University of Alabama at Birmingham is developing a continuum of care for SCI patients. The perspectives of individuals with SCI are critical to designing a person-centered approach to the continuum. OBJECTIVE: This study sought to explore the lived experiences of individuals with SCI after their injury, as well as obtain the perspectives of therapists working with SCI patients. METHODS: Ten persons ranging in age from 23 to 65 years old and living with SCI were recruited to participate in in-depth interviews. We utilized a grounded theory approach to develop descriptive codes and themes. RESULTS: Our analysis highlighted domains that are critical to the lives of individuals with SCI including: planning for life after SCI, intrinsic motivation, environmental barriers, financial barriers, role of family, friends, and social networks, and relationships with medical providers. A key theme was the need for more information about how to manage their health condition, including the development of plans that are tailored to their specific needs. CONCLUSIONS: Individuals with an SCI need access to a continuum of care that addresses both medical and social needs.

Burnout and Leadership Style in Behavioral Health Care: a Literature Review.

Burnout among behavioral health care providers and employees is associated with poor patient and provider outcomes. Leadership style has generally been identified as a means of reducing burnout, yet it is unclear whether some leadership styles are more effective than others at mitigating burnout. Additionally, behavioral health care is provided in a variety of contexts and a leadership style employed in one context may not be effective in another. The purpose of this paper was to review the literature on leadership style and burnout in behavioral health care contexts to identify the different leadership styles and contexts in which the relationship between the two constructs was studied. Studies were categorized based on the leadership style, study design, research methods, and study context. Findings of this review provide insights into potential approaches to prevent employee burnout and its attending costs, as well as ways to improve future research in this critical area.