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Brumm, Susan DReadmissions, Telehealth, and a Handoff to Primary Care in Veterans with Diabetes
Doctor of Nursing Practice Degree Program in Population Health Leadership DNP, Xavier University, 2018, Nursing
Diabetes is a disease more prevalent in the veteran population and contributes to higher readmission rates. The Veteran Affairs is the largest integrated health care system in the United States which made it possible to investigate continuity of care from inpatient to outpatient. This project involved the testing of a post-discharge transition program to reduce readmissions and glycated hemoglobin. The model for improvement was the method used and the framework applied was the complex adaptive chronic care which compels change in communication and integration of care. Project aims were to increase collaboration between inpatient and the Patient Aligned Care Team nurses using a written handoff note from an inpatient nurse practitioner who was the diabetes educator after a 30-day transition program. If titration of insulin was still needed after the transition program, the handoff note was sent to a pharmacist. The final aim was to monitor the percentage of patients consenting to telehealth using remote monitoring. Implementation of the project included using small tests of change (plan-do-study-act cycles) and took place from September, 2017 to February, 2018. Process measures monitored were the percentage of patients who had a handoff signed by the nurse or pharmacist and percentage of patients consenting to remote monitoring post discharge. Population outcomes monitored were the percent of uncontrolled diabetes patients who were readmitted 60-days post-discharge and the monthly percentage of patients with glycated hemoglobin >9.0% in the medical center. Readmissions continued a downward trend during the project period. The author recommends continuation of the post-discharge transition care program and further evaluation of costs and benefits

Committee:

Betsy List, PhD, MPH, RN (Committee Chair); Susan Allen, PhD, RN-BC (Committee Co-Chair)

Subjects:

Health Care; Health Care Management; Medicine; Nursing

Keywords:

Transition Care; transitions of care; readmissions; diabetes; telehealth; remote monitoring; veterans; handoff to primary care; inpatient to outpatient; glycated hemoglobin; A1c; integration of care; continuity of care; complex adaptive chronic care

Sigurdsson, HaukurIcelandic Primary Care Physicians’ Perceived Competence in Detection and Treatment of Behavior Disorders
Master of Arts (MA), Bowling Green State University, 2007, Psychology/Clinical
While mental disorders are prevalent in primary health care settings, they often go undetected and untreated. There are no records to be found on studies of the effectiveness of Icelandic primary care physicians in diagnosing and treating mental illness. However, it is likely that the Icelandic primary health care system is not significantly different from systems in other countries that show poor detection and treatment of mental illness. The present study is the first study aimed at evaluating Icelandic primary care physicians’ experience with mental health problems and perceived competence in detection and treatment of behavior disorders. Furthermore, it is the first empirical attempt to assess the need for improved primary mental health care in Iceland. This exploratory study was designed to assess primary care physician’s perception of: 1) Prevalence and significance of different behavior disorders in the primary health care clinics, 2) their ability to detect and treat behavior disorders within the primary health care system, 3) the physician’s access to mental health services as well as quality of communication with mental health professionals, and 4) barriers to adequate mental health care within the Icelandic primary health care system. Main results suggest that Icelandic primary care physicians correctly identify that they, among all health care workers, are the ones seeing the highest proportion of people in the community suffering from mental health problems. They also correctly identify that depression and anxiety are the most prevalent groups of behavior disorders in primary care. However, while they seem to be quite confident in their ability to treat and detect mental illness, extensive amount of research from around the world show extremely poor detection and treatment of behavior disorders in primary care. Most Icelandic primary care physicians view the detection and treatment of mental illness in their clinic as adequate or good. However, most agree that limited time with patients and limited access to mental health professionals are factors that interfere with adequate mental health services in their clinic. Implications for mental health care in the Icelandic primary care system are discussed.

Committee:

William O'Brien (Advisor)

Keywords:

Primary care; Primary care psychology; Primary care physicians; Mental health care; Primary mental health care; Mental illness; Behavior disorders; Perceived competence; Detection; Treatment

Heston, Jennifer L.The Role of Direct Care Workers in Person-Centered Home Care
Doctor of Philosophy, Miami University, 2017, Gerontology
The concept of person-centered care (PCC) has gained increasing attention within the provision of long-term services and supports, particularly within home and community-based services (HCBS). Recent regulatory mandates require that states receiving federal funding must provide HCBS through a person-centered planning process and according to the preferences, values, and goals of consumers. Within HCBS, direct care workers (DCWs) have the most contact with consumers and assist them with intimate personal care and household tasks. This positions DCWs as the crucial link between assessment of consumer preferences and their service delivery experience. Person-centered assessment and service delivery have the potential to provide greater quality of life for HCBS consumers and to streamline service packages to be as efficient and effective as possible. However, a clear understanding of the current home care processes related to consumer preferences is needed. Using qualitative methods, this study examined current processes through which personal preference information is gathered, assessed, communicated, and incorporated into the daily practice of DCWs employed in agency settings. The findings reveal a framework that is helpful in understanding the complex processes associated with HCBS provision, factors that support DCWs in providing PCC, barriers that may affect the ability of DCWs and provider agencies to effectively carry out PCC mandates, and questions related to PCC in home care that may have philosophical, ethical, and legal implications.

Committee:

Suzanne Kunkel, PhD (Committee Chair); Abbott Katherine, PhD (Committee Member); Applebaum Robert , PhD (Committee Member); Roberts Amy , PhD (Committee Member); Straker Jane, PhD (Committee Member)

Subjects:

Gerontology; Health Care; Public Policy; Social Research

Keywords:

person-centered care; direct care workers; home care; home and community-based services; home care agencies

Austin, Jacob BrendanA Phenomenological Investigation of Physician Job Satisfaction in Rural Integrated Primary Care
Psy. D., Antioch University, 2012, Antioch New England: Clinical Psychology
The job satisfaction of rural primary care physicians is of import given the crucial role these physicians play in rural health care systems and their consistent decline in numbers nationwide. The professional isolation of practicing in rural areas, particularly in accessing specialty care, creates greater burdens for rural physicians than their more urban counterparts, which likely contributes to their low level of job satisfaction. The shortage of mental health providers in rural areas in particular is thought to create a burden for rural primary care physicians, who generally neither have the time, training, nor expertise to adequately deal with complex mental health difficulties. Thus, integrated primary care—the provision of mental health services in the clinical flow of primary care medicine through the employment of behavioral health consultants—might reasonably improve rural physician satisfaction. Due perhaps to the novelty of this practice in rural primary care clinics, little research has examined this idea. This study uses a qualitative methodology—interpretive phenomenological analysis—to explore how rural physicians in integrated primary care settings experienced this innovative practice. Connections of this practice to physician job satisfaction are discussed, as are the implications toward facilitating this service in rural primary care practices. Limitations of this study are considered and directions for future research suggested. This research concludes with a personal reflection on my experience as a trainee in a rural integrated primary care clinic.

