Governance Processes and Change Within Organizational Participants of Multi‐sectoral Community Health Care Alliances: The Mediating Role of Vision, Mission, Strategy Agreement and Perceived Alliance Value

Multi‐sectoral community health care alliances are organizations that bring together individuals and organizations from different industry sectors to work collaboratively on improving the health and health care in local communities. Long‐term success and sustainability of alliances are dependent on their ability to galvanize participants to take action within their ‘home’ organizations and institutionalize the vision, goals, and programs within participating organizations and the broader community. The purpose of this study was to investigate two mechanisms by which alliance leadership and management processes may promote such changes within organizations participating in alliances. The findings of the study suggest that, despite modest levels of change undertaken by participating organizations, more positive perceptions of alliance leadership, decision making, and conflict management were associated with a greater likelihood of participating organizations making changes as a result of their participation in the alliance, in part by promoting greater vision, mission, and strategy agreement and higher levels of perceived value. Leadership processes had a stronger relationship with change within participating organizations than decision‐making style and conflict management processes. Open‐ended responses by participants indicated that participating organizations most often incorporated new measures or goals into their existing portfolio of strategic plans and activities in response to alliance participation.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/116987/1/ajcp9618.pd

Does Market Structure Affect Access to Ambulatory Care?: The Relationship Between Provider Supply, Inter-organizational Relationships, and Ambulatory Care Sensitive Hospitalizations.

Adequate access to health services remains a fundamental challenge for the U.S. health care system. Ambulatory care sensitive hospitalizations (ACSH) are increasingly used as indicators of access in health services research. Importantly, most empirical research on ACSH has overlooked or narrowly defined the role of organizations in improving or impeding access. Using a coordination-and-control theoretical framework, this study examined whether the structural characteristics of markets such as provider capacity, provider composition, and inter-organizational relationships affect acute care, chronic care, and aggregate ACSH rates. The study used a longitudinal, pooled cross-sectional design that examined 58 California markets for the years 1998 through 2005. The unit of analysis was the market-year and the final analytic sample included 450 observations. The most robust findings pertained to provider composition, where the ratio of home health agencies, skilled nursing facilities, and physician organizations to hospitals were significantly and negatively associated with ACSH rates. Provider capacity and inter-organizational relationships generally failed to demonstrate significant relationships with ACSH rates. Contrasting results between provider capacity and provider composition suggest that the effects of provider supply may depend upon how supply is measured. Supplementary analysis examined these relationships on a condition-specific basis and suggested that the effects of inter-organizational relationships may be limited to specific clinical conditions. Specifically, the analysis found that the proportion of hospitals with a formal physician organization relationship was associated with higher hospitalization rates for pneumonia, angina, asthma, and congestive heart failure. In contrast, the proportion of hospitals in a market with a formal nursing home relationship was significantly associated with lower hospitalization rates for perforated appendix, angina, asthma, and hypertension. Likewise, the proportion of hospitals in a market that owned an insurance product was associated with lower hospitalization rates for congestive heart failure, chronic obstructive pulmonary disease, and uncontrolled diabetes. These results suggest that the relationship between market structure and ACSH rates may depend upon the medical condition and the type(s) of organizations under study. Overall, these findings raise questions about the appropriateness of combining clinical conditions into aggregated hospitalization rates and the conclusions of studies that use such approaches to study ACSH.Ph.D.Health Services Organization & PolicyUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/64713/1/lrh_1.pd

The Relationship between External Environment and Physician E-mail Communication: The Mediating Role of Health Information Technology (HIT) Availability

