'It was hell in the community': a qualitative study of maternal and child health care during health care worker strikes in Kenya.

BACKGROUND: Health care workers in Kenya have launched major strikes in the public health sector in the past decade but the impact of strikes on health systems is under-explored. We conducted a qualitative study to investigate maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers (CHVs), and health facility managers. METHODS: We conducted in-depth interviews and focus group discussions (FGDs) with three populations: women who were pregnant in 2017, CHVs, and health facility managers. Women who were pregnant in 2017 were part of a previous study. All participants were recruited using convenience sampling from a single County in western Kenya. Interviews and FGDs were conducted in English or Kiswahili using semi-structured guides that probed women's pregnancy experiences and maternal and child health services in 2017. Interviews and FGDs were audio-recorded, translated, and transcribed. Content analysis followed a thematic framework approach using deductive and inductive approaches. RESULTS: Forty-three women and 22 CHVs participated in 4 FGDs and 3 FGDs, respectively, and 8 health facility managers participated in interviews. CHVs and health facility managers were majority female (80%). Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and had indirect economic effects due to households paying for services in the private sector. Participants felt it was the poor, particularly poor women, who were most affected since they were more likely to rely on public services, while CHVs highlighted their own poor working conditions in response to strikes by physicians and nurses. Strikes strained relationships and trust between communities and the health system that were identified as essential to maternal and child health care. CONCLUSION: We found that the impacts of strikes by health care workers in 2017 extended beyond negative health and economic effects and exacerbated fundamental inequities in the health system. While this study was conducted in one County, our findings suggest several potential avenues for strengthening maternal and child health care in Kenya that were highlighted by nationwide strikes in 2017.

Reliability and Validity of a Further Tested Appreciative Management Scale.

BACKGROUND AND PURPOSE: Managers need evidence-based methods to evaluate their management skills. To further test the appreciative management scale (AMS 1.0) to create a practical instrument to be used in evaluating appreciative management. METHODS: For further testing, a new survey was conducted among social and healthcare managers (n = 734) in Finland. Confirmatory factor analysis (CFA) was used to assess the scale validity and Cronbach's alpha coefficients the internal consistency. RESULTS: The validated AMS 2.0 scale includes 24 items. The values measuring validity and reliability were good, with an Rool Mean Square Error of Approximation (RMSEA) of 0.072, Average Variance Extracted (AVE) values between 0.532 and 0.634, and Composite Reliability (CR) values ranging between 0.850 and 0.914. The Cronbach's alpha of the whole scale was 0.944. CONCLUSIONS: AMS 2.0 is a reliable and valid means to measure appreciative management as proved by confirmatory factor analysis.

How Women and Men Executives Perceive Healthcare Workplaces.

EXECUTIVE SUMMARY: Healthcare organizations that can attract and retain talented women executives have the advantage over their peers. In 2018, the American College of Healthcare Executives (ACHE) conducted the sixth in a series of surveys of its members to compare the career attainments, attitudes, and workplace experiences of men and women healthcare executives. Data from the 2018 survey indicate that women healthcare executives with 5 to 20 years of experience in the field are significantly less likely than their male peers to perceive their employers as gender-neutral regarding key employment factors such as hiring, promotion, evaluation, and compensation. Further, the results indicate there has been little to no improvement in many of these outcomes since ACHE began measuring these perceptions more than a decade ago. The perception that an employing organization is lacking in gender equity is also associated with lower overall satisfaction, engagement, and willingness to stay with the organization on the part of women executives.

Exploring the role of managers in the development of a safety culture in seven French healthcare facilities: a qualitative study.

