Health services for women in outpatient substance abuse treatment

OBJECTIVE: To evaluate how a sample of outpatient substance abuse treatment units respond to organizational and environmental influences by adopting and implementing treatment services for women. DATA SOURCES: The National Drug Abuse Treatment System Survey from 1995 and 2000, a national survey of outpatient substance abuse treatment units. STUDY DESIGN: Health services for women are the dependent variables. The predictors include organizational and environmental factors that represent resource dependence and institutional pressures for the treatment unit. Logistic regression and Heckman selection models were used to test hypotheses. DATA COLLECTION: Program directors and clinical supervisors at each treatment unit were interviewed by telephone in 1995 and 2000. PRINCIPAL FINDINGS: Units that depended on specific funding for women's programs and that depended on government funds were more likely to adopt, but not necessarily implement, women's services. Methadone units and units that train more staff to work with women were more likely to adopt as well as implement women's services. Private not-for-profit units were more likely to adopt some services, while for-profit units were less so. However, in general, neither for-profit nor not-for-profit units significantly implemented services. There was evidence that the odds of adopting services were greater in 2000 than 1995 for two services, but were otherwise stable. CONCLUSIONS: There is considerable variation in the adoption and implementation of women's services. In addition, not all adopted services were significantly implemented, which could reflect limited organizational resources and/or conflicting expectations. This also suggests that referral mechanisms to these services, and therefore access, may not be adequate. Government funds and specific funds for women's programs are important resources for the provision of these services. Women's services appear more available in methadone units, suggesting that regulation has been influential and that the recent methadone accreditation system should be evaluated. Staff training may be one strategy to encourage implementation of these services. For the most part, the adoption of services for women did not change between 1995 and 2000.     

Public Health Systems: A Social Networks Perspective

Objective. To examine the relationship between public health system network density and organizational centrality in public health systems and public health governance, community size, and health status in three public health domains.
Data Sources/Study Setting. During the fall and the winter of 2007–2008, primary data were collected on the organization and composition of eight rural public health systems.
Study Design. Multivariate analysis and network graphical tools are used in a case comparative design to examine public health system network density and organizational centrality in the domains of adolescent health, senior health, and preparedness. Differences associated with public health governance (centralized, decentralized), urbanization (micropolitan, noncore), health status, public health domain, and collaboration area are described.
Data Collection/Extraction Methods. Site visit interviews with key informants from local organizations and a web-based survey administered to local stakeholders.
Principal Findings. Governance, urbanization, public health domain, and health status are associated with public health system network structures. The centrality of local health departments (LHDs) varies across public health domains and urbanization. Collaboration is greater in assessment, assurance, and advocacy than in seeking funding.
Conclusions. If public health system organization is causally related to improved health status, studying individual system components such as LHDs will prove insufficient for studying the impact of public health systems.     

The clubhouse as an empowering setting

Attention to psychosocial rehabilitation (PSR) practice has expanded in recent years. However, social work research studies on PSR are not numerous. This study focuses on operational characteristics of clubhouses, a major PSR program model, and the organizational attributes (including resource levels) that predict the extent to which the clubhouse constitutes an empowering setting. The authors present data from a statewide sample of 30 clubhouses, annually serving nearly 4,000 consumers (adults with serious mental illnesses), based on interviews of clubhouse directors, on-site observations, and government information sources. Results indicate that users were predominantly male, white, and middle age; about one-third had a major functional disability. There were wide variations in member characteristics as well as in resource levels. In terms of empowerment, this sample of clubs averaged rather low levels of member involvement in governance and operations but seemed to provide members with opportunities and assistance in making their own decisions. The empowerment variables had different predictors, including client characteristics, urban-related characteristics, staffing, and resource levels. Implications for social work practice in PSR settings are discussed.     

