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

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

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 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

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

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

Does the Provision of High-Technology Health Services Change After the Privatization of Public Hospitals?

Background: Public hospitals hold a key role in providing health care services especially to individuals without health insurance, those who are partially covered by health insurance, and low income population. However, some of these hospitals have converted to private status. The objective of this study was to assess the effect of the ownership conversion of public hospitals into private status on the provision of high-technology health services. Methods: This study used a non-experimental longitudinal design based on merged secondary data from the American Hospital Association annual survey, the Area Health Resources File, and the Local Area Unemployment Statistics [1997–2013]. The dependent variable “high-technology health services” was measured using Saidin index. There were 492 non-federal acute care public hospitals (n=8,335 hospital-year observations) in our sample, of which 104 (21%) converted to private status (75 converted to private not-for-profit and 29 converted to for-profit hospitals). The independent variable “privatization” referred to ownership conversion from public to either private not-for-profit or private for-profit status. We ran two fixed-effects linear regressions to measure the impact of privatization on high-technology services offering. Results: Our key findings suggested that privatization was associated with a decrease in Saidin index (β=−0.74; P=0.016; 95% CI: −1.34 to −1.38). For-profit privatization was associated with a greater decrease in Saidin index (β=−1.29; P=0.024; 95% CI: −2.41 to −0.17), compared with an insignificant decrease for not-for-profit privatization (β=−0.56; P=0.106; 95% CI: −1.25 to 0.12). Conclusions: Given the excessive cost of high-technology health services and the change in the hospitals’ mission after privatization, privatized hospitals tend to reduce the number of high-technology health services they provide

High Medicaid Nursing Homes: Organizational and Market Factors Associated With Financial Performance

High Medicaid nursing homes (85% and higher of Medicaid residents) operate in resource-constrained environments. High Medicaid nursing homes (on average) have lower quality and poorer financial performance. However, there is significant variation in performance among high Medicaid nursing homes. The purpose of this study is to examine the organizational and market factors that may be associated with better financial performance among high Medicaid nursing homes. Data sources included Long-Term Care Focus (LTCFocus), Centers for Medicare and Medicaid Services’ (CMS) Medicare Cost Reports, CMS Nursing Home Compare, and the Area Health Resource File (AHRF) for 2009-2015. There were approximately 1108 facilities with high Medicaid per year. The dependent variables are nursing homes operating and total margin. The independent variables included size, chain affiliation, occupancy rate, percent Medicare, market competition, and county socioeconomic status. Control variables included staffing variables, resident quality, for-profit status, acuity index, percent minorities in the facility, percent Medicaid residents, metropolitan area, and Medicare Advantage penetration. Data were analyzed using generalized estimating equations with state and year fixed effects. Results suggest that organizational and market slack resources are associated with performance differentials among high Medicaid nursing homes. Higher financial performing facilities are characterized as having nurse practitioners/physician assistants, more beds, higher occupancy rate, higher Medicare and Medicaid census, and being for-profit and located in less competitive markets. Higher levels of Registered Nurse (RN) skill mix result in lower financial performance in high Medicaid nursing homes. Policy and managerial implications of the study are discussed

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

Organizational Culture and High Medicaid Nursing Homes Financial Performance

Background and Objectives: This paper investigates the relationship between organizational culture and financial performance in under-resourced nursing homes (85% or higher Medicaid residents). Research Design and Methods: We tested whether the type of organizational culture (clan, adhocracy, market, and hierarchical) was associated with higher financial performance, measured by the operating margin. Survey data of 341 nursing home administrators were collected in 2017–2018 and merged with secondary datasets with facility and market characteristics. We used multiple regression analysis to test our hypotheses. Results: We found that a market culture was positively associated with higher operating margin. On the other hand, having a clan, hierarchical, or non-dominant culture was associated with lower financial performance, compared to a market culture. Discussion and Implications: Ensuring the financial viability of high-Medicaid nursing homes is important since they provide care to low-income residents and a high proportion of racial/ethnic minorities. Our findings suggest that having a market culture with an external orientation may be associated with better financial performance among these nursing homes