RECOMMENDED STRATEGIES FOR PUBLIC IN AN ERA OF ACCESS THROUGH THE AFFORDABLE CARE ACT

By

Amanda Thompson

A Research Study Presented to the Faculty of the Department of Public Policy and Administration School of Business and

CALIFORNIA STATE UNIVERSITY, BAKERSFIELD

In Partial Fulfillment of the Requirements for the Degree of

MASTER OF SCIENCE IN HEALTH CARE ADMINISTRAION

Spring 2016

Copyright

By

Amanda Thompson

2016

Recommended Strategies for Public Hospitals in an Era of Access

Through the Affordable Care Act

By Amanda Thompson

This thesis or project has been accepted on behalf of the Department of Public Policy and Administration by their supervisory committee:

R. Steven Daniels, PhD Date First Reader

Chandrasekhar Commuri, PhD Date Second Reader

TABLE OF CONTENTS

Executive Summary………………………………………………………………………………ii Chapter 1. Introduction Background………………………………………………………………………………..1 Statement of the Problem……………………………………………………………….....3 Methods and Procedures of the study……………………………………………………..3 Significance of the study…………………………………………………………………..3 Chapter 2. Literature Review History……………………………………………………………………………………..4 Emergence of Public Hospitals……………………………………………………………5 Medicare and Medicaid…………………………………………………………………....6 Joint Commission and Accreditation……………………………………………………...6 Changing Marketplace………………………………………………………………….....8 Access……………………………………………………………………………………..8 Quality…………………………………………………………………………………….9 Population Health Initiative……………………………………………………………...10 Community Needs Assessment…………………………………………………………..11 Triple AIM……………………………………………………………………………….13 Age Demographics……………………………………………………………………….15 Staff Shortages…………………………………………………………………………...16 Healthcare Initiatives…………………………………………………………………….17 Chapter 3. Evaluation Design Research Design………………………………………………………………………….19 IRB Approval…………………………………………………………………………….20 Data Collection…………………………………………………………………………..20 Data Analysis…………………………………………………………………………….21 Limitations……………………………………………………………………………….22 Chapter 4. Results and Discussion Community Health Needs Assessment…………………………………………………..24 Solutions…………………………………………………………………………………29 Strategies…………………………………………………………………………………31 Conclusion……………………………………………………………………………….32 Chapter 5. Conclusions and Recommendations Conclusions………………………………………………………………………………33 Recommendations………………………………………………………………………..33 References………………………………………………………………………………………..35 Appendix A: IRB……………………………………………………………………………………38 B: List of Tables and Figures…………………………………………………………….39

EXECUTIVE SUMMARY

The Affordable Care Act (PPACA) is having a major impact on many of the nation’s hospitals due to the demand for care, increased revenues, and lower uncompensated care costs for the uninsured (Cunningham et al., 2015). Currently, public hospitals see the bulk of the population and with the PPACA and California opting for the Medi-Cal expansion, have more choices, and public hospitals must find ways to keep their census high in order to stay afloat and compete for healthcare. The research method for this project is applied research of the recommended strategies for public hospitals in an era of the PPACA. The research analyzes data from public hospitals and analyzes age demographics, healthcare access, staffing shortages; community needs assessments, and healthcare initiatives. The report describes and evaluates results of this research to provide public hospitals valuable and meaningful information on improvement strategies for their hospital. Implementing the strategies will allow a hospital to prepare for future changes in healthcare, to operate under a clear vision, to engage and motivate employees, to transform leadership and accountability, and to promote organizational collaboration. Improvement strategies put forth in this report are to:

 Establish an independent governance structure

 Secure local funding sources

 Attract privately-insured patients through branding and strategic staffing

 Implement the Triple Aim Approach to healthcare

 Focus on community needs assessments

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CHAPTER 1

INTRODUCTION

Background

In 2008, Barack Obama became President of the United States. Since the United States was overdue for a change in healthcare, he made his main campaign focus Healthcare Reform.

According to the U.S. Census Bureau, there were 49.9 million uninsured residents in the United

States in 2010 (Coffin et al., 2013). According to the World Health Organization (WHO), the

United States spends more on healthcare per capita than any other industrialized country (Coffin et al., 2013). The United States care system is ranked as the highest cost, 37th in overall performance, 72nd in overall level of health, and 1st in responsiveness.

The Patient Protection and Affordable Care Act (PPACA) became law on March 23,

2010, which was upheld by the Supreme Court on June 28, 2012. This act advocated “healthcare is a right, not a privilege” with main goals of minimizing the number of uninsured Americans and making healthcare available to everyone at an affordable price (Coffin et al., 2013). With full implementation, its reforms are predicted to obtain coverage of 94% of the population.

Approximately 24 million are to remain without coverage. The Affordable Care Act represents an effort to reframe the financial relationship between Americans and the healthcare system to stem the health insurance crisis that has enveloped individuals, families, communities, health care system, and economy as a whole (Rosenbaum, January-February 2011). The ACA has five aims it plans to achieve.

