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Although social work research is commonly rooted within social service settings, it can be difficult for social work researchers and practitioners to develop and sustain participatory studies that specifically promote knowledge sharing and service improvement involving organisational practice. One participatory approach is practice research (PR), which involves social work researchers and practitioners collaborating to define, understand and try to improve the delivery of health and social care services and organisational structures and processes. The two goals of this commentary are to introduce essential methods and approaches to PR and to identify points of connection involving PR and social service organisational studies. Our specific focus on PR in statutory, voluntary and private social service organisations reflects efforts to connect practice, theory and qualitative and quantitative research methods to develop and share organisationally-situated knowledge.

BACKGROUND: This study examines the use of career ladders for medical assistants (MAs) in primary care practices as a mechanism for increasing wages and career opportunity for MAs. A growing body of research on primary care suggests that successful expansion of support staff roles such as MAs may have positive organizational and quality of care outcomes, but little is known about worker outcomes. OBJECTIVE: Evaluate the effectiveness of career ladders in improving wages and career opportunity among MAs. DESIGN: We use a mixed-methods design to evaluate the impact of career ladders on MA job quality. PARTICIPANTS: We draw on interview data collected from 115 key informants at four large health systems (ranging from 24 to 29 clinics each), and we analyze wage and employment data for MAs from primary care clinics in the four health systems in the sample. APPROACH: We describe the MA career ladder context and infrastructure within primary care clinics and evaluate the rewards to MAs for participation in the career ladder programs. KEY RESULTS: The expanded roles within career ladders for MAs focused on the following four clinical and educational areas: panel management and care coordination, EHR documentation support, supporting delivery of person-centered care, and supervision and training. The three primary components of the career ladder infrastructure were training and education for MAs and providers, credentialing and certification for MAs, and differentiated job levels for MAs. The use of career ladders in the four large health systems in our case study sample resulted in yearly income increases ranging from $3000 to $10,000 annually. CONCLUSION: Investing in career ladders in primary care clinics can improve MA job quality while also potentially addressing issues of equity, efficiency, and quality in the health care sector. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-06814-5.

Background Primary care telephone access has been associated with patient satisfaction and emergency department utilization even after accounting for objective appointment wait times. However, relatively little is known about how to best structure and manage telephone access in primary care. Objective Assess how primary care telephone access is structured and managed and explore how variation in telephone management may affect primary care teams and patients. Design We used 2016 administrative and patient survey data to select six Veterans Administration medical centers (VAMCs) with above-average primary care access (time to third next available appointment) but variable patient-reported access, geographic region, and urbanicity. Semi-structured interviews were conducted August –October 2017. Participants Forty-three key stakeholders knowledgeable about primary care, telephone management, and operational priorities nationally and/or within each VAMC. Key Results Telephone access was organized and managed differently across sites. Regional call centers were perceived as more efficient but less flexible in tailoring processes to meet local needs. Patient preferences for speaking with their own care teams were cited as a reason to manage telephone access locally rather than regionally, particularly in rural sites. Sites with high patient-rated access described call center functions as well-integrated with primary care team workflow, while those with low patient-rated access perceived telephone management practices as negatively affecting primary care team workload. Call center understaffing was a major barrier to optimal telephone access in all six sites, though rural sites reported greater challenges with provider recruitment and retention. Conclusions In VA, efforts to improve telephone access have focused on centralizing call center operations but current call center performance metrics do not account for the extent to which call center functions are integrated with primary care workflows or may impact patient experience. Efforts to improve primary care access should carefully consider impact of telephone management practices on providers and patients.

Policy makers are increasingly investing in programs focused on identifying and addressing the nonmedical needs of high-utilizing Medicaid beneficiaries, yet little is known about these programs’ i...

