Provision of chaplaincy services in U.S. hospitals: A strategic conformity perspective.

BACKGROUND: Increasingly, hospitals are expected to provide patient-centered care that attends to patients' health needs, including spiritual care needs. Chaplaincy services help to meet patients' spiritual care needs, which have been shown to have a positive impact on health outcomes. Variation in the provision of chaplaincy services suggests hospitals do not uniformly conform to the expectation of making chaplaincy services available. PURPOSE: The aim of this study was to examine the availability and factors that influence hospitals' provision of chaplaincy services. METHODOLOGY: Data were combined from the American Hospital Association annual surveys with the Area Health Resource File at the county level from 2010 to 2019. Observations on general, acute-care community hospitals were analyzed (45,384 hospital-year observations) using logistic regression that clustered standard errors at the hospital level. RESULTS: Hospitals with Joint Commission accreditation, more staffed beds, nonprofit and government ownership, teaching status, one or more intensive care units, a higher percentage of Medicare inpatient days, church affiliation, and system membership were more likely to provide chaplaincy services than their counterparts. Certification as a trauma hospital and market competition showed no influence on the provision of chaplaincy services. CONCLUSION: The lack of chaplaincy services in many hospitals may be due to limited resources, workforce shortage, or a lack of consensus on scope and nature of chaplaincy services. PRACTICE IMPLICATIONS: Chaplaincy services are an underutilized resource that influences patient experience, clinician burnout and turnover, and the goal of ensuring care is patient-centered. Administrators should consider stronger partnerships where services are provided; researchers and policymakers should consider how the lack of these services in some hospitals may reinforce existing health disparities.

Examining Factors Associated with Utilization of Chaplains in the Acute Care Setting.

Hospitalized persons want their spiritual needs addressed and discussed by the healthcare team, but medical providers and nurses lack the necessary training. Patients want chaplaincy care, but very few receive it, and little is known about utilization factors. To identify the population characteristics associated with the utilization of chaplaincy services, hospitalization data from March 2012 to July 2017 were analyzed (N = 15,242 patients). Religiously affiliated individuals and those with the most acute health needs were more likely to receive chaplaincy care and received more total care. Patient-centered healthcare models may need to evaluate strategic integration of spiritual care beyond reactive spiritual care provision.

U.S. Health Care Expenditure Across Income Groups by Age and Type of Care.

Health care expenditure (HCE) does not significantly vary by income in the U.S. However, health outcomes vary significantly by income. To understand the disconnection, we used the Medical Expenditure Panel Survey (MEPS) data and adjusted HCE for utilization and stratified it by income and age. We showed that the adjusted HCE is significantly higher among lower-income Americans, especially at older ages. At age 45-64, for example, the adjusted HCE for the poor, low-income, and high-income were $10,552; $7,118; and $5,300 in 2015 prices, respectively. We also found that children from lower-income families receive less nonurgent, preventive care than those from higher-income families. However, adults from lower-income families use much more urgent care than those from higher-income families. Our results, alongside the evidence of continuously widening gaps in mortality and morbidity rates among income groups, raise policy-relevant questions about the optimal age profile of health care provision, particularly among lower-income groups.

Organizational factors affecting successful physician-system integration: A qualitative study of Washington State health executives.

BACKGROUND: Health care delivery is moving toward a value-based environment, which calls for increased integration between physician groups and health systems. Health executives sit at a key nexus point for determining how and when physician-system integration occurs. PURPOSE: The objective of this study was to identify the organizational factors that health executives perceived to have made physician-system integration successful. METHODOLOGY/APPROACH: We used a multiple-case study research design. We conducted semistructured, qualitative interviews with 25 health executives in the roles of CEO, chief medical officer, chief financial officer and physician group chief executives from eight of Washington State's largest integrated delivery systems. To guide our analysis, we employed open systems theory and Porter's Value Chain to identify physician group and hospital factors that were integral to successful integration. RESULTS: Using the executives' perspectives, the factors grouped into three themes: (1) organizational structure-a mix of integration contracts united by common structural characteristics between physician groups and hospitals); (2) organizational culture-alignment of leadership between physician groups and hospitals; and (3) strategic resources-designated resources to establish and support care coordination activities. CONCLUSION: Our work indicates that health systems should focus on the pathway to integration success through the alignment of structure (not just the integration contract), culture, and resources and not on an end goal of the physician employment model. PRACTICE IMPLICATIONS: Health system executives are key drivers for when and how physician groups are integrated into health services organizations. This article provides executives with an evidence-based model to aid in formulating integration approaches that combine elements of organizational structure, organizational culture, and strategic resources.