“The first and central aim is to achieve near-universal coverage and do so through shared

responsibility among government, individuals, and employers. The second aim is to

improve the fairness, quality, and affordability of health insurance coverage. A third aim 1

is to improve healthcare value, quality, and efficiency while reducing wasteful spending

and making the healthcare system more accountable to a diverse patient population. A

fourth aim is to strengthen primary health-care access while bringing about longer-term

changes in the availability of primary and preventative health care. A fifth and final aim

is to make strategic investments in the public’s health, through both an expansion of

clinical preventative care and community investments (Rosenbaum, January-February

2011).”

While there are many benefits from the ACA, there are also downfalls and consequences.

Although healthcare has become more affordable for certain population groups and has allowed individuals with pre-existing conditions insurance, it also raised premiums for a lot of people who already had health insurance. Fines have also been enforced for individuals who do not have insurance and the fine has been promised to increase over time. Taxes have increased and the middle class is becoming responsible for subsidizing the poorer populations. Businesses have also started cutting employee hours to avoid covering employees. Businesses with 50 or more full time employees must offer insurance. Businesses are avoiding this buy cutting hours to 30 hours per week instead of the standard 40.

The Affordable Care Act is having a major impact on many of the nation’s hospitals due to the demand for care, increased patient revenues, and lower uncompensated care costs for the uninsured (Cunningham et al., 2015). Since the ACA has anticipated higher patient care revenues, it has decided to make reductions in Medicaid Disproportionate Share Hospital (DSH) payments. These payments support hospitals that serve a large number of Medicaid and the uninsured patients to help the hospital cover the costs of care given that is uncompensated.

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Statement of Problem

The total number of U.S. registered community hospitals is 4,926 (American Hospital

Association, 2006-2016). Currently, public hospitals see the bulk of the California patient population. The state of California opted into the Medi-Cal expansion plan. They cannot turn away any patient without insurance and the Medi-Cal patients must come to their hospital.

Private hospitals do see Medi-Cal patients but transport them to public hospitals once they are stabilized. Governor Brown is pushing toward Medi-Cal being Universal Healthcare for

California. If this happens, patients will be able to choose which hospital they would like to go to. Patients would be able to choose any without having to only go to a . This also leads to the problem of Fee For Service (FFS) taking a cut of 15 percent or more and the reimbursement rates being Medi-Cal capitation rates. With the PPACA and

California opting for the Medi-Cal expansion, public hospitals must figure out ways to keep their census at the hospital high in order to stay afloat. In light of this problem, what are strategies for public hospitals to address?

Methods and Procedures of the Study

The research method for this project will be a review and analysis of recommended strategies for public hospitals in an era of the Patient Protection and Affordable Care Act. The researcher will analyze data from hospital entities, which includes a synthesis of previously completed community needs assessments.

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Significance of the Study

The results of this research will provide public hospitals valuable and meaningful information on strategies for their hospital. Implementing the strategies will allow the hospital to be prepared for future changes in healthcare.

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CHAPTER 2

LITERATURE REVIEW

The purpose of this section is to discuss the history of public hospitals and the need for delivering quality healthcare. The first part of this section is a literature review of the history of public hospitals, concept analysis, and quality analysis. This section will also focus on public hospital strategies to consider in light of healthcare reform.

History of Hospitals

In the 19th century, the United States was a largely rural society. Most American’s gave birth and suffered illness, including at home. Hospitals in the United States emerged from institutions that provided care and custody for the ailing poor. Public hospitals trace their ancestry to development of cities and community efforts to shelter and care for the chronically ill, deprived and disabled. The Nation’s first hospital was founded in 1751. This hospital was

Pennsylvania Hospital and Benjamin Franklin was a key founder of this hospital (Wall, 1998)

Evolution of hospitals in the Western World was influenced by a number of social and cultural developments (Wall, 1998).

During most of the 19th century, only socially marginal, poor, or isolated received medical care in institutions in the United States (Wall, 1998). If the middle or upper class became ill, their families tended to them at home (Starr, 1982; Rosenberg, 1987). This included routine surgeries performed at home. By the late 19th century, society became increasingly industrialized and mobile, and as medical practice grew in sophistication and complexity, the notion that responsible families and caring communities took care of their own become more difficult to apply (Wall, 1998). played a crucial role in the shift from home to hospitals. 5

Privately-supported voluntary hospitals, products of Protestant patronage and stewardship for the poor, were managed by trustees and funded by public subscription, bequests, and philanthropic donations (Wall, 1998) Catholic sisters and brothers were the owners, nurses and administrator of Catholic institutions, which relied primarily on fundraising abilities along with patient fees (Wall, 1998) established proprietary hospitals that supplemented the wealth and income of owners, whereas not-for profit voluntary and religious hospitals took no share of hospital income (Rosenberg, 1987). Physicians also provided the impulse for the establishment of early hospitals as a means of provider and as a source of prestige (Starr, 1982).