Committee:

James Fauth, PhD (Committee Chair); Thomas Stearns, PhD (Committee Member); Amanda Houle, PsyD (Committee Member)

Subjects:

Clinical Psychology

Keywords:

Primary Care Behavioral Health; Rural Integrated Primary Care; Integrated Primary Care; Primary Care Physician Job Satisfaction; Rural Physician Job Satisfaction

Riggs, Jennifer SueThe Influence of Home Care Nursing Visit Pattern on Heart Failure Patient Outcomes
Doctor of Philosophy, Case Western Reserve University, 2009, Nursing
The relationship between patient characteristics, frontloading nursing visits and home care heart failure (HF) patient outcomes was investigated in this descriptive correlational study, guided by Andersen’s Behavioral Model. Patient characteristics were age, gender, race (predisposing), Medicaid, primary caregiver (enabling), prior hospitalization, HF severity, and comorbidity (need). Frontloading nursing visits was the health service variable. Patient outcomes were dyspnea, oral medication management and activities of daily living (ADL) status at home care discharge and hospitalization during the home care episode. CMS OASIS, home health claims and Medicare Provider Analysis and Review data were merged to construct the 2005 national Medicare-certified home health HF patient population (N=82,258). Logistic regression was used for the dyspnea, oral medication and hospitalization models; multiple regression was used for ADL status.The study population was elderly (mean age 81 years), mostly (62.5%) female and white (83%). Comorbidity was prevalent, but the overlap of comorbidity, disability and geriatric syndromes revealed the extent and complexity of multimorbidity of this patient population. Key findings indicated that older patients were less likely to have dyspnea on discharge, while older patients were more likely to need assistance with oral medication management at discharge. Older age and being female were associated with more ADL impairment at discharge, while baseline ADL status was a very weak predictor. The association between frontloading and the dyspnea and medication outcomes was weak; no significant association was identified with the ADL outcome. For the hospitalization outcome models, findings indicated that patients with Medicaid, more severe HF and more baseline ADL impairment were more likely to have a hospitalization during home care while patients with a prior hospitalization were less likely. Patients who received frontloading were considerably less likely to have a hospitalization. Findings of this study may inform practice and policy. Nursing assessment on home care admission may assist nurses and managers to identify patients at higher risk for selected outcomes, including hospitalization. Future studies need to clarify and extend our knowledge about nursing sensitive outcomes of home care and the effect of frontloading on outcomes for heart failure and other home care patients.

Committee:

Elizabeth Madigan, PhD (Committee Chair); Siran Koroukian, PhD (Committee Member); Shirley Moore, PhD (Committee Member); Susan Tullai-McGuinness, PhD (Committee Member)

Subjects:

Gerontology; Health Care; Nursing

Keywords:

home health care; skilled home care; home health care nursing; home care nursing; heart failure

Perazzo, Joseph DTranslating the News: A Grounded Theory of Care Initiation by Individuals Living with HIV
PhD, University of Cincinnati, 2015, Nursing: Nursing - Doctoral Program
Background: Despite tremendous advances in HIV treatment, less than 30% of the more than 1 million people living with HIV in the US are achieving optimal treatment outcomes. Researchers have recognized that there is an urgent need to understand factors and processes that influence individuals with HIV to initiate HIV care. Purpose: The specific aims of the study were to develop a theoretical framework to explain the psychosocial process of care initiation in individuals living with HIV to identify the critical junctures, defined as pivotal events reported by study participants, that influence individuals living with HIV in their decision to initiate HIV care Methods: Grounded theory was the method used to analyze in-depth interviews with individuals living with HIV. A team of IRB-approved researchers analyzed the data using three levels of coding: Open coding, selective coding, and theoretical coding. Analysis was conducted with an aim of identifying the psychosocial process of care initiation by individuals living with HIV. Results: 30 individuals living with HIV (28 men, 2 women) participated in the study. Participants shared their stories about how they went from learning that they had HIV to the point of HIV care initiation. The core category discovered in the data was concept of HIV as news. News, by definition, is impactful information that was not previously known that is delivered by one party and received by another. Participants described a process in which they progressed through five distinct stages: a) receiving the news, b) interpreting the news, c) incorporating the news, d) acting on the news, and e) moving beyond the news. Each stage was moderated by influential factors including perceived susceptibility to HIV infection, symptoms, HIV information, and feedback from others. The initial receipt of the news was typically interpreted as `bad news’. However, through reflection, interaction with others, and information seeking, participants learned that HIV was not a death sentence and that there are treatment options available to them. In effect, the participants were able to translate the news, often beginning as something bad, but changing into something good. The constructed framework is known as “Translating the News: A Grounded Theory of HIV Care Initiation” Conclusion: Individuals who are diagnosed with HIV often encounter a myriad of challenges at the point of diagnosis. Individuals are able to move through the care initiation process with fewer complications when they are provided with encouragement and information, particularly about their treatment options. The key to successful care initiation is helping individuals with HIV to realize that while the diagnosis may seem like bad news, there is also good news: HIV is not a death sentence.

