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Addressing hospital readmissions as a managed care model within a federally qualified health center: an evaluation study

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Addressing Hospital Readmissions as a Managed Care Model within a Federally Qualified
Health Center: An Evaluation Study

by

Samere Reid

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

December 2020

Copyright 2020 Samere Reid
ii

DEDICATION

This work is dedicated to a generation yet to come: may you surpass everything that I

have done.

iii

ACKNOWLEDGMENTS
“Praise be to the Lord my Rock, who trains my hands for war, my fingers for battle.”
Psalms 144:1 NIV
Thank you, Lord, for the chance to be your voice and your hands. Thank you for the
grace to write, for ordering my steps, and for providing a channel to serve your people. Take this
small offering and make it feed multitudes.
To my husband and partner in progress: thank you for believing in me. Thank you for
pushing me. Thank you for speaking up to get me moving and biting your tongue to let me fly.
Thank you for being the consummate academic and the hardest working person I know. You
inspire me every day, and I would not have made it to this day without you. For being a patient
facilitator of my purpose, I am forever grateful.
To my family, thank you for always instilling in me that I will always be a winner.
To Dr. Krop, my chair. Thank you for your grace, patience, and flexibility. Your
commitment to your students has made all the difference in this process. Thank you for always
being able to direct me to the light at the end of the tunnel, and for shepherding this work from
start to finish.
My dissertation committee members, Dr. Larry Hausner and Dr. Jennifer Phillips, thank
you for your eyes for detail and helping me to make this work the best it could be.
To my prayer partners, my sisters in Christ: I feel honored to share the bond of friendship
with you. How many times have you brought me apples of gold in settings of silver to get me
through a moment of confusion or weariness? Too many to count. I would be lost without the
words of guidance that you were gracious enough to vessel on my behalf, and I'd be dry without
those times of fellowship with you. Please know that this achievement belongs to you as well.
iv

TABLE OF CONTENTS
DEDICATION ................................................................................................................................ ii
ACKNOWLEDGMENTS ............................................................................................................. iii
List of Tables ............................................................................................................................... viii
List of Figures ................................................................................................................................ ix
Abstract ............................................................................................................................................x
CHAPTER ONE: INTRODUCTION ..........................................................................................1
Introduction to the Problem of Practice .......................................................................................1
Organizational Context and Mission ............................................................................................2
Organizational Goal .....................................................................................................................4
Related Literature .........................................................................................................................5
Importance of Addressing the Problem ........................................................................................7
Description of Stakeholder Groups ..............................................................................................8
Stakeholder Performance Goals ...................................................................................................8
Stakeholder Group of Focus .........................................................................................................9
Purpose of the Project and Questions .........................................................................................10
Methodological Framework .......................................................................................................10
Organization of Project ..............................................................................................................11
CHAPTER TWO: REVIEW OF THE LITERATURE ...........................................................12
Literature on the Problem of Practice ........................................................................................12
Background on Hospital Readmissions .............................................................................12
The HRRP ..............................................................................................................13
Concerns and Criticisms of the HRRP...................................................................14
Disparities in Readmissions ...............................................................................................15
Socioeconomic Disparities.....................................................................................16
Racial and Ethnic Disparities .................................................................................16
The Role of Primary Care ..................................................................................................17
Access to Primary Care ..........................................................................................17
Types of Access Barriers .......................................................................................18
Factors Contributing to Readmissions ...............................................................................19
Discharge Planning ................................................................................................19
Discharge Communication.....................................................................................20
v

Transition of Care ..................................................................................................21
Conclusion ..................................................................................................................................23
Clark and Estes’ (2008) Knowledge, Motivation and Organizational Influences Framework ..23
Stakeholder Knowledge, Motivation, and Organizational Influences .......................................24
Knowledge and Skills ........................................................................................................24
Knowledge of Readmissions Risk Factors ............................................................26
Elements Involved in Transitioning Care ..............................................................27
Motivation ..........................................................................................................................29
Expectancy Value Theory ......................................................................................29
Self-Efficacy Theory ..............................................................................................31
Self- versus Collective Efficacy.............................................................................33
Organization .......................................................................................................................35
Culture....................................................................................................................35
Cultural Models .........................................................................................36
Cultural Settings.........................................................................................37
Leadership ..............................................................................................................39
Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and the
Organizational Context .............................................................................................................41
Conclusion ..................................................................................................................................45
CHAPTER THREE: METHODOLOGY .................................................................................46
Introduction to the Methodology ................................................................................................46
Sampling and Recruitment .........................................................................................................46
Participating Stakeholders .................................................................................................46
Interview Sampling Criteria and Rationale........................................................................47
Criterion 1 ..............................................................................................................47
Criterion 2 ..............................................................................................................47
Criterion 3 ..............................................................................................................47
Interview Sampling Strategy and Rationale ...............................................................................48
Explanation for Choices .....................................................................................................49
Qualitative Data Collection and Instrumentation .......................................................................49
Documents and Artifacts....................................................................................................49
Interviews ...........................................................................................................................50
Interview Protocol ..................................................................................................50
Interview Procedures .............................................................................................51
Credibility and Trustworthiness .................................................................................................53
vi

Ethics..................................................................................................................................54
Limitations and Delimitations ............................................................................................56
Conclusion ..................................................................................................................................57
CHAPTER FOUR: RESULTS AND FINDINGS .....................................................................58
Participants .................................................................................................................................59
Document Analysis ....................................................................................................................60
Findings for Assumed Knowledge Influences ...........................................................................60
Declarative Knowledge of Factors that Contribute to High Hospital Readmission ..........62
Clinical Risk Factors ..............................................................................................62
The Role of Family Support as a Clinical and Social Risk Factor ........................64
Family Member and Caregiver Integration as a Risk Factor .................................64
Risk Factors from Social Determinants of Health .................................................66
Procedural Knowledge of How to Effectively Transition Patient Care .............................67
Discharge Planning ................................................................................................68
Clinical Assessments by the Inter-Disciplinary Team ...........................................69
Medication Management .......................................................................................70
Home Environment Assessment ............................................................................71
Findings for Assumed Motivation Influences ............................................................................72
Value of Their Efforts in Reducing Readmission Rates ....................................................73
Efficacy in Their Ability to Make Changes That Positively Impact Hospital Readmissions
................................................................................................................................................77
Self-Efficacy ..........................................................................................................78
Collective Efficacy.................................................................................................80
Findings for Assumed Organization Influences .........................................................................81
Leaders as Designers of Effective Learning Processes ......................................................83
Cultural Models: Assess Alignment of Site-Level Cultural Norms with the Tenets of
Managed Care ....................................................................................................................87
PACE as a Unique Model ......................................................................................88
Balancing Cost and Quality ...................................................................................89
Cultural Settings: Assess IDT Alignment in Relation to the Stakeholder Goal ................90
Critical Thinking ....................................................................................................91
Communication Dynamics.....................................................................................92
vii

Conclusion ..................................................................................................................................94
CHAPTER FIVE: SOLUTIONS, IMPLEMENTATION AND EVALUATION ..................96
PACE Leader Continuing Needs ................................................................................................97
Proposed Recommendations ......................................................................................................98
Recommendation 1: VHC will create spaces and structures for cross-disciplinary training
and the development of teamwork competencies ..............................................................98
Recommendation 2: VHC will invest in training to support the development of critical
thinking skills among IDT members..................................................................................99
Recommendation 3: VHC will develop and deploy a mentorship program for providers as
a component of new provider onboarding .......................................................................100
Recommendation 4: VHC will support the development of annualized functional training
regimen for functional disciplines ...................................................................................100
Implementation and Evaluation Plan .......................................................................................101
Level 4: Results and Leading Indicators ..........................................................................102
Level 3: Behavior .............................................................................................................103
Level 2: Learning .............................................................................................................105
Level 1: Reaction .............................................................................................................108
Evaluation Tools ..............................................................................................................109
Summary ..................................................................................................................................111
Future Research ........................................................................................................................112
Conclusion ................................................................................................................................112
REFERENCES ............................................................................................................................115
Appendix A...........................................................................................................................133
Appendix B ...........................................................................................................................137
Appendix C ...........................................................................................................................139
Appendix D...........................................................................................................................140

viii

LIST OF TABLES
Table 1. Organizational Mission, Global Goal and Stakeholder Performance Goals 8
Table 2. Knowledge Influence, Knowledge Type, and Knowledge Influence Assessment 28
Table 3. Assumed Motivational Influence and Motivational Influence Assessment 34
Table 4. Assumed Organizational Influence and Organizational Influence Assessment 40
Table 5. Demographic Composition of Leaders Interviewed 59
Table 6. Summary of Results and Explanation for Knowledge Needs 61
Table 7. Summary of Declarative Knowledge Demonstration Results 62
Table 8. Summary of Results and Explanation for Motivation Needs 73
Table 9. Summary of Self-Efficacy and Collective Efficacy Results 78
Table 10. Summary of Results and Explanation for Organizational Needs 82
Table 11. Proportion of Leader Time Dedicated to Team Learning 84
Table 12. Summary of Findings 94
Table 13. Continuing Needs 97
Table 14. Outcomes, Metrics, and Methods for External and Internal Outcomes 102
Table 15. Critical Behaviors, Metrics, Methods, and Timing for PACE Leaders 104
Table 16. Required Drivers to Support PACE Leaders’ Critical Behaviors 104
Table 17. Components of Learning for the Program 107
Table 18. Components to Measure Reactions to the Program 109

ix

LIST OF FIGURES
Figure 1. Relationship between VHC, PACE, and Funding Sources 4
Figure 2. PACE Conceptual Framework 43
Figure 3. Reponses to Question of Whether Readmission is a Problem in PACE 74
Figure 4. Readmissions Dashboard 111

x

Abstract
This study is grounded in a number of learning, motivation, and organizational change theories,
all of which are applied through the lens of the Clark and Estes (2008) gap analytic framework to
the topic of hospital readmissions in a managed care model of geriatric primary care at a
Federally Qualified Health Center (FQHC). The purpose of this project was to evaluate the
factors that influence hospital readmission rates within a managed care model situated within a
larger fee-for-service context. This qualitative study employed document review and gathered
interview data from 10 healthcare professionals in the United States. This project finds key areas
to address in the arenas of collective efficacy, leader empowerment, and the embedding of
managed care best practices at the level of patient-facing teams. This project recommends a
robust, multi-dimensional approach to training for various internal stakeholder groups, including
mentorship, critical thinking, cross-disciplinary training, and investment in the growth of
teamwork competencies.
1