Recognizing that social factors influence patient health outcomes and utilization, health systems have developed interventions to address patients' social needs. Care coordination across the health care and social service sectors is a distinct and important strategy to address social determinants of health, but limited information exists about how care coordination operates in this context. To address this gap, the authors conducted a systematic review of peer-reviewed publications that document the coordination of health care and social services in the United States. After a structured elimination process, 25 publications of 19 programs were synthesized to identify patterns in care coordination implementation. Results indicate that patient needs assessment, in-person patient contact, and standardized care coordination protocols are common across programs that bridge health care and social services. Publications discussing these programs often provide limited detail on other key elements of care coordination, especially the nature of referrals and care coordinator caseload. Additional research is needed to document critical elements of program implementation and to evaluate program impacts.

The complexity of human service delivery means that contracts are often incomplete or contingent. When contracted services or products are complex, relational contracting can function as a critical informal accountability mechanism. This study introduces and tests a conceptual framework of relational processes and organizational factors hypothesized to inform private human service contract outcomes. Data from a 2015 survey of private nonprofit and for-profit human service organizations in five counties are used to examine factors associated with two proximal indicators of success in human service contracting: commitment to and satisfaction with the contract relationship. Findings provide support for our conceptual framework, highlight the multidimensional nature of trust and commitment, and identify key differences in the relational processes associated with commitment and satisfaction to the contract relationship. Communication quality, trust, and flexibility were associated with satisfaction, whereas interdependence, flexibility, and asset specificity were associated with longer-term commitment to the contract relationship. For-profit ownership was associated with lower commitment and satisfaction. Implications for research and practice are discussed.

Efforts to reform primary care increasingly focus on redesigning care in ways that utilize nonprovider staff such as medical assistants (MAs), but the implementation of MA role redesign efforts remains understudied in the U.S. health care literature. This article draws on rich, longitudinal case study data collected from four health care systems across the United States to examine critical challenges in the planning, implementation, and early sustainment of MA role redesign efforts in primary care. During the planning period, challenges included recruitment of highly trained MAs, compliance with organizational and state regulations regarding MA scope of practice, provision of consistent training across primary care clinics, and creation of career ladders that provided tiered compensation for MAs. During active implementation, challenges included provider training and preventing MA burnout. Strategies for addressing challenges in MA role redesign efforts are discussed, as well as early sustainment of program practices and organizational policies.

Private child and family serving agencies operate within a turbulent environment characterized by changing client needs, interorganizational competition, resource scarcity, and demand for a...

ObjectiveThe study objective was to examine the association between mental health staffing at health centers funded by the Health Resources and Services Administration (HRSA) and patients' receipt of mental health treatment.MethodsData were from the 2014 HRSA-funded Health Center Patient Survey and the 2013 Uniform Data System. Colocation of any mental health staff, including psychiatrists, psychologists, and other licensed staff, was examined. The outcomes of interest were whether a patient received any mental treatment and received any such treatment on site (at the health center). Analyses were conducted with multilevel generalized structural equation logistic regression models for 4,575 patients ages 18-64.ResultsPatients attending health centers with at least one mental health full-time equivalent (FTE) per 2,000 patients had a higher predicted probability of receiving mental health treatment (32%) compared with those attending centers with fewer than one such FTE (24%) or no such staffing (22%). Among patients who received this treatment, those at health centers with no staffing had a significantly lower predicted probability of receiving such treatment on site (28%), compared with patients at health centers with fewer than one such FTE (49%) and with at least one such FTE (65%). The predicted probability of receiving such treatment on site was significantly higher if there was a colocated psychiatrist versus no psychiatrist (58% versus 40%).ConclusionsColocating mental health staff at health centers increases the probability of patients' access to such treatment on site as well as from off-site providers.

Clinical-community partnerships can improve access and receipt of preventive health services in community settings. Understanding how to sustain their potential benefits is warranted. Qualitative case-study of the Faith Community Health Partnership (FCHP), a collaboration between faith-community nurses and community organizations sustained over 25 years. We used content analysis principles to report on partnership sustainability themes identified through semi-structured interviews with FCHP partners (n = 18). Factors supporting partnership sustainability: Maintaining partners' commitment over time; strategic resource-sharing; facilitating engagement; and preserving partnership flexibility. Sustaining clinical-community partnerships is a dynamic and continuous process requiring significant time, effort, and resources on behalf of partners.

