Cindy L. Cain

The Power of Community Voices for Enhancing Community Health Needs Assessments.

As required by the Affordable Care Act, Community Health Needs Assessments (CHNAs) are formalized processes nonprofit hospitals must perform at least every 3 years. CHNAs are designed to help hospitals better tailor health services to the needs of local residents. However, CHNAs most often use quantitative, population-level data, and rarely incorporate the actual voices of local community members. This is particularly a problem for meeting the needs of residents who are also racial or ethnic minorities. This article discusses one model for integrating residents’ voices into the CHNA process. In this model, we videotaped interviews with community members and then coded and analyzed interview data to identify underlying themes. We created a short video aimed at starting conversations about community members’ concerns. In addition to demonstrating how other nonprofit hospitals may use qualitative data in the CHNA process, this article illustrates how adding qualitative data may change how we think about health promotion. We find that community members requested that health care providers view culture as a health resource, foster community connections, and be present in the community.

Culture and Palliative Care: Preferences, Communication, Meaning, and Mutual Decision Making

Palliative care is gaining acceptance across the world. However, even when palliative care resources exist, both the delivery and distribution of services too often are neither equitably nor acceptably provided to diverse population groups. The goal of this study was to illustrate tensions in the delivery of palliative care for diverse patient populations to help clinicians to improve care for all. We begin by defining and differentiating culture, race, and ethnicity, so that these terms-often used interchangeably-are not conflated and are more effectively used in caring for diverse populations. We then present examples from an integrative literature review of recent research on culture and palliative care to illustrate both how and why varied responses to pain and suffering occur in different patterns, focusing on four areas of palliative care: the formation of care preferences, communication patterns, different meanings of suffering, and decision-making processes about care. For each area, we provide international and multiethnic examples of variations that emphasize the need for personalization of care and the avoidance of stereotyping beliefs and practices without considering individual circumstances and life histories. We conclude with recommendations for improving palliative care research and practice with cultural perspectives, emphasizing the need to work in partnerships with patients, their family members, and communities to identify and negotiate culturally meaningful care, promote quality of life, and ensure the highest quality palliative care for all, both domestically and internationally.

Helpfulness, Trust, and Safety of Neighborhoods: Social Capital, Household Income, and Self-Reported Health of Older Adults

Background and Objectives Growing literature documents that where you live has an impact on your health, due in part to social capital. Building on social capital literature, we assess how subjective appraisals of neighborhood quality are associated with self-reported health (SRH) for older adults. Research Design and Methods Cross-sectional analysis of the 2014 California Health Interview Survey, a representative survey of diverse, noninstitutionalized California residents. We use three measures of neighborhood quality: trustworthy neighbors, helpful neighbors, and feeling safe. Using weighted ordinary least squares regression, we assess the associations of trust, helpfulness, and safety to SRH, controlling for neighborhood, demographic, and health care variables. We then examine how these associations vary by household income. Results We find that characterizing neighbors as helpful and feeling safe are associated with better SRH, even controlling for community, demographic, and health care variables. However, the importance of these dimensions varies across household income: helpfulness is positively associated, whereas trust is negatively associated with SRH for lower income residents; safety is positively associated with SRH in all but the lowest income residents. These findings show that social capital dimensions work differently from one another, and differentially affect the health of older adults. Discussion and Implications Scholarly analyses of neighborhood effects should include a range of social capital measures and stratify by household income. Our findings may also inform priority setting for social capital programs, especially for older adults with limited economic resources. Policies and programs should consider actions that raise perceptions of helpfulness and safety.

Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women’s health primary care

The Veterans Health Administration (VHA) has undertaken primary care transformation based on patient-centered medical home (PCMH) tenets. VHA PCMH models are designed for the predominantly male Veteran population, and require tailoring to meet women Veterans’ needs. We used evidence-based quality improvement (EBQI), a stakeholder-driven implementation strategy, in a cluster randomized controlled trial across 12 sites (eight EBQI, four control) that are members of a Practice-Based Research Network. EBQI involves engaging multilevel, inter-professional leaders and staff as stakeholders in reviewing evidence and setting QI priorities. The goal of this analysis was to examine processes of engaging stakeholders in early implementation of EBQI to tailor VHA’s medical home for women. Four inter-professional regional stakeholder planning meetings were conducted; these meetings engaged stakeholders by providing regional data about gender disparities in Veterans’ care experiences. Subsequent to each meeting, qualitative interviews were conducted with 87 key stakeholders (leaders and staff). Stakeholders were asked to describe QI efforts and the use of data to change aspects of care, including women’s health care. Interview transcripts were summarized and coded using a hybrid deductive/inductive analytic approach. The presentation of regional-level data about gender disparities resulted in heightened awareness and stakeholder buy-in and decision-making related to women’s health-focused QI. Interviews revealed that stakeholders were familiar with QI, with regional and facility leaders aware of inter-disciplinary committees and efforts to foster organizational change, including PCMH transformation. These efforts did not typically focus on women’s health, though some informal efforts had been undertaken. Barriers to engaging in QI included lack of communication across clinical service lines, fluidity in staffing, and lack of protected time. Inter-professional, multilevel stakeholders need to be engaged in implementation early, with data and discussion that convey the importance and relevance of a new initiative. Stakeholder perspectives on institutional norms (e.g., gender norms) and readiness for population-specific QI are useful drivers of clinical initiatives designed to transform care for clinical subpopulations.