BACKGROUND: Numerous studies have been conducted over the past 15 years to assess safety culture within healthcare facilities; in general, these studies have shown the pivotal role that managers play in its development. However, little is known about what healthcare managers actually do to support this development, and how caregivers and managers represent managers'role. Thus the objectives of this study were to explore: i) caregivers and managers' perceptions and representations of safety, ii) the role of managers in the development of safety culture as perceived by themselves and by caregivers, iii) managers' activities related to the development of safety culture. METHODS: An exploratory, multicentre, qualitative study was conducted from May 2014 to March 2015 in seven healthcare facilities in France. Semi-structured interviews were conducted with managers (frontline, middle and top level) and caregivers (doctors, nurses and nurse assistants) and on-site observations of two managers were carried out in all facilities. A thematic analysis of semi-structured interviews was performed. Observed activities were categorised using Luthans' typology of managerial activities. RESULTS: Participants in semi-structured interviews (44 managers and 21 caregivers) expressed positive perceptions of the level of safety in their facility. Support from frontline management was particularly appreciated, while support from top managers was identified as an area for improvement. Six main categories of safety-related activities were both observed among managers and regularly expressed by participants. However, caregivers' expectations of their managers and managerial perceptions of these expectations only partially overlapped. CONCLUSIONS: The present study highlights current categories of managerial activities that foster safety culture, and points out an important gap between caregivers' expectations of their managers, and managerial perceptions of these expectations. The findings underline the need to allow more time for managers and caregivers to talk about safety issues. The results could be used to develop training programs to help healthcare managers to understand their role in the development of safety culture.

Burnout Syndrome in Family Health Strategy Managers. / Síndrome de Burnout em gerentes da Estratégia de Saúde da Família.

This paper analyzed the Burnout Syndrome (BS) among the managers of the Family Health Strategy (ESF) in the city of Rio de Janeiro and its associations with factors that influence the presence/absence of BS among these professionals. This is a descriptive study that used data from a questionnaire consisting of two parts: 1) manager profile and factors that could influence the presence of Burnout; 2) Maslach Burnout Inventory. The return rate was 63.5% (143) of the 225 questionnaires sent. The ESF managers are generally nurses (68.6%), young (63.6% under 39 years) female (76.9%), who have acted as managers for less than 5 years (85.2%). A BS presence was identified in 11.2% of the managers. The factors of an organizational nature were those that obtained the highest number of variables with an association. These data point to the need to make changes in the organizational practices of services and changes in work processes. Further studies on these issues can contribute to this.

Este artigo analisou a Síndrome de Burnout (SB) entre os gerentes da Estratégia de Saúde da Família (ESF) no Município do Rio de Janeiro e suas associações entre os fatores que influenciam a presença/ausência da SB nesses profissionais. Com natureza descritiva, ele utilizou um questionário, composto de duas partes: 1) perfil do gerente e fatores que possam influenciar a presença de Burnout; 2) Inventário Maslach Burnout Inventory. A taxa percentual de retorno foi de 63,5% (143) dos 225 enviados. Os gerentes da ESF são em geral, enfermeiros (68,6%), jovens (74,5% até 39 anos), do sexo feminino (76,9%) e que atuam na gerência há menos de 5 anos (85,2%). A presença da SB foi identificada em 11,2% dos gerentes. Os fatores de natureza organizacional foram os que obtiveram maior número de variáveis com associação. Esses dados apontam para necessidade de realização de mudanças nas práticas organizativas de serviços e de mudanças nos processos de trabalho. A realização de outros estudos, que aprofundem estas questões, pode contribuir neste sentido.

Síndrome de Burnout em gerentes da Estratégia de Saúde da Família / Burnout Syndrome in Family Health Strategy Managers

Resumo Este artigo analisou a Síndrome de Burnout (SB) entre os gerentes da Estratégia de Saúde da Família (ESF) no Município do Rio de Janeiro e suas associações entre os fatores que influenciam a presença/ausência da SB nesses profissionais. Com natureza descritiva, ele utilizou um questionário, composto de duas partes: 1) perfil do gerente e fatores que possam influenciar a presença de Burnout; 2) Inventário Maslach Burnout Inventory. A taxa percentual de retorno foi de 63,5% (143) dos 225 enviados. Os gerentes da ESF são em geral, enfermeiros (68,6%), jovens (74,5% até 39 anos), do sexo feminino (76,9%) e que atuam na gerência há menos de 5 anos (85,2%). A presença da SB foi identificada em 11,2% dos gerentes. Os fatores de natureza organizacional foram os que obtiveram maior número de variáveis com associação. Esses dados apontam para necessidade de realização de mudanças nas práticas organizativas de serviços e de mudanças nos processos de trabalho. A realização de outros estudos, que aprofundem estas questões, pode contribuir neste sentido.