Emergence of Public Hospitals

As physicians looked to the future with a new sense of hope, hospitals became symbolic of their new optimism and authority. Public hospitals trace their origins back to the time of the

Civil War. Although federal, state and local governments had given support to hospitals earlier in the century, the government became increasingly important in health care system after the war, adding huge amounts of money to hospital enterprises (Wall, 1998). States and countries established some public hospitals originally, while municipalities established others. Public and not-for-profit hospitals became crucial components to the rapid expanse of the medical field. The

Hill Burton Act of 1947 provided funds for the construction and expansion of community hospitals (Wall, 1998).

All hospitals before the 1920s operated with little to no money. They were a place to go in hopes that illness might be treated and cured. Cost for staff and nurses tended to be lower.

The 1980s witnessed the growth of for-profit hospital networks, resulting in increased vulnerability of smaller not-for profit institutions (Prince, Ramanan, 1994).

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Medicare and Medicaid

Medicare and Medicaid established in 1965 provided money for the care of the aged and the poor (Callahan & Wassunna, 2006). Two serious problems erupted after the law was passed

(Califano, 2015). One of the first problems that arose is that doctors might not participate. The other problem came under the enacted 1964 Civil Rights Act. Hospitals that received federal funds had to be desegregated (Califano, 2015). By 1967 and 1968, misguided assumptions lead to the realization that the rise of healthcare costs was accelerating dramatically. In 1968, the

President’s Special Message to Congress: “Health in America” (Johnson, 1968) sounded the alarm on rising costs and cited major deficiencies. The three deficiencies were:

a) Tilt of insurance policies that encourage doctors and patients to choose hospitalization

b) Fee-for-service system with no strong economic incentives to encourage doctors to avoid

providing care that is unnecessary

c) The fact that hospitals charge on a cost basis, which places no penalty on inefficient

operations.

Joint Commission and Accreditation

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) was founded in 1951 as a private, not-for- profit organization that evaluates and accredits hospital and other healthcare organizations (Patterson, 1995). JCAHO places emphasis on actual performance. The Joint Commission on Accreditation of Healthcare Organizations accredits more than 5,200 hospitals and more than 6,000 other organizations (Patterson,

1995). In 1987, The Joint Commission launched its Agenda for Change (Patterson, 1995).

The objective of this agenda was to create a more modern and sophisticated accreditation

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process that would place emphasis on performance. Three major initiatives of the Agenda for Change involved (Patterson, 1995):

a) Reformulation of Joint Commission standards to emphasize actual organization

performance of important functions;

b) Redesign of the process to provide more interactive on-site evaluation

and education

c) Development of an indicator measurement system (IMSystem) to support

performance improvement in hospitals and other patient care settings

The mission of the Joint Commission is to ultimately improve quality of healthcare

provided. The services they provide are effective, appropriate, timely, efficient,

respectful and responsive. JCAHO meets its mission by (Patterson, 1995);

a) Establishing measures of the performance of healthcare organizations

b) Using the measure to objectively and rigorously evaluate these

healthcare organizations

c) Providing interpretations of measurements both to healthcare

organizations and to the public

d) Provide education and consultation to healthcare organizations and to

others on using the interpreted measurement both for decision-making

purposes and for improving the quality of care and services provided.

Changing Marketplace

The United States is experiencing many changes with one of those changes including the

“graying” or aging of the population. This is one of the most dramatic shifts in the population

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(Berkowitz et al., 2013). By 2030, there will be 72.1 million adults over the age of 65, which is more than twice the amount from 2000 (Berkowitz et al., 2013). With the aging population, there will also be a slight decline in the growth rate between the years 2040 and 2050.

Life expectancy for this Baby Boomer generation has increased more in the last 30 years then ever before. Men can be expected to reach age 84 while women are expected to reach age

86 (Berkowitz et al., 2013). Improved control of infectious and other advances in and have contributed to this increase (Berkowitz et al., 2013). The needs and demands that will be brought forward with the aging population have encouraged the growth of geriatric medicine. Unfortunately, the majority of the aging population will experience chronic disease and impairments in ability to perform activities of daily living (ADLs) (American

Geriatrics Society, 2005). Geriatricians will be the key leaders of change to achieve the goals of geriatric medicine and improve and prepare for health of this population. As the population lives longer, the amount of money the United States spends on healthcare each year increases. Longer lifespans brings more chronic . Currently, the U.S. spends $200 billion a year on

Alzheimer’s disease (Black, 2014). This is just one of many chronic diseases that can occur as the population ages.

Access

The Patient Protection Affordable Care Act brings about access for all. Access now allows individuals to decide which hospital they want to provide their care. They no longer have to go to the public hospital but can choose to go to any private hospital. This creates a new burden for public hospitals because they now have to step up and be just as competitive as any private hospital.

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Quality

Demonstrating the highest standards of healthcare quality should be top priority for healthcare organizations because it increases the likelihood of desired health outcomes for individuals and populations (Institute of Medicine, 2001). The United States healthcare system falls short in quality when comparing to other countries. The Institute of Medicine (IOM) offers six aims to help improve the delivery of healthcare. Healthcare organizations strive to meet the following aims (Institute of Medicine, 2001):

1. Safe: this aim means that safety must be a priority of the system (IOM, 2001).

2. Effective: this aim should match science with neither underuse nor overuse of the best

available techniques (IOM, 2001).