Committee:

Donna Martsolf, Ph.D. R.N. (Committee Chair); Judith Feinberg, M.D. Ph.D. (Committee Member); Donna Shambley-Ebron, Ph.D. (Committee Member)

Subjects:

Nursing

Keywords:

HIV;Care Initiation;Grounded Theory;HIV Care Factors;HIV Care;HIV Care Theory

Yao, XiaoxiDo Long Work Hours Impede Workers’ Ability to Obtain Health Services?
Doctor of Philosophy, The Ohio State University, 2014, Public Health
Background: Currently, Americans receive only about half of the recommended health care. The Patient Protection and Affordable Care Act expands health insurance coverage to nearly everyone and eliminates patient cost-sharing for many preventive services. However, individuals may still face difficulties in obtaining needed care (e.g., language and cultural issues, lack of qualified practitioners, and having no usual source of care). Individuals may also forgo obtaining health care because they are busy with other competing activities and commitments, such as working in jobs having especially long work hours. Purpose: My dissertation aims at ascertaining whether working long hours diminishes workers’ ability to obtain needed health services. This dissertation contains three studies. Study 1 aims at assessing whether long work hours impede workers’ access to preventive health services. A secondary aim is to examine whether this relationship varies among occupations or industries. Study 2 aims at assessing for workers with diabetes, whether working long hours impedes their ability to obtain needed diabetes and preventive health services. Study 2 also examines whether that relationship varies by gender. A third aim is to assess if the relationship between long work hours and access to preventive health services varies according to whether the workers have diabetes or not. Study 3 focuses on dual-earner couples who both work full time, and examines the effects of the combined work hours of a couple on access to preventive health services. Secondary aims of Study 3 include whether the relationship varies by family type (e.g., couples with no child, one child, two or more children) and by gender. Methods: Data from the 2002-2010 Medical Expenditure Panel Survey (MEPS) were used to measure employees’ work hours and their use of selected health services. Multivariate logistic regression analyses were performed to test the association between long hours and service utilization among full-time workers with private health insurance. Results: Employees working over 60 hours per week were significantly more likely to fail to obtain dental check-ups at least twice a year or a biennial mammogram. Among workers with diabetes, working long hours had no impact on access to diabetes services, but significantly impeded their access to regular preventive health services. Long work hours also have a much larger adverse impact on access to preventive health services for workers with diabetes compared to those without diabetes. Long combined work hours of a dual-earner couple create barriers for individual workers to obtain flu vaccinations. The effect is especially evident among women with at least one young child and among women with two or more children. Conclusions: The study found that long work hours might create barriers to accessing particular preventive health services. Certain sub-populations of full-time workers, such as workers with diabetes and dual-earner couples with children, are especially at high risk of not receiving care owing to the need to work long hours. Employer programs should be considered that help reduce the need for excessively long work hours and help facilitate access to recommended preventive services.

Committee:

Allard Dembe (Advisor); Thomas Wickizer (Committee Member); Bo Lu (Committee Member)

Subjects:

Health Care; Occupational Health; Public Health

Keywords:

Long Work Hours, Access to Health Care, Barriers to Care, Preventive Health Care, Chronic Care, Diabetes, Time Pressure, Dual-Earner Couples, Mammogram, Dental Check-up, Flu Vaccination, Overtime, Work-Family Conflict, Number of Children, Age of Children

McCune, Susana LauraineWorlds of Connection: A Hermeneutic Formulation of the Interdisciplinary Relational Model of Care
Psy. D., Antioch University, 2015, Antioch Seattle: Clinical Psychology
Despite a general agreement across health care disciplines that Advanced Care Planning (ACP) and Advanced Directives (ADs) add important elements to a patient's end-of-life care desires, and can inform their loved ones and advocates, help create ease of mind, and enhance quality of care, they continue to remain significantly underused. More than half of Americans transition to chronic and terminal illness without having completed them. The aim of this study was to increase the frequency and enhance the quality of communication about Advance Directives and Advance Care Planning within the clinical relationship. The resulting Interdisciplinary Relational Model of Care (IRMOC) can help clinicians engage in more frequent and effective communication about ADs and ACP. This ontological hermeneutic study considered scholarly and professional, practice-based health services literature, along with juridical, legislative, policy, and philosophical texts that have informed previous models of care. Tacit and explicit phenomena, conditions, and practices of communication about ADs and ACP in the patient-clinician relationship were identified. In response to the phenomena, conditions, and practices identified in this study the IRMOC was formulated and applied to communication about Advance Directives and Advance Care Planning in the patient clinician relationship. The IRMOC was then expanded, made more nuanced, and contextualized within the overall philosophical, theoretical, and practical frameworks that informed the model. The electronic version of this dissertation is at OhioLink ETD Center, www.ohiolink.edu/etd

Committee:

Philip Cushman, PhD (Committee Chair); Mary Wieneke, PhD (Committee Member); Judith Gordon, PhD (Committee Member)

Subjects:

Aging; Clinical Psychology; Communication; Counseling Psychology; Gerontology; Health Care; Health Education; Health Sciences; Medical Ethics; Medicine; Oncology; Philosophy of Science; Psychology; Psychotherapy; Public Health Education; Therapy

Keywords:

Advance care planning; advance directives; end-of-life care; psychology; relational psychoanalysis; compassion; communication; hermeneutics; Interdisciplinary Relational Model of Care; aging; gerontology; health care; health education; medical ethics

Cloud-Buckner, Jennifer M.Managing Patient Test Data in Primary Care: Developing and Evaluating a System for Test Tracking to Enhance Processes, Safety, and Understanding of Performance
Doctor of Philosophy (PhD), Wright State University, 2012, Engineering PhD

Patient testing is vital for primary care and serves as a gateway to specialty healthcare. Patient safety is worsened when testing orders (e.g., laboratory, imaging orders) are not tracked, results are lost, or abnormal results lack patient notification and follow-up. Non-standardized testing management reduces resilience; affects clinical outcomes; and increases errors, costs, workload, and delays.

