M. Kathryn Stewart

Impact of a smoke-free hospital campus policy on employee and consumer behavior.

Objective. Although smoke-free hospital campuses can provide a strong health message and protect patients, they are few in number due to employee retention and public relations concerns. We evaluated the effects of implementing a clean air policy on employee attitudes, recruitment, and retention; hospital utilization; and consumer satisfaction in 2003 through 2005. Methods. We conducted research at a university hospital campus with supplemental data from an affiliated hospital campus. Our evaluation included (1) measurement of employee attitudes during the year before and year after policy implementation using a cross-sectional, anonymous survey; (2) focus group discussions held with supervisors and security personnel; and (3) key informant interviews conducted with administrators. Secondary analysis included review of employment records and exit interviews, and monitoring of hospital utilization and patient satisfaction data. Results. Employee attitudes toward the policy were supportive (83.3%) at both institutions and increased significantly (89.8%) at post-test at the university hospital campus. Qualitatively, administrator and supervisor attitudes were similarly favorable. There was no evidence on either campus of an increase in employee separations or a decrease in new hiring after the policy was implemented. On neither campus was there a change in bed occupancy or mean daily census. Standard measures of consumer satisfaction were also unchanged at both sites. Conclusion. A campus-wide smoke-free policy had no detrimental effect on measures of employee or consumer attitudes or behaviors.

Recruitment of rural health care providers: a regional recruiter strategy.

CONTEXT Access to care in rural areas is a major problem. Despite more than 20% of the US population residing in these areas, only 9% of physicians practice there. Extensive research has documented multiple issues that affect where physicians decide to locate and maintain practices. Creative strategies have been used to influence these recruitment and retention decisions. An emerging strategy, borne out of the Robert Wood Johnson Foundations Southern Rural Access Program (SRAP), effectively uses a targeted regional approach to assist rural communities and health care facilities in assessing health care needs and recruiting primary care providers. PURPOSE This article examines the issues surrounding recruitment and retention of primary care providers to rural areas and describes the experiences of the regional recruitment strategy in several states and in particular in the Mississippi Delta region of Arkansas. METHODS A case study approach is used to examine the targeted regional recruiter strategy in the Mississippi Delta region of Arkansas. FINDINGS The regional recruiter strategy, which combines traditional recruitment efforts with community development activities, has been successful in recruiting health care providers to rural communities. The cost-effective strategy can be easily replicated in other rural states. CONCLUSIONS Community factors affect provider decisions on practice locations. Addressing community factors in recruitment efforts through community development activities may increase their success.

Family planning provider referral, facilitation behavior, and patient follow-up for abnormal Pap smears.

Objectives. Family planning (FP) clinics are important access points for cervical cancer screening and referrals for follow-up care for abnormal Papanicolaou (Pap) smears for a substantial number of U.S. women. Because little is known about referral and facilitation practices in these clinics or client action based on referrals, we sought to determine FP provider referral and facilitation practices when seeing FP clients with abnormal Pap smear results, and FP client follow-up for abnormal Pap smears due to FP provider referrals. Methods. We conducted a mail survey of Medicaid-enrolled FP providers in Arkansas and Alabama, and conducted a telephone survey with a sample of FP clients of those providers responding to the provider survey. Results. Major provider factors associated with referral included rural location, health department and clinic institutional setting, large Title X practice/clinic size, and high FP clinic focus. Major factors associated with facilitation included rural location, non-physician specialty, health department and clinic institutional setting, and small Title X clinic size. Of women reporting abnormal results, 62.4% reported follow-up care. Of those who received follow-up care, 40.0% received some care and a referral from their FP provider. A major factor associated with clients seeking follow-up care was being told by their FP provider where to go for follow-up care. Age was a major factor associated with clients actually obtaining follow-up care. Conclusions. Where follow-up care is not available at the FP site, referrals are critical and are a major factor associated with whether women seek care for the condition. Interventions to increase follow-up rates should focus on provider and system features, rather than clients.

Health status in the Mississippi River Delta region.