Abstract This paper analyzed the Burnout Syndrome (BS) among the managers of the Family Health Strategy (ESF) in the city of Rio de Janeiro and its associations with factors that influence the presence/absence of BS among these professionals. This is a descriptive study that used data from a questionnaire consisting of two parts: 1) manager profile and factors that could influence the presence of Burnout; 2) Maslach Burnout Inventory. The return rate was 63.5% (143) of the 225 questionnaires sent. The ESF managers are generally nurses (68.6%), young (63.6% under 39 years) female (76.9%), who have acted as managers for less than 5 years (85.2%). A BS presence was identified in 11.2% of the managers. The factors of an organizational nature were those that obtained the highest number of variables with an association. These data point to the need to make changes in the organizational practices of services and changes in work processes. Further studies on these issues can contribute to this.

Influenza vaccine acceptance by healthcare workers in Saudi Arabia: A questionnaire-based analysis.

The aim of this study was to gauge the reasons for accepting or declining influenza vaccine in healthcare staff in Saudi Arabia. A questionnaire was administered to healthcare workers in Saudi Arabia. In all, 633 respondents who provided gender, nationality and profession were included. Reasons for vaccine uptake or refusal were assessed according to profession and educational level. Uptake of vaccine was lower in the period from 2010 to 2014 (3-13.3%) compared to pre-2010 figures (20.7%), rising to 44.1% in 2015. Comparing data for 'never having been vaccinated' to 'being vaccinated in 2015', there was no significant difference in distribution between nurses (9.27% v 38.8%), physicians (13.9% v 56.0%) and laboratory technicians (15.9% v 33.5%) (p= 0.08). The top reason for vaccination was protection of self and family, while the top reason for refusal was not considering the vaccine to be necessary. Education level had no significant effect on the likelihood of being vaccinated. Improvement of healthcare worker vaccination levels in Saudi Arabia might be achieved by addressing staff concerns on vaccine safety and efficacy, emphasizing the potential dangers of influenza and capitalizing on the staff's focus on protecting themselves and their families.

Elder abuse and neglect: an overlooked patient safety issue. A focus group study of nursing home leaders' perceptions of elder abuse and neglect.

BACKGROUND: The definition and understanding of elder abuse and neglect in nursing homes can vary in different jurisdictions as well as among health care staff, researchers, family members and residents themselves. Different understandings of what constitutes abuse and its severity make it difficult to compare findings in the literature on elder abuse in nursing homes and complicate identification, reporting, and managing the problem. Knowledge about nursing home leaders' perceptions of elder abuse and neglect is of particular interest since their understanding of the phenomenon will affect what they signal to staff as important to report and how they investigate adverse events to ensure residents' safety. The aim of the study was to explore nursing home leaders' perceptions of elder abuse and neglect. METHODS: A qualitative exploratory study with six focus group interviews with 28 nursing home leaders in the role of care managers was conducted. Nursing home leaders' perceptions of different types of abuse within different situations were explored. The constant comparative method was used to analyse the data. RESULTS: The results of this study indicate that elder abuse and neglect are an overlooked patient safety issue. Three analytical categories emerged from the analyses: 1) Abuse from co-residents: 'A normal part of nursing home life'; resident-to-resident aggression appeared to be so commonplace that care leaders perceived it as normal and had no strategy for handling it; 2) Abuse from relatives: 'A private affair'; relatives with abusive behaviour visiting nursing homes residents was described as difficult and something that should be kept between the resident and the relatives; 3) Abuse from direct-care staff: 'An unthinkable event'; staff-to-resident abuse was considered to be difficult to talk about and viewed as not being in accordance with the leaders' trust in their employees. CONCLUSIONS: Findings in the present study show that care managers lack awareness of elder abuse and neglect, and that elder abuse is an overlooked patient safety issue. The consequence is that nursing home residents are at risk of being harmed and distressed. Care managers lack knowledge and strategies to identify and adequately manage abuse and neglect in nursing homes.

A comparative analysis of work-family conflict among staff, managerial, and executive nurses.