CHAPTER ONE: INTRODUCTION

Introduction to the Problem of Practice

The structure of the U.S. healthcare system gives rise to inequities in health outcomes for
different segments of the population. Historically disadvantaged or underserved groups are less
likely to have the necessary screenings and other preventive measures that would be handled in a
primary care setting, and are more likely to experience both inadequate treatment for health
conditions as well as lower overall quality of health services (Birkmeyer, Gu, Baser, Morris, &
Birkmeyer, 2008; Institute of Medicine, 2003; Shi, Chen, Nie, Zhu, & Hu, 2014). These groups
are also more likely to be uninsured or underinsured, or experience other barriers to accessing
primary care that lead to greater utilization of emergency departments (EDs) for conditions that
could be handled in a primary care setting and higher likelihood of being readmitted to the
hospital after being discharged. (Cheung, Wiler, Lowe, & Ginde, 2012; Wright, Potter, &
Trivedi, 2015). These inequitable outcomes, or health disparities, manifest across lines of race
and class, and are most apparent in the realm of chronic diseases like cancer, where the incidence
rates and mortality rates are higher and survival times shorter for the most common cancers
among blacks than non-Hispanic whites (Adams et al., 2015). Inequitable access to high quality
primary care is a critical driver of both racial and socioeconomic disparities in health outcomes
across multiple realms, including hospital readmissions (Cancino, 2017; Siegel, Miller, & Jemal,
2017). According to the Centers for Medicare and Medicaid Services (CMS), a hospital
readmission is defined as “any hospitalization within 30 days of the discharge after an index
hospitalization to the same or a different hospital within the state” (Angraal et al., 2018, p. 3).
These persistent inequities among minority groups and poor inner-city and rural populations
have implications for the health of the entire country, including higher costs of care (CDC, 2013;
2

Shi, Chen, Nie, Zhu, & Hu, 2014; Ward, Schiller, & Goodman, 2012) which results from, among
other factors, higher hospital utilization (Cheung et al., 2012).
Organizational Context and Mission

Versa Health Corporation (VHC) is a pseudonym for a non-profit healthcare provider that
operates as a Federally Qualified Health Center (FQHC) with locations throughout Southern
California. As a FQHC, VHC is required to provide comprehensive preventive and primary
healthcare services without regard for the patient’s ability to pay (Adams et al., 2015). VHC
provides primary healthcare services to medically underserved populations in Southern
California in order to reduce healthcare disparities and facilitate improved health outcomes for
poor and vulnerable populations. The organization’s headquarters are located in Los Angeles,
with care delivery occurring in the approximately 50 clinical sites that are spread throughout Los
Angeles, Orange, Riverside, and San Bernardino counties. The populations served by the
organization include beneficiaries of Medi-Cal—the California state administered Medicaid
health insurance program for low income individuals and families, and Medicare—the federally
administered health insurance program for seniors over the age of 65. VHC also provides access
to primary care and specialty providers for commercially insured patients as well as those
without insurance on a fee-for-service basis. Medicare and Medi-Cal are the main funding
sources for VHC’s patients.
VHC also provides services for frail elderly adults, aged 85 or older, through the Program
for All-Inclusive Care for the Elderly (PACE), at eight of its sites. In this specialized geriatric
program, PACE patients are treated through a managed care model, meaning that the
organization receives fixed, capitated payments through Medicare and Medi-Cal (i.e., from the
federal and state governments) on a per-member basis in order to provide a range of care
3

interventions meant to effectively manage the care of each person while reducing costs by
keeping them healthy. While VHC assumes only partial risk for its commercial, Medi-Cal, and
Medicare patients, it assumes full risk for PACE participants, meaning that the organization is
responsible for the full cost of the medical needs of its PACE population, including any
hospitalizations. PACE centers provide comprehensive primary care and wraparound services to
support their participants in living independently for as long as possible in their communities and
avoiding institutionalization. Wraparound services bring together both generalists and specialist
service delivery in a collaborative, comprehensive framework that addresses diverse, multi-
faceted patient needs in a coordinated way (Bruns, Sather, Pullmann, & Stambaugh, 2011;
Walter & Petr, 2011) while keeping the patient at the center. VHC PACE’s care model is known
for having a holistic, team-based approach to care, with the patients’ nutritional, behavioral, and
physiological health needs being addressed at the same time and by the same team that takes care
of their medical needs. Given that PACE is the only division within VHC currently utilizing a
full managed care model, PACE provides a test case for how to effectively deliver healthcare
services through a managed care model for underserved populations. Figure 1 depicts the
relationships between VHC, the PACE program, and sources of funding. Eligible patients who
are enrolled in public insurance programs—Medicare and Medicaid—are covered by particular
health plans. These health plans administer the benefits and assign patients to healthcare
organizations, including VHC, and the funding attached to each patient flows into the
organization as well.
PACE and VHC have not been exempt from the upheaval brought on by the COVID-19
pandemic and have seen their models and priorities shift in its wake. The research presented here
addresses the core model that has existed for the last approximately 20 years at PACE, with an
4

understanding that this will undoubtedly shift and change in the years to come.
Figure 1

Relationship between VHC, PACE, and Funding Sources

Organizational Goal
Versa Health Corp (VHC) has a goal of fulfilling all the requirements to become a 4.5
star rated provider of primary care to its targeted population of Latino and other underserved
minority groups in Southern California by May of 2020. The star rating—with 5 stars as the
maximum—is an indicator of the quality of care provided and is determined by the California
Department of Public Health (CDPH) Office of the Patient Advocate (OPA). Healthcare quality
relates to the way in which healthcare services delivered impact the desired health outcomes
(Sadoughi, Nasiri & Ahmadi, 2018). High quality programs either improve these outcomes or
increase the likelihood that the desired outcomes will be achieved. VHC leadership views the
attainment of a 4.5 star rating, which is comprised of many components, as a proxy for the
aggregate quality of care it provides to its patients. The star rating therefore serves as an
indicator that the organization is able to deliver a range of improved health outcomes for a broad
array of patients. VHC has chosen to include various quality measures in its annual set of
organizational goals, including 30-day all cause hospital readmission rates. The PACE program’s
5

ability to manage and minimize hospital readmission rates is an important contributor to VHC’s
quality star rating.
Hospital readmission rates have also been identified by the National PACE Association
(NPA) as one of the focus measures that demonstrates the value and quality of the PACE model
of care. Hence, PACE hospital readmission rates both reflect the quality of the PACE program
and impact the larger organization’s overall quality rating. Additionally, given that PACE serves
the greatest proportion of Medicare patients within VHC, and the experience of these patients is
given most weight in the star rating process, PACE’s performance on measures of quality
(including readmission rates) is integral to the achievement of VHC’s organizational goal.
The executive team established this goal at its annual retreat in 2015, where it determined
that the organization would only make progress towards its mission if it grew in the quality of
care provided, which was then rated at 3.5 stars, while expanding its membership base. Because
performance on this goal has varied over the years but has consistently fallen short of the goal, it
remains an important component of the organization’s strategic direction. The achievement of
VHC’s goal will be measured by the CDPH Office of the Patient Advocate (OPA). The OPA is
an office within the state of California Department of Public Health that rates medical groups
using measures related to quality of care and patient experience. Report cards published by the
OPA are meant to be guides for consumers in selecting healthcare providers, and are also used
by healthcare organizations as a benchmark for the totality of the quality of care provided.
Related Literature

Designed for frail older adults who would be eligible for nursing home care based on
state criteria, PACE is an innovative model of geriatric care that was originally pioneered in the
San Francisco Bay area by On Lok in the 1970s and is now rapidly being replicated across the
6

country (Eng, Pedulla, Eleazer, Mccann, & Fox, 1997; Fretwell, Old, Zwan, & Simhadri, 2015).
The program leverages strong relationships with family members and interdisciplinary teams
who provide care across multiple contexts to pursue its goal of maintaining the independence of
its participants and keeping them living in the community with access to the full spectrum of
supports and services they need to live independent lives and avoid institutionalization (Eng et
al., 1997; Fretwell et al., 2015; Wieland et al., 2000). PACE attracts participants that are eligible
for both Medicaid and Medicare (“dual eligibles”) and is funded through a fixed monthly
reimbursement from both Medicare and Medicaid, in exchange for which the program delivers
comprehensive care, bearing responsibility for any costs incurred beyond the capitation payment
(Eng et al., 1997; Fretwell et al., 2015).
The dual eligible population that PACE serves tends to be largely from racial and ethnic
minority groups, who are at or below the federal poverty line, and have been found to face
greater barriers in access to care (Cheung et al., 2012; Wright et al., 2015). These barriers to
accessing quality primary care in a timely and culturally appropriate way have led to high rates
of hospital readmissions for this group, particularly for elderly individuals (Ilaobuchi, Mi, Tu, &
Counsell, 2014; Njeru et al., 2015; Wright et al., 2015). This is evidenced by the findings that
Medicare patients are readmitted at a rate that is almost twice that of privately insured patients,
and patients who have incomes below 200% of the federal poverty threshold are 30% more
likely to be readmitted than those who had higher incomes (Gorina et al., 2015; Hines et al.,
2014). Research also suggests that poorer patients not only have poorer outcomes in general, but
also are at higher risk for readmission following an initial hospitalization (Cope, Jonkman,
Quach, Ahlborg, & Connor, 2018). Despite higher rates of medical conditions and mortality-
incidence ratios for breast, colorectal, and prostate cancers (Adams et al., 2010; Cancino, 2017;
7