Objectives: The purpose of the study was to determine if and where there were counties with significantly better or poorer health than others in the region. Methods: Using Z scores for 6 mortality-related measures, this study identifies counties within the Delta states with the highest and lowest rates. Results: Although Delta counties account for only 33% of the counties in the eight target states, they represent the majority of counties with the highest mortality measures, and represent the minority of counties with positive health outcomes. Conclusions: These findings confirm the appropriateness of targeting interventions, and help pinpoint places where better health is being achieved despite high poverty and other risk factors, where important lessons can be drawn.

Improving access to capital for health care infrastructure: the experience of the Southern Rural Access Program's revolving loan fund.

Lack of access to affordable capital is a formidable barrier that compromises rural health care infrastructure development in poor rural areas. Commercial lending institutions are often limited in their ability to respond to those needs due to traditional lending criteria: creditworthiness, equity, management ability, experiences, and cash flow or profits. In the Southern Rural Access Program, a development model more frequently used in other sectors has been successfully applied to health care to help clear these hurdles. This paper describes the 5 operational loan funds in Arkansas, Louisiana, Mississippi, South Carolina, and West Virginia receiving support from the Southern Rural Access Program. Two models of loan funds have evolved: those led by health agencies and those led by community development finance institutions whose mission is rural economic development. This paper outlines major distinctive features of these 2 approaches and describes major implementation challenges these loan funds face. Key accomplishments are high-lighted, including the ability to leverage additional resources from state, federal, philanthropic, and private sources through these funds. These loan fund programs provide models for other states interested in improving access to capital to help build the rural health care infrastructure while making health care more economically viable through integration with other community development initiatives.

Health research participants’ preferences for receiving research results

Background: Participants in health research studies typically express interest in receiving the results from the studies in which they participate. However, participants’ preferences and experiences related to receiving the results are not well understood. In general, the existing studies have had relatively small sample sizes and typically address specific and often sensitive issues within targeted populations. Methods: This study used an online survey to explore attitudes and experiences of registrants in ResearchMatch, a large database of past, present, and potential health research participants. Survey respondents provided information related to whether or not they received research results from studies in which they participated, the methods used to communicate the results, their satisfaction with the results, and when and how they would like to receive research results from future studies. In all, 70,699 ResearchMatch registrants were notified of the study’s topic. Of the 5207 registrants who requested full information about the study, 3381 respondents completed the survey. Results: Approximately 33% of respondents with previous health research participation reported receiving the results. Approximately half of respondents with previous research participation reported no opportunity to request the results. However, almost all respondents said researchers should always or sometimes offer the results to participants. Respondents expressed particular interest in the results related to their (or a loved one’s) health, as well as information about studies’ purposes and any medical advances based on the results. In general, respondents’ most preferred dissemination methods for the results were email and website postings. The least desirable dissemination methods for the results included Twitter, conference calls, and text messages. Across all the results, we compare the responses of respondents with and without previous research participation experience and those who have worked in research organizations versus those who have not. Compared to respondents who have previous participation experience, a greater proportion of respondents with no participation experience indicated that the results should always be shared with participants. Likewise, respondents with no participation experience placed higher importance on the receipt of each type of results’ information included in the survey. Conclusion: We present findings from a survey assessing attitudes and experiences of a broad sample of respondents that addresses gaps in knowledge related to participants’ preferences for receiving the results. The study’s findings highlight the potential for inconsistency between respondents’ expressed preferences to receive specific types of results via specific methods and researchers’ unwillingness or inability to provide them. We present specific recommendations to shift the approach of new studies to investigate participants’ preferences for receiving research results.

Why do patients keep coming back? Results of a Readmitted Patient Survey

Hospital readmissions can negatively impact cost and patient outcomes. Predictors of 30-day readmissions have been primarily identified using medical claims data. Reported here are results of a patient survey developed as part of regular hospital quality assurance activities. Two-thirds of patients reported good discharge experiences but were still readmitted. One-third of patients discharged had a post-discharge doctor appointment scheduled; half were readmitted before that scheduled appointment. Results suggest post-discharge experiences could be improved, especially the timing of follow up doctor appointments. Identified weaknesses in the survey process highlight need for engagement of survey methodologists in efforts to understand patient experiences.