BACKGROUND: Nurses frequently are caught between the demands of work and family. While studies have explored this issue among staff nurses, none have compared nurse leaders to staff nurses. This study compares work-family conflict (WFC) and family-work conflict (FWC) among staff, managerial, and executive nurses. METHODS: In this survey design, 20% of registered nurses were randomly sampled across Florida with a 9% response rate. Survey questions included personal, professional, and work environment characteristics and perceptions of WFC/FWC. Analyses of variance tested the differences between- and within-group scores for WFC/FWC for staff, managerial, and executive nurses. Ordinary Least Squares regressions tested the relationships between personal, professional and work environment measures, focusing on the three different nursing roles, and WFC/FWC scores. FINDINGS: Nurses experienced more WFC than FWC. Staff nurses experienced significantly less WFC than nurse managers and nurse executives (analysis of variance mean difference -0.881 and -2.693, respectively). Nonwhite nurses experienced more WFC and FWC than white nurses. Longer shift length predicted greater WFC. FWC was lower with paid leave for childbirth. DISCUSSION: Higher WFC among nurse managers and executives may discourage nurses from taking on or staying in leadership roles. Efforts must be taken to decrease WFC/FWC among nurses in these roles.

Impact of training and professional development on health management and leadership competence.

PURPOSE: Training to improve health management and leadership competence is recommended. However, there is limited evidence showing the impact of training on competence. The purpose of this paper is to evaluate the evidence for the impact of training and professional development on health management and leadership competence. DESIGN/METHODOLOGY/APPROACH: A systematic review was conducted using a mixed-methods design. Studies using qualitative, quantitative or mixed-methods design were included. The following electronic databases were searched to October 2018: CENTRAL, CINAHL, EMBASE, ERIC, NEDLINE and PsycINFO. Study eligibility and methodological quality were assessed independently by two review authors. Data from qualitative studies were synthesised using thematic analysis. For quantitative studies, odds ratio (OR) or mean difference (MD) and 95% confidence interval (CI) were calculated for each intervention. Where appropriate, qualitative and quantitative data were integrated into a single synthesis using Bayesian methods. FINDINGS: In total, 19 studies were identified for inclusion in the review. Training and professional development interventions using flexible, multiple training techniques tailored to organisational contexts can improve individual competence and performance. Such training is typified by a leadership development programme. There was insufficient evidence to determine the effects of interventions on organisational performance. ORIGINALITY/VALUE: This is the first systematic review evaluating the impact of training and professional development interventions on health management and leadership competence.

The growing pains of physician-administration relationships in an academic medical center and the effects on physician engagement.

BACKGROUND: Physician engagement has become a key metric for healthcare leadership and is associated with better healthcare outcomes. However, engagement tends to be low and difficult to measure and improve. This study sought to efficiently characterize the professional cultural dynamics between physicians and administrators at an academic hospital and how those dynamics affect physician engagement. MATERIALS AND METHODS: A qualitative mixed methods analysis was completed in 6 weeks, consisting of a preliminary analysis of the hospital system's history that was used to purposefully recruit 20 physicians across specialties and 20 healthcare administrators across management levels for semi-structured interviews and observation. Participation rates of 77% (20/26) and 83% (20/24) were achieved for physicians and administrators, respectively. Cohorts consisted of equal numbers of men and women with experience ranging from 1 to 35 years within the organization. Field notes and transcripts were systematically analyzed using an iterative inductive-deductive approach. Emergent themes were presented and discussed with approximately 400 physicians and administrators within the organization to assess validity and which results were most meaningful. RESULTS & DISCUSSION: This investigation indicated a professional cultural disconnect was undermining efforts to improve physician engagement. This disconnect was further complicated by a minority (10%) not believing an issue existed and conflicting connotations not readily perceived by participants who often offered similar solutions. Physicians and administrators felt these results accurately reflected their realities and used this information as a common language to plan targeted interventions to improve physician engagement. Limitations of the study included its cross-sectional nature with a modest sample size at a single institution. CONCLUSIONS: A qualitative mixed methods analysis efficiently identified professional cultural barriers within an academic hospital to serve as an institution-specific guide to improving physician engagement.

[Informed Consent - Vision and Perspectives of Adolescents, Parents and Professionals: Multicentric Study in Six Hospitals].