Prior research has found that 25% of women veterans who are new to the Department of Veterans Affairs (VA) health care system discontinue services within 3 years of initial use. Although it has been suggested that providing more gender-sensitive care might improve women veterans' health care experiences, no study has yet documented an empirical relationship between clinic and provider factors associated with the provision of gender-sensitive care and women veterans' care discontinuity.Surveys of primary care providers (n = 82) and staff members (n = 108) from 12 VA medical centers were linked to administrative data for women veteran patients with at least one primary care visit in 2014 and 2015 (n = 9,958). Patient care discontinuity was operationalized as having no additional primary care visit within 3 years after the patient's baseline visit. Key indicators of gender-sensitive comprehensive primary care included type of medical home (women's health-focused vs. general primary care), workforce gender sensitivity, team functioning, perceived quality of provider/staff communication, leadership support for medical home implementation, and other structural components of care delivery (e.g., chaperone availability). We used logistic regression to assess the association between these indicators and women's care discontinuity, measuring discontinuity for both new and continuing VA users and controlling for patient characteristics.Eleven percent of women patients discontinued primary care within 3 years. Poor workforce gender sensitivity (lowest quartile vs. top three quartiles) was significantly associated with higher odds of discontinuity (odds ratio, 1.26; 95% confidence interval, 1.01-1.57); other indicators were not associated with discontinuity.This study is the first to document a relationship between workforce gender sensitivity and women veterans' care continuity. This finding underscores the need for additional attention to enhancing workforce gender sensitivity in VA.

RESEARCH OBJECTIVE: Research suggests that about 80% of women veterans receiving care at the Department of Veterans Affairs (VA) have experienced at least one trauma in their lifetimes, including military sexual trauma or combat‐related trauma. Trauma‐sensitive communication reflects an understanding of the impact of trauma and the needs of trauma survivors during health care encounters. We explored whether provider gender sensitivity is associated with positive ratings of trauma‐sensitive communication among women veteran patients. STUDY DESIGN: We conducted cross‐sectional surveys of providers to measure provider gender sensitivity using 10 survey items adapted from the Gender Awareness Inventory‐VA. Example items included “Sometimes I wish VA primary care clinics had only male patients.” We averaged responses in 5‐point Likert scales to create a composite score, with a higher score indicating higher sensitivity. We used cross‐sectional surveys of patients to measure women veterans' perspectives of trauma‐sensitive communication: providers (1) asked about any serious problems or stresses in life (yes vs no), (2) made sure they were comfortable before any treatments or examinations (always vs otherwise), and (3) made them feel comfortable talking about emotional issues (very comfortable vs otherwise). We linked survey responses of providers to women veterans via VA primary care visit information in 2014. We used logistic regression to predict each measure of trauma‐sensitive communication, controlling for women veterans' age, race, and ethnicity, a service‐connected disability, military sexual trauma, physical and mental comorbidities, and primary care and mental health visits in 2014. All analyses were weighted for survey nonresponses. POPULATION STUDIED: A total of 94 primary care providers (PCPs) (33% response rate) and 1395 women veterans (45% response rate) from 12 VA medical centers (VAMCs) completed the surveys between 2014 and 2015. After linking women veterans to PCPs, they had visited for primary care or women's health at the same 12 VAMCs in 2014, and the analyses included 804 women veterans and 58 PCPs who responded to the surveys. PRINCIPAL FINDINGS: Overall, 80.3% of women veterans reported that their PCPs asked about any serious problems or stresses in life, 79.3% reported that PCPs always made sure they were comfortable before any treatments or examinations, and 55.6% felt very comfortable talking with PCPs about emotional issues. After adjusting for covariates, higher provider gender sensitivity score was associated with more women veterans reporting that (1) PCPs asked about any serious problems or stresses in life (AOR: 1.33, 95% CI: 1.08‐1.63), (2) PCPs always made sure they were comfortable before any treatments or examinations (AOR: 1.10, 95% CI: 0.91‐1.34), and (3) they felt very comfortable talking with PCPs about emotional issues (AOR: 1.11, 95% CI: 0.93‐1.30). CONCLUSIONS: Overall, women veterans' ratings of trauma‐sensitive communication were positive. Higher provider sensitivity was associated with greater trauma‐sensitive communication. IMPLICATIONS FOR POLICY OR PRACTICE: Strategies to improve provider readiness to care for women veterans and their gender sensitivity can improve trauma‐sensitive communication with women veterans. PRIMARY FUNDING SOURCE: Department of Veterans Affairs.