Staff Turnover in Assertive Community Treatment (Act) Teams: The Role of Team Climate

Staff turnover in Assertive Community Treatment (ACT) teams can result in interrupted services and diminished support for clients. This paper examines the effect of team climate, defined as team members’ shared perceptions of their work environment, on turnover and individual outcomes that mediate the climate-turnover relationship. We focus on two climate dimensions: safety and quality climate and constructive conflict climate. Using survey data collected from 26 ACT teams, our analyses highlight the importance of safety and quality climate in reducing turnover, and job satisfaction as the main mediator linking team climate to turnover. The findings offer practical implications for team management.

Changes in Quality of Life Among Enrollees in Hennepin Health: A Medicaid Expansion ACO:

Despite limited program evaluations of Medicaid accountable care organizations (ACOs), no studies have examined if cost-saving goals negatively affect quality of life and health care experiences of low-income enrollees. The Hennepin Health ACO uses an integrated care model to address the physical, behavioral, and social needs of Medicaid expansion enrollees. As part of a larger evaluation, we conducted semistructured interviews with 35 primary care using Hennepin Health members enrolled for 2 or more years. Using fuzzy set qualitative comparative analysis, we assessed enrollee complexity and use of the care model and improvements in quality of life. We found improved quality of life was consistently associated with strong bonds to primary care, consistent mental health care, and support from extended care team members. Comprehensive, integrated care models within ACOs may improve quality of life for low-income Medicaid enrollees through coordinated primary and mental health care.

Identity work within attempts to transform healthcare: Invisible team processes:

Studies have shown that workers’ identities matter for a host of individual and organizational outcomes. However, the question of how identities work becomes more complex when considering settings where workers must negotiate multiple – and sometimes conflicting – identities. Interprofessional healthcare teams are one such setting. Within interprofessional teams, workers are expected to adopt both professional and team-based identities, sometimes leading to confusion and conflicts. Using longitudinal qualitative analyses of healthcare team members’ reflective audio diaries, we document identity work of one team as they attempted to create and adopt a new approach to care. We analyze 176 recordings over 30 weeks and find that: team members experience multiple identification targets more or less conflicting, depending on the organizational context; team members from different professional backgrounds experience identity processes differently; and conflicts with others affect how team members see themselves and one another. These findings enrich our understanding of how multiple identities are reconciled in the workplace, and illustrate hidden aspects of forming and sustaining team-based work.

A mixed methods study of emotional exhaustion: Energizing and depleting work within an innovative healthcare team

ABSTRACT This mixed methods study documents emotional exhaustion experiences among care team members during the development of an innovative team approach for caring for adults with serious illness. A mixed methods study design was employed to examine depleting work experiences that may produce emotional exhaustion, and energizing aspects of the work that may increase meaningfulness of work, thus reducing emotional exhaustion. The population studied included team members involved in care for adults with serious illness (n = 18). Team members were surveyed quarterly over an 18-month period using the Maslach Burnout Inventory (MBI). The MBI measures burnout, defined as the inability to continue work because of the interactional toll of the work. Analyses of MBI data show that although overall levels of burnout are low, 89% of team members reported moderate/high levels of emotional exhaustion during at least one survey period. In order to understand the kinds of work experiences that may produce or ameliorate emotional exhaustion, qualitative interviews were also conducted with team members at the end of the 18-month period. Major qualitative findings indicate that disputes within the team, environmental pressures, and standardisation of meaningful work leave team members feeling depleted. Having authentic relationships with patients, working as a team, believing in the care model, and practicing autonomy and creativity help team members to restore their emotional energy. Supports for team members’ well-being are critical for continued innovation. We conclude with recommendations for improving team members’ well-being.

Labors of Love: Nursing Homes and the Structures of Care Work

Danny winds up in juvenile detention. In this story, as in others, Kemo is a key figure who keeps his distance from Ralph. Ralph knows about him through other people, but doesn’t know him directly. Almost invisible in his narratives, however, are the girlfriends, wives, and children of gang members, although Ralph acknowledges that family members are most often the people who care for wounded ‘‘gang-bangers.’’ The writing in this book is vivid and evocative, almost poetic at times, as Ralph muses on blue lights, tattoos, and railroad ties. He engages with a wide range of literature, both in the text and in forty pages of endnotes. He challenges ‘‘the idea that urban blacks are always already threating’’ (p. 174), an idea that facilitates violence against young men such as Albert Derrion and Trayvon Martin, and calls us to collaborate with Eastwoodians for a more just future. What that collaboration might be is left unspecified, but action on the fallout from the national mortgage crisis and the ongoing Illinois budget crisis, among other issues, come to mind. In his concluding chapter, Ralph asks, ‘‘How does a ‘renegade’ like Danny or Tiko learn to hone and refine a personal story of struggle, like Amy or Justin have done? How does a person mobilize this pent-up potential?’’ (p. 177). His book is not able to offer an answer to this question, probably because he did not set out to do so. An answer to that question might focus on institutional policy, or life trajectories, or systematic comparisons between those who avoid, minimize, or exit gang activity and those who remain in gangs. In the postscript, Ralph reports on a renegade dream come true. In the summer of 2012 an exhibit was mounted on the history of the Divine Knights as a result of a collaboration among Mr. Otis and other residents, a museum, and a university. The following winter, Mr. Otis passed away at the age of 74. It seems likely that the cover photo for the book is from the memorial service in his honor: people gathered in front of a modest frame house, holding candles aloft in the night. Labors of Love: Nursing Homes and the Structures of Care Work, by Jason Rodriquez. New York: New York University Press, 2014. 206 pp.

User-centered design to improve clinical decision support in primary care

24.00 paper. ISBN: 9781479864300.