3. Patient-centered: individual patient’s culture, social context, and specific needs deserve

respect, and the patient should play an active role in making decisions about her own

care (IOM, 2001).

4. Timely: unintended waiting that doesn’t provide information or time for healing is a

system defect. Prompt attention benefits both the patient and the caregiver (IOM, 2001).

5. Efficient: constantly seeking to reduce the waste and cost of supplies, equipment, space,

capital, ideas, time, and opportunities (IOM, 2001).

6. Equitable: Race, ethnicity, gender, and income should not prevent anyone in the world

from receiving high-quality care (IOM, 2001).

Population Health Initiatives

Experts hope that the healthcare reform law's requirement that hospitals make their community needs assessments “widely available” to the public will provide greater transparency

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so community stakeholders and local governments can better hold them accountable for providing community health improvement programs and other benefits (Johnson, 2014).

The increase of chronic diseases demands a search for more effective strategies to prevent and manage them (Barr et al., 2003). The Chronic Care Model (CCM) improved functional and clinical outcomes for disease management are the result of productive interactions between informed, activated patients and the prepared, proactive practice team of clinicians and healthcare professionals (Barr et al., 2003). Teams work to improve the four focuses of self- management support, delivery system design, decision support and clinical information systems

(Barr et al., 2003).

Figure 1: Chronic Care Model

Introduction. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.

The influence of social, economic and cultural determinants of health suggests the need for a comprehensive and collaborative approach to improving health (Barr et al., 2003.

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“Population Health Promotion” is becoming a common way to integrate evidence of the broader determinants of health with the actions of health promotion (Hamilton & Bhatti, 1996). An integration of population health into the prevention and management of chronic disease would broaden the chronic care model by directing additional efforts to reducing burden of chronic disease and not just by reducing the impact on those who have disease but by supporting people and communities to be healthy (Barr et al., 2003).

Figure 2: The Expanded Chronic Care Model: Integrating Population Health Promotion

Glasgow, R, Orleans, C, Wagner, E, Curry, S, Solberg, L (2001).

Community Needs Assessment

The Affordable Care Act’s community health needs assessment requirements are intended to ensure tax-exempt hospitals’ responsiveness to their communities priority health needs (Somerville et al., 2015). These community health needs assessments must be conducted and publicized every three years. When conducting a needs assessment, community input is 12

taken into account. The hospital must not define its community in a way that excludes

“medically underserved, low income, or minority populations (Somerville et al., 2015).”

Community health needs assessments identifies hospitals and may enable hospitals to stand out to the community. Needs assessments may prove to be a successful process for entities to showcase their unique strengths that will enable them to identify community-perceived health needs and to develop mechanisms to address these needs (Fields et al., 2013). The following categories are included in a needs assessment:

. Description of community served

. Existing healthcare resources

. Prioritization of the community’s health needs.

Hospitals are also required to develop and execute an implementation strategy for meeting the needs identified in the assessment (Healthcare Executive, 2015). These requirements provide an unprecedented opportunity for health systems, public health departments and community-based organizations to work together to produce one comprehensive community assessment, coordinate planning and leverage such plans to improve population health (Healthcare Executive, 2015).

Non-profit hospitals need to move away from prioritizing their needs on their strengths. A bigger impact is made when you move away from favoring specific services to working collaboratively with the community organizations. Targeting populations that are at highest risk, such as obesity and behavioral health, begins to impact and address the socioeconomic disparities that impact health and healthcare (Healthcare Executive, 2015).

Four ways hospital leaders can improve are listed below, including the community health needs assessment process, community benefit spending and efforts to improve population health in the communities served (Healthcare Executive, 2015).

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a) Conduct a community health needs assessment that effectively captures the

community’s assets and prioritizes health needs.

i. Must clearly define community and identify needs of both

geographic areas and subpopulations (Laderman et al., 2015).

b) Increase collaboration between multiple hospitals, public health departments and

community organizations in a geographical area (Laderman et al., 2015).

i. Successful partnerships require formal documentation of

commitment and focus on both technical and strategic aspects of

work.

c) Create better links between community health needs assessments and the

allocation of community benefit resources.

i. A hospital’s community benefit office can be a champion for

transition to population management (Healthcare Executive,

2015).

d) Measure the impact with a mixed-methods approach and a shared data system.

i. Shared set of measures is useful for hospitals to measure impact

and facilitates aggregating measure to priority area and entire

communities, states, regions and even nationally (Healthcare

Executive, 2015)

Triple Aim Approach

Federal, State, Insurers, and healthcare providers across the nation are moving toward building a person-centered approach to healthcare. Healthcare professionals strive to reach and attain the “Triple Aim” of better health, better outcomes, and lower costs (Albaroudi & Gage,

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2015). A shift in change from focusing on cost containment to value based systems can be seen nationwide. The Triple Aim recognizes the value of family caregivers. Triple Aim can be defined as the following (Albaroudi & Gage, 2015):

a) Better care

a. Improving quality by making care person-centered, reliable and safe.