BackgroundCross-system interventions can help integrate services across different service delivery systems but require organizations to establish strong collaborative relationships for implementation. Contingency theory suggests that the effectiveness of different collaborative strategies (i.e. specific ways organizations align operations and services) varies by context. This paper describes a study of different strategies for fostering collaboration between child welfare and substance abuse treatment agencies and the conditions under which they are effective for implementation. We also describe the development and piloting of the Collaborating Across Systems for Program Implementation (CASPI) tool—a decision-making guide intended to help researchers and organizational leaders identify and use appropriate collaborative strategies for their context.Methods/designThis multisite longitudinal, mixed methods study, leverages a naturally occurring implementation initiative -- in up to 17 Ohio counties -- to implement Ohio START (Sobriety Treatment and Reducing Trauma). START is a child welfare model that requires strong collaboration with local substance use treatment organizations to promote integrated services. During the first two years, we will identify collaborative strategies associated with improved START implementation (penetration and fidelity) and service delivery outcomes (timeliness), given system, and organizational features. We will conduct a convergent mixed methods study drawing on worker surveys, agency documents, administrative data, formal partner agreements, and group interviews. Data will be integrated and analyzed using Qualitative Comparative Analysis (QCA). To develop the CASPI, an expert panel comprised of implementation experts, and community stakeholders will convene to synthesize our findings and develop contents (including a decision tree). During the final year of the study, we will assess the acceptability, appropriateness, and feasibility of the CASPI in a randomized vignette experiment, and a pilot-test with 3 child welfare agencies that have not yet implemented START.DiscussionOur results will lay the groundwork for a larger controlled trial that will test the CASPI’s effectiveness for supporting effective and efficient implementation of cross-system interventions like START. The CASPI is expected to help leaders and researchers select and use collaboration strategies tailored to their context and be applicable in a wide range of settings including rural communities. Our work also advances system-level implementation strategies.Trial registrationNCT03931005, Registered April 29, 2019.

Background: Cross-system interventions can help integrate services across different service delivery systems but require organizations to establish strong collaborative relationships for implementation. Contingency theory suggests that the effectiveness of different collaborative strategies (i.e. specific ways organizations align operations and services) varies by context. This paper describes a study of different strategies for fostering collaboration between child welfare and substance abuse treatment agencies and the conditions under which they are effective for implementation. We also describe the development and piloting of the Collaborating Across Systems for Program Implementation (CASPI) tool—a decision-making guide intended to help researchers and organizational leaders identify and use appropriate collaborative strategies for their context.Methods/Design: This multisite longitudinal, mixed methods study, leverages a naturally occurring implementation initiative -- in up to 17 Ohio counties -- to implement Ohio START (Sobriety Treatment and Reducing Trauma). START is a child welfare model that requires strong collaboration with local substance use treatment organizations to promote integrated services. During the first two years, we will identify collaborative strategies associated with improved START implementation (penetration and fidelity) and service delivery outcomes (timeliness), given system, and organizational features. We will conduct a convergent mixed methods study drawing on worker surveys, agency documents, administrative data, formal partner agreements, and group interviews. Data will be integrated and analyzed using Qualitative Comparative Analysis (QCA). To develop the CASPI, an expert panel comprised of implementation experts, and community stakeholders will convene to synthesize our findings and develop contents (including a decision tree). During the final year of the study, we will assess the acceptability, appropriateness, and feasibility of the CASPI in a randomized vignette experiment, and a pilot-test with 3 child welfare agencies that have not yet implemented START.Discussion: Our results will lay the groundwork for a larger controlled trial that will test the CASPI’s effectiveness for supporting effective and efficient implementation of cross-system interventions like START. The CASPI is expected to help leaders and researchers select and use collaboration strategies tailored to their context and be applicable in a wide range of settings including rural communities. Our work also advances system-level implementation strategies.Trial Registration: NCT03931005, Registered April 29, 2019, https://clinicaltrials.gov/ct2/show/NCT03931005Contributions to the Literature · Implementing cross-system interventions depends on strong collaboration. Yet, collaborative strategies vary and the conditions under which they are most effective for implementation are unclear. · This study will (1) examine the collaborative strategies associated with implementation of a cross-system intervention that aligns child welfare and substance use treatment systems, (2) develop the Collaborating Across Systems for Program Implementation (CASPI) tool, a flexible decision support for organizational leaders, and (3) pilot test CASPI with organizational leaders. · Our study is intended to advance the effectiveness and efficiency of implementing cross-system interventions by helping leaders identify challenges, and effective collaborative strategies that address them.