Delgiannidis, 2017), poor urban and rural areas have lower access to care than their urban
counterparts. Bodenheimer & Pham (2010) found that “21 percent of the U.S. population lives in
[rural and poor urban areas], but only 10% of physicians practice in those areas” (p. 802).
Research suggests that access to primary care, social determinants of health, discharge planning,
and transitioning care are important factors that impact a patient’s likelihood of readmission
(Cheung et al., 2012; Cope et al., 2018; Jencks et al., 2009; Kripalani et al., 2007; Misky, Wald
& Coleman, 2010).
Importance of Addressing the Problem

The PACE program’s ability to reduce hospital readmission rates is a key component in
VHC’s overall quality rating. The importance of evaluating VHC’s performance against its
global goal of attaining a 4.5 star quality rating, and the intermediate PACE program goal of
reducing hospital readmission rates arises from a variety of sources. First, the organization (both
VHC and the PACE program) stands to risk funding—both through losing members and
contracts with health plans—if this issue is not addressed. Additionally, without adequate
attention to the issue of high rates of hospital readmission, the organization will face higher costs
of care as it seeks to take on more risk for its population. It also risks falling short of its mission
to provide quality care to underserved populations. On a societal level, the impact of greater
hospital readmissions for certain populations is the extension of inequities in healthcare for
vulnerable patients close to the end of life. If the issue of hospital readmissions is not addressed,
the cost to society will continue to increase without a solution that brings relief to those impacted
most (Cope et al., 2018; Shi et al., 2014).

8

Description of Stakeholder Groups

The key stakeholders for accomplishing the organizational goal of a 4.5 star quality
rating—to which the intermediate PACE program goal of achieving an all-case 30-day
readmission rate of 15% is a key contributor—are the VHC executive team, the VHC Program of
All-Inclusive Care for the Elderly (PACE) leaders, and VHC PACE patients, who are also
referred to as participants. The VHC executive team is comprised of six members, all of whom
are executive vice presidents who, along with the CEO, play the role of chief officers in the areas
of strategy, operations, medical affairs, administration, and finance. The VHC executive team
provides leadership and direction to the organization and guides the allocation of resources. The
PACE leadership team is comprised of fifteen members, with titles ranging from director to
medical director to vice president. The PACE leadership team is responsible for providing
program level oversight, ensuring administrative and operational efficiency, and pursuing growth
opportunities. The PACE leadership also includes site or center leaders, who oversee the day to
day operation of PACE sites. PACE patients (“participants”) are frail individuals, most of whom
are over the age of 85, who would otherwise qualify to be in a skilled nursing facility (SNF).
Stakeholder Performance Goals

Table 1

Organizational Mission, Global Goal and Stakeholder Performance Goals
Organizational Mission
VHC provides primary health care services to medically underserved populations in Southern
California in order to reduce healthcare disparities and facilitate improved health outcomes for
poor and vulnerable populations.
Organizational Performance Goal
9

By December 2020, VHC will attain a 4.5 star quality rating
VHC Executive Team PACE Leadership PACE Patients
By November 2020, the VHC
executive team will develop a
strategic plan to improve
quality by addressing
avoidable hospitalizations.
By October 2020, 100% of
VHC PACE site leaders will
identify opportunities to
reduce its 30-day readmission
rate to 15% for all diagnoses.
By September 2020, 100% of
VHC PACE patients will have
a care plan within three days of
enrollment.

Stakeholder Group of Focus

Every employee of VHC plays a role in its realization of the organization’s mission,
which is to reduce healthcare disparities by consistently providing quality care to all patients
without regard for the patient’s ability to pay. While a complete analysis would assess all
stakeholder groups and their contribution to this goal, for the purposes of this study, the focus
will be on PACE leadership. The VHC PACE program provides comprehensive care and access
to wraparound services for frail, elderly, and / or nursing home eligible senior adults. PACE is
the signature program of VHC and is an internal leader in the provision of cost-effective, high
quality care to all participants, thus, PACE leaders play a significant role in the accomplishment
of the organization’s mission. According to the organization’s strategic plan, the PACE
leadership’s goal is to pursue high quality primary care for its patients by achieving a 30-day
readmission rate of 15% for all diagnoses by October 2020, in support of the broader
organizational goal of pursuing a 4.5 star quality rating. This goal was developed by PACE
leadership in collaboration with the executive team and was based on prior year performance in
that same metric and national benchmarks. If the PACE goal is not achieved and 30-day hospital
10

readmission rates increase, then the organization risks not achieving the desired 4.5 star rating,
incurring higher costs of care, and jeopardizing its relationships with health plans.

Purpose of the Project and Questions
The purpose of this project is to evaluate PACE leadership’s knowledge, motivation, and
organizational needs to reduce the 30-day readmission rate and help VHC reach its performance
goal of being a 4.5 star rated healthcare provider. While a complete performance evaluation
would focus on all stakeholders, for practical purposes the stakeholder to be focused on in this
analysis is PACE leadership – both administrative and clinical. This analysis will focus on the
knowledge, motivation, and organizational factors that impact the PACE team’s ability to meet
its goal.
Accordingly, the questions that guide this study are:
1. What are the knowledge, motivation, and organizational factors related to PACE
leaders’ ability to achieve their goals for reducing all-cause 30-day readmission rates?
2. What is the interaction between PACE organizational culture and stakeholder
knowledge and motivation that either enables or hinders PACE leaders in their pursuit
of reduced 30-day hospital readmission rates?
3. What are recommended interventions that would enable PACE leaders to accomplish
their performance goal of achieving an all-cause 30-day readmission rate of 15%?
Methodological Framework
The Clark and Estes (2008) gap analytic framework is the foundation of this study. The
gap analytic framework is built on the knowledge, motivation, and organizational levers that not
11

only influence performance, but also enable the diagnosis of performance gaps at the individual
and organizational levels. This project will employ qualitative data gathering and analysis to
address the research questions identified. PACE leadership’s current performance in relationship
to the organizational goal will be assessed using document analysis and interviews. Research-
based solutions will be recommended and evaluated in a comprehensive manner (Clark & Estes,
2008).
Organization of Project
This study is organized into five chapters. This chapter provided the reader with the key
concepts and terminology commonly found in a discussion about hospital readmission rates. The
organization’s mission, goals and stakeholders as well as the review of the evaluation framework
was also provided. Chapter Two provides a review of current literature surrounding the scope of
the study. Topics of contributing factors for hospital readmissions, the role of primary care in
hospital readmissions, the managed care model of healthcare delivery, leadership and culture will
be addressed. Chapter Two also details the knowledge, motivation and organizational elements
to be examined as part of the gap analytic framework. Chapter Three covers the methodology
used for the choice of participants, data collection and analysis. In Chapter Four, the data and
results are described and analyzed. Chapter Five provides recommendations for practice, based
on data and literature as well as recommendations for an implementation and evaluation plan.

12

CHAPTER TWO: REVIEW OF THE LITERATURE
Hospital readmission rates are indicators of both the quality of care being delivered in
inpatient settings and access to primary healthcare. Barriers to primary care disproportionately
affect the demographic segments served by VersaHealth Corp (VHC) (Kangovi, et al., 2013;
Long, Genao & Horwitz, 2013). This literature review will examine contributing factors to and
root causes of hospital readmissions. The review begins with general research on the problem of
hospital readmission and gives an overview of issues within the readmissions literature,
including racial and socioeconomic disparities in readmission rates, and the role of primary care
in addressing the problem of readmissions. Next, the review presents an outline of contributing
factors that impact a health system’s ability to effectively manage care across sites and through
critical transitions of care. After the general research literature is discussed, the review then
pivots to the specific knowledge, motivational, and organizational influences—components of
the Clark and Estes (2008) gap analysis conceptual framework—that impact the PACE
leadership’s ability to achieve their goal of reducing hospital readmission rates among their
cohorts of patients.
Literature on the Problem of Practice
Background on Hospital Readmissions
According to the Centers for Medicare and Medicaid Services (CMS), a hospital
readmission is defined as “any hospitalization within 30 days of the discharge after an index
hospitalization to the same or a different hospital within the state” (Angraal et al., 2018, p. 3).
The criteria for what can be considered a readmission is painted in broad strokes, with any
follow-up hospitalization counting as a readmission regardless of whether or not the subsequent
hospital admission was related to the first, as long as it happened in the same state and was not
13

planned ahead of time (Virapongse & Misky, 2018). Since even readmissions that occur at
different hospitals from the first are also counted within this number, it is no surprise that
planned rehospitalizations only account for about 10% of the total admissions within a given
year nationwide (Jencks, Williams, & Coleman, 2009). The remaining 90% of readmissions have
been identified as an area of focus in the fight against rising healthcare costs, which topped $3
trillion in 2016 (Zohrabian, Kapp, & Simoes, 2018).
The burden of unplanned readmissions on the healthcare system has been well-
documented (Englander, Michaels, Chan, & Kansagara, 2014; Lee, Williams, Lalor, Brown, &
Haines, 2018). In 2011, unplanned readmissions accounted for millions of hospitalizations and
over $41 billion dollars in associated costs (Hines, Barrett, Jiang, & Steiner, 2014; Lee, Liu,
Borza, Qin, Li, Urish, et al, 2019). Because upwards of 20% of Medicare patients are readmitted
within 30 days and tend to stay up to 13% longer in a subsequent hospitalization than during
their first admission - thereby using more resources and incurring additional costs (Gorina, Pratt,
Kramarow, & Elgaddal, 2015; Jencks, Williams, & Coleman, 2009; Riverin, Li, Naimi, &
Strumpf, 2017), readmissions have become a national priority. The many dimensions of cost
associated with the frequency and volume of hospital visits in a short time frame also make the
topic an important one (Englander et al., 2014; Joynt & Jha, 2011; Stefan et al., 2012).
Additionally, from a quality perspective, readmissions have been identified as a target for
improvement efforts in the hope of reducing the likelihood of harm and improving care for
patients (Cox, Sadiraj, Schnier, & Sweeney, 2016; Joynt & Jha, 2012; Joynt & Jha, 2013; Stefan
et al., 2012).
The HRRP
14