To address the need for testing management improvements, this research followed four phases in six objectives: (1) In Phase I initial survey, assess perceptions, attitudes, and behaviors of practicing healthcare clinicians and administrators about testing, safety, and technology; (2) In Phase II system design, design a low-cost system prototype that manages primary care testing processes for individual patients, supports safety and resilience, and measures overall clinic testing performance for continuous improvement efforts; (3) In Phase III laboratory experiment, evaluate system prototype for effectiveness in managing testing management processes, including test ordering, results review, notification, and tracking; (4) In Phase III, evaluate effectiveness of technology specifically designed to enforce, support, nurture, and measure safety- including individual safety awareness, attitudes, actions, resilience, and safety culture; (5) In Phase III, evaluate effectiveness of the testing management system prototype for increasing understanding of overall clinic testing performance; (6)In Phase IV clinical review, evaluate a revised prototype with primary care clinicians for its perceived effectiveness and potential for process, safety, and performance improvements.

This research resulted in a test management system prototype that was effective in managing and standardizing testing processes; showed effectiveness for some aspects of safety, situation awareness, and resilience; and was effective in developing user understanding of clinic performance in testing processes. This system can be used for future product development.

Based on theories of resilience, organizational and safety culture, systems safety, and situation awareness, this research also contributes to an increased understanding of requirements to design health information technology that enforces, supports, nurtures, and measures safety.

Committee:

Jennie J. Gallimore, PhD (Advisor); Craig M. Harvey, PhD, PE (Committee Member); Yan Liu, PhD (Committee Member); Pratik J. Parikh, PhD (Committee Member); Rosalyn P. Scott, MD, MSHA (Committee Member)

Subjects:

Engineering; Health Care; Health Care Management; Industrial Engineering; Information Technology

Keywords:

testing management; clinic management; situation awareness; resilience; patient safety; quality of health care; delivery of health care; primary health care

Kim, So-YunThe effect of long-term care insurance on the first nursing home entry and home care use: using duration analysis
Doctor of Philosophy, The Ohio State University, 2009, Family Resource Management

The main purpose of this study was to examine whether Long-Term Care Insurance (LTCI) ownership causes moral hazard in the Long-Term Care (LTC) market. By accounting for the endogeneity of LTCI ownership and LTC utilization, this study explored the unbiased effect of LTCI ownership on LTC utilization using duration analysis. In addition, this study presented the determinants of LTCI purchase and those of first LTC use of the elderly.

Using the longitudinal data from 1998-2004 HRS (Health and Retirement Study), the first LTC use among the elderly who are 65 and older were analyzed. Two duration models were employed accounting for the endogeneity of LTCI purchase and LTC use: Cox model used lagged LTCI values and the discrete time model used the LTCI values predicted in the two-stage estimation. Findings from the two models were very consistent.

Based on the two-period utility model, this study estimated LTCI purchase and first LTC use. As for LTCI purchase, the elderly with higher income and non-housing assets were more likely to buy LTCI. Denying the concern of adverse selection in the LTCI market, those who had poor health conditions were less likely to buy LTCI. And those who had informal caregivers were less likely to purchase LTCI, implying that informal care and formal LTC are substitutes.

LTCI ownership increased the use of nursing home care, indicating some moral hazard in the nursing home care. And no moral hazard was found in the home care market. Medicaid eligibility significantly increased LTC use, while income and non-housing assets had negligible effect on LTC utilization, suggesting that financial resources are not important factors that determine LTC use. In addition, health limitations substantially increased LTC use, and availability of informal caregivers decreased the probability of using LTC.

With the findings that LTCI ownership would not generate substantial moral hazard in the LTC market, this study provideed evidences to support the policy initiatives to expand LTCI market to reduce public LTC spending. In addition, policy implications to secure LTC market and expand LTCI market were discussed.

Committee:

Gong-Soog Hong (Advisor); Catherine P. Montalto (Advisor); Kathryn Stafford (Committee Member); Robert Scharff (Committee Member)

Subjects:

Health Care

Keywords:

long-term care; nursing home; home care; long-term care insurance; Cox's model; discrete time model; Health and Retirement Study

Stock, Kathryn MREHABILITATION STAFF PERCEPTIONS OF END-OF-LIFE CARE IN LONG-TERM CARE FACILITIES
Master of Arts, Miami University, 2007, Speech Pathology and Audiology
The purpose of this study was to identify case load size, utilization of services, overall stress levels and the overall clinical perspectives of rehabilitation professionals working with end-of-life (EOL) patients. Results revealed few rehabilitation professionals worked on palliative care teams and rehabilitation professionals reported low numbers of EOL care patients on caseloads. Eighty-five percent of the participants perceived they had a role to play in EOL care. EOL care education, years experience and field of practice were not significant predictors of rehabilitation staff stress levels. No significant difference was found between the three professional groups’ perceptions of key factors influencing quality-of-life, suggesting an overall agreement between perspectives related to professional roles and the goals of the rehabilitation team in EOL care.

Committee:

Laura Kelly (Advisor)

Keywords:

End-of-Life Care; Palliative Care; Rehabilitation Services; Long-Term Care Facilities

Abramson, Beth S.How Managed Behavioral Health Care Impacts Psychotherapeutic Practices
Psy. D., Antioch University, 2012, Antioch New England: Clinical Psychology
The cost of health and mental health care is a growing problem for the United States. Managed care evolved as a way to continue providing quality services in a cost-effective fashion. In the mental health field, some individuals believe managed care reduces the quality of treatment. This exploratory study investigates current sentiments among mental health clinicians regarding managed care’s impact on mental health treatment and looks at how clinicians practice in light of managed care’s guidelines for treating patients. This study explores the current impact of managed care compared with managed care’s first detectable impact in the 1980s.