Policy makers are increasingly investing in programs focused on identifying and addressing the nonmedical needs of high-utilizing Medicaid beneficiaries, yet little is known about these programs' implementation. This study provides an overview of early progress in and strategies used to implement California's Whole Person Care (WPC) Pilot Program, a $3 billion Medicaid Section 1115(a) waiver demonstration project focused on improving the integrated delivery of health, behavioral health, and social services for Medicaid beneficiaries who use acute and costly services in multiple service sectors. WPC pilots reported significant progress in developing partnerships, data-sharing infrastructure, and services needed to coordinate care for identified patient populations. We also identified major barriers to WPC implementation, such as difficulty identifying and engaging eligible beneficiaries and the lack of affordable housing. Our findings offer insights to leaders and policy makers interested in testing new approaches for improving the health and well-being of medically and socially complex patients.

Background Gender sensitivity of providers and staff has assumed increasing importance in closing historical gender disparities in health care quality and outcomes. The Department of Veterans Affairs (VA) has implemented several initiatives intended to improve gender sensitivity of its health care workforce. The current study examines practice- and individual-level characteristics associated with gender sensitivity of primary care providers (PCPs) and staff. Methods We surveyed PCPs and staff (nurses, medical assistants, and clerks) at 12 VA medical centers (VAMCs) (n = 256 of 649; response rate, 39%). Gender sensitivity was measured using a 10-item scale adapted from the Gender Awareness Inventory-VA. We used weighted multivariate regression with maximum likelihood estimation to identify individual- and practice-level characteristics associated with gender sensitivity of PCPs and staff. Results PCPs and staff had similar gender sensitivity but differed in most characteristics associated with that gender sensitivity. Among PCPs, women's health training and positive communication with others in the clinic were associated with greater gender sensitivity. For staff, prior work experience caring for women, working in Women's Health Patient-Aligned Care Teams, and rural location were associated with greater gender sensitivity, whereas more years of VA service was associated with lower gender sensitivity. Working at VA medical centers with a higher volume of women veteran patients was associated with greater gender sensitivity for both PCPs and staff. Conclusions Women's health training and experience in working with other women's health professionals are strongly correlated with greater gender sensitivity in the clinical workforce.

Government contracts and grants constitute the largest funding source for the majority of nonprofit organizations. Contracts for complex services, such as those involved in delivering human service...

Despite emerging evidence of contracting for evidence-based practices (EBP), little research has studied how managers lead contract-based human service delivery. A 2015 survey of 193 managers from five San Francisco Bay Area county human service departments examined the relationship between contract-based service coordination (i.e., structuring cross-sector services, coordinating client referrals and eligibility, overseeing EBP implementation) and the predictors of managerial role, involvement, and boundary spanning. Multivariate regression results suggested that county managers identified fewer service coordination challenges if they were at the executive and program levels, had greater contract involvement, and engaged in contract-focused boundary spanning. In conclusion, we underscore the organizational and managerial dimensions of contract-based service delivery.