In response to the problem of high rates of hospital readmissions, CMS introduced the
Hospital Readmissions Reduction Program (HRRP), a program aimed at reducing the levels of
rehospitalization for particular conditions and therefore, the cost to Medicare (Chatterjee &
Werner, 2019; Joynt & Jha, 2013). The program targets conditions that carry both a high
likelihood of readmission for a variety of clinical reasons and significant cost of total care as a
result of high readmissions. CMS has chosen to focus on six conditions and/or procedures—
acute myocardial infarction, also known as heart attack, congestive heart failure (CHF),
pneumonia, chronic obstructive pulmonary disease (COPD), elective hip and knee replacement,
and coronary artery bypass graft (CABG)—three of which are among the top 10 most costly
conditions, each with over $1 billion in related costs (Hines et al., 2014; Joynt & Jha, 2011;
Joynt & Jha, 2013). Based on an annual review of admissions data, CMS determines thresholds
for what constitutes excess readmissions within particular hospital peer groups. The program
works by withholding up to three percent of hospitals’ Medicare reimbursements as a way of
penalizing those hospitals whose 30-day readmission rates are high relative to other acute-care
providers that carry a similar proportion of Medicare and Medicaid patients (Cox et al., 2016;
Joynt & Jha, 2013).
Concerns and Criticisms of the HRRP
While the HRRP has seen results—30-day readmission rates for Medicare beneficiaries
have declined for patients with heart attack, heart failure, and pneumonia (Angraal et al.,
2018)—it is not without its critics. Some argue that the major assumption behind the program—
that all or most rehospitalizations are preventable—is flawed, and that in the absence of more
concrete data to that end, readmission rates cannot be used as an indicator of the quality of care
(Englander et al., 2014; Kansagaraet al., 2011). Others have taken issue with the time frame
15

within which readmissions are counted, arguing that it is more useful to monitor readmissions
within a week of discharge, the first two weeks after major surgery, and up to 90 days after
leaving the hospital (Joynt & Jha, 2013; Kini et al., 2018; Lee, Liu, Borza, Qin et al, 2019).
Finally, there are concerns that the HRRP might do more harm than good by taking
resources away from hospitals that serve as safety net institutions, as they are more likely to have
higher readmission rates than hospitals that serve fewer low-income Medicare patients
(Chaiyachati, Qi, & Werner, 2018; Joynt & Jha, 2011). Research has shown that “hospitals
caring for large proportions of Medicare patients from low socioeconomic backgrounds do not
differ substantially in their performance on CMS’ publicly reported thirty-day risk-standardized
readmission rates from hospitals with very few patients of low socioeconomic status” (Bernheim,
Parzynski, Horwitz, Lin, Araas, Ross, & Krumholz, 2016, p. 1468). In spite of this, Chaiyachati,
Qi, and Werner (2018) found that safety net hospitals are penalized more often than hospitals
that see fewer poor patients and, after taking into consideration the populations they tend to
serve, that the HRRP may have had the effect of substantially widening disparities between
white and black patients.
Disparities in Readmissions
The HRRP’s focus on Medicare beneficiaries—meaning those who are 65 or over—
stems from the high costs of caring for older patients (Mitchell, Sadikova & Jack, 2012). Indeed,
despite their higher likelihood of having access to a primary care doctor, older patients are more
prone to adverse outcomes following time spent in the hospital and are more likely to be
readmitted at both 30 and 90 day intervals due to age, the presence of comorbidities, and other
social factors (Jencks, Williams, & Coleman, 2009; Lee et al., 2018; Misky, Wald, & Coleman,
16

2010). Further, the disparities that exist between Medicare and privately insured patients get
wider when socioeconomic status and race are taken into account (Keeney et al., 2015).
Socioeconomic Disparities
While it is well known that inequities in healthcare exist in the United States (Ferraro,
2006), how these play out among elderly populations is an emerging field of study. Researchers
agree that socioeconomically disadvantaged patients are at higher risk of readmission (Cope,
Jonkman, Quach, Ahlborg, & Connor, 2018; Joynt & Jha, 2013). Hines, Barrett, Jiang and
Steiner (2014) found that Medicare patients have readmission rates that almost double those of
privately insured patients, and Gorina, Pratt, Kramarow, and Elgaddal (2015) reported that those
patients with incomes of less than 200% of the poverty threshold had a readmission rate of 1.3
times the readmission rate of those whose incomes were above that threshold. This increased risk
arises from both medical and social sources. Low SES patients have a higher prevalence of
chronic conditions (Cheung, Wiler, Lowe, & Ginde, 2012) as well as mental health and
substance abuse disorders (Englander et al., 2014), in addition to the burden of pre-existing
disparities in care (Cope et al., 2018). Poorer patients also face access barriers in the areas of
medications, timely primary care, and the important social supports required for positive post-
discharge outcomes (Englander, et al., 2014; Joynt & Jha, 2013).
Racial and Ethnic Disparities
When examined through the lens of race, disparities emerge along the dimensions of both
disease related risk factors and social determinants of health. Non-hispanic black patients were
not only significantly more likely to be readmitted than their white counterparts (Gorina, et al.,
2015; Joynt, Orav, & Jha, 2011) for key conditions covered by the HRRP, a multi-year cohort
study of almost 60 million patients demonstrated that they also had worsening readmission rates
17

for conditions not targeted by the program (Chaiyachati, Qi, & Werner, 2018). Rodriguez, Joynt,
López, Saldaña, and Jha (2011) note that elderly non-white Hispanic patients are more likely
than whites to be readmitted for both heart attack and heart failure. One key similarity among
minority patients is that their elevated risk of readmission relative to their nonminority peers is
related to the site of care. Despite the assertion from Bernheim et al. (2016) that lower
socioeconomic status is not associated with increased readmission rates, researchers agree that
for racial minorities, higher readmission rates are at least partly due to the fact that they tend to
receive care in lower quality safety net hospitals (Rodriguez, Joynt, López, Saldaña, & Jha 2011;
Joynt, Orav, & Jha, 2011; Chaiyachati, Qi, & Werner, 2018). Other reasons include limited
education, housing instability, access to medications, access to follow-up care, low health
literacy, lack of employment, absence of informal caregivers and a shortage of the social capital
required to recover from an acute health event (Chatterjee, 2019; Keeney et al., 2015; Ursan et
al., 2016).
The Role of Primary Care
Primary care offices are usually the first stop for patients in the case of scheduled
hospitalizations. Primary care providers, in the ideal scenario, are the patient’s community-based
anchors of care both before and after hospitalization. The integral role of primary care, despite
being outside the hospital setting, to reducing readmissions, will be explored in this section.
Access to Primary Care
High readmission rates do not only reflect poorly on the hospital in which inpatient care
takes place but are also a reflection of the broader health system. Riverin et al (2017) notes that
more than the association made between readmissions and quality of care delivered to individual
patients, high readmission rates are symptomatic of broader systemic ills - poor coordination
18

across sites and inadequate integration of healthcare delivery. Cheung, Wiler, Lowe, and Ginde
(2012) also point out that poor health system performance is evidenced by not only high
readmission rates, but also barriers to primary care.
Types of Access Barriers
Barriers to primary care are those factors that negatively impact patients’ ability to access
the first line of care possible from a non-specialized physician (Misky, et al., 2017). These
include infrastructure problems, cost, availability of physicians, timeliness of follow-up and the
quality of primary care received (Kripalani, et al., 2014). Among Medicare recipients, despite
having insurance, cost has been raised as an issue impacting access to routine care (Virapongse
& Misky, 2018). Whether related to the cost of care in the form of co-payments / co-insurance,
or broader needs such as transport, cost needs play a role in patients’ care-seeking behaviors
(Misky, Wald, & Coleman, 2010). The post-discharge period is a critical one (Kangovi, et al.,
2013). Therefore, timeliness of follow-up can be a determinant of whether a recently discharged
patient needs to return to the hospital. Lack of timely follow up with a primary care physician
(PCP) both increased the risk of readmission for the same condition and decreased the likelihood
that the hospital physician’s recommendation would be executed (Misky, Wald, & Coleman,
2010). Limited adherence to post-discharge orders due to access challenges is an issue that is
compounded and made more complex to tackle by the provider shortages in certain geographic
areas that have higher concentrations of poor patients (Misky et al., 2017). Timeliness of follow-
up in a primary care setting is also impacted by “infrastructure barriers” such as long wait times
and limited opening hours (Hefner, Wexler, & McAlearney, 2014, p. 137), which act as hurdles
in the patient’s quest to access primary care.
19