Committee:

Victor Pantesco, EdD (Committee Chair); David Hamolsky, PsyD (Committee Member); William Slammon, PhD (Committee Member)

Subjects:

Clinical Psychology

Keywords:

managed care; managed behavioral health; ethics and managed care; attitudes and managed care

Dunning, DebraSeamless service: Collaboration and partnership of a non-publicly funded child care organization located within a site with multiple publicly-funded agencies
Doctor of Philosophy, The Ohio State University, 2004, Human Development and Family Science
This research study is a two-year ethnographic study examining the nature of collaboration, its development through stages and its relevance in the real-life collaboration of a multi-children and family publicly funded agencies and non-publicly funded child care. Along with studying the nature of the collaboration and its development is the individual story of the child care organization and how it fits into the site and its story. This study builds on the premise of a sociocultural perspective by taking a comprehensive look across contexts; situating itself in multiple layers which are independent yet interrelated. It further builds on the “situated perspective” on the individual story of the one of the agencies involved in the collaboration who is fundamentally different from the other agencies in that it is not publicly funded. The collaboration is analyzed by comparing the developmental stages of collaborations as shown in the research literature and by historical documents and interviews from key stakeholders in the collaborative process of the site. The individual story of the child care organization is told by the teachers and represents their “voice” in that this story is theirs. Along with the teachers’ viewpoint, observations in the classroom and key stakeholders collaborate the feelings and perceptions that the child care staff feels in being marginalized as child care workers. The study extends the literature base on collaboration by re-conceptualizing the development of collaboration from a linear pathway to a circular pathway surrounded by multiple contexts in which the partnership is situated and located. Thinking of collaboration as an on-going development path that should be re-visited throughout the life of the collaboration will help this particular partnership to continue to grow and develop throughout the years. It will also help this particular partnership and others who try to replicate a similar partnership among agencies and organizations to continually re-invest in the vision, the mission statement and to remember the historical contexts in which the collaboration effort was formed, developed, implemented and evaluated.

Committee:

Patrick McKenry (Advisor)

Keywords:

CHILD CARE; YWCA; COLLABORATION; CHILD; teachers; child care workers; CARE

Baidoo, RhodalineToward a Comprehensive Healthcare System in Ghana
Master of Arts (MA), Ohio University, 2009, International Development Studies (International Studies)

Presently, Ghana is confronted with a health crisis, driven by enormous burden of diseases and poverty. The current health care system, predominantly modern, has proven inept in meeting the needs of Ghanaians as many continually die from preventable diseases. The quality of services available, the geographical access to this care, efficiency of service delivery, and availability of adequate resources to finance and sustain health systems, have placed unnecessary barriers to access available care in Ghana. Continuous decline of health care has consistently failed to compliment the increasing population growth. As a result, the deteriorating healthcare system has forced the majority of the population to seek alternative healthcare services. Traditional health care system, which is the oldest medical system in the country, has once again become the initial avenue of accessing care for about 75% of the population. Traditional health care system is effective, cost-effective, culturally accepted, and have consistently been argued as an effective system that can aid and complement governments’s efforts at ensuring equitable health care. Yet, it remains unintegrated into the current health care structure, and hence remains untapped.

This study sought to analyze and evaluate the importance of full integration of traditional health system as a way of maximizing health care accesses, use, and availability to the public. The study identifies the historical trends of both health care systems, reviews current health policies and examines the benefits of integrating traditional health care system into the mainstream health care delivery.

The method employed in this study was qualitative one, using semi-structured interviews to gather data. Thirty-three respondents consisting of 12 individuals and 2 focus groups (from Tema Municipality), and 8 key informants (government officials and traditional healers), who uses or have knowledge about the traditional health care system, were selected for this study.

Research findings from in-depth interviews indicated that traditional health care system is widely used, inexpensive, effective with fewer side effects, and easily available and accessible to majority citizens. The results of this study also indicated that traditional health care system is culturally accepted, as it is guarded by a shared local knowledge system that instructs its proper use. The majority of respondents are overwhelming in favor of a policy driven integration process, citing the possible socio-economic benefits of that such an integrated health care system will provide.

Committee:

Francis E. Godwyll, PhD (Committee Chair); Mandi Chikombero, PhD (Committee Member); Thomas Smucker, PhD (Committee Member); Jie Li Li, PhD (Advisor)

Subjects:

Health; Health Care; International Relations; Public Health

Keywords:

Ghana health policy; Traditional medicine; Herbal medicine; Modern health care system;health care integration; traditional health care system

Nelson, Heather McKayWhat Matters Most: PASSPORT Home Care Aides' Views on Ohio's Initial Steps to Implement Person-centered Care
Master of Gerontological Studies, Miami University, 2015, Gerontology
The purpose of this research was to document the experiences of the PASSPORT home care aides in using What Matters Most: A Guide for my Support and Care (WMM) developed by Scripps Gerontology Center. The WMM Guide, pilot-tested in southern Ohio, provides a formal structure to document a consumer’s needs, strengths, goals and service preferences. Data were collected through semi-structured interviews with seven home care aides. Findings revealed that all of the home care aides found value in the information, especially if the WMM Guide is received prior to the start of services. Second, while they were not familiar with person-centered care terminology, they all described an approach to care that is consistent with person-centeredness. Third, provider level buy-in for person-centered care, supported through training and policy change, will be essential to the success of this initiative.

Committee:

Suzanne Kunkel (Committee Chair); Joan Fopma-Loy (Committee Member); Jane Straker (Committee Member)

Subjects:

Aging; Gerontology; Health Care

Keywords:

person-centered care; home care aides; home health care; home and community based Medicaid waiver programs

Siders, Rebecca AnnVoices from the Inside: Gender and the Meaning of Care
Doctor of Philosophy, Case Western Reserve University, 2016, Sociology
In the current reality of care work, what gets counted as care is unilaterally imposed upon care-recipients. As passive consumers of care services, recipients are almost universally treated in the caregiving literatures as irrelevant to the systemic social processes that frame the discourse of care. This is paradoxical in that the recipient is the sole object of the care process. This dissertation is concerned with the relation of the meaning of care to the recipient, specifically, residents in long-term care (LTC). It departs from previous research by shifting the traditional resident as an “object of care” to a “human actor with expertise” in the matter of care. A central premise is that LTC cannot claim to understand care adequately without the perspective of residents. The purpose is to understand when residents are cared-for and identify what they mean when asked about care. Only then can care providers improve quality care.