Low parent engagement is frequently identified as a barrier to effective implementation of family-based childhood obesity prevention and control programs. A more nuanced understanding of factors affecting parent engagement is important for improving implementation and, ultimately, program efficacy. This qualitative study examined factors influencing parent engagement in a family-based childhood obesity prevention and control program. Semistructured interviews informed by the health belief model and the transtheoretical model were conducted with 22 predominantly Latina mothers following the scheduled conclusion of program activities. Spanish- and English-language interviews were transcribed, translated into English (if Spanish), coded, and summarized using established protocols. Differences between parents who attended at least two thirds of program activities and those who did not were examined. There were no significant demographic differences between parents who did and did not complete two thirds of program activities. Findings indicated that differences in parent engagement may be at least partially explained by differences in parental motivations for participating and in barriers and facilitators, such as children’s level of support and enthusiasm for the program. Parents were highly satisfied with the program content and the community health workers who delivered the program. This study adds to emergent literature regarding parents’ experiences in family-based childhood obesity prevention and control programs. Potential targets for improving program engagement are discussed.

OBJECTIVE:To examine predisposing, enabling, and need-related factors associated with dental utilization by children involved with the child welfare system (CWS). METHODS:Data were analyzed from the National Survey of Child and Adolescent Well-Being (NSCAW; Wave II), a national probability sample of children (2-17years) following a welfare assessment during 2008-2009 (n = 2806). Caregiver-reported child receipt of dental services in the past year was the outcome in weighted logistic regression models. RESULTS:Two-thirds of children had a recent dental visit. Older children (OR 2.95, 95% CI 2.06,4.21 for ages 6-11; OR 2.47, CI 1.82, 3.37 for ages 12-17, compared to ages 2-5) were more likely to have visited the dentist, as were children of more educated caregivers (OR 1.68; CI 1.20, 2.36 for high school, OR 2.45; CI 1.71, 3.52 for more than high school). Children without a usual source of care (OR 0.50; CI 0.27, 0.94) and those living with non-biological parents had lower odds of a recent visit (OR 0.64; CI 0.43, 0.97). Children with dental problems were twice as likely to have a recent visit (OR 2.02; CI 1.21, 3.38), while children with unmet needs who could not afford care had lower odds of utilizing services (OR 0.28; CI 0.16, 0.46). CONCLUSIONS FOR PRACTICE:Many children in the CWS, especially younger children (ages 2-5), did not have a reported dental visit in the past year. Cost was a barrier, and caregiver status was associated with the likelihood of obtaining dental care. Health and social service providers should refer these children for dental care.

Strong ties with and dependence on public agencies for service contracts can influence private human service organizations’ operations. Using data from the National Survey of Private Child and Fami...

In response to demands of funders and interorganizational competition, nonprofit human service organizations have invested in performance measurement to demonstrate the effectiveness and efficiency...

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.

Background Several factors besides appointment availability can influence access to care. Among these factors are the diverse challenges that patients may experience in navigating the healthcare system. However, the relationship between these challenges or “hassles” and delaying or forgoing care has not been assessed. Methods We examined the relationship between healthcare system hassles and delaying or forgoing needed care. We used data from a 2016 Veterans Affairs (VA) survey of women veterans (N = 821) who were active users of primary care (3+ primary care visits in the past year) at any of 12 VA medical centers. The main independent variable was a measure of 16 healthcare system hassles, encompassing a wide range of clinically-relevant aspects of patient experience, such as uncertainty about when/how to take a medication or difficulty getting questions answered between appointments. The outcome was a self-reported measure of delaying or forgoing needed care. We used logistic regression to estimate this outcome as a function of hassles, adjusting for age, comorbidities, and health care utilization. Survey weights accounted for within-site clustering, nonproportional sampling, and nonresponse. Results Overall, 26% of participants reported 0 hassles, and 39% reported 4 or more. Reporting 4 or more hassles (vs. 0) was associated with a roughly 5-fold increase in the predicted probability of delaying or forgoing care. Conclusion Addressing healthcare system hassles could yield unexpected benefits to realized access.