While external barriers to timely access to primary care are a reality for many patients,
for others, the perceived timeliness of the physician’s response to patient concerns and patient
impressions of the PCP’s ability to tackle urgent issues also impacted their decisions on whether
to reach out to their PCP when such a relationship existed (Long, Genao, & Horwitz, 2013).
Given that active PCP involvement has been found to be a key success factor across a variety of
interventions aimed at reducing readmissions (Misky, Wald, & Coleman, 2010), perceptions of
PCP responsiveness and capabilities that reduce patient confidence in the value or quality of this
critical relationship also function as barriers to care that increase readmission risk.
Finally, insurance status and insurance type have emerged as factors in patients’ ability to
access timely primary care follow-up, with Medicaid patients being both more likely to face
barriers and find themselves faced with more barriers than their privately insured counterparts
(Cheung et al., 2012; Misky, Wald, & Coleman, 2010)
Factors Contributing to Readmissions
The penalties introduced by the HRRP have had the effect of increasing institutional
attention to reducing readmission rates (Angraal, et al., 2018). Hospitals now deploy strategies
to mitigate the risk of having a patient re-enter the hospital, including discharge planning and
managing discharge communications as part of executing the discharge (Cope et al., 2018;
Kripalani et al., 2007).
Discharge Planning
Discharge, the process of transitioning from inpatient to outpatient care, is a critical step
on the care continuum (Middleton, et al., 2018). Discharge involves a shift in responsibility from
the hospital’s care team to the patient, caregiver, and primary care physician (Kripalani, Jackson,
Schnipper, & Coleman, 2007). Discharge summaries, the documents that guide this handoff of
20

patient care from hospital to community, suffer from the same gaps in completeness and
timeliness that afflict the macro-level transition process (Kripalani et al., 2007; Kripalani,
LeFevre, Phillips, Williams, Basaviah, & Baker, 2007).
Discharge planning typically begins far in advance of the patient’s discharge date
(Kansagara et al., 2011). The process is complex, involving multiple actors and including steps
such as clarifying vaccinations, reviewing prescriptions, and outlining instructions to support
patients as they move into a different site of care (Stefan et al., 2012; Kansagara et al., 2011).
One key process in discharge planning is medical reconciliation (Englander et al., 2014).
Though some may treat it as a one-time event, medical reconciliation is actually an ongoing
process that monitors and adjusts the slate of prescription drugs that are assigned to the patient,
taking into consideration the medicines—and behavioral changes based on route of
administration—that are or were needed prior to, during, and after hospitalization in order to
avoid ameliorable adverse drug events (Kripalani, et al., 2007).
Discharge Communication
Communication—whether between providers or between providers and patients—is
essential to ensuring continuity of care during the discharge process (Middleton, et al., 2018).
Poor communication, whether in the form of incomplete information transfer among clinicians of
patients departing without a full understanding of what is required of them post-discharge, has
been shown to impact both direct clinical outcomes and the quality of follow-up care: two factors
that are closely linked with readmission risk (Kripalani et al., 2007). Despite the clear need for
collaboration among hospitalists and primary care physicians, communications across the
context of care remains inadequate (Cope et al., 2018; Jencks, Williams, & Coleman, 2009; Lee,
et al., 2018).
21

From the patient perspective, barriers to communication and understanding arise from a
number of angles. Power gradients with providers, unfulfilled expectations, and the sense that
providers are not invested in ensuring care beyond the boundaries of the hospital all lead to
misalignment, which has the effect of not only endangering clinical outcomes, but also reducing
trust in medical professionals, particularly in low SES populations (Cope et al., 2018).
Once the discharge process is complete, care of the formerly hospitalized patient is
transferred either to an acute care setting such as a skilled nursing facility or to the patient’s
home. Medication management and communication are critical components of the transition in
either case, as poorly enacted transitions of care may lead to medical errors and thereby increase
the risk of readmission (Englander et al., 2014; Lee, Liu, Borza et al., 2019).
Despite the HRRP's focus on hospitals as the sole targets of penalties for 30-day
readmissions, the issue of readmission prevention is hardly one-dimensional, and is complex in
ways that stretch beyond the walls of the hospital (Ilaobuchi, Mi, Tu & Counsell, 2014). High
hospital readmission rates can point to systemic failures, treatment gaps that originate in the
hospital, or factors that pertain uniquely to the patient or live squarely at the community level
and are therefore outside of the hospital's control (Joynt & Jha, 2012; Lee, et al., 2018). As a
result of the manifold factors at play, communication between and among providers across care
settings is critical to managing the immediate transition of care (Kripalani et al., 2007) and the
subsequent coordination of care across multiple providers.
Transition of Care
Poor transition of care is a common contributing factor for readmissions among older
adults, making the first days to weeks after discharge a particularly important period to be
addressed if readmission risk is to be reduced (Ilaobuchi et al., 2014; Misky et al., 2010). The
22

timeliness of outpatient primary care is a major risk factor, with studies showing that the
readmission risk is 10 times higher for patients who go without follow-up appointments (Cope,
et al, 2018). Yet up to half of Medicare patients who were readmitted within 30 days were not
seen in the outpatient setting (Jencks, Williams, & Coleman, 2009) and over half of the study
participants in a large urban academic center had higher rates of readmission due to the absence
of timely follow-up with a PCP following discharge (Misky et al., 2010). Timely follow-up is
indispensable to transferring care in a way that captures and properly prioritizes all relevant
patient information in order to enhance care by ensuring continuity, and is therefore a key
success factor in effectively transitioning care from hospital to community, particularly for
vulnerable patients (Cope et al., 2018; Kripalani et al., 2007; Misky et al., 2010).
In addition to the timeliness of follow-up, the available quality of care is also a relevant
factor that impacts the transition of care. When compared with faculty-level physicians, the
hospitalized patients of physician residents had lower rates of timely follow-up and were less
likely to see their own provider upon discharge, making it no surprise that they were found to
both have higher rates of actual readmissions and were up to 25% more likely to be readmitted
within 30 days than patients whose PCPs were faculty members (Doctoroff, Mcnally, Vanka,
Nall, & Mukamal, 2014). Given the additional use of resources inherent in readmissions, the
impacts of the quality and experience of medical practitioners is one reason why "better
community health care services … are associated with lower Medicare expenditures" (Gorina et
al., 2015, p. 2). While timeliness of follow up is impacted by patient factors such as cost,
insurance-related limitations, and transportation (Misky et al., 2010), the quality of physician and
degree of contact among care teams during the care transition process is entirely out of the
patient's hands.
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Conclusion
Hospital readmissions have been thoroughly studied from the perspective of hospitals,
but less so from the point of view of primary care provider organizations. This gap in the existing
literature is an important one because primary care organizations, such as VHC, are responsible
for patient care both before they enter the hospital and after they transition out. This dissertation
addresses this gap in the literature by approaching the topic of readmissions from the perspective
of a community-based primary care organization with a patient population that is at high risk for
readmission. The next section of this review examines this problem of practice through the lens
of the knowledge, motivation, and organizational factors that influence VHC PACE leaders’
actions in pursuit of their goal to achieve an all-cause hospital readmission rate of 15% for the
patients under their care.
Clark and Estes’ (2008) Knowledge, Motivation and Organizational Influences Framework
Clark and Estes (2008) outline a conceptual framework that enables the diagnosis and
generation of solutions to address performance gaps at the individual and organizational levels.
This gap analysis framework presents a problem-solving process that is built on the pillars of
knowledge, motivation, and organizational (KMO) influences as the mutually exclusive yet
critically reinforcing set of factors that impact performance. This KMO framework provides the
lens through which to analyze the gap between intended and actual performance on an individual
stakeholder goal relative to the global organizational goal (Clark & Estes, 2008). The gap
analysis also provides the starting point from which to assess evidence-based solutions and
supports to address different types of performance gaps. The structure of the framework is suited
to form a bridge between research and practice as it analyzes each of the assumed KMO
influences based on theoretical foundations, field- or context-specific academic research, and
24

current practices within the organization being studied. Below, each element in the KMO
framework will be discussed in turn in order to develop a gap analysis of the PACE leaders’
performance on their stakeholder goal of reducing all-cause 30-day hospital readmission rates.
Stakeholder Knowledge, Motivation, and Organizational Influences
In this section, the knowledge, motivation, and organizational elements of the gap
analysis framework will be examined in the context of related literature and current
organizational practice. This section begins with the assumed knowledge influences impacting
the PACE leadership’s ability to reach their stakeholder goal, with a summary table for each that
reflects the specific constructs under consideration.
Knowledge and Skills
The stakeholder goal of managing post-acute care in order to improve outcomes and
decrease readmission rates is a performance problem across the healthcare sector. In order to
establish a basis from which to assess options for performance improvement, relevant literature
that focuses on knowledge-related influences that impact the achievement of the goal will be
reviewed. The importance of examining knowledge and skills in promoting organizational
change and performance relative to goals originates from the essential role that knowledge plays
in performance and the importance of knowledge factors in assessing and correcting performance
gaps. If people do not know what is required of them or how to accomplish what is set before
them, then they will not achieve their goals. In employing the metaphor of ‘people as cars,’ Clark
and Estes (2008) liken knowledge to the “engine and transmission system” (p. 43) in order to
demonstrate the centrality of knowledge and skills to individual performance, and therefore to
organizational performance. In like fashion, Rueda (2011) makes the case that learning and
25

knowledge gaps must be addressed before one can function effectively in a particular role,
circumstance, or context.
Anderson and Krathwohl (2001) proposed revisions to Bloom’s taxonomy that included
the categorization of four different types of knowledge: factual, conceptual, procedural, and
metacognitive knowledge. According to Krathwohl (2002), factual knowledge refers to specific
terms, elements, or details related to a discipline while conceptual knowledge captures the
principles, theories, models, and other classifications that speak to the inter-relationships
between elements of a system. Procedural knowledge encompasses not only the skills required to
perform a task, but also the rules about when and how to apply these skills or procedures
(Krathwohl, 2002; Rueda, 2011). Finally, metacognitive knowledge refers to “knowledge of
cognition in general as well as awareness and knowledge of one’s own cognition” (Krathwohl,
2002, p. 214). If procedural knowledge is concerned with how a task is accomplished, then
metacognitive knowledge provides the why and the when, giving both context and appropriate
conditions for the application of problem-solving techniques (Rueda, 2011).
It is important to categorize knowledge types because ‘to know’ something takes on
different meaning based on the knowledge type, and appropriate goals for the development of
knowledge can only be set when the correct cognitive processes related to the acquisition of
knowledge have been identified (Nguyen, Seddaiu & Roggero, 2019; Rueda, 2011). PACE
leaders need to be aware of the knowledge required to limit and prevent unnecessary hospital re-
entries from the standpoint of the elements involved in reducing readmissions (declarative /
factual knowledge) as well as the factors that contribute to high readmissions based on their
patient mix (declarative / conceptual knowledge). They must also know what steps to take
clinically and operationally to transition the care of patients who have been discharged from the
26