How state-funded home care programs respond to changes in Medicare home health care: resource allocation decisions on the front line

OBJECTIVE: To examine how case managers in a state-funded home care program allocate home care services in response to information about a client's Medicare home health care status, with particular attention to the influence of work environment. DATA SOURCES/STUDY SETTING: Primary data collected on 355 case managers and 26 agency directors employed in June 1999 by 26 of the 27 regional agencies administering the Massachusetts Home Care Program for low-income elders. STUDY DESIGN: Data were collected in a cross-sectional survey study design. A case manager survey included measures of work environment, demographics, and factorial survey vignette clients (N = 2,054), for which case managers assessed service eligibility levels. An agency director survey included measures of management practices. DATA COLLECTION/EXTRACTION METHODS: Hierarchical linear models estimated the effects of work environment on the relationship between client receipt of Medicare home health care and care plan levels while controlling for case-mix differences in agencies' clients. PRINCIPAL FINDINGS: Case managers did not supplement extant Medicare home health services, but did allocate more generous service plans to clients who have had Medicare home health care services recently terminated. This finding persisted when controlling for case mix and did not vary by work environment. Work environment affected overall care plan levels. CONCLUSIONS: Study findings indicate systematic patterns of frontline resource allocation shaping the relationships among community-based long-term care payment sources. Further, results illustrate how nonuniform implementation of upper-level initiatives may be partially attributed to work environment characteristics.     

Evidences on weaknesses and strengths from health financing after decentralization: lessons from Latin American countries

OBJECTIVE: The main objective was to identify trends and evidence on health financing after health care decentralization. STUDY DESIGN: Evaluative research with a before-after design integrating qualitative and quantitative analysis. Taking into account feasibility, political and technical criteria, three Latin American countries were selected as study populations: Mexico, Nicaragua and Peru. DATA SOURCES: The methodology had two main phases. In the first phase, the study referred to secondary sources of data and documents to obtain information about the following variables: type of decentralization implemented, source of finance, funds of financing, providers, final use of resources and mechanisms for resource allocation. In the second phase, the study referred to primary data collected in a survey of key personnel from the health sectors of each country. FINDINGS: The trends and evidence reported in all five financing indicators may identify major weaknesses and strengths in health financing. CONCLUSIONS: Weaknesses: a lack of human resources trained in health economics who can implement changes, a lack of financial resource independence between the local and central levels, the negative behavior of the main macro-economic variables, and the difficulty in developing new financing alternatives. Strengths: the sharing between the central level and local levels of responsibility for financing health services, the implementation of new organizational structures for the follow-up of financial changes at the local level, the development and implementation of new financial allocation mechanisms taking as a basis the efficiency and equity principles, new technique of a per-capita adjustment factor corrected at the local health needs, and the increase of financing contributions from households and local levels of government.     

医疗卫生改革背景下医疗设备管理的思考

目的:探索医疗卫生改革(医改)背景下医院医疗设备管理的组织与实施.方法:通过文献调研和实践经验总结,对医改背景下医院医疗设备的经费保障、设备购置和组织管理进行分析研究.结果:医改背景下医疗设备经费保障应当多元、设备购置注重适宜、组织管理必须规范.结论:公立医院应当主动适应当前我国正在进行的医疗卫生改革,重视并抓好医疗设备管理.     

Implementing QA programs in managed care health plans: factors contributing to success

PURPOSE: The purpose of this paper is to identify the factors that contribute to the success or failure of quality assurance programs implemented by Israeli managed care health plans. DESIGN/METHODOLOGY/APPROACH: An in-depth study of seven quality assurance programs was conducted, comparing successful with unsuccessful ones using the comparative "case study" method. Employing a semi-structured questionnaire, 42 program directors and professionals in the field were interviewed. FINDINGS: A number of factors associated with the programs' success emerged. Those external to the program included: ongoing management support, resource allocation, information system support and perceived financial benefit for the organization. Internal factors included: leadership, perceived problem's importance, laying the groundwork in the field, involving field staff in planning and implementation and staff motivation. ORIGINALITY/VALUE: The study provides insights into ways to encourage the implementation of successful quality assurance programs in the special organizational context of managed care health plans. As the implementation relies heavily on data, one important precondition is the development of computerized information systems to facilitate ongoing data collection. It is also necessary from the planning stage to take into account organizational factors that affect success.     