OBJECTIVE: To examine the relationship between care fragmentation and patient ratings of care quality and identify potentially actionable mediators. DATA SOURCES/STUDY SETTING: 2015 telephone survey of 1395 women Veterans with three or more visits in primary care and/or women's health care in the prior year at 12 Veterans Affairs (VA) medical centers. STUDY DESIGN: Cross‐sectional analysis. DATA COLLECTION/EXTRACTION METHODS: We operationalized lower care fragmentation as receiving VA‐only care versus dual use of VA/non‐VA care. Participants rated VA care quality (overall care, women's health care (WH), and primary care (PC)) and three aspects of their patient experience (ease of access to services, provider communication, and gender sensitivity of VA environments). We examined associations between care fragmentation and care ratings and applied the Karlson‐Holm‐Breen decomposition method to test for mediation by aspects of patients’ experience. PRINCIPAL FINDINGS: Lower care fragmentation was associated with higher ratings of care quality (odds ratios [95% CI] for overall care: 1.57 [1.14;2.17]; WH: 1.65 [1.20;2.27]; PC: 1.41 [1.10;1.82]). Relationships were mediated by patient‐rated provider communication and gender sensitivity (26‐54 percent and 14‐15 percent of total effects, respectively). Ease of access was associated with higher care ratings (odds ratios [95% CI] for overall care: 2.93 [2.25;3.81]; WH: 2.81 [2.15;3.68]; PC: 2.33 [1.63;3.33], in models with the three types of patient care experiences included), but did not mediate the association of care fragmentation and care ratings. CONCLUSIONS: Potential negative effects of care fragmentation on care quality ratings could be mitigated by attention to quality of patient‐provider communication and gender sensitivity of VA environments.

Author(s): Chuang, Emmeline; Pourat, Nadereh; Chen, Xiao; Lee, Christopher; Zhou, Weihao; Daniel, Marlon; Hoang, Hank; Sripipatana, Alek | Abstract: INTRODUCTION:Community health centers provide care to underserved populations least likely to adhere to cancer screening guidelines, but vary in their ability to ensure eligible patients are identified and screened. This study examines organizational factors associated with cervical and colorectal cancer screening rates among health centers funded by the Health Resources and Services Administration (HRSA). METHODS:Data were drawn from the 2015 Uniform Data System and analyzed using negative binomial regression. RESULTS:On average, 53% of eligible health center patients were screened for cervical cancer and 37% for colorectal cancer. Organizational characteristics positively associated with cancer screening rates include provider-patient staffing ratios, electronic health record status, percentage revenue from public capitated managed care, and local primary care provider availability. Percentage of homeless patients was negatively associated with screening. CONCLUSION:Efforts to improve cancer screening among underserved populations should address organizational factors that may contribute to disparities in screening uptake.

While private human service organizations face institutional pressures to collaborate, market-based pressures also generate competition, giving rise to complex interorganizational relationships. The current study draws on institutional and resource dependence theories to examine institutional and market-based environmental pressures on the intensity of collaboration and competition among private human service organizations. Using data from the National Survey of Private Child and Family Serving Agencies, we find that the intensity of interorganizational relationships is associated with market-based and mimetic pressures but not with other institutional factors. These findings suggest practical implications for human service leaders focused on managing interorganizational collaboration and competition.

Human service agencies serve a growing number of adults with behavioural health needs. Despite these agencies' key role in identifying need and facilitating services, many individuals do not receive care or end services prematurely. Few studies have explored the experiences of families referred to behavioural health services by such agencies or the extent to which families' perceptions of service need align with those of treatment providers and frontline workers. This study presents findings from a qualitative study of caregivers involved with child welfare agencies who were referred to behavioural health services. Researchers reviewed agencies' case records and conducted in-depth interviews with 16 caregivers, 9 child welfare caseworkers and 12 behavioural health treatment counsellors. Findings suggest that when deciding to engage in services, caregivers weigh not only their individual and family behavioural health needs but also potential agency intervention, including loss of child custody. Many professionals reported that involvement with a child welfare agency hindered the caregiver's disclosure of behavioural healthcare needs. Implications for managers and practitioners are discussed.