hospital (procedural knowledge), as well as when and how to employ the strategies at their
disposal for maximum effectiveness (metacognitive knowledge).
Based on a review of the relevant literature, two knowledge influences that are related to
These influences – declarative and procedural knowledge – were selected because “both
procedural and declarative knowledge are essential to cognitive agents in complex
environments” (Sun, Merrill & Peterson, 2001, 9. 205). PACE leaders’ performance on their
stakeholder goal will be explored in the next section. These knowledge influences will then be
discussed in terms of the knowledge categories into which they fall as the backdrop from which
to determine how these knowledge gaps should be assessed.
Knowledge of Readmission Risk Factors
In order to better manage hospital readmissions among older, publicly insured patients
who have multiple chronic conditions, functional decline, or are impacted by both baseline and
advanced risk factors for readmission, PACE leaders need to understand the nuances of this
population segment, including how these risk factors present (Long, Genao & Horwitz, 2013).
This includes declarative awareness of both the prevalent risk factors at play, and the interactions
among or between these variables. Such knowledge is an essential prerequisite to designing,
developing, and deploying the appropriate interventions based on the specific characteristics of
their patients, as the presence of declarative knowledge can support the communication of
knowledge to others and facilitate the transfer of skills (Sun, Merrill & Peterson, 2001).
Using claims data for older and chronically-ill patients enrolled in traditional and team-
based primary care practices, Riverin, Li, Naimi, and Strumpf, (2017) compared 90-day post-
discharge outcomes related to ED visits, readmission rates, and mortality. They found that as
many as 20% of patients of 65 years or older were readmitted within 20 days of being discharged
27

from the hospital, regardless of the reason for their initial admission (Riverin et al., 2017).
Barriers to care have a significant impact on whether patients can access the primary care health
services needed, at the time that care is needed, in the right location (Carlson, Menegazzi, &
Callaway, 2013; Cheung, Wiler, Lowe, & Ginde 2012). Interventions deployed with the intent of
reducing readmissions among older adults must be based on the risk factors for this population,
which include factors that are social in nature - e.g., living alone, use of social services; of a
medical nature - e.g., functional status, cardiac or respiratory diagnosis; or both, which covers
variables such as the patient’s destination after discharge (Dobrzanska & Newell, 2006;
Iloabuchi et al., 2014). Declarative knowledge of these factors will be assessed because
“organizational practice is based and dependent upon both individual and collective declarative
knowledge” (Kump, Muskaliuk, Cress & Kimmerle, 2015, p.7).
Elements Involved in Transitioning Care
PACE leaders need to expand their knowledge of how to guide the transition of patient
care from a hospital setting back to the primary care provider in order to take an important step
towards their goal to reduce hospital readmissions among their patient population. This is
necessary because once developed, this procedural knowledge of how to achieve a result by
following a particular sequence is accessed and used efficiently (Hallet, Nunes & Bryant, 2010;
Sun, Merrill & Peterson, 2001).
Improving the coordination of care and promoting the use of primary care facilities are
two key steps to reducing the number of patients that return to the hospital after initial discharge
by facilitating effective care transitions (Jencks, Williams & Coleman, 2009). Given that the
days and weeks post-discharge represent a particularly high risk time for readmissions (Joynt &
Jha, 2013; Misky, Wald & Coleman, 2010), ensuring that care is continued at the appropriate
28

level despite a shift in the context of care is critical to maintaining patient health and keeping
them out of the hospital. Improved care coordination and integration of the experience of care
across settings is integral to not only improved patient satisfaction and higher quality outcomes,
but also lower hospital readmission rates (Foster et al, 2018; Riverin et al., 2017). Because care
coordination usually begins with the primary care provider, promoting the use of existing
primary care centers, including Federally Qualified Health Centers, is also a lever that can be
used to set the stage before hospital entry, and providing an anchoring site for the continuation of
care post-discharge (Carlson, Menegazzi, & Callaway, 2013; Foster et al, 2018; Wright, Potter,
& Trivedi, 2015).
Table 2 gives an overview of the knowledge influences relevant to PACE leaders, in
addition to the knowledge types and proposed means of assessment. The organizational mission,
global goal, and stakeholder goal are also identified.
Table 2
Knowledge Influence, Knowledge Type, and Knowledge Influence Assessment
Organizational Mission
VHC provides primary health care services to medically underserved populations in Southern
California in order to reduce healthcare disparities and facilitate improved health outcomes for
poor and vulnerable populations.

Organizational Global Goal
By December 2020, VHC will attain a 4.5 star quality rating

Stakeholder Goal
PACE Leadership’s goal is to achieve a 30-day readmission rate of 15% for all diagnoses by
October 2020.

Knowledge Influence Knowledge Type Knowledge Influence
Assessment
29

Motivation
A crucial step in closing the gap between actual and desired hospital readmission rates is
examining whether there are motivational barriers that impact the performance of PACE leaders.
Before any potential motivational challenges can be assessed, the motivational influences must
be identified. Motivation is a construct that is influenced by many variables. Two important
motivational influences are self-efficacy and value (Rueda, 2011). The following section
explores the motivational influences of value and self-efficacy, as well as the foundational
theories behind them. This exploration of motivational influences and theories will set the stage
for a discussion of PACE leaders' motivation relative to their stakeholder goal of keeping
patients out of the hospital by reducing readmissions.
Expectancy Value Theory
It is assumed that PACE leaders need to value the outcome of reduced readmission
(utility value) and be able to communicate that value to their staff. Another assumption at play is
that they must also value the process required to achieve this goal (attainment value), the
tradeoffs required to meet the goal (cost value), and derive enjoyment from engaging in activities
that keep patients healthier while keeping costs down (intrinsic value) (Rueda, 2011).
Jacquelynne Eccles was a major figure in expounding expectancy value theory, which defined
value as the importance that one has for a task and noted that motivation for a task will be higher
PACE leaders need to know the
risk factors that contribute to high
hospital readmission
Conceptual PACE leaders asked to identify
three risk factors for hospital re-
admission
PACE leaders need to know how
to effectively transition patient
care from an inpatient to an
ambulatory setting
Procedural PACE leaders asked to share
critical steps required for
transition of care
30

when one finds the task both important and desirable, and feels optimistic that the outcome will
be positive (Eccles & Wigfield, 2002). The more one possesses positive expectations of success
and high significance for the task, the more motivated one is to make an active choice, apply
mental effort, and persist through challenges (Clark & Estes, 2008). Value for a task can be
conceptualized through the following dimensions: intrinsic value – importance based on intrinsic
interest; attainment value – the personal importance of a task based on its alignment with one’s
identity; utility value – the connection between accomplishing the task and achieving a future
goal; and, cost value – the perceived tradeoff involved in accomplishing the task in terms of
time, money, energy, or other resources (Eccles, 2006; Rueda, 2011). While intrinsic values
signals the immediate reward to be gained, utility value can be considered the importance placed
on delayed rewards (Galla, Amemiya & Wang, 2018).
Despite existing as a separate construct from intrinsic value, research studies have shown
that utility value is associated with task interest and enjoyment in educational and other settings
(Kale & Akcaoglu, 2017; Durik, Shechter, Noh, Rozek, & Harackiewicz, 2015). An
ethnographic case study conducted by Mcdonald, Harrison, Checkland, Campbell, and Roland
(2007) in British primary care centers found that where financial incentives were attached to
quality metrics, motivation remained high among physicians, despite concerns from other staff.
The utility value of the tasks involved in achieving quality targets was effectively increased for
at least some team members (Mcdonald, et al., 2007). Kjellström, Avby, Areskoug-Josefsson,
Gäre, and Bäck (2017) found that the motivation of healthcare professionals in Sweden was
impacted by both intrinsic interest and organizational goals. Given this link between utility value
and intrinsic value, and the fact that utility value reflects perceptions of the meaningfulness and
relevance of a task (Kale & Akcaoglu, 2017), it comes as no surprise that in healthcare, linking
31

proposed changes and improvement efforts to professional values such as the delivery of high
quality patient care increases the engagement levels of healthcare workers participating in these
efforts (Kjellström, et al., 2017; Mcdonald, et al., 2007).
Managerial motivation is significantly impacted by the perceived value of external
rewards (Kominis & Emmanuel, 2007). While performance and engagement are incentivized
through primarily financial rewards in other sectors, research affirms that features of the
healthcare sector require greater attention to value (Berdud, Cabases & Nieto, 2016). As Berdud,
Cabases, and Nieto (2016) argue, it is possible for monetary rewards and intrinsic motivations to
act as substitutes for each other, such that the application of financial incentives could have a
crowding out effect on providers who otherwise see themselves as being intrinsically motivated,
rather than driven by the potential for external financial reward.
It has also been found that managers within healthcare organizations play an important
role in connecting staff with the overarching goals of the organization (Korlén, Essén, Lindgren,
Amer-Wahlin, & Schwarz, 2017). Specifically, healthcare managers tend to utilize various
strategies—such as tailoring incentives to individuals and translating goals into practical terms to
aid the sense-making process for staff—in order to make the goal meaningful to those whose day
to day work influences performance against the goal (Korlén, et al., 2017). PACE leaders
therefore need to see the value of reducing hospital readmissions as a core element of how they
and their teams provide quality care to their patients. The stakeholder goal needs to be perceived
in light of how it contributes to the overall mission of the organization and interpreted in terms of
its alignment to the professional values and ethos of care and concern that motivate healthcare
workers.
Self-efficacy Theory
32