Program structure and counselor-client contact in outpatient substance abuse treatment

OBJECTIVES: To examine organizational structural attributes associated with counselor-client contact. DATA SOURCES: Data were collected in 2004 and 2005 for a federally funded project, which simultaneously examines organizational structure, functioning, and resources among outpatient substance abuse treatment programs. STUDY DESIGN: The study uses a naturalistic design to investigate organizational structure measures-ownership, accreditation, and supplemental services-as predictors of time in counseling and case management, and caseload size, controlling for geographic differences. DATA COLLECTION: Directors at 116 outpatient drug-free treatment programs located in four regions across the U.S. (Great Lakes, Gulf Coast, Northwest, and Southeast) voluntarily completed a survey about program structure. PRIMARY FINDINGS: Clients received more counseling hours in programs that were "intensive," publicly owned, accredited, and had a lower proportion of recently hired counselors. More case management hours were offered in "intensive," private-for-profit or publicly owned (versus private-nonprofit) programs, serving a lower proportion of dual-diagnosis clients, and providing more on-site supplemental services. Smaller caseloads were found in programs that were accredited and had a smaller average client census and a lower proportion of criminal justice referred clients. CONCLUSIONS: Organizational attributes are related to counselor-client contact and may have implications for staff turnover and service quality.     

Adolescent Substance Abuse Treatment Resource Allocation in Rural and Frontier Conditions: The Impact of Including Organizational Readiness to Change

ABSTRACT:  Context: Rural and frontier states are significantly affected by substance abuse and poverty. The high rate of substance abuse coupled with high levels of dependence on state-funded treatment systems places a burden on rural treatment systems and makes resource allocation a central planning issue. Purpose: The goal of this study was to combine substance abuse treatment need data with organizational readiness to change data to create a rank-ordered listing of residential treatment providers to answer the following questions: Do program priority rankings change when organizational readiness to change is included in a need-based resource allocation algorithm? Methods: Three methodological procedures were used to determine program priority rankings among 14 residential adolescent treatment programs in 8 Wyoming counties: (1) a social indicators analysis of crime data, (2) synthetic estimates of substance abuse treatment need, and (3) analysis of organizational change data from the directors and staff at adolescent residential treatment programs. Findings: Program need rankings based on crime data and synthetic estimates of substance abuse treatment need shifted when organizational readiness to change data was added to the algorithm. Conclusions: There is much to be gained from considering organizational readiness to change when selecting programs for funding. It plays a central role in the successful diffusion of evidence-based practices within and among programs. Including this measure in the resource allocation process can help planners identify programs that will be more apt to adopt a best practice. This is critical for making decisions about where to allocate scarce treatment resources.     

Survival strategies for Michigan's health care safety net providers

OBJECTIVE: To understand key adaptive strategies considered by health care safety net organizations serving uninsured and underinsured populations in Michigan. DATA SOURCES/STUDY SETTING: Primary data collected through interviews at community-based free clinics, family planning clinics, local public health departments, and Federally Qualified Health Centers from 2002 to 2003. RESEARCH DESIGN: In each of six service areas in Michigan, we conducted a multiple-site case study of the four organizations noted above. We conducted interviews with the administrator, the medical or clinical director, the financial or marketing director, and a member of the board of directors. We interviewed 74 respondents at 20 organizations. PRINCIPAL FINDINGS: Organizations perceive that unmet need is expanding faster than organizational capacity; organizations are unable to keep up with demand. Other threats to survival include a sicker patient population and difficulty in retaining staff (particularly nurses). Most clinics are adopting explicit business strategies to survive. To maintain financial viability, clinics are: considering or implementing fees; recruiting insured patients; expanding fundraising activities; reducing services; or turning away patients. Collaborative strategies, such as partnerships with hospitals, have been difficult to implement. Clinics are struggling with how to define their mission given the environment and threats to survival. CONCLUSIONS: Adaptive strategies remain a work in progress, but will not be sufficient to respond to increasing service demands. Increased federal funding, or, ideally, a national health insurance program, may be the only viable option for expanding organizational capacity.     

Infection in social networks: using network analysis to identify high-risk individuals

Simulation studies using susceptible-infectious-recovered models were conducted to estimate individuals' risk of infection and time to infection in small-world and randomly mixing networks. Infection transmitted more rapidly but ultimately resulted in fewer infected individuals in the small-world, compared with the random, network. The ability of measures of network centrality to identify high-risk individuals was also assessed. "Centrality" describes an individual's position in a population; numerous parameters are available to assess this attribute. Here, the authors use the centrality measures degree (number of contacts), random-walk betweenness (a measure of the proportion of times an individual lies on the path between other individuals), shortest-path betweenness (the proportion of times an individual lies on the shortest path between other individuals), and farness (the sum of the number of steps between an individual and all other individuals). Each was associated with time to infection and risk of infection in the simulated outbreaks. In the networks examined, degree (which is the most readily measured) was at least as good as other network parameters in predicting risk of infection. Identification of more central individuals in populations may be used to inform surveillance and infection control strategies.     