Maltreated children experience a variety of adverse outcomes including substance use problems. Although previous research indicated that there may be distinct trajectories of substance use among these youth, studies have examined them as if they were a single homogeneous group.The goals of this study were to explore substance use trajectories among child welfare-involved youth and to identify characteristics that distinguish substance use trajectories.Data from the National Survey of Child and Adolescent Well-Being (NSCAW II) were used. Multilevel latent growth mixture modeling (MLGMM) was performed using a subsample of 625 youth from ages 11-17 years investigated for maltreatment in 2008-2009. Measures included self-reported use of substance use during the previous 30 days, demographic characteristics, maltreatment history, placement in out-of-home care, and behavioral health problems.MLGMM identified two distinct substance use trajectory classes including High Stable Substance Use and Rapid Progression Use. Findings suggest that the experience of physical abuse is the key factor that distinguishes the two groups. When the effects of class-specific covariates were examined, results suggest that involvement in substance use behavior and its escalation vary between groups and are affected by youth's different previous experiences. Conclusions/Importance: The results have important implications for understanding individual differences in substance use behavior over time and how these differences were shaped by youth's experiences of family adversity. Study findings may be helpful for developing and enhancing the effectiveness of interventions targeted at decreasing substance use behaviors in child welfare-involved youth.

BACKGROUND: Insurance benefit features play a role in determining access to specialty mental health care. Previous research, primarily examining the effects of copayments, coinsurance, and deductibles in a fee-for-service setting, has concluded that specialty mental health use is highly sensitive to changes in financial requirements. Less is known about the effects of other benefit features and the effects of all of these features in a managed care environment. AIMS OF THE STUDY: Determine whether increased generosity of three types of benefit features was associated with increases in specialty mental health use and expenditures in a managed care setting. Secondary analyses investigated whether these associations varied by income level. METHODS: A first-differences design used linked claims, enrollment, and benefit data for 1,242,949 non-elderly adults (aged 18–64) with employer-sponsored insurance, before (2009) and after (2011) national behavioral health parity implementation. The data were provided by a large national managed behavioral health organization. Benefit design features included combined cost sharing from copayment and coinsurance, deductibles, the presence of annual use limits, cost sharing penalties associated with services used without getting required prior-authorization, and provider network. Outcomes included visits/days, total expenditures and patient out-of-pocket expenditures for individual psychotherapy and inpatient use, with separate values for in-network and out-of-network (OON) service use. Ordinary least squares regression was performed on change scores (2011 minus 2009 values) of all outcomes to implement the first-differences study design and normalize distributions of otherwise heavily skewed (towards zero) variables. Regressions stratified by higher income (>=$75,000) and net worth (>=$100,000) and lower income/net worth were also conducted. RESULTS: For in-network individual psychotherapy, larger increases in cost sharing from copayment and coinsurance were modestly associated with larger decreases in use and total expenditures (β(visits)=−0.00008, p-value=0.030; β(totalexpenditures)=$−0.00629, p-value=0.011), and elimination of treatment limits was associated with larger increases in use (β=0.09637, p-value=0.002) and total expenditures (β=$6.57506, p-value=0.001). These results were observed among all enrollees of plans that covered in-network and out-of-network plans and among a sub-set of these enrollees who did not change plans between 2009 and 2011. Benefit features had fewer associations with inpatient care and OON services. DISCUSSION: Elimination of limits was associated with small average increases in in-network individual psychotherapy utilization and expenditures. Cost sharing sensitivities of individual psychotherapy visits to financial requirements reported here were small, and resembled previous findings based in a managed care setting, which were smaller than findings based on the fee-for-service settings. Cost sharing may not pose a practical barrier to specialty behavioral health for non-elderly adults with employer-sponsored managed care plans. However, the influence of cost sharing may vary by specific healthcare needs, something that should be explored in further research.

Social work has long been identified with child welfare, and research has generally found that child welfare caseworkers with a social work degree are better prepared than aseworkers with other degrees. Little knowledge exists though about the relationship between caseworker professional background and caregiver behavioral health service use or their satisfaction with the caseworker. Using data from the National Survey of Child and Adolescent Well-Being, we found no significant relationships between having a social work degree and caregiver use of services or satisfaction with the caseworker. More research is needed to clarify how caseworker characteristics, including professional preparation, influence child welfare outcomes.