• Building Nursing Leadership Capacity for the State of Maryland

      Franklin, Patricia; Montgomery, Kathryn Lothschuetz (2016-06-26)
    • Cost and utilization of health services for substance dependent women before and after the initiation of substance dependence treatment

      Feeney, Elaine Ruth; Soeken, Karen (2000)
      The purpose of this study was to examine the cost and frequency of health services utilization by substance dependent women before and after the initiation of substance dependence treatment in a Medicaid population. The specific goal of the study was to determine whether cost and frequency of health services utilization are different before and after the subject has begun substance dependence treatment. The design was a secondary analysis of the Maryland Medicaid Claims Database created by the Maryland Center for Health Program Development and Management. The sample consisted of 114 females, the total number of female Maryland Medicaid recipients age 18 or older, who were residents of Baltimore City and were new to substance dependence treatment during the first half of fiscal year 1997 for whom complete data were available. Data were selected from the database and analyzed using paired t-tests and multiple regression to test four hypotheses related to cost and frequency of health services utilization. Both frequency and cost of health services were higher in the six month period following the initiation of substance dependence treatment than for the six month period before. These findings suggest that the severity of the consequences of substance dependence for women, as reported in the literature, was demonstrated in the Maryland Medicaid population. The findings also suggest that the initiation of substance dependence treatment may have brought about a behavioral change of renewed caring for self. Further research is needed regarding the specific services utilized and documented outcomes in order to design appropriate health care delivery systems for this population.
    • Firearm Injuries in Maryland, 2005-2014: Trends, Recidivism, and Costs

      THURMAN, PAUL; Johantgen, Mary E.; 0000-00022134-8415 (2018)
      Background: Violent injuries related to firearms are common in the U.S., whether accidental or intentional. Restrictions on use of Federal dollars for research on injury prevention involving firearms has limited our knowledge of how firearm injury impacts the health care system. The objectives of this study are to characterize firearm injuries (FI) in Maryland, quantify recidivism, and to describe hospital treatment and their associated costs for Maryland. Methods: ED and inpatient hospital records utilizing E codes consistent with FI were linked across visits to create unique cases from 2005-2014. Recidivism was defined as any subsequent ED visit or hospitalization for FI. The relationship of social determinants of health derived from US Census data to the rate of FI hospitalization by zip code were examined with generalized linear models, as were FI associated hospital costs. Results: Those with a FI are primarily single young black males, with overall hospitalizations decreasing over the time period. While 9% died in their initial FI, recidivism occurred in 3% of the individuals. Personal Disadvantaged (IRR = 1.13) and Working Disadvantaged (IRR = 1.04) factors were associated with increased rates of FI within zip codes. Hospital costs were significantly predicted by being self-pay/charitable and injury severity, with estimated mean costs for one FI of $47,364. In 2013, FI hospitalizations totaled $14m, of which 25% (n=129) accounted for over $10m. Discussion and Implications: FI hospitalizations are decreasing and are increasingly linked to social determinants of health, which require multifaceted interventions with short term goals of interrupting ongoing violence and long-term goals of preventing future violence. The states are absorbing much of the health cost burden. Further research is needed, which should include developing a registry linking hospitalizations, deaths, and crime data that can be used to evaluate trends and effectiveness of interventions.
    • Health IT Adoption in Home Health Agencies

      Koru, Gunes; Alhuwail, Dari; Norcio, Anthony; Topaz, Max; Mills, Mary Etta C. (2014)
      Introduction: Home care is an important component of the patient-centered continuum of care. Effective home care can help patients recover and recuperate successfully. Furthermore, it can reduce healthcare costs by preventing some of the avoidable and costly acute care and emergency services. Home health agencies (HHAs) providing home care can greatly benefit from adopting health information technology (IT) solutions such as electronic health records. However, HHAs experienced eligibility problems in receiving incentives under the recent HITECH act, and they have limited resources to invest in health IT. Therefore, it is important to create the maximum value possible for the organization by ensuring that health IT addresses the correctly identified and prioritized challenges and opportunities to reduce costs, improve the quality of care, and optimize health outcomes. It is also necessary to maximize efficiency, reducing the overhead costs by addressing the contextual determinants of health IT adoption in HHAs. To obtain and categorize evidence about the challenges and opportunities of HHAs and the contextual determinants of HHAs, we conducted a qualitative study of health IT adoption in Maryland HHAs...
    • The impact of the state of Maryland's Medicaid mental health carve-out on access-to-care for patients in a suburban health care system