b) Healthy people/healthy communities

a. Improving U.S. population health by addressing behavioral, social and

environmental determinants of health

c) Affordable care

a. Reducing the cost of quality care

The Agency for Healthcare Research and Quality (AHRQ) has developed steps to make the

Triple Aim approach a reality. The following steps can be a road map to success and are considered six priorities (Albaroudi & Gage, 2015).

a) Reduction of harm in the delivery of care

b) Engagement of each person and family as partners in care

c) Promote effective communication about and coordination of care

d) Promote the most effective prevention and treatment practices for leading cases of

mortality

e) Work with communities to promote health living

f) Make quality care more affordable by developing and disseminating new delivery

methods

The use of family caregivers allows for individuals to remain successful in their communities. Caregivers also contribute to experience of care received for the patients and the reduction of healthcare total costs for that individual. A goal of the triple aim is to move toward a

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focus on the voice of the patient receiving services rather than to remain at specific standards set out by an organization. Development of measures that express the family experience and needs would help ensure the success of the Triple Aim.

Age Demographics

The U.S. population is expected to increase 18 percent between 2005 and 2025, while during the same time the population above the age of sixty-five will increase 73 percent (Colwill,

J et. al., 2008). This group seeks care twice the rate of those under the age of sixty-five. Life expectancy for this Baby Boomer generation has increased more in the last 30 years then ever before. Men can be expected to reach age 84 while women are expected to reach age 86

(Berkowitz et al., 2013).

Figure 3: Number of Persons 65+, 1900 to 2060

Administration on Aging: U.S Census Bureau, Population Estimates and Projections

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Figure 4: Projected Supply and Demand, Physicians, 2008-2020 (All Specialties)

The Looming Doctor Shortage: William Faloon March 2013 Staffing Shortage

The U.S. population is growing rapidly and the trends show an increased use of healthcare services and raise concerns about future shortages (Colwill et al., 2008) By the year of 2025, the nation will be short 35,000 to 44,000 adult-care generalists practicing and general (Colwill et al., 2008).

The shortages will also affect nursing. Lower nurse-to-patient ratios can lead to poor patient outcomes. Inadequate nurse staffing has been associated with adverse occurrences. These occurrences include medication errors, decubitus ulcers, pneumonia, and both post operation and urinary tract infections (Duffield et al., 2003).

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Figure 5: Projected Shortage of Qualified Registered Nurses in USA

The shortage of nurses may create a shift from requiring skilled and knowledgeable nurses to hiring more unskilled workers as a substitute to close the staffing gap. This would increase dissatisfaction amongst nurses and lead to an even greater shortage long term (Dufield et al., 2003).

Countries such as the United States, United Kingdom, Australia, and Canada, have an aging nursing workforce. Many of the nurses were born in the baby boomer generation. This means the most experienced nurses will be leaving the profession at a time when the demand is the highest. As workload increases, generalists in regions with greater supply may accept more patients, but elsewhere will close their practice to new patients (Colwill et. al., 2008).

Healthcare Initiatives

The Institute of Healthcare Improvement has implemented initiatives to be deployed throughout the healthcare industry. The initiatives include the following;

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a) 100 Million Healthier Lives: a global initiative aiming to fundamentally

transform the way the world thinks and acts to improve health and well-being by

2020 (2016 Institute for Healthcare Improvement).

b) Leadership Alliance: an exclusive leadership initiative for ambitious healthcare

system executives and their teams with two jobs to deliver great healthcare and

high value today, and innovate for the emerging health and healthcare models of

tomorrow (2016 Institute for Healthcare Improvement).

c) Triple Aim: imitative to better understand new models that can improve the

individual patient experience and the health of entire communities at a

reasonable per capita cost (2016 Institute for Healthcare Improvement).

d) Person- and Family-Centered Care Initiatives: aimed at building will and

exploring best practice for engaging patients and family members in improving

care, while building a network of patient and family advisors whose experience is

combined with advanced skills in collaborating for improvement (2016 Institute

for Healthcare Improvement).

Performance Improvement Initiatives should be at the forefront of organizations. The framework known as the Three System Approach for performance improvement should be considered in healthcare. The Three System Approach is based on improving measurements and analytics, creating permanent cross-functional workgroup teams who are able to focus on identifying, developing and monitoring the effect of quality improvements, and deploying a data- driven approach to implement evidence-based best practices. These three areas are distinguished by the names: analytics system, deployment system, and content system.

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CHAPTER THREE

EVALUATION DESIGN

Research Design

The purpose of this research is to provide public hospitals with strategies to address healthcare challenges in light of the PPACA. Implementing the strategies will better prepare a hospital for future changes in healthcare. Chapter Two reviewed the literature of hospitals and important changes and challenges that hospitals face. This section will consist of a non- experimental research design, data sample, data collection, data analysis, and approval by the

Institutional Review Board (IRB). This applied research is categorized as a non-experimental program evaluation. Program evaluations are generally done for one or more of the following: program improvement, accountability, knowledge generation, and political ruses or public relations (Rossi, 2004).

a) Program evaluation: Evaluation findings may be intended to furnish information

that will guide program improvement (Rossi, 2004).

b) Accountability: Use of social resources such as taxpayer dollars by human service

programs is justified on the grounds that thee programs make beneficial

contributions to society (Rossi, 2004).

c) Knowledge generation: some evaluations are not intended to directly inform

decisions related to specific programs in place or contemplated but mainly

describe the nature and effects of an intervention for broader purposes and

audiences (Rossi, 2004).