INTRODUCTION: According to the Convention on the Rights of Children and the national standards of the Portuguese Directorate-General for Health, adolescents have the right to make decisions about their own health. The aim of this study was to identify the dynamics of the implementation of assent and informed consent in hospital settings. MATERIAL AND METHODS: Cross-sectional and multicentre study based on surveys, which included adolescents from 14 to 18 years and their parents. Heads of departments of Pediatrics and attending physicians were also interviewed. RESULTS: 194 responses from adolescents and parents were collected, and 46 interviews were conducted with physicians and heads of department. Adolescents and parents consider participation in decision making important, but parents value their own participation significantly higher (91.7% vs 47.8%, p < 0.001 in the 14 - 15 year group, 91.8% vs 53, (89.6% vs 69.6%, p = 0.016 in the 14 - 15 year group, 91.8% vs 69.4%, p = 0.005 in the 16 - 17 years group). Information leaflets are difficult to understand by teenagers. The eight heads of department felt that doctors have awareness towards communication with teenagers but have little time available. Of the 38 attending physicians, 36 said they had learned from their older colleagues and confirmed gaps in postgraduate training. DISCUSSION: This pioneering study in Portugal enabled the identification of areas that can be optimized, through health education programs for parents and adolescents, written information that is adequate to the different age groups, training in undergraduate education for medical students and also education in health institutions for professionals. CONCLUSION: Adolescents and parents, are unaware of legal and ethical standards for consent and assent. The implementation of the adolescents' right to informed assent / informed consent was not observed. Our proposal is to implement local programs for adolescents and parents.

Introdução: A Convenção sobre os Direitos das Crianças e normas nacionais da Direção Geral da Saúde conferem aos adolescentes o direito às decisões sobre a sua saúde. O objectivo deste estudo foi identificar as dinâmicas de implementação do assentimento e do consentimento informado, em ambiente hospitalar. Material e Métodos: Estudo transversal e multicêntrico realizado a partir de inquéritos. Incluídos adolescentes dos 14 aos 18 anos e pais respectivos. Foram ainda entrevistados os diretores de serviço e assistentes hospitalares. Resultados: Obtiveram-se 194 respostas de adolescentes e pais e efetuaram-se 46 entrevistas a médicos e diretores dos serviços. Adolescentes e pais consideram importante a participação no processo de decisão mas os pais valorizam de forma significativamente superior a sua participação (91,7% vs 47,8%, p < 0,001 no grupo 14 - 15 anos; 91,8% vs 53,1%, p = 0,001, no grupo 16 - 17 anos), bem como a do médico (89,6% vs 69,6%, p = 0,016 no grupo 14 - 15 anos; 91,8% vs 69,4%, p = 0,005 no grupo 16 - 17 anos). Os folhetos informativos são pouco perceptíveis pelos adolescentes. Os oito diretores consideraram que os médicos estão sensibilizados para comunicar com os adolescentes mas têm pouco tempo disponível. Dos 38 assistentes, 36 afirma ter aprendido com os colegas mais velhos e confirmam lacunas na formação pós graduada. Discussão: Este estudo pioneiro em Portugal permitiu a identificação de áreas passíveis de otimização, através de programas da educação para a saúde para pais e adolescentes, informação escrita adequada à idade e formação no ensino pré graduado para estudantes de Medicina e educação nas instituições de saúde para os profissionais. Conclusão: Os adolescentes e pais desconhecem as normas legais e éticas quanto ao consentimento e assentimento. Não fica demonstrada a implementação do direito dos adolescentes ao assentimento informado / consentimento informado. Propõem-se programas locais de sensibilização para adolescentes e pais.

Hepatitis C testing in substance use disorder treatment: the role of program managers in adoption of testing services.

BACKGROUND: Health care organizations do not adopt best practices as often or quickly as they merit. This gap in the integration of best practices into routine practice remains a significant public health concern. The role of program managers in the adoption of best practices has seldom been investigated. METHODS: We investigated the association between characteristics of program managers and the adoption of hepatitis C virus (HCV) testing services in opioid treatment programs (OTPs). Data came from the 2005 (n = 187) and 2011 (n = 196) National Drug Abuse Treatment System Survey (NDATSS). We used multivariate regression models to examine correlates of the adoption of HCV testing. We included covariates describing program manager characteristics, such as their race/ethnicity, education, and their sources of information about developments in the field of substance use disorder treatment. We also controlled for characteristics of OTPs and the client populations they serve. RESULTS: Program managers were predominantly white and female. A large proportion of program managers had post-graduate education. Program managers expressed strong support for preventive services, but they reported making limited use of available sources of information about developments in the field of substance use disorder (SUD) treatment. The provision of any HCV testing (either on-site or off-site) in OTPs was positively associated with the extent to which a program manager was supportive of preventive services. Among OTPs offering any HCV testing to their clients, on-site HCV testing was more common among programs with an African American manager. It was also more common when program managers relied on a variety of information sources about developments in SUD treatment. CONCLUSIONS: Various characteristics of program managers are associated with the adoption of HCV testing in OTPs. Promoting diversity among program managers, and increasing managers' access to information about developments in SUD treatment, may help foster the adoption of best practices.