PACE leaders need to feel confident in their abilities to engage as both people managers
and clinical leaders in the various processes required to achieve the stakeholder goal of reduced
30-day hospital readmission rates. While Bandura (2005) distinguished self-efficacy as judgment
about personal, task specific performance, Pajares (2006) elaborates on this by noting that self-
efficacy is not just about one's beliefs about his or her capability to learn or perform in general,
but specifically, to produce a particular level of performance. These beliefs and self-perceptions
about the ability to perform arise from four main sources: mastery experiences, vicarious
experiences, social persuasions, and physiological reactions (Pajares, 2006; Rueda, 2011). The
most powerful of these sources is mastery experiences (Rueda, 2011), as a prior experience of
success on a task contributes to increased confidence in one's ability to reproduce that success
and reinforces the belief that one is capable of taking actions that achieve the desired effects.
Additionally, the act of observing the successes of peers functions as a vicarious experience for
learners, hence modeling acts as a source of self-efficacy beliefs (Pajares, 2006). Social
persuasions and physiological reactions involve the incorporation of environmental data, whether
in the form of feedback from others or information about one's own affective and emotional
states, into the determination of one's capability to accomplish task goals at the desired level
(Clark & Estes, 2008; Pajares, 2006).
High self-efficacy has been linked to high work performance (Çetin & Askun, 2018),
taking on greater challenges and persisting longer (Bandura, 2005; Franco, Bennett, & Kanfer,
2002), and going above and beyond the formal requirement of one’s role in order to provide
excellent patient care (Salanova, Lorente, Chambel, & Martinez, 2011). Positive judgments of
one’s internal and external capabilities to accomplish the core functions of one’s professional
role have been found to be central to improving work outcomes, enhancing performance, and
33

sustaining commitment in the healthcare sector (Franco, Bennett & Kanfer, 2002; Pillai &
Williams, 2004; Walumbwa, Bruce, Avolio, & Zhu, 2008).
Self- versus Collective Efficacy
One important feature to note about efficacy is that, as a lens through which to view the
dimensions of human agency, it is a construct that transcends the individual. Whereas individual
self-efficacy focuses on perceptions of the self that inform beliefs about one's ability to perform,
collective efficacy is "the shared belief in the power to produce effects by collective action"
(Bandura, 2000, p. 75). Collective efficacy is the product of both shared skills and knowledge of
individual group members, as well as their ability to work well together (Bandura, 2000;
Walumbwa, Wang, Lawler & Shi, 2004). Higher confidence in the individual's or group's ability
to do what is asked of them is an important driver of motivation.
Self-efficacy can be connected to collective efficacy in a number of ways, including
through building confidence in the competencies required for both one’s role and for being an
effective team member (Tasa, Sears & Schat, 2010). For instance, LeBlanc et al., (2010)
conducted a longitudinal study of nurses in the intensive care unit and found that the nurses'
efficacy beliefs were predictive of their future collaborative practice and that organizational
performance in the area of collaboration could be improved by strengthening the nurses' sense of
efficacy. Indeed, Clark (2005) commented that “interdependent teams are most motivated when
they trust both the expertise and collaborativeness of other team members as well as the
determination of weaker members on their team to invest maximum effort to build their
expertise” (p. 16).
It is assumed that PACE leaders will need to have not only a high sense of personal self-
efficacy, but also a high level of collective efficacy if they are to be successful at creating
34

working environments that are conducive to achieving the stated goal of reduced hospital
readmissions (Turner, 2017). High collective efficacy fosters resilience and commitment while
reducing undesirable behaviors such as lateness or absenteeism in workers (Bandura, 2005;
Walumbwa, Wang, Lawler, & Shi, 2004). Chou, Lin and Chou (2012) note that “when team
members perceive a higher degree of collective efficacy, they are capable of … enabling better
performance for the team” (p. 383). Conversely, low collective efficacy has been associated with
lower performance and higher collective anxiety under certain conditions, based on group
composition (Salanova, Llorens, Cifre, Martinez & Schaufeli, 2003). Given the role that PACE
leaders play, the importance of building agency at the group level by fostering a sense of
collective efficacy cannot be overstated.
Table 3 captures the assumed motivational influences impacting PACE leaders’ ability to
accomplish their goal, in addition to how these potential influences could be assessed. The
organizational mission, global goal, and stakeholder goal are also identified.
Table 3
Assumed Motivational Influence and Motivational Influence Assessment
Organizational Mission
VHC provides primary health care services to medically underserved populations in Southern
California in order to reduce healthcare disparities and facilitate improved health outcomes for
poor and vulnerable populations.

Organizational Global Goal
By December 2020, VHC will attain a 4.5 star quality rating

Stakeholder Goal
PACE Leadership’s goal is to achieve a 30-day readmission rate of 15% for all diagnoses by
October 2020.

Assumed Motivation Influences Motivational Influence Assessment
35

Organization
Two primary organizational influences that will be examined throughout this study are
culture and leadership. Key sources that speak to the nature of culture and the role it plays in
organizational change will be reviewed, as will the nature and role of leadership in the context of
change. Table 4 summarizes the assumed organizational influences and how they were assessed.
Culture
The organization needs to be able to identify the levers needed to shift the culture in
support of performance goals and know how to use these levers to shift their culture. A key
feature of any culture is that it is shared (Berger, 2014; Erez and Gati, 2004; Schein, 2017). It is a
collective phenomenon, which makes it a unique influence to examine at the organizational
level, as unlike the knowledge and motivation factors, culture cannot be isolated and assessed at
the level of the individual (Schein, 2017; Schneider, Brief, & Guzzo, 1996). While Schein (2017)
emphasized that culture is accumulated shared learning that has proven adaptive in the face of
internal and external ecological challenges over time, Erez and Gati (2004) highlight the fact that
culture is composed of shared systems of meaning, and Berger (2014) notes that the shared
nature of different types of knowledge is a defining feature of culture. Among these knowledge
types and forming the basis for mental and social networks of meaning are established
assumptions and values that are internalized by those who are members of or participants in a

Utility value – PACE leaders need to see the
value of their efforts in reducing hospital
readmission rates
Semi-structured interviews exploring value
for reducing readmissions
Self- and collective efficacy – PACE leaders need
to believe that they are capable of making
changes that positively impact hospital
readmissions
Semi-structured interviews exploring self
and collective efficacy for the tasks involved
in reducing readmissions
36

particular culture (Berger, 2014; Erez & Gati, 2004; Schein, 2017; Schneider, Brief, & Guzzo,
1996). These values and assumptions guide behavior, are actively and passively transmitted to
and then expressed by new members of the group, and are extremely difficult to confront or
change precisely because they are hidden (Erez & Gati, 2004; Schein, 2017; Schneider, Brief, &
Guzzo, 1996). Some argue that since culture is not subject to direct intervention, when it comes
to changing culture, the focus should be on climate: the tangible, observable, describable
artifacts, habits, routines, and behaviors that reflect and reinforce the underlying assumptions of
the culture (Schein, 2017; Schneider, Brief, & Guzzo, 1996). However, the fact remains that it is
this level of culture—core assumptions and values—that must be the target of organizational
change efforts if the effects of such efforts are to take hold. Culture is an important driving force
in organizations, and because it is, more often than not, impossible to directly manipulate, two
useful concepts that help create a bridge to apprehending and implementing cultural change—
cultural models and cultural settings—will be employed to assess culture-related organizational
influences.
Cultural models. Cultural models are the shared normative understandings about the
way the world actually works or ought to work (Gallimore & Goldernberg, 2001). Given that
PACE is situated at the intersection of two cultural models, the organization needs to assess the
alignment of site-level cultural norms with the tenets of managed care (Erez & Gati, 2004;
Schein, 2017), as PACE staff are also potentially influenced by the conflicting norms and mental
schema of the broader VHC enterprise, which is not a managed care organization (MCO).
Assessment of alignment to managed care at the level of each PACE center is an important first
step in understanding any gaps that may exist in the PACE approach to reducing hospital
readmissions, which out to be rooted in the tenets of managed care. The central belief within the
37

managed care cultural model is that quality of care delivered can be improved while reducing
cost (Noble & Klein, 2001; Tietze, 2003). In order to achieve the imperative of reducing costs
while improving care, the model employs financial incentives to encourage a greater focus on
prevention, coordination of care across healthcare delivery settings, and the reduction of
unnecessary tests, services, and procedures (Tietze, 2003; Trombetta, 2017). This stands in
contrast to the fee-for-service cultural model, where the organization is rewarded for caring for a
higher volume of patients (Di Guida, Gyrd-Hansen & Oxholm, 2019), which is the cultural
model of VHC. While improvements in the quality of healthcare outcomes and reductions in cost
can be achieved through targeted interventions, Rosen et al (2018) emphasize that the success of
such efforts is both moderated by and requires alignment with organizational culture. Therefore,
alignment between the PACE culture—even at the level of individual sites and teams—and the
broader cultural model of managed care is an important factor that impacts the organization’s
ability to achieve its goals.
Gallimore and Goldernberg (2001) argue that because of the mutually reinforcing nature
of cultural models and cultural settings, changing cultural models requires changing the settings
in which culture is lived out, therefore cultural settings, such as the Inter-Disciplinary Team
(IDT) at PACE—the major organ that addresses hospital admissions and readmission for PACE
participants—are a key component of this study.
Cultural settings. Cultural settings include the day to day physical and relational
contexts in which the shared values, ideals, and beliefs that comprise cultural models are both
derived and played out (Gallimore & Goldernberg, 2001). One instance of a cultural setting that
provides a platform for actualizing the schema valued by the broader cultural model of managed
care is the interdisciplinary team, or IDT for short. It is assumed that the organization needs to
38

continually assess the alignment of IDT goals, structures, and competencies relative to the
objective of reduced readmissions in order to maintain alignment with organizational goals and
the tenets of managed care practice.
The IDT practices a model of team-based care in which the knowledge, expertise, and
approaches from different professional disciplines are brought to bear in a way that keeps the
patient at the center and aims to improve the quality, safety, and experience of care delivery
(Casimiro et al., 2014; Rosen et al., 2018). Teams are defined as groups of interdependent
individuals who pursue a common goal and who possess, collectively, the skills required to
achieve the goals relevant to the team (Clark, 2005). Teams are considered a mechanism for
organizational learning (McDaniel, Driebe & Lanham, 2013). Becker (2004) observed that teams
enact routines in order to coordinate their efforts and conserve cognitive resources while storing
collective knowledge – an argument that is also echoed by Gibson (2001).
The literature on teamwork within healthcare is largely affirming of the association
between reliable, collaborative teams that communicate effectively and quality outcomes for
patients (Rosen et al., 2018; Sidney, 2015). Some have found that forced teamwork has
contributed to reinforced occupational divisions, role boundary conflict, and diminished equity
of voice across occupational groups, (Finn, Learmouth & Reedy, 2010). However, the prevailing
thought in the field is that interventions focused on building trust and strengthening team
capabilities such as adaptability, conflict resolution, situational awareness, and assertive
communication lead to better coordination of care and improved outcomes (Casimiro et al.,
2014; Rosen et al., 2018). The development of these competencies is highly influenced by the
leadership of the organization and making changes in this area requires leaders to take on new
roles.
39