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d) Political ruses or public relations: Sometimes the true purpose of the evaluation,

at least for those who initiate it, has little to do with actually obtaining

information about program performance (Rossi, 2004).

The most common frameworks to program evaluation are needs assessment, assessment of program theory, assessment of program process, impact assessment, and efficiency assessment

(Rossi, 2004). A synthesis of preexisting needs assessment findings and research of Kern County will be the main focus.

IRB Approval and Confidentiality

Prior to conducting research, the Human Subject Protocol was completed and the IRB acknowledged this research study does not involve human subjects. This study is classified as an exempt protocol by the IRB and does not require monitoring by the IRB. The data collection process will solely be web-based research. See Appendix A for IRB approval letter.

Data Collection and Analysis

The data collection process was solely web-based. Data received came from Internet databases consisting of peer-reviewed articles. The articles included in this document will consist of articles related to public hospitals, quality, access, IOM six aims, population health, triple aim, and community needs assessment.

The web-based research databases being used are coming from the Stern Library journals and articles database. These databases include EBSCOhost, Google Scholar, and PubMed to name a few. The major search terms used are as follows: recommended strategies, public hospitals, access, community needs assessments, and affordable care act.

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Content analysis was used to research completed community health needs assessments from organizations to determine findings and recommendations. Content analysis is a research technique used to make replicable and valid inference by interpreting and coding textual material

(Duriau et al., 2007). By systematically evaluating texts (e.g., documents, oral communication, and graphics), qualitative data can be converted into quantitative data. Although the method has been used frequently in social sciences, only recently has it become more prevalent among organizational scholars (Duriau et al., 2007)

The data analysis portion of the research included both qualitative and quantitative measures found by the researcher. The data analysis process incorporated researching the importance and impact of:

. Community Health Needs Assessments in Kern County

. Statistics in Kern County vs. California

. education

. staffing shortages

. Marketing and Branding

Content analysis was used in order to develop a set of categories to recommend certain strategies.

The quantitative elements are age demographics and healthcare demand (patient increase). The qualitative elements are access, which creates more healthcare choices and competition between private and public hospitals, and emerging healthcare initiatives. In analyzing these impacts, the relationship between stakeholders is considered in order to develop recommendations for public hospitals through strategic management.

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Limitations

A limitation of this study is time. Due to project timeframe, the goal of achieving more in-depth analysis on the scope was inhibited. Research found in the community was synthesized to analyze the data to interpret recommendations and strategies. Obtaining data from the public hospital in Kern County was limited. With more data, more elements could have been studied to add more significance to the evaluation. Another limitation to the framework approach of this study is danger of becoming process rather than outcome focused. Lastly, a limitation to this research is information gaps that may impact ability to assess health needs accurately. Since the information used in this research is secondary, there may be gaps in the findings due to timeframes and changing demographics, which can allow for disparities when examining health issues in the community.

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CHAPTER FOUR

RESULTS AND DISCUSSION

The purpose of this chapter is to present findings of the analysis and to discuss implications on strategies for public hospitals. The goal of this study was to determine strategies to help public hospitals during an era where access has changed due to the Affordable Care Act.

Currently, public hospitals see the bulk of the California patient population. The state of

California opted into the Medi-Cal expansion plan. They cannot turn away any patient without insurance and the Medi-Cal patients must come to their hospital. Private hospitals do see Medi-

Cal patients but transport them to public hospitals once they are stabilized. In this chapter, the researcher reviews data from community needs assessments to incorporate recommended strategies.

Community Health Needs Assessment

Community Health Needs Assessments are used to prioritize and identify health needs in the community. With the findings from these assessments, hospitals are able to implement improvement plans and community activities to promote success. In this study, the research used available data to identify problematic conditions. Secondary data was collected from local and county sources addressing demographics and health access. The framework for the community health needs assessment connects public health and prevention, physical, social and economic environment, and the health care system. One of the main components of community health needs assessments involves interviewing and surveying members of the community. These interviews provide significant findings and information.

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In Kern County, there are a handful of large hospitals. Three of them, San Joaquin

Community Hospital, Mercy Hospital and Memorial Hospital conducted a needs assessment for the 2016 year. The analysis of their research came from surveys and primary data collection to validate secondary data findings. The survey questions focused on the following topics: biggest health issues in the community, problems faced accessing health care, where residents are receiving routine health care services, types of services needed in the community, and asking what would make it easier to obtain care. Participants were asked to provide additional comments as well. Analyzing these comments allowed for the process of comparing and combining responses to identify trends and themes. When comparing the outcomes of these surveys between the three hospitals, one of the top three common trends was access to care.