Community Engagement in Health-Related Research: A Case Study of a Community-Linked Research Infrastructure, Jefferson County, Arkansas, 2011-2013.

Background Underrepresentation of racial minorities in research contributes to health inequities. Important factors contributing to low levels of research participation include limited access to health care and research opportunities, lack of perceived relevance, power differences, participant burden, and absence of trust. We describe an enhanced model of community engagement in which we developed a community-linked research infrastructure to involve minorities in research both as participants and as partners engaged in issue selection, study design, and implementation. Community Context We implemented this effort in Jefferson County, Arkansas, which has a predominantly black population, bears a disproportionate burden of chronic disease, and has death rates above state and national averages. Methods Building on existing community–academic partnerships, we engaged new partners and adapted a successful community health worker model to connect community residents to services and relevant research. We formed a community advisory board, a research collaborative, a health registry, and a resource directory. Outcome Newly formed community–academic partnerships resulted in many joint grant submissions and new projects. Community health workers contacted 2,665 black and 913 white community residents from December 2011 through April 2013. Eighty-five percent of blacks and 88% of whites were willing to be re-contacted about research of potential interest. Implementation challenges were addressed by balancing the needs of science with community needs and priorities. Interpretation Our experience indicates investments in community-linked research infrastructure can be fruitful and should be considered by academic health centers when assessing institutional research infrastructure needs.

Linking Residents to Long-Term Care Services: First-Year Findings from the Community Connector Program Evaluation

Background: Long-term care (LTC) is a major health policy issue owing to increasing LTC expenditures and the anticipated growth in the aging population. However, accessing LTC services, especially home- and community-based LTC services, is often difficult. Objectives: This manuscript describes the Community Connector Program, the first known program to use a model in which community health workers (CHWs) help to connect adults in need of LTC to such services. We examine the community–university–government agency partnership created to implement and evaluate the program, summarize the evaluation design, and provide first-year implementation results. Methods: Descriptive statistics were used to characterize persons served and services to which persons were connected. The quasi-experimental evaluation design, which is planned to estimate the programs impact on LTC service utilization and costs within the Arkansas Medicaid program, is described. Results: Community Connectors linked 686 persons (92% >18 years, 80% African American, 58% female) to at least one needed service. Only 39% of adults served needed LTC based on an LTC screening tool. Nearly all (93%) adults in need of LTC had health insurance; 53% had Medicare; 37%, both Medicare and Medicaid; and 11%, Medicaid. Community Connectors referred adults in need of LTC to 68 agencies and helped them to connect to services to address an average of two needs per adult. Conclusions: Preliminary results from the first-year implementation evaluation indicate the program is effective in linking persons to needed LTC, although program refinements were made to improve targeting of intended program recipients.

Health research participants are not receiving research results: a collaborative solution is needed

Health research participants want the results of the studies in which they participate but do not typically receive them. Researchers generally express support for sharing results with participants but, in practice, may be unprepared or unwilling to do so. Many funders call for increased dissemination of research results beyond academic and clinical audiences, but few funders sponsor research to improve result sharing with participants. Although the solution appears straightforward (e.g., funders could incentivize researchers to share results with participants), there are critical gaps in knowledge that suggest the need for a more deliberate approach. For example, what ethical or practical concerns discourage researchers from returning results to participants? What exactly do participants plan to do with the results that they would like to receive? What are the best channels of communication for sharing results with particular participant populations? To address these knowledge gaps, we argue for a collaborative process to develop a research agenda related to result sharing with participants. With support and encouragement by funders, such research should evaluate the effects of different types of results (and results from different types of studies) on participants’ behaviors, attitudes, and emotions; it should also examine the researchers’ ethical, financial, logistical, methodological, and skill-related concerns and constraints related to sharing results with participants. Over time, collaborative research between researchers and participants can yield an evolving set of evidence-based guidelines for ethical, effective result sharing with participants.