Background: Physician e-mail communication, with patients and other providers, is one of the cornerstones of effective care coordination but varies significantly across physicians. A physician's external environment may contribute to such variations by enabling or constraining a physician's ability to adopt innovations such as health information technology (HIT) that can be used to support e-mail communication. Purpose: The aim of the study was to examine whether the relationship of the external environment and physician e-mail communication with patients and other providers is mediated by the practice's HIT availability. Methodology: The data were obtained from the Health Tracking Physician Survey (2008) and the Area Resource File (2008). Cross-sectional multivariable subgroup path analysis was used to investigate the mediating role of HIT availability across 2,850 U.S. physicians. Findings: Solo physicians' perceptions about malpractice were associated with 0.97 lower odds (p < .05) of e-mail communication with patients and other providers, as compared to group and hospital practices, even when mediated by HIT availability. Subgroup analyses indicated that different types of practices are responsive to the different dimensions of the external environment. Specifically, solo practitioners were more responsive to the availability of resources in their environment, with per capita income associated with lower likelihood of physician e-mail communication (OR = 0.99, p < .01). In contrast, physicians working in the group practices were more responsive to the complexity of their environment, with a physician's perception of practicing in environments with higher malpractice risks associated with greater information technology availability, which in turn was associated with a greater likelihood of communicating via e-mail with patients (OR = 1.02, p < .05) and other physicians (OR = 1.03, p < .001). Practical Applications: The association between physician e-mail communication and the external environment is mediated by the practice's HIT availability. Efforts to improve physician e-mail communication and HIT adoption may need to reflect the varied perceptions of different types of practices

The perceived importance of intersectoral collaboration by health care alliances

There is growing interest in the use of intersectoral collaboration (e.g., alliances, coalitions, partnerships) to address complex, health‐related issues in local communities. Relatively little empirical research, however, has examined how to foster and sustain collaboration across sectors during later stages of development, despite a recognition that the needs and goals for collaboration may change over time. The purpose of this study was to address this gap by examining the perceptions of alliance participants regarding the importance of collaborating with different industry sectors as alliances transitioned from stable, prescriptive foundation support to a more uncertain future. Our findings suggest that, in addition to the contextual characteristics highlighted in previous research, the perceived importance of intersectoral collaboration varies for different types of alliances and participants. Moreover, the salience of these characteristics varied for different types of collaboration, in our case, collaboration with nonmedical health care sectors and nonhealth care sectors. Collectively, our findings point to the importance of thinking more comprehensively, across multiple levels of influence, when considering ways to foster or sustain intersectoral collaboration.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149327/1/jcop22158.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149327/2/jcop22158_am.pd

The Challenges of Capacity Building in the Aligning Forces for Quality Alliances

Summarizes the challenges and trade-offs in infrastructure and governance as well as stakeholder relations and participation, such as inclusive versus efficient decision making, in an alliance to coordinate regional healthcare improvement activities

Decision‐Making Fairness and Consensus Building in Multisector Community Health Alliances: A Mixed‐Methods Analysis

Given their inherently diverse composition and potentially competing interests, a foundational activity of community health alliances is establishing consensus on the vision and strategies for achieving its goals. Using an organizational justice framework, we examined whether member perceptions of fairness in alliances' decision‐making processes are associated with the perceived level of consensus among members regarding the alliance vision and strategies. We used a mixed‐methods design to examine the relationship between perceptions of fairness and consensus within fourteen multisector community health alliances. Quantitative analysis found the perceived level of consensus to be positively associated with decision‐making transparency (procedural fairness), inclusiveness (procedural fairness), and benefits relative to costs (distributive fairness). Qualitative analysis indicated that the consensus‐building process is facilitated by using formal decision‐making frameworks and engaging alliance members in decision‐making processes early. Alliance leaders may be more successful at building consensus when they recognize the need to appeal to a member's sense of procedural and distributive fairness, and, perhaps equally important, recognize when one rather than the other is called for and draw upon decision‐making processes that most clearly evoke that sense of fairness. Our findings reinforce the importance of fairness in building and sustaining capacity for improving community health.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/102197/1/21086_ftp.pd

Examining the Relationship between Community Orientation and Hospital Financial Performance

A community orientation strategy may be a socially responsible way for hospitals to simultaneously improve financial performance and community health, in accordance with the Affordable Care Act. Using data from the AHA Annual Survey, AHRF, and CMS Cost Reports, this study examined the association between hospital community orientation and three measures of financial performance, and whether that relationship differs for some types of hospitals. The analysis revealed that hospital community orientation was positively associated with total margin and that not-for-profit hospitals engaging in higher levels of community orientation experienced lower operating margins, on average, relative to for-profit hospital