Committee:

William Dannefer (Committee Chair); Gunhild Hagestad (Committee Member); Eva Kahana (Committee Member); Peter Whitehouse (Committee Member)

Subjects:

Sociology

Keywords:

care, care recipient, elder, residents, long-term care, MDS,

Chouteau, Wendy AUse of a Portable Medical Summary to Provide Continuity across Systems of Care as Youth with Medical Complexity Transition to Adult Care
Doctor of Nursing Practice Degree Program in Population Health Leadership DNP, Xavier University, 2018, Nursing
Children with special health care needs are surviving into adulthood in increasing numbers, as improvements in care and treatments increase the likelihood of survival. A technical brief published by the Agency for Healthcare Research and Quality reports more than 750,000 of children with medical complexity transition to adult care every year. Fewer than half have the resources needed to adequately make the transition successfully (McPheeters et al., 2014). The use of a portable medical summary was recommended in a Consensus Statement by the AAP, AAFP and ACP in 2002 (American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine [AAP, AAFP, ACP-ASIM], 2002) and by Got Transition/Center for Health Care Transition Improvement as part of the “Six Core Elements for Health Care Transition” (National Alliance to Advance Adolescent Health, 2014, p. 2). The purpose of the project was to increase the number of Pediatric Medical Complexity Algorithm (PMCA) Tier 2 and 3 patients, aged 16-24, who were seen each week for well care or chronic care management visits that have a portable medical summary updated in the past six months from zero to 90%. In this scholarly project, PDSA cycles were used to test the feasibility and usefulness of the portable medical summary, an electronic tool developed in the electronic health record, and shared with families. The portable medical summary was evaluated by providers and families and their feedback led to modifications for its improvement. By the conclusion of this DNP project, there was an increase to 100% of youth who had a portable medical summary initiated.

Committee:

Susan Allen, Ph.D. RN-BC (Committee Chair); Betsy List, Ph.D. MPH RN (Committee Member)

Subjects:

Health Care; Health Care Management; Nursing

Keywords:

Transition to adult care; Portable Medical Summary; Medical complexity; Children and youth with special health care needs; Patient summary; Transfer of care; Chronic illness

Vincent, Alexander C.What Do People Entering the Field of Long-Term Care Administration Need to Know?
Master of Arts, Miami University, 2012, Gerontology
Given the rapidly changing world of long-term care and the evolving role of administrators and the regulatory standards they are required to meet, it is not clear what new administrators coming into the field need to know to practice effectively. The purpose of this study is to learn out what people entering the field of long-term care administration need to know from licensed administrators. This qualitative study used a three-pronged approach to examine: required curriculum for administrators (Core of Knowledge, Administrator in Training, and licensure testing), relevant texts on effective long-term care administration, and advice about effective practices from seasoned administrators. Seven administrators participated in in-depth interviews. Findings indicate that administrators felt they lacked knowledge in many key areas including: knowing the scope of what the job entails, personnel management, financial management, and documentation. They also stressed that love of older residents was a key component of job success.

Committee:

Kathryn de Medeiros, PhD (Committee Chair); Suzanne Kunkel, PhD (Committee Member); Robert Applebaum, PhD (Committee Member)

Subjects:

Aging; Gerontology; Health Care Management

Keywords:

long-term care administration; long term care; core of knowledge; health care administration; aging; administrator training

Dean-Haidet, Catherine AnneThanatopoiesis: The Relational Matrix of Spiritual End-of-Life Care
Doctor of Philosophy, The Ohio State University, 2012, Comparative Studies

Contemporary research practices in palliative medicine attempt to reduce, define, and study spirituality in end-of-life care with “scientific rigor” by isolating what counts as “spiritual.” Contrary to this move, informants from multisite hospice and bereavement spaces in this ethnographic study insist that encounters with death and dying lead to irreducible transformations that cannot be quantified or objectively defined. I argue that humans are irreducibly beings-in-relation (intimacy) rather than essentially isolated individuals (integrity), and thus “spiritual end-of-life care” necessitates attention to fluid, inextricably woven personal and relational processes. The thick social matrix of end-of-life scenarios supports the use of research methods and ethical models that acknowledge the contingent, particular, culturally embedded nature of humans as beings-in-relation. To that end, contemporary scholarship in the study of religion and feminist ethics can contribute much to debates about spirituality in end-of-life care.

This study specifically analyzes relational orientations between the living and the dead to illustrate complex transformations during mourning. Using Thomas Kasulis’s intimacy/integrity heuristic to analyze ethnographic interview texts, I argue that the death of a beloved other ruptures relational boundaries and destabilizes the mourner’s imagined relation to the self, to the deceased, and to others. Narratives attest to oscillation among a range of wildly fluctuating relational orientations, yet suggest that internal relation to the deceased persists long after the death. Informants report intense affective dynamics akin to “labor,” yet these are interpreted as continued intimacy with the deceased. Esoteric experiences are framed tentatively, yet mourners see them as comforting “true signs” of connection to the deceased. Beliefs about death are speculative, personal, eclectic, and do not rely on participation in a religious tradition, yet all informants believe in “something,” most notably a belief in loving relation. These complex and fluid features of transformed relation in end-of-life care resist attempts to be objectified, reduced, contained, or isolated as is customary in scientific investigations.

Researchers in end-of-life spiritual care must be open to the inability of the human to be objectively and statically defined, reduced, bound, or understood in isolation from others in co-emerging cultural processes. These findings suggest that some feminist models are more suited to end-of-life dilemmas than principle-based ethical models. Principle-based ethics that construct the human as an independent, autonomous, and rational being fall apart in end-of-life settings where illness often renders the dying person unable to make decisions. The ethics of care assumes relation is ontologically basic to human life, and accept dependence and interdependence as realities in end-of-life scenarios, paving the way for collaborative decision-making in circles of care.

In the final analysis, what matters more than a precise normative definition of spirituality in end-of-life settings is the ability of caregivers to enter into internal relation with the dying person as someone who is inextricably embedded in expansive relational webs. Thus, I suggest that some of the most salient issues in spiritual care involve ways to cultivate capacities for deep listening, compassion, receptivity, and response-ability in caregivers.

Committee:

Thomas Kasulis, Phd (Advisor); Tanya Erzen, Phd (Committee Member); Daniel Reff, Phd (Committee Member)

Subjects:

Religion

Keywords:

thanatopoiesis; mourning; spirituality; end-of-life care; intimacy/integrity heuristic; feminist ethics of care; relation; hospice; palliative care

Visaria, Jay L.A Model Comparing Drug Utilization and Pharmaceutical Expenditures in Community and Mail-Order Pharmacy in a Retiree Population
Doctor of Philosophy, The Ohio State University, 2008, Pharmacy

Pharmaceutical products are distributed through several distribution channels such as retail, hospital, and mail order. Cost containment is the major impetus driving the development of mail order pharmacy. However, currently available empirical evidence that does not support the substitution of community pharmacy by mail order services to reduce overall drug expenditures.