The Contribution of Physician-System Integrating Structure to Select Health System Outcomes.

Physician groups are increasingly being vertically integrated with hospitals and health systems; yet, the evidence on the impact of physician-system integration on health system outcomes is mixed. The objective of this study was to examine the impact of increased physician-system integration on select health system outcomes. We used a mixed-methods approach: (1) a fixed-effects multivariate mediation analysis; and (2) a qualitative analysis of interviews with health executives (n = 25). Our findings showed that hospitals spent $633 375.22 to $827 110.24 for each "level" increase in integration. This relationship was attenuated, however, by the presence of care coordination mechanisms.

Organizational capacity for change in health care: Development and validation of a scale.

BACKGROUND: We do not have a strong understanding of a health care organization's capacity for attempting and completing multiple and sometimes competing change initiatives. Capacity for change implementation is a critical success factor as the health care industry is faced with ongoing demands for change and transformation because of technological advances, market forces, and regulatory environment. PURPOSE: The aim of this study was to develop and validate a tool to measure health care organizations' capacity to change by building upon previous conceptualizations of absorptive capacity and organizational readiness for change. METHODOLOGY/APPROACH: A multistep process was used to develop the organizational capacity for change survey. The survey was sent to two populations requesting answers to questions about the organization's leadership, culture, and technologies in use throughout the organization. Exploratory and confirmatory factor analyses were conducted to validate the survey as a measurement tool for organizational capacity for change in the health care setting. FINDINGS: The resulting organizational capacity for change measurement tool proves to be a valid and reliable method of evaluating a hospital's capacity for change through the measurement of the population's perceptions related to leadership, culture, and organizational technologies. PRACTICAL IMPLICATIONS: The organizational capacity for change measurement tool can help health care managers and leaders evaluate the capacity of employees, departments, and teams for change before large-scale implementation.

Mental Illness and Mental Healthcare Receipt among Hospitalized Veterans with Serious Physical Illnesses.

BACKGROUND: Psychosocial distress among patients with limited life expectancy influences treatment decisions, treatment adherence, and physical health. Veterans may be at elevated risk of psychosocial distress at the end of life, and understanding their mental healthcare needs may help identify hospitalized patients to whom psychiatric services should be targeted. OBJECTIVE: To examine mental illness prevalence and mental health treatment rates among a national sample of hospitalized veterans with serious physical illnesses. Design, Subjects, and Measurements: This was a retrospective study of 11,286 veterans hospitalized in a Veterans Health Administration acute care facility in fiscal year 2011 with diagnoses of advanced cancer, congestive heart failure, chronic obstructive pulmonary disease, and/or advanced HIV/AIDS. Prevalent and incident mental illness diagnoses during and before hospitalization and rates of psychotherapy and psychotropic use among patients with incident depression and anxiety were measured. RESULTS: At least one-quarter of the patients in our sample had a mental illness or substance use disorder. The most common diagnoses at hospitalization were depression (11.4%), followed by alcohol abuse or dependence (5.5%), and post-traumatic stress disorder (4.9%). Of the 831 patients with incident past-year depression and 258 with incident past-year anxiety, nearly two-thirds received at least some psychotherapy or guideline-concordant medication within 90 days of diagnosis. Of 191 patients with incident depression and 47 with incident anxiety at time of hospitalization, fewer than half received mental healthcare before discharge. CONCLUSIONS: Many veterans hospitalized with serious physical illnesses have comorbid mental illnesses and may benefit from depression and anxiety treatment.

Variation in Utilization of Health Care Services for Rural VA Enrollees With Mental Health-Related Diagnoses.

PURPOSE: Rural-dwelling Department of Veterans Affairs (VA) enrollees are at high risk for a wide variety of mental health-related disorders. The objective of this study is to examine the variation in the types of mental and nonmental health services received by rural VA enrollees who have a mental health-related diagnosis. METHODS: The Andersen and Aday behavioral model of health services use and the Agency for Healthcare Research and Quality Medical Expenditure Panel Survey (MEPS) data were used to examine how VA enrollees with mental health-related diagnoses accessed places of care from 1999 to 2009. Population survey weights were applied to the MEPS data, and logit regression was conducted to model how predisposing, enabling, and need factors influence rural veteran health services use (measured by visits to different places of care). Analyses were performed on the subpopulations: rural VA, rural non-VA, urban VA, and urban non-VA enrollees. FINDINGS: For all types of care, both rural and urban VA enrollees received care from inpatient, outpatient, office-based, and emergency room settings at higher odds than urban non-VA enrollees. Rural VA enrollees also received all types of care from inpatient, office-based, and emergency room settings at higher odds than urban VA enrollees. Rural VA enrollees had higher odds of a mental health visit of any kind compared to urban VA and non-VA enrollees. CONCLUSIONS: Based on these variations, the VA may want to develop strategies to increase screening efforts in inpatient settings and emergency rooms to further capture rural VA enrollees who have undiagnosed mental health conditions.