      Corey-Lisle, Patricia Katherine; Trinkoff, Alison M. (2000)
      In recent years, providing care for individuals with severe mental illness has consumed increasing state and federal financial resources, with State Medicaid systems bearing the heaviest burden. Managed care strategies have been initiated by public mental health systems as a mechanism to control expenses. The state of Maryland implemented a mental health carve-out on July 1, 1997. The purpose of the present study is to describe the effects of the carve-out on access-to-care for individuals using emergency department services in one suburban health care system. Data for this study included all episodes of emergency crisis care in pre-implementation (1996-1997) and post-implementation (1998-1999) time periods. These data were examined within the context of the Behavioral Model of Health Service Use (Andersen, 1995) to describe the interrelationships among external environment, predisposing characteristics, and enabling resources on use of health services. Use of health services was operationalized by four outcomes: disposition, length of stay, number of visits, and recidivism. There were a total of 2986 episodes, initiated by 1928 individuals. Logistic regression demonstrated that when controlling for predisposing characteristics and enabling resources, the likelihood of inpatient admission did not change after initiation of the program. Moreover, there was not a significant change in the number of emergency visits. The assessment of recidivism demonstrated that only psychotic disorders (a predisposing characteristic) were a significant predictor of 30-day repeat visits. Multiple regression models examining the impact of the carve-out on length of stay demonstrated a significant increase in the emergency department length of stay (F = 5.47, p = .05) following the implementation of the carve-out. While benefits associated with improved coordination of services might be expected with the implementation of the carve-out, there was not a change in inpatient admissions, number of emergency visits, or recidivism. Additionally, there was a significant increase in the amount of time required to assess patients and to provide an appropriate disposition. The limited study sample and data prohibit generalizability. Considering that evaluations of mental health carve-outs are limited, this study reflects that anticipated benefits have not been experienced in emergency departments.
    • Implementation of an education program to improve Smith Island, Maryland residents' knowledge and attributes of healthier eating practices and benefits of physical activity

      Windemuth, Brenda (2011)
      Introduction: Obesity rates in the United States have drastically increased over the past twenty years. According to the Center for Disease Control and Prevention, the obesity rate for adults has nearly doubled since 1990, reaching as high as 32.2 percent among adult men and 35.5 percent among adult women (Flegal, 2010). Obesity is associated with increased health risks for many health related conditions which include diabetes, cardiovascular disease, stroke, cancer, sleep apnea, and a modestly elevated risk for all cause mortality. Educating the community on healthy eating and exercise practices is one strategy to develop skills which can then be used to facilitate behavioral changes. One rural community with increased obesity rates is Smith Island, Maryland. This community has special challenges to obtain a healthy lifestyle including a unique aspect of cultural sensitivity and need to be given the opportunity for obesity prevention in an isolated environment. Although there have been small measures to reduce obesity. These have isolated events, but a program has been established for this community. Purpose: The objective of this capstone project was to determine if a cultural sensitive educational program increases the knowledge of healthy eating practices and benefits of physical activity among residents of Smith Island. Design: A one-group, pre-test post-test, pre-experimental design was used to compare knowledge scores of Smith Island residents before and after an educational program on healthier eating and benefits of physical activity. Sample: A convenience sample of 25 residents living on Smith Island was recruited to participate in the program. Data Sources: The subjects completed a pretest prior to participating in a culturally modified educational program based on Dietary Guidelines for Adult Americans. Participants completed a post-test after the program had been given. Results: A dependent t-test was used to determine if there is a difference between pre-test and post-test attitudes and scores following the educational intervention. Overall, participants scored higher on the post-test as compared to the pre-test (t=.28, p<0.001). Additionally, the participants felt more confident in making changes in their food choices (t = -4.64, p<0.001) and making a nutritious meal for their families (t= - 4.54, p< 0.001). Conclusions/Implications: There was an increase in knowledge of healthy eating practices and benefits of physical activity in a rural community through the use of culturally sensitive educational tools. Thus, the implications of the study demonstrate the need for culturally appropriate educational tools that focus on improving healthier eating habits and benefits of physical activity as a plausible strategy to reduce risk for obesity.
    • Practitioners' perceptions on ethical aspects of managed care

      Ulrich, Connie Marie; Soeken, Karen (2001)
      The environment of managed care has created ethical concerns for practitioners with respect to professional autonomy and ethical practice associated with clinical decision-making. Yet, knowledge and research in this area is limited. The primary purpose of this research was to investigate the influence of individual, organizational, and societal/market contextual factors on practitioners' perceptions of ethical aspects of the managed care environment. In addition, a secondary purpose was to investigate the effect of different data collection methods on response rates. The conceptual model developed for the study derived primarily from Cooper's framework for ethical conduct and principal/agent theory. This study was a cross-sectional, descriptive survey design using a mailed self-administered questionnaire. Data were obtained from a random sample of 700 nurse practitioners (NPs) in the state of Maryland with a response rate of 42.4%. Thirty percent of the sample (n = 210) was provided a disk-by-mail (DBM) option for responding. A slightly higher response rate was indicated for the DBM sample in comparison to respondents who only received the paper-and-pencil measure (45.8% vs. 42.4%). A majority of respondents indicated ethical concerns regarding individual autonomy (78.4%) and personal values/ethics being compromised (67.1%). Moreover, 80% of the sample perceived it necessary to bend managed care guidelines. Significant differences were noted for ethical concern ( p < .001), ethical environment (p < .001), ethical conflict in practice (p < .001), and autonomy (p < .05) in relationship to practice setting. NPs in a staff/group model HMO were less ethically concerned, perceived the ethical environment more positively, and had lower ethical conflict scores. Based on the multiple regression results, a path model was proposed and tested using structural modeling. The perception of the ethical environment, ethical concerns, and the importance of governmental regulation explained 44% of the variance in ethical conflict in practice scores. An idealistic moral philosophy, ethical concerns, ethics content in a continuing education program, and the percentage of the client population enrolled in managed care explained 12% of the variance in autonomy scores. The analysis provided initial support for the model, indicating the importance of ethical considerations in a framework of healthcare.
    • Quantifying Neighborhood-Level Social Determinants of Potentially Preventable Emergency Department Visits in Maryland