In Kern County, the breakdown of insured vs. uninsured individuals is showed below.

Table 1: Insurance Coverage for Adults, Teens and Children

Insured Uninsured

Kern County 90.9% 9.1%

California 88.1% 11.9%

Source: California Health Interview Survey, 2014

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Table 2: Insurance Coverage by Type of Coverage

Kern County California

Employment-based 37.1% 44.8%

Medicaid 31.8% 22.5%

Private Insurance 12.5% 6.4%

Medicare 9.1% 13.4%

Other Public 0.3% 1.0%

No Insurance 9.1% 11.9%

Source: California Health Interview Survey, 2014

For the finding of access of care and research from EBSCOhost, Kern County ranks 55 out of 58 California counties for clinical care. This includes ratios of population to care providers. The data show significantly fewer primary care physicians and other health providers for its population. As mentioned in the literature review in chapter two, shortages of qualified staff such as nurses and physicians is seen as a growing problem not only at the county level but nationwide.

Table 3: Ratio of Population to Health Care Providers

Kern County California

Primary Care Physicians 2,014:1 1,294:1

Dentists 2,155:1 1,291:1

Mental Health providers 697:1 376:1

Source: County Health Rankings, 2015.

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Delay of care has also influenced access to healthcare. It is important for residents to find a medical “home base” in their community. Having a medical home base will improve continuity of care and eliminate visits to an emergency room that can be deemed unnecessary.

Table 4: Delay of Care

Kern County California

Delayed or no medical care in the last 12 months 7.9% 11.3%

Delayed or no prescription medicine in the last 12 months 8.4% 8.7%

Source: California Health Interview Survey, 2014

Figure 6: Delayed Care for Kern County vs. California

12.00%

10.00%

8.00%

6.00% Kern County California 4.00%

2.00%

0.00% Delayed or no Medical Delayed or no Care Prescription

This can also decrease delay in care because the residents are using their primary care physician.

Health People 2020 is a benchmark mentioned in the literature review section of this study. More than 85.4% of residents in Kern County have reported a regular source of medical care.

However, this is lower than the Healthy People 2020 benchmark of 89.4%.

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Table 5: Sources of Care

Kern County California

Dr. Office/HMO/Kaiser 54.1 60.7% Permanente Community clinic /government clinic / 25.8% 23.0% ER/Urgent Care 2.6% 1.4%

Other 3.0% 0.7%

No source of care 14.6% 14.2%

Source: California Health Interview Survey, 2014

Figure 7: Sources of Care California vs. Kern County California 4 1% 3 5 1% 14%

2 1 23% 61%

Kern County 5 4 14% 3% 3 3% 1 2 54% 26%

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In synthesizing the data from the needs assessments, stakeholders identified barriers to healthcare access. Some of these barriers found in these 2016 Community Health Needs

Assessments included the following:

 At risk families generally do not seek care on a regular basis due to being in

survivor mode; long term health isn’t an investment made (2016 Community

Health Needs Assessment)

 One option for health care, which contributes to long wait times, the need to take

time off work, and concern that there may not be a remedy (2016 Community

Health Needs Assessment).

 Specialty care needed that forces families to go out of the county due to not

having specific specialty in the area (2016 Community Health Needs

Assessment).

 List of doctors under the ACA are given out but doctors really aren’t accepting

that insurance or wait times for appointments are months out (2016 Community

Health Needs Assessment).

 Extreme shortages of specialists including endocrinologists (2016 Community

Health Needs Assessment).

 Shortage of primary care physicians (2016 Community Health Needs

Assessment).

 Difficulty of attracting providers to Kern County due to air quality and hot

summers (2016 Community Health Needs Assessment).

Kern County is a rural area. Right now not every single specialty is routinely needed which causes many families to travel for appointments for some specialty services.

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Solutions

Staffing Shortages

As seen in the data collected from the 2016 Community Health Needs Assessments and

EBSCOhost, physician to patient ratios and nurses to patient ratios are a significant problem. In order to help relieve this issue, hospitals should secure local funding sources. Strong funding can secure resources and help with incentivizing physicians and nurses to come work at your hospital. Due to the geographic area, climate, and air quality concerns, physicians and nurses may require hire pay in order to want to stay here to work. Hiring traveling and/or temporary nurses is beneficial but also more expensive. Another strategy to help staffing shortages is for a public hospital to have its own governance structure. This way, the hospital is not waiting on a board’s approval on staffing. The hospital is able to make decisions promptly when needed.

Specialties

Due to the lack of specialists in Kern County, in order for public hospitals to stay competitive with private hospitals, telemedicine should be mainstreamed into the standard of care process. Specialties such as and Mental Health can be two services that are streamlined to tele-health. In order to be successful, telemedicine should be treated the same as going to see a physician in person. The atmosphere needs to feel the same for the patient. It is important to develop a project plan, manageable milestones, and realistic expectations. Annual evaluations should be conducted to continually improve the program.