Success factors for strategic change initiatives: a qualitative study of healthcare administrators' perspectives.

Success factors related to the implementation of change initiatives are well documented and discussed in the management literature, but they are seldom studied in healthcare organizations engaged in multiple strategic change initiatives. The purpose of this study was to identify key success factors related to implementation of change initiatives based on rich qualitative data gathered from health leader interviews at two large health systems implementing multiple change initiatives. In-depth personal interviews with 61 healthcare leaders in the two large systems were conducted and inductive qualitative analysis was employed to identify success factors associated with 13 change initiatives. Results from this analysis were compared to success factors identified in the literature, and generalizations were drawn that add significantly to the management literature, especially to that in the healthcare sector. Ten specific success factors were identified for the implementation of change initiatives. The top three success factors were (1) culture and values, (2) business processes, and (3) people and engagement. Two of the identified success factors are unique to the healthcare sector and not found in the literature on change models: service quality and client satisfaction (ranked fourth of 10) and access to information (ranked ninth). Results demonstrate the importance of human resource functions, alignment of culture and values with change, and business processes that facilitate effective communication and access to information to achieve many change initiatives. The responses also suggest opportunities for leaders of healthcare organizations to more formally recognize the degree to which various change initiatives are dependent on one another.

Species identification of Cannabis sativa using real-time quantitative PCR (qPCR).

Most narcotics-related cases in the United States involve Cannabis sativa. Material is typically identified based on the cystolithic hairs on the leaves and with chemical tests to identify of the presence of cannabinoids. Suspect seeds are germinated into a viable plant so that morphological and chemical tests can be conducted. Seed germination, however, causes undue analytical delays. DNA analyses that involve the chloroplast and nuclear genomes have been developed for identification of C. sativa materials, but they require several nanograms of template DNA. Using the trnL 3' exon-trnF intragenic spacer regions within the C. sativa chloroplast, we have developed a real-time quantitative PCR assay that is capable of identifying picogram amounts of chloroplast DNA for species determination of suspected C. sativa material. This assay provides forensic science laboratories with a quick and reliable method to identify an unknown sample as C. sativa.

Health care administrators' perspectives on the role of absorptive capacity for strategic change initiatives: a qualitative study.

BACKGROUND: The dimensions of absorptive capacity (ACAP) are defined, and the importance of ACAP is established in the management literature, but the concept has not been applied to health care organizations attempting to implement multiple strategic initiatives. PURPOSE: The aim of this study was to test the utility of ACAP by analyzing health care administrators' experiences with multiple strategic initiatives within two health systems. METHODOLOGY: Results are drawn from administrators' assessments of multiple initiatives within two health systems using in-depth personal interviews with a total of 61 health care administrators. Data analysis was performed following deductive qualitative analysis guidelines. Interview transcripts were coded based on the four dimensions of ACAP: acquiring, assimilating, internalizing/transforming, and exploiting knowledge. Furthermore, we link results related to utilization of management resources, including number of key personnel involved and time consumption, to dimensions of ACAP. FINDINGS: Participants' description of multiple strategic change initiatives confirmed the importance of the four ACAP dimensions. ACAP can be a useful framework to assess organizational capacity with respect to the organization's ability to concurrently implement multiple strategic initiatives. This capacity specifically revolves around human capital requirements from upper management based on the initiatives' location or stage within the ACAP framework. PRACTICE IMPLICATIONS: Strategic change initiatives in health care can be usefully viewed from an ACAP perspective. There is a tendency for those strategic initiatives ranking higher in priority and time consumption to reflect more advanced dimensions of ACAP (assimilate and transform), whereas few initiatives were identified in the ACAP "exploit" dimension. This may suggest that health care leaders tend to no longer identify as strategic initiatives those innovations that have moved to the exploitation stage or that less attention is given to the exploitation elements of a strategic initiative than to the earlier stages.

Do Medicaid incentive payments boost quality? Florida's direct care staffing adjustment program.