The objective of this study was to compare drug utilization and pharmaceutical expenditures by simulating the effects of community pharmacy on drug utilization for a retiree patient population using mail order pharmacy. The data used for the analysis were pharmacy claims data for the period January 2000-September 2005. Drug claims for each patient were aggregated into courses of drug therapy (CDTs) representing unique patient IDs and unique drug products. Utilization differences between community and mail-order pharmacy were assumed to occur only at the last claim for each CDT. The simulation model employed to estimate the difference in drug utilization using mail-order pharmacy claims data assumed that discontinuation in community pharmacy would follow a random pattern.

A comparison basket of products with at least one claim in both community and mail-order pharmacy during each year from 2000-2005 were selected. Unit costs and expenditures for the medications in the basket were compared across community and mail-order pharmacy.

Seventy two and a half percent of the CDTs dispensed were intended for maintenance therapy and maintenance therapy was more concentrated in mail-order pharmacy as compared to community pharmacy. The use of mail-order pharmacy services resulted in an increase in drug utilization of 2.96% over community pharmacy and a reduction in pharmaceutical expenditures by 10.0-13.0% from 2000-2005. The unit total gross costs in community pharmacy were higher for about half of all products in the comparison basket of products.

The differences in pharmaceutical expenditures between community and mail-order pharmacy were explained by differences in acquisition costs, dispensing fees, and administrative costs. Rebates were not included in the analysis. Decision makers should carefully evaluate the utilization and cost effects that could result from the implementation of mail-order pharmacy programs.

Committee:

Enrique Seoane, PhD (Advisor); Sheryl Szeinbach, PhD, RPh (Advisor); Judith Schwartzbaum, PhD (Committee Member); Rosa Rodriguez-Monguio, PhD (Committee Member)

Subjects:

Pharmaceuticals

Keywords:

pharmacy; pharmaceutical distribution; managed care; mail-order; mail order; community; PBM; pharmacy benefit management; managed care pharmacy; pharmaceutical expenditures; drug expenditures; pharmaceutical utilization; drug utilization

Lindabury, Jennifer KateNursing Home Use Expectations: The Influence of Family Structure
Master of Gerontological Studies, Miami University, 2010, Gerontology
This study analyzes expected nursing home use, and particularly the ways in which family structure is related to expectations. Using data from the 2006 Health and Retirement Study, I use multiple regression analysis to examine how measures of family structure (including daughters and sons, household structure, proximity to family, and previous and current marital status) are related to perceived nursing home risk. Results show that being female, age, ADL limitations, and having long term care insurance are related to increased expectation of use, while subjective health, having a parent or child in the household, or having a daughter are related to decreased expectations of use. Although several factors are related to expectations of nursing home use in ways consistent with actual use, marital status, having living brothers and sisters, and having local family are not significantly related to expected nursing home use. Policy implications of the findings are discussed.

Committee:

Jennifer Bulanda Roebuck (Committee Chair); Robert Applebaum (Committee Member); Ronald Bulanda (Committee Member)

Subjects:

Families and Family Life; Gerontology; Health Care; Nursing; Social Research; Sociology; Womens Studies

Keywords:

expectations; nursing home use; family structure; cohabitation; HRS; caregiving; long term care; long term care insurance; health and retirement study;

Saunders-Adams, Stacey M.Reunification and Reentry in Child Welfare: A Systematic Review and Meta-analysis
Doctor of Philosophy, The Ohio State University, 2011, Social Work
Reunification of children in foster care is one of the most critical times in a child welfare case. If not planned for correctly, returning a child to its family of origin can result in great risk of harm to the child and can subsequently result in reentry to care. Several services designed to increase the likelihood of reunification success have been developed, but few have been subject to rigorous evaluation. In this systematic review and meta-analysis, these services are evaluated to determine if they are effective in increasing likelihood of reunification success. Characteristics of families, children and other supportive services are examined to determine which, if any, impact reunification success. Services and characteristics are described, and some are identified as promising practices. Unfortunately, the quality and quantity of rigorous research limit the ability to draw conclusions about service effectiveness. The only service-related finding that achieved significance was that families who receive supportive services have lesser odds of reunification. Implications for social work research and practice are presented.

Committee:

Denise E. Bronson, PhD (Committee Chair); Rudolph Alexander, Jr. PhD (Committee Member); Tom Gregoire, PhD (Committee Member)

Subjects:

Social Work

Keywords:

reunification; re-entry; foster care; child abuse; neglect; substitute care; systematic review; meta-analysis

Jorina, MariaDeterminants of Satisfaction and Willingness to Recommend: Physician and Patient Perspectives
Doctor of Philosophy, The Ohio State University, 2013, Public Health
Today, when the U.S. health care system is undergoing significant transformations geared towards improving quality of, increasing access to and making more affordable health care services, hospitals are committed to attracting and retaining highly qualified physicians. At the same time, hospitals, in addition to providing excellent care, are interested in attracting new patients. Positive word-of-mouth is believed to be one of the most effective strategies for attracting both qualified physicians and loyal patients. While human resources management literature has demonstrated the link between satisfaction and willingness to recommend, very little research in this area has been conducted in the health care setting. This dissertation project was aimed at developing an in-depth understanding of factors affecting physician and patient willingness to recommend. The project consisted of three studies. The first study was qualitative in design and consisted of 14 interviews with physicians working at a Midwestern Academic Medical Center. The physicians’ views on the factors influencing their job satisfaction were explored. It was discovered that physicians held different beliefs about job satisfaction drivers and the factors associated with job dissatisfaction. Additionally, the respondents identified taking care of patients as being one of the most rewarding aspects of the job. Finally, it was possible to distinguish between factors common among academic medical centers and specific characteristics of the medical center under investigation that were associated with job satisfaction. The second study analyzed data obtained from 1,030 physician satisfaction surveys collected at the medical center during 2009-2011 to measure the impact of various aspects of the work environment and job satisfaction on physicians’ willingness to recommend the medical center as a place of work. A series of logistic regressions revealed that job satisfaction, communication with administration, collaborative efforts between physicians and the medical center to improve quality of care, and physician-nurses collaboration were significantly and positively associated with willingness to recommend. The third study analyzed data from 11,344 patients who were hospitalized at the medical center and completed post-discharge satisfaction surveys between 2009-2011. A series of logistic regressions tested the relationships between various characteristics of the hospitalization experience, satisfaction with care and patients’ willingness to recommend the medical center to others. The analyses demonstrated that overall satisfaction with care, as well as satisfaction with personal aspects of care, tests and treatments, and care delivered by physician were all significantly and positively associated with patients’ willingness to recommend. Additionally, the study tested the relationship between physicians’ job satisfaction and patients’ willingness to recommend. This relationship was not significant. This dissertation project not only provides important insight into physician and patient perspectives on satisfaction and willingness to recommend, but also offers practical guidelines to health care managers, leaders, and physicians on ways hospitals could serve as attractive employers and excellent providers of care.