Engaging patients as partners in research: Factors associated with awareness, interest, and engagement as research partners

Objectives: There is growing interest in engaging patients in healthcare research, which raises important questions about the factors that may promote such engagement. The purpose of this study was to examine the association between patient characteristics and three aspects of patient engagement in the medical research process: awareness, interest, and actual participation. Methods: Cross-sectional, bivariate analyses were employed using the 2014 Health Information National Trends Survey. Results: Analyses suggest modest levels of interest among respondents engaging as patient partners in the research process (37.7% of respondents), low level of awareness of what patient engagement in research was (15.3% of respondents), and a very low level of actual participation (2.7% of respondents). Respondents of higher socioeconomic status and with more positive patient attitudes regarding their health and healthcare were more likely to be interested in research. In comparison, relatively few patient characteristics were significantly associated with patient awareness and actual participation in research. Conclusion: Although it is promising that people are interested in being engaged in research, the results suggest that there is work to be done to raise awareness of these engagement opportunities. Likewise, the gap between awareness and participation highlights opportunities to identify why patients may be reluctant to participate even when they are aware of research opportunities

Charting a Course:A Research Agenda for Studying the Governance of Health Care Networks

Networked forms of organizing in health care are increasingly viewed as an effective means of addressing "wicked", multifaceted health and societal challenges. This is because networks attempt to address these challenges via collaborative approaches in which diverse stakeholders together define the problem(s) and implement solutions. Consequently, there has been a sharp increase in the number and types of networks used in health care. Despite this growth, our understanding of how these networks are governed has not kept pace. The purpose of this chapter is to chart a research agenda for scholars who are interested in studying health care network governance (i.e., the systems of rules and decision-making within networks), which is of particular importance in deliberate networks between organizations. We do so based on our knowledge of the literature and interviews with subject matter experts, both of which are used to identify core network governance concepts that represent gaps in our current knowledge. Our analysis identified various conceptualizations of networks and of their governance, as well as four primary knowledge gaps: "bread and butter" studies of network governance in health care, the role of single organizations in managing health care networks, governance through the life-cycle stages of health care networks, and governing across the multiple levels of health care networks. We first seek to provide some conceptual clarity around networks and network governance. Subsequently, we describe some of the challenges that researchers may confront while addressing the associated knowledge gaps and potential ways to overcome these challenges.</p

Environmental Factors Associated with Physician\u27s Engagement in Communication Activities

BACKGROUND: Communication between patients and providers is a crucial component of effective care coordination and is associated with a number of desired patient and provider outcomes. Despite these benefits, physician-patient and physician-physician communication occurs infrequently. PURPOSE: The purpose of this study was to examine the relationship between a medical practice\u27s external environment and physician engagement in communication activities. METHODOLOGY/APPROACH: This was a cross-sectional examination of 4,299 U.S. physicians\u27 self-reported engagement in communication activities. Communication was operationalized as physician\u27s time spent on communication with patients and other providers during a typical work day. The explanatory variables were measures of environmental complexity, dynamism, and munificence. Data sources were the Health Tracking Physician Survey, the Area Resource File database, and the Dartmouth Atlas. Binary logistic regression was used to estimate the association between the environmental factors and physician engagement in communication activities. FINDINGS: Several environmental factors, including per capita income (odds ratio range, 1.17-1.38), urban location (odds ratio range, 1.08-1.45), fluctuations in Health Maintenance Organization penetration (odds ratio range, 3.47-13.22), poverty (odds ratio range, 0.80-0.97) and population rates (odds ratio range, 1.01-1.02), and the presence of a malpractice crisis (odds ratio range, 0.22-0.43), were significantly associated with communication. PRACTICE IMPLICATIONS: Certain aspects of a physician\u27s external environment are associated with different modes of communication with different recipients (patients and providers). This knowledge can be used by health care managers and policy makers who strive to improve communication between different stakeholders within the health care system (e.g., patient and providers)