Beginning in April 2000 and continuing for 21 months, Florida's legislature allocated $31.6 million (annualized) to nursing homes through a Medicaid direct care staffing adjustment. Florida's legislature paid the highest incentives to nursing homes with the lowest staffing levels and the greatest percentage of Medicaid residents--the bottom tier of quality. Using Donabedian's structure-process-outcomes framework, this study tracks changes in staffing, wages, process of care, and outcomes. The incentive payments increased staffing and wages in nursing home processes (decreased restraint use and feeding tubes) for the facilities receiving the largest amount of money but had no change on pressure sores or decline in activities of daily living. The group receiving the lowest incentives payment (those highest staffed at baseline) saw significant improvement in two quality measures: pressure sores and decline in activities of daily living. All providers receiving more resources improved on deficiency scores, suggesting more Medicaid spending improves quality of care regardless of total incentive payments.

Nursing home financial performance: the role of ownership and chain affiliation.

BACKGROUND: The nursing home industry serves one of the most vulnerable populations, and its financial sustainability is a matter of public concern. However, limited empirical evidence exists on the impact of ownership and chain affiliation on nursing home financial performance. PURPOSES: The aim of this study was to examine the joint effects of ownership and chain affiliation on the financial performance of the nursing home industry for the study period 1999-2004 on a national sample of 11,236 nursing homes per year. METHODOLOGY/APPROACH: Data included the Medicare Cost Reports; the Online Survey, Certification, and Reporting file; and the Area Resource File. Dependent variables included operating and total margins. Independent variables included four ownership/chain affiliation combinations: for-profit chain, for-profit independent, not-for-profit chain, and not-for-profit independent. Random effects generalized least square regressions were performed. FINDINGS: Results show that for-profit nursing homes delivered better financial performance than not-for-profit facilities did across both operating and total margins. However, the relationship between chain affiliation and financial performance was more nuanced. In the case of operating margin, chain-affiliated facilities delivered superior financial performance irrespective of ownership type; however, in the case of total margin, independents outperformed chain-affiliated facilities among for-profits. PRACTICE IMPLICATIONS: Our findings show an interactive effect of ownership and chain affiliation on nursing home financial performance, suggesting the pursuit of different organizational strategies by different ownership/chain affiliation subgroups (for-profit chain, for-profit independent, not-for-profit chain, and not-for-profit independent), with implications for financial performance. For-profit independent nursing homes managed to be the top performing group in terms of overall financial despite the operating financial advantage of for-profit chain-affiliated nursing homes. Similarly, not-for-profit independent nursing homes and not-for-profit chain homes had comparable overall financial performance despite the operating financial advantage of chain homes.

The influence of nurse staffing levels on quality of care in nursing homes.

OBJECTIVE: This study examines the relationship between increasing certified nursing assistants (CNAs) and licensed nurse staffing ratios and deficiencies in Florida nursing homes over a 4-year period. METHODS: Data from Florida staffing reports and the Online Survey Certification and Reporting database examine the relationship among staffing levels and deficiency citations for 663 Florida nursing homes between 2002 and 2005. Using a generalized estimating equation approach in SAS Proc Genmod, we estimate the relationship between CNA and licensed nursing staff, and facilities' total deficiency score and quality of care deficiency scores-calculated using the Centers for Medicare and Medicaid Services' Nursing Home Compare Five-Star Quality Rating System, which accounts for the complexity of the scope and severity of the cittions. RESULTS: Our results confirmed that higher CNA staffing levels were predictors of lower total deficiency scores and quality of care deficiency scores after controlling for facility characteristics. CONCLUSION: With a large sample size, repeated measure design, and advanced methods, we have found a relationship between CNA staffing and nursing home quality.

Outsourcing administrative functions: service organization demonstrations and Florida Medicaid PCCM program costs.

This study examines the cost implications of outsourcing Medicaid functions to the private sector. We examine the expenditures for enrollees in three Medicaid primary care case management (PCCM) demonstration projects compared to Florida's PCCM program from February 2002-February 2003. The RAND two-part model was used to analyze the medica expenditures for enrollees in each program. After adjusting for sociodemographic factors and the probability of service use, we found that all three demonstration projects reduced expenditures compared to the PCCM program. The implications from the study are that Medicaid programs may want to consider outsourcing PCCM functions after further studies examine the utilization experience for enrollees in these programs.

Individual factors associated with intentions to leave among directors of nursing in nursing homes.