Nursing home report card and performance gap.

BACKGROUND: With the aging of our society, concerns about the quality of nursing homes have been increasing. The Nursing Home Compare (NHC) report card is believed to reduce information asymmetry between the facility and potential residents and, consequently, improve nursing home quality. However, there is limited evidence about how nursing homes use this publicly disseminated performance information. PURPOSE: The aim of this study was to analyze the performance gap between nursing home administrators' self-assessment and the NHC report card performance ratings and explore the factors contributing to the gap. METHODOLOGY: All 515 Medicare- and Medicaid-certified nursing homes in Indiana were surveyed between August and December 2013. The response rate was approximately 45%. The survey data were compared with the NHC data to identify the gap. Ordered logistic regression analysis was conducted. FINDINGS: Despite voluntary participation, a reasonably high response rate, and anonymity, this study found that 62% of respondents either under- or overrated their facilities' performance, with the majority overrating their performance. The following factors were associated with a smaller performance gap: nonprofit or government-owned status, higher staffing levels, a higher percentage of hours worked by registered nurses, and a higher market concentration. Longer work experience and greater county occupancy rates were associated with a larger performance gap. PRACTICE IMPLICATIONS: The significant gap implies that administrators either do not regularly review the NHC report card or do not concur with the NHC ratings. To reduce the gap and thereby improve performance, it is necessary to stabilize the administrators' position so that administrators know how they stand in the market and are consequently better equipped to successfully respond to the market. Facilities may also need to provide regular training on current technologies and facilitate use of the NHC report card, targeting administrators who are old and have many years of work experience.

Use of information technology for medication management in residential care facilities: correlates of facility characteristics.

The effectiveness of information technology in resolving medication problems has been well documented. Long-term care settings such as residential care facilities (RCFs) may see the benefits of using such technologies in addressing the problem of medication errors among their resident population, who are usually older and have numerous chronic conditions. The aim of this study was two-fold: to examine the extent of use of Electronic Medication Management (EMM) in RCFs and to analyze the organizational factors associated with the use of EMM functionalities in RCFs. Data on RCFs were obtained from the 2010 National Survey of Residential Care Facilities. The association between facility, director and staff, and resident characteristics of RCFs and adoption of four EMM functionalities was assessed through multivariate logistic regression. The four EMM functionalities included were maintaining lists of medications, ordering for prescriptions, maintaining active medication allergy lists, and warning of drug interactions or contraindications. About 12% of the RCFs adopted all four EMM functionalities. Additionally, maintaining lists of medications had the highest adoption rate (34.5%), followed by maintaining active medication allergy lists (31.6%), ordering for prescriptions (19.7%), and warning of drug interactions or contraindications (17.9%). Facility size and ownership status were significantly associated with adoption of all four EMM functionalities. Medicaid certification status, facility director's age, education and license status, and the use of personal care aides in the RCF were significantly associated with the adoption of some of the EMM functionalities. EMM is expected to improve the quality of care and patient safety in long-term care facilities including RCFs. The extent of adoption of the four EMM functionalities is relatively low in RCFs. Some RCFs may strategize to use these functionalities to cater to the increasing demands from the market and also to provide better quality of care.

Effects of staffing choices on collaborative care for depression at primary care clinics in Minnesota.

OBJECTIVE: This study assessed associations between staffing of a collaborative care program for depression and enrollment in the program and remission rates. METHODS: Data were collected from depression care registries at 63 primary care clinics that participated in the initiative through early 2012. Project leaders at the 12 medical groups that operate the clinics were surveyed about the background of care managers and clinic characteristics. Generalized linear mixed models assessed associations of care manager background and configuration of staffing with enrollment and remission rates. RESULTS: Enrollment was higher (p=.050) and there was a trend toward higher remission rates (p=.105) at clinics where care managers were dedicated exclusively to depression care. No differences in outcomes were obtained by registered nurses versus certified medical assistants and licensed practical nurses. CONCLUSIONS: Hiring dedicated paraprofessional care managers may maximize the cost-effectiveness of collaborative care programs and should be supported by regulations and reimbursement policies.