Committee:

Ann McAlearney, ScD (Committee Chair); Sarah Anderson, PhD (Committee Member); Eric Seiber, PhD (Committee Member)

Subjects:

Health Care Management

Keywords:

job satisfaction; patient satisfaction; willingness to recommend; positive word-of-mouth; academic medical center; patient-centered care; care quality; outcomes measurement; physician-patient relationship; communication

Lark, EliseMaking Space for Dying: Portraits of Living with Dying
Ph.D., Antioch University, 2014, Leadership and Change
In Making Space for Dying: Portraits of Living with Dying, I describe the everyday lived experience of dying and the care culture within freestanding, community-based, end-of-life residences (CBEOLR) utilizing portraiture and arts-based research. I craft four case studies into "portraits," based on interviews, on-site visits, up-close observation, and field notes. In the person-centered portraits, I reveal the inner landscape of two terminally ill women, with data represented in poetry. In the place-centered portraits, I "map" the social topography of two CBEOLRs to illustrate how lives and care of the dying are emplaced, from the perspectives of community leaders, residence staff, volunteers, family members, and residents, with data presented as aesthetic (storied) narrative. Collage and photographs further enhance the text. Little has been written about the meaning of home and the centrality of a home-like environment in the healthcare milieu, specifically in the context of the end-of-life care setting. My research helps to fill a gap in understanding care culture in the freestanding CBEOLR, a care-setting genre rarely examined in the literature. Additionally, my study develops the notion of a "good place to die" and introduces the Home for the Dying, a CBEOLR model unique to New York State. Lastly, building on the literature on liminality, and informed by clinical practice as an oncology social worker, my study specifically highlights the terminal stage of cancer and introduces the concept terminal liminality, characterized by descent. Two broad dimensions emerged: Nesting-in-Being and Nesting-in-Place. Together, these dimensions created a framework for exploring care culture and ways of working with existential suffering. The bird's nest, as a utilitarian though temporal structure, provided an elegant metaphor for the special end-of-life residence. Three linked sub-themes related to care culture emerged, Nest of Simple Things (meaning making), Nest of Belonging (community making), and Nest of Everydayness (home making). Implications for leading change in end-of-life care highlight an initiative to establish and maintain a CBEOLR in my own community. This dissertation contains embedded jpg images and two supplemental files [MP4 video, MP3 audio]. The electronic version of this Dissertation is at AURA, http://aura.antioch.edu/etds/ and OhioLink ETD Center, www.ohiolink.edu/etd

Committee:

Carolyn Kenny, PhD (Committee Chair); Alan E. Guskin, PhD (Committee Member); Carol S. Weisse, PhD (Committee Member); Timothy E. Quill, MD (Other)

Subjects:

Aging; Behavioral Sciences; Families and Family Life; Gerontology; Health Care; Individual and Family Studies; Medicine; Oncology; Public Health; Social Psychology; Social Work

Keywords:

dying and death; community-based end-of-life residence; hospice; home; care setting; care culture; terminal liminality; portraiture; arts-based research; terminal cancer

Womack, Monica S.African-American Students' Perceptions of Their Student-Teacher Relationship with White College Instructors and Academic Achievement While Enrolled in Early College High School
Doctor of Philosophy, University of Akron, 2015, Secondary Education
The primary purpose of this qualitative study was to gain a more in-depth understanding of the student-teacher relationships and academic achievement of seven African American students who are from the millennial generation. This in-depth understanding was based on their perceptions of their student-teacher relationships with White college faculty members while they were enrolled in Early College High School. Early College High School (ECHS) is a specific type of dual enrollment program that provides the opportunity for high school students to enroll in high school and college courses and simultaneously earn their high school diploma and college credits toward an Associate Degree. Students begin their ECHS experience in the ninth grade. The seven participants in this study were all in their senior year of ECHS who had more experiences with White college faculty members at a Predominantly White Institution (PWI) than any other students in the program. Based on the analysis of the transcripts from an interview questionnaire, semi-structured interviews, classroom observations, and a focus group the emergent themes indicated that students perceived their student-teacher relationships as interactive and interpersonal, additionally they defined their personal definition of academic achievement as learning perseverance. The students felt as if their college instructors cared about them authentically which contributed to them working harder; however, caring instructors were less important than the positive self-image they believed academic achievement gave them as African Americans in society and their communities. The concept of care in this study was operationalized through Critical Race Theory, an Ethic of Care, and Womanist Caring.

Committee:

Lisa Lenhart, Dr. (Advisor); Qetler Jensrud, Dr. (Committee Member); Jennifer Milam, Dr. (Committee Member); John Queener, Dr. (Committee Member); Sandra Spickard-Prettyman, Dr. (Committee Member)

Subjects:

African Americans; Education; Secondary Education; Teacher Education; Teaching

Keywords:

African American; millennial generation; care; Critical Race Theory; Ethic of Care; Womanist; Early College High School; Dual Enrollment;

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