The American General Hospital as a Complex Social System

Based on data from and about the medical, nursing, and administrative staffs in a probability sample of general hospitals, involving 41 institutions and some 2,400 respondents, certain aspects of the hospital social system are examined in each of the following basic problem-areas: organizational and member goal attainment; availability and allocation of organizational resources; organizational coordination; social integration; intraorganizational strain; and organizational adaptation. These areas are examined separately and in relation to one another, as a basis for understanding and assessing the overall effectiveness of the hospital as a complex social organization. Hospital effectiveness is viewed in the context of open system theory, as a joint function of the relative success with which the organization handles its problems in these key areas. Findings concerning a number of social-psychological variables in each area are presented and discussed, with emphasis on the interdependence of the areas and on organizational issues and implications. The results show some of the basic strengths and weaknesses of the system. Important differences associated with hospital size and affiliation are also discussed to illustrate the typical profile of the American general hospital and significant variations from it. Similarly, differences among the principal groups in the system are presented, where appropriate. Finally, promising directions for future organizational research in the hospital field are briefly presented.     

Ecological analysis of the first generation of community clinical oncology programs.

OBJECTIVE. An ecological framework is proposed for assessing factors important to consider in allocating funds to promote sound performance of interorganizational programs. DATA SOURCE/STUDY SETTING. This framework is used to examine the first generation of Community Clinical Oncology Programs (CCOPs) funded by the National Cancer Institute (NCI) from 1983-1986 to coordinate clinical research activity at the local level. The research reported is based on secondary data collected for the Community Cancer Care Evaluation at the Fred Hutchinson Cancer Center. STUDY DESIGN. A repeated measures design was used to analyze differences in the level and patterns of CCOP productivity, a measure of the number of patients enrolled on NCI-approved Phase III trials. The predictive dimensions include (1) measures of environmental inputs (population density, organizational dominance, professional support, NCI funding); (2) measures of organizational inputs (number of hospitals, number of staff, number of physicians, NCI experience, clinical research experience); and (3) structural measures (functional specialization, administrative concentration). Predicted relationships were assessed using general linear models procedures. DATA COLLECTION/EXTRACTION METHODS. Data obtained from NCI files were supplemented by interviews with NCI personnel and published statistics. PRINCIPAL FINDINGS. Funding level, clinical research experience, and number of staff are the most important predictors of patient enrollment. Clinical research experience has a positive relationship with patient enrollment and a negative association with changes in enrollment. The reversal is explained by the influence of the CCOPs that had the greatest amount of clinical research experience at the beginning of the program. CONCLUSIONS. The ecological approach provides a useful framework for understanding factors that should be considered in funding interorganizational programs and promoting their development. Most importantly, results suggest that a somewhat different approach is needed to initiate programs rather than to expand existing programs.     

Implementation of Evidence-Based Practice and Organizational Performance

Administrators of mental health services may expect evidence-based practice (EBP) to offer strategic benefits. Existing theory suggests that the benefits of implementing EBP vary by organizational characteristics. This paper presents a conceptual framework for considering how implementation impacts organizational performance. The framework is developed as a system dynamics simulation model based on existing literature, organizational theory, and key informant interviews with mental health services administrators and clinical directors. Results from the simulations show how gains in performance depended on organizations’ initial inertia and initial efficiency and that only the most efficient organizations may see benefits in organizational performance from implementing EBP. Implications for administrators, policy makers, and services researchers are discussed.     

发展型人力资源管理实践对公立医院医务人员创新绩效的影响及中介效应

目的：分析发展型人力资源管理实践对公立医院医务人员创新绩效的影响,以及心理授权和组织认同在其中的中介作用。方法：基于发展型人力资源管理实践量表、创新绩效量表、心理授权量表和组织认同量表对北京市公立医院1 898名医务人员开展问卷调查。利用Amos 23.0软件构建结构方程模型进行中介效应检验。结果：北京市公立医院医务人员的发展型人力资源管理实践、心理授权、组织认同和创新绩效两两之间呈显著正相关;发展型人力资源管理实践会影响创新绩效,总效应为0.605,其中直接效应值为0.205,占总效应的33.88%。同时存在一条间接影响路径,即心理授权的独立中介作用,其中介效应值为0.377;而组织认同的中介效应不显著。结论：发展型人力资源管理实践会直接或间接地通过心理授权影响公立医院医务人员的创新绩效,提示公立医院管理者在提高创新绩效时要尤为重视发展型人力资源管理的作用,并且需特别注意提高医务人员的心理授权。     