      Rowe, Gina C.; Johantgen, Mary E. (2013)
      Background: Potentially preventable hospital admissions (PPAs) and emergency department (ED) visits (PPVs) are those that might have been prevented if patients had received better primary care. A significant number of ED visits in the United States and about a third of those in Maryland are "ambulatory care sensitive," or potentially preventable. Geographic variation in PPV rates reflects community-level differences in primary care access, social determinants of health-seeking behavior, and health disparities. Higher rates are noted in poor communities and vulnerable populations. Purpose: To compare and explain the geographic variance in Maryland PPV rates for total and uninsured populations and test the predictive value of regression models developed using generalized linear regression and geographic information systems. Analysis of geographic variance in PPV rates across the Baltimore metropolitan statistical area (MSA) used neighborhood-level social determinants to determine whether social capital can mediate the negative impact of living in a disadvantaged neighborhood on PPV rates. Methods: Two cross-sectional, ecologic regression analyses of secondary data aggregated to the zip code tabulation level were conducted. Generalized linear and geographic regression models were built using SPSS and ArcGIS statistical software, and results were compared to determine which model(s) best explained geographic variance in PPV rates. Social capital measures were obtained from the Baltimore Ecosystem Study. Results: In Maryland, geographic hot spots of increased PPV rates were highly correlated for uninsured and total populations, but uninsured PPV rates were more clustered in urban areas. Poisson and geographically weighted regression (GWR) models explained the most PPV rate variance. Significant predictors were per capita income, female-headed households, and level of education. In the Baltimore MSA, Poisson and GWR models predicted 85-86% of PPV rate variance; relative poverty and female-headed households were significant predictors but percent uninsured and per capita primary care physicians were not. Social capital was a significant partial mediator of all measures of neighborhood disadvantage reviewed. Conclusion: Communities with high social capital may offer health-protective benefits to residents, even mediating the negative impact of living in a disadvantaged neighborhood. Reducing PPVs requires consideration of population-level health-seeking behaviors and promotion of neighborhood-level social capital, particularly for single mothers.
    • The relationship of prenatal care utilization and tobacco and alcohol use to perinatal and neonatal outcomes: A secondary analysis

      Stuhlmuller, Patricia Lynn; Allen, Karen, Ph.D., R.N. (1998)
      1991 birth and death certificate information for Maryland state residents was used to examine the relationship of entry into prenatal care and number of follow-up visits to the birth outcomes of gestational age, birthweight and neonatal and postneonatal mortality. The impact of maternal race, age, education, marital status, pregnancy history and behaviors were also investigated. The live birth file contained 42,019 cases; 64% were white and 36% were black. Women in the sample ranged in age from 12 to 48 years with an average age of 26.5 years. The linked infant birth/death file contained 227 cases; 60% of the infants died in the neonatal period and 40% died postneonatally. Black infants comprised 66% of the infant deaths and white infants comprised 33%. Correlational analyses, logistic regression analyses and hierarchical multiple regression analyses were used to address the research questions. Analyses were computed for the total sample and sub samples of white and black women. Alcohol use was significantly correlated with age of infant death for the total sample and for whites but not for blacks. Tobacco use was not significantly correlated with infant death. Women in the total sample and black women who used tobacco and alcohol tended to have low birthweight and low gestational age infants. For whites, tobacco use was related to low gestational age and low birthweight. Logistic regression analyses showed that women who had more prenatal visits were more likely to have infants who died postneonatally. Time of entry into prenatal care had no effect on timing of infant death. Hierarchical multiple regression models were better able to explain variance in birthweight verses gestational age. Having prenatal care and more prenatal follow-up visits were found to be significant predictors of high gestational age and birthweight for the total sample, blacks and whites. The impact of the maternal demographics, pregnancy history and maternal behavior variables were found to vary by race. Implications for health care providers rendering prenatal care are discussed.