Marketing and Branding

Marketing plays a critical role in the success of an organization. In times of growing population and staffing shortages, positive branding can help drive community members to the public hospital over private hospitals. Effective branding can enhance a public hospital’s image and draw quality staff. When completing a Community Health Needs Assessment, different areas

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and trends are addressed that the community believes should be improved. This is the perfect opportunity for a hospital to implement specific improvements into their strategic, business, and marketing plans. Public hospitals can promote and market specialties that they offer that other hospitals may lack.

Education

It is important to provide education to the community regarding their options when it comes to their health. Many members of the community are not sure how insurance works and tend to go straight to the emergency room rather than find or use a primary care physician.

Implementing a Triple Aim approach will allow for patients to be more involved and proactive in their care and promote healthy living and quality of care. As described in Chapter 2, the Triple

Aim approach focuses on better care, affordable care, healthy and happy communities.

Education plays a key role in partnering with the community to promote healthy living and preventive care. Delay of treatment may decrease due to implementation of this strategy.

Implementing questions regarding the knowledge the community has regarding their health into the needs assessment will help hospitals obtain information regarding the specific education needed. This could be how to find a doctor, how to receive screenings, information on health fairs, etc. Bringing in community members and speaking with them will help give them the attention they need and allow them to learn and take information back to their families and the community.

Strategic Planning

It is important for hospitals to implement strategies that address challenges identified in

Community Health Needs Assessments because healthcare in the U.S. is a complex system and difficult to understand for the general public. Strategic planning allows the hospital to operate

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under a clear vision, to engage and motivate employees, to transform leadership and accountability, and allows for organizational collaboration. These elements are all needed in order for an organization to become successful. Strategic plans can cover all areas such as hospital governance, branding, staffing, public funding, and process improvement. It is important for organizations to develop strategic plans, business plans, and marketing plans to set goals and keep the organization on a path to reach the goals. There should be clear alignment between needs assessments and strategic plans. Strategic plans must be continually refreshed to stay current with healthcare advances.

Conclusion

This chapter provided analysis to implement and recommend strategies that will be discussed in Chapter 5.

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CHAPTER FIVE

CONCLUSIONS AND RECOMMENDATIONS

Conclusion

The Affordable Care Act has affected public hospitals and placed financial burden on public hospitals that provide care to low-income patients. In order to stay financially afloat, public hospitals need to follow the Institute of Medicine’s six aims of quality and implement the

Triple Aim Approach to integrate quality healthcare, affordable healthcare, and overall community wellbeing. A Community Health Needs Assessment can provide the framework for strategic improvement plans.

Recommendations

To improve the quality of healthcare provided in the community and encourage the public to choose a public hospital over private, the following recommendations are put forth based on results of the data analysis:

The first recommendation is to establish an independent governance structure. Public hospitals often answer to a board and wait for the boards’ approval when implementing strategies and tactics. An independent structure will allow more flexibility for change and decision-making can be streamlined and more effective.

A second recommendation is to secure local funding sources. This will provide resources for public hospitals to be able to plan and predict. Public hospitals normally break even. Being predictable will allow for implementation of change and growth. Public hospitals can implement proactive billing strategies to align with forecasts and revenue collection efforts.

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A third recommendation is to attract privately insured patients. Public hospitals can achieve this by improving their facilities and rebranding to make the entity more appealing.

Branding is important because it creates brand loyalty, name awareness, and perceived quality.

Strategic staffing efforts can also help in attraction. The common consensus when it comes to hospitals is comfort and wait times. Implementing a strategy to allow effective patient handling will increase the outcome of members wanting to come back to the same hospital. Branding not only increases membership but it also can help enhance image of the work environment and attract physicians and nurses to want to work at the hospital.

The fourth recommendation is to implement the Triple Aim approach to healthcare. This new and innovative approach focuses on better care, affordable care, and healthy and happy communities. The road map includes the following steps in order to be successful; reduction of harm in the delivery of care, engagement of each person and family as partners in care, promote effective communication about and coordination of care, promote the most effective prevention and treatment practice for leading causes of mortality, work with communities in promoting healthy living, and make quality of care more affordable by developing and disseminating new delivery methods (Albaroudi & Gage, 2015).

The final and perhaps most important recommendation is to focus on the Community

Health Needs Assessments. Hospitals are required to perform these but it is important to study the findings carefully and endeavor to incorporate the communities’ wants and needs into strategic plans, business plans, and marketing plans in order to continually set and achieve goals and reach success.

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APPENDIX A

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APPENDIX B

List of Tables

Table 1: Insurance Coverage for Adults, Teens and Children

Table 2: Insurance Coverage by Type or Coverage

Table 3: Ratio of Population to Health Care Providers

Table 4: Delay of Care

Table 5: Sources of Care

List of Figures

Figure 1: Chronic Care Model

Figure 2: The Expanded Chronic Care Model: Integrating Population Health Promotion

Figure 3: Number of Persons 65+, 1900 to 2060

Figure 4: Projected Supply and Demand, Physicians, 2008-2020 (All Specialties)

Figure 5: Projected Shortages of Qualified Registered Nurses in USA

Figure 6: Delayed Care for Kern County vs. California

Figure 7: Sources of Care California vs. Kern County

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