Emotion in health care: the cost of caring

PURPOSE: The purpose of this paper is to understand the centrality of emotion, and how that emotion both created and contributed to meaning, in the communication of health professionals who worked in a regional pilot program for cancer screening. DESIGN/METHODOLOGY/APPROACH: As the third phase of a larger study, thematic analysis of semi-structured interviews was carried out with the 19 members of the professional groups, which comprised the service. Brief comments were included from the questionnaire survey in phases 1 and 2 of the study to demonstrate the overflow effects on those served by the organization. FINDINGS: Emotion was found to be a critical component in the communication interface between the groups. The complexity of the way in which emotion was managed with the client group overflowed into the management of the communication process between the professional groups in the organization. However, it was not always recognised, and thus created difficulties for a number of staff. RESEARCH LIMITATIONS/IMPLICATIONS: Although the research was limited to one health-care organization, it is possible that other health professions are experiencing similar situations as they cope with the certainty of unending change. Also, although secondary interviews were carried out to ensure that themes were credible to participants, it is possible that carrying out the interviews in the work environment may have constrained some participants. ORIGINALITY/VALUE: Stresses the importance of the emotional component of communication and how it is recognised to facilitate effective working relationships and support staff coping with change and heavy workloads in health-care organizations.     

Optimal investment in a portfolio of HIV prevention programs.

OBJECTIVES: In this article, the authors determine the optimal allocation of HIV prevention funds and investigate the impact of different allocation methods on health outcomes. METHODS: The authors present a resource allocation model that can be used to determine the allocation of HIV prevention funds that maximizes quality-adjusted life years (or life years) gained or HIV infections averted in a population over a specified time horizon. They apply the model to determine the allocation of a limited budget among 3 types of HIV prevention programs in a population of injection drug users and nonusers: needle exchange programs, methadone maintenance treatment, and condom availability programs. For each prevention program, the authors estimate a production function that relates the amount invested to the associated change in risky behavior. RESULTS: The authors determine the optimal allocation of funds for both objective functions for a high-prevalence population and a low-prevalence population. They also consider the allocation of funds under several common rules of thumb that are used to allocate HIV prevention resources. It is shown that simpler allocation methods (e.g., allocation based on HIV incidence or notions of equity among population groups) may lead to alloctions that do not yield the maximum health benefit. CONCLUSIONS: The optimal allocation of HIV prevention funds in a population depends on HIV prevalence and incidence, the objective function, the production functions for the prevention programs, and other factors. Consideration of cost, equity, and social and political norms may be important when allocating HIV prevention funds. The model presented in this article can help decision makers determine the health consequences of different allocations of funds.     

Three faces of integrative coordination: a model of interorganizational relations in community-based health and human services.

OBJECTIVE. This study develops a theoretically justified, network-based model of integrative coordination in community-based health and human services, and it uses this model to measure and compare coordination in six elder service systems. DATA SOURCES AND STUDY SETTING. We collected data between 1989 and 1991 in six Alabama counties, including two major MSAs, two small MSAs, and two rural areas. STUDY DESIGN AND DATA COLLECTION/EXTRACTION METHODS. Our measurement of coordination is based on patterns of interorganizational relationships connecting the agencies constituting a community-based health and human services system. Within each site, we interviewed representatives from these agencies, asking them to indicate client referral, generalized support, and agenda-setting relationships they had developed with each of the other agencies in the system. Using network analysis procedures we then identified the network associated with each of these organizational functions (i.e., service delivery, administration, and planning) in each site, and we assessed levels of coordination in each network. PRINCIPAL FINDINGS. Our measure of integrative coordination is consistent with other indicators of coordination we derive from our data, suggesting its validity. In addition, levels of integrative coordination across sites for each organizational function are generally comparable. Comparisons across sites show integrative coordination to be consistently highest for service delivery networks and lowest for planning networks. CONCLUSIONS. Previous attempts to assess interorganizational coordination without regard to organizational function are subject to misinterpretation. The differing interorganizational dynamics involved in service delivery, administration, and planning appear to generate different patterns of interorganizational relationships, and different levels of coordination.