BACKGROUND: Although the importance of nurse leadership stability and participation in decision making in nursing homes is well established, scarce literature exists on determinants of intent to leave among directors of nursing (DONs) in nursing homes. PURPOSE: : The purpose of this study was to examine factors associated with DON intent to leave in nursing homes. METHODOLOGY: We examined potential factors associated with DON intent to leave at three levels: individual DON characteristics, facility, and county-level market factors. A survey of nurse supervisors in Texas nursing homes, the 2003 Texas Nursing Facility Medicaid Cost Report, and the Area Resource File were merged. We only included respondents who identified themselves as DONs in this study (572 observations). We examined bivariate differences in individual DON characteristics on the basis of facility ownership (for-profit versus not-for-profit homes) and geographic location (urban versus rural location). We constructed three alternative logit models to explore the relationships between DON intent to leave and DON, facility, and market characteristics. FINDINGS: DONs working in for-profit homes were more inclined to leave, less satisfied with their job, and had lower levels of perceived empowerment in terms of autonomy. Educational level and intention to leave were significantly higher for DONs working in urban areas. Job satisfaction was significantly and inversely associated with intent to leave in all three models. Higher perceived salary competitiveness and level of empowerment were associated with reduced odds of intending to leave. Higher educational levels were associated with higher odds of intentions to leave. PRACTICE IMPLICATIONS: Nursing homes should focus on improving DON job satisfaction, empowerment in decision making, and salary competitiveness when designing retention strategies for DONs.

Florida's efforts to improve quality of nursing home care through nurse staffing standards, regulation, and Medicaid reimbursement.

Between 1999 and 2007, Florida implemented two initiatives combining legislative, regulatory, and reimbursement strategies to increase nurse staffing levels in nursing homes to improve quality of care. Despite a $40 million incentive package allocated for direct-care staffing, per-resident-day staffing increased only after legislative requirements mandated minimum nursing hours per resident day. Total Medicaid expenditures grew by $1.1 billion over the 8 years; per diem rates increased 65% to reimburse providers' costs. Registered nurses' hours decreased, while licensed nurses' and paraprofessionals' hours increased. This article describes the impact of staffing policy changes, includes stakeholders' views about approaches to achieve quality outcomes, and documents state policy implementation efforts. Seven lessons from the implementation of state nurse staffing standards to improve quality of care outcomes are also presented.

Outsourcing veterans for long-term care: comparison of community and state veterans' nursing homes.

This study compares the characteristics of state veterans' nursing homes and community nursing homes with VA per-diem residentes between 1999 - 2002. A structure, process, and outcome model was used to examine whether there was any difference in the multi-dimensional quality measures among the three types of community nursing homes (for profit, not-for-profit, and government) and state veterans' nursing homes. For profit community nursing homes were less likely to achieve nurse staffing standards while government facilities were more likely to achieve CNA staffing standards when compared to the state veterans' homes. All community nursing homes had a lower prevelance of tube feeds and catheterization when compared to state veterans' nursing homes. Only government community nursing homes had significantly lower quality of life deficiencies and pressure sore prevelance when compared to state veterans' nursing homes. Vigilant monitoring of all long-term care facilities utilized by veterans is needed.

Evaluating Florida's Medicaid provider services network demonstration.

RESEARCH OBJECTIVE: To evaluate the design, development, and implementation of Florida's Medicaid provider service network (PSN) demonstration, and the implications of that demonstration for subsequent Medicaid Reform in Florida. DATA SOURCES, DATA COLLECTION: Organizational analyses were based on archival and enrollment data obtained from Florida's Medicaid program and the South Florida Community Care Network, as well as key informant interviews. Closely related fiscal analyses utilized Medicaid claims data from March 1999 through October 2001 extracted from the Florida Medicaid Management Information System. STUDY DESIGN: The organizational analyses reported here were based on a structured case study research design. PRINCIPAL FINDINGS: Almost every aspect of the development of the new organizational form (PSN) took longer and was more difficult than anticipated. Prior organizational experience with insurance functions proved to be an asset. While fiscal analyses indicated that the program saved the state of Florida a significant amount of money, tracking the precise origin of the savings proved to be challenging. CONCLUSIONS: By most standards, the PSN program was observed to meet its stated objectives. Based in part on this conclusion, the state chose to extend the use of PSNs within its 2006 Medicaid Reform initiative.

Characteristics of community nursing homes serving per diem veterans, 1999 to 2002.

This study compared the characteristics of community nursing homes where veterans received their care with those of facilities that did not treat veterans from 1999 to 2002 using the Centers for Medicare and Medicaid Services (CMS) Online Survey Certification and Reporting system data merged with the CMS Minimum Data Set. A structure, process, and outcome model was used to examine whether the presence of per diem veterans had any impact on multidimensional quality measures. Facilities with any veterans were less likely to meet recommended nurse staffing standards; more likely to have patients with tube feeding, new catheterizations, and mobility restraints; and more likely to have actual harm citations and new pressure sores, plus quality-of-care, quality-of-life, and total deficiencies, than facilities without veterans. The implications of this study are that the U.S. Department of Veterans Affairs may need to examine its contracting policies with community facilities to understand both quality and selection effects that may be occurring.