Leadership
This study assumes that the organization needs to equip leaders with the competencies
required for systems thinking if they are to move in the direction of becoming a learning
organization. Traditionally, the primary role of leaders has been generally accepted as that of
providing direction and influencing collective action in the pursuit of a goal that is aligned with
the chosen direction (Northouse, 2015). Indeed, Burke (2018) underscores the indispensable role
that leadership plays in organizational change when he notes that “without leadership, planned
organizational change will never be realized” (p. 296). While the global role that leaders play is
generally accepted, dimensions of this role shift in relation to the specific dynamics of
organizational change, requiring different foci and competencies of organizational leaders.
Organizational change is, by nature, a learning process (Burke, 2018). Leaders impact
organizational learning at least partially by the routines that they institutionalize and the culture
they build (Brusoni & Rosenkranz, 2014; Schein, 2017). Within healthcare, the concept of
complex adaptive systems provides an organizing framework for analyzing and interacting with
change in a highly dynamic system, whose outputs are impacted by multiple stakeholders
(Lipsitz, 2012; McDaniel, Driebe, & Lanham, 2013; Sturmberg & Lanham, 2014). Leaders
within MCOs are expected to deliver on the mandates of quality, affordability, and maintaining
and enhancing the health of populations (Berwick, Nolan & Whittington, 2008). The Institute of
Medicine (2012) notes that while healthcare organizations should be learning organizations
designed with the patient at the center, the current state of the industry is a system with “few
elements that are systematic” and “impaired by the weight of its own complexity” (p. 5-2).
40

It is assumed that in order for PACE to function as a learning organization, the
organization needs to empower leaders as designers of purpose, vision, and effective learning
processes (Senge, 1990). The role of the leader as learning facilitator has been well documented
(Schein, 2017; Schneider, Brief, & Guzzo, 1996; Schwandt & Marquardt, 1999; Senge, 1990).
The leader facilitates learning by enabling sense-making (Senge, Lichtenstein, Kaeufer,
Bradbury, & Carroll, 2007; Schwandt & Marquardt, 1999), by managing the formation and
evolution of climate and culture through the establishment of practices, rewards, policies,
routines, and structures that contribute to the changing of hearts and minds (Bernstein & Linsky,
2016; Schein, 2017; Schneider, Brief, & Guzzo, 1996; Senge, 1990), by demonstrating a
commitment to learning (Schneider, Brief, & Guzzo, 1996), and by encouraging and cultivating
systems thinking, which focuses on interrelationships and dynamic complexity (Senge, 1990;
Senge, 2006).
Table 4
Assumed Organizational Influence and Organizational Influence Assessment
Organizational Mission
VHC provides primary health care services to medically underserved populations in Southern
California in order to reduce healthcare disparities and facilitate improved health outcomes for
poor and vulnerable populations.

Organizational Global Goal
By December 2020, VHC will attain a 4.5 star quality rating

Stakeholder Goal
PACE Leadership’s goal is to achieve a 30-day readmission rate of 15% for all diagnoses by
October 2020.

Assumed Organizational Influences Organizational Influence Assessment

41

Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and
the Organizational Context
A conceptual framework is a visual or verbal map of the relationships between the ideas,
theories, concepts, and beliefs from which the research problem is derived (Maxwell, 2013). The
purpose of the conceptual framework is to serve as a foundational ‘chassis’ upon which the
design of the study is to be built. The conceptual framework provides both justification and
context for the study by painting a picture of why the research problem matters against the
backdrop of the concepts, theories, and assumptions and expectations that inform the
researcher’s position (Maxwell, 2013; Merriam & Tisdell, 2016). It is a construction that takes
into account relevant bodies of knowledge and positions them in relation to each other in a way
that provides support for the research questions and the design by which those questions will be
addressed (Merriam & Tisdell, 2016). The influences presented from a knowledge, motivation,
and organizational standpoint are presented individually for the purpose of clarity however, in
reality, these factors do not exist in isolation. The purpose of the conceptual framework is to
outline the researcher’s perspective on how these influences interact to inform the problem of
practice.
Cultural models – The organization needs to
assess alignment of site-level cultural norms with
tenets of managed care
Semi-structured interviews exploring cultural
norms across sites
Cultural settings – The organization needs to
assess IDT alignment in relation to stakeholder
goal of achieving 15% readmission rate
Semi-structured interviews exploring
features of the IDT as a cultural setting
Leadership – The organization needs to empower
leaders as designers of effective learning
processes
Semi-structured interviews exploring leaders
role in facilitating learning at the system
level
42

The research problem of practice for this dissertation study explores the knowledge,
motivational, and organizational factors that influence the PACE leaders’ ability to meet their
goal of reduced hospital readmission rates among their patient population. The conceptual
framework will illustrate how these factors influence and act upon each other to impact the
stakeholder goal. Given the researcher’s positioning as a member of the strategy team, which is
charged with stewarding the production, measurement, monitoring, and reporting of enterprise
goals, experiential knowledge plays a significant role in the selection of the research problem in
terms of availability of data to support and report on the problem. However, because the
researcher works outside of the PACE structure, there is some distance from the organization’s
governing assumptions. Despite this being the case, provision must be made to attenuate issues
of bias that may impact the process of inquiry, while allowing for critical subjectivity (Maxwell,
2013).
While there is a body of research that engages with different aspects of the managed care
model of healthcare delivery, the vast majority of this emergent field is grounded in lessons
based on practice rather than theory. Reducing hospital readmissions is a national issue for
hospitals, primary care centers, and the Centers for Medicaid and Medicare Services (CMS),
which instituted the Hospital Readmission Reduction Program (HRRP), including a penalty for
hospitals with excessive readmissions (Cope, Jonkman, Quach, Ahlborg, & Connor, 2018; Lee,
et al., 2019). The HRRP was established because hospital readmissions represent potential
threats to patient safety, cost over $40 billion annually in 2011, and have generated close to $2
billion in penalties since 2012, including $528 million in fiscal year 2017 (American Hospital
Association, 2017; Englander, Michaels, Chan, & Kansagara, 2014; Lee et al., 2019)

43

Figure 2
PACE Conceptual Framework

Figure 2 illustrates KMO influences impacting PACE leaders’ ability to meet their
readmissions goal. Knowledge factors at the conceptual and procedural levels influence PACE
leaders’ ability to impact the goal through management of high-risk populations and coordinating
transitions of care (Foster et al, 2018; Riverin, Li, Naimi, & Strumpf, 2017). PACE leaders’
motivation is influenced by their value for the task of reducing readmissions, and their belief in
their ability as leaders and as teams to reduce the number of patients who return to the hospital
within 30 days of discharge (Bandura, 2005; Eccles and Wigfield, 2002). Motivational factors
are impacted by the degree of knowledge and expertise that PACE leaders possess, and
knowledge influences are, in turn, impacted by PACE leaders’ motivation to expand their
knowledge base across knowledge types, and to implement new ways of operating that align
with the needs of their patient populations within the managed care framework. Both knowledge
and motivational factors interact with the organizational influences of culture and leadership in
44

interesting and dynamic ways, as both culture and leadership impact the knowledge that is
prioritized, the confidence with which stakeholders approach their tasks, and the value they
assign to their goals.
In terms of organizational influences, it is important to note that PACE is situated within
two different cultural contexts, simultaneously, as illustrated by the area of overlap within the
diagram. The first is the fee-for-service (FFS) cultural model, which is the dominant mode of
organization and operation at VHC. Within the FFS system, activity is rewarded—sometimes at
the expense of results—as payments are made on a per-service basis, encouraging actions that
increase the volume of visits and discouraging the actions that reflect shared responsibility for
outcomes through every episode of care (Lipsitz, 2012; McDaniel, Driebe, & Lanham, 2013).
The second is the managed care cultural model, in which care coordination is valued, as is cost
effectiveness, access to care, and quality of care (Tietze, 2003). Managed care, with its emphasis
on reducing the number of unnecessary procedures, stands in stark opposition to the FFS model.
PACE is a managed care clinic that is located under the broader umbrella of an organization that
operates its other clinics under a FFS model. In the context of this clash of values, the concept of
healthcare as a complex adaptive system (Lipsitz, 2012; McDaniel, Driebe, & Lanham, 2013) is
used to ground PACE within healthcare more broadly, and to anchor managed care more
specifically, with its focus on the relationships surrounding and supporting patient care across
settings. Given the intricate and inherently intertwined nature of culture and leadership (Schein,
2017), the role of leadership as described by Senge (1990) and others will be a prominent
component of the discussion of the culture and climate in which PACE leaders pursue their
goals.

45

Conclusion
This evaluative study sought to identify the knowledge, motivation, and organizational
influences on PACE leaders in the pursuit of their goal of reducing all-cause hospital
readmissions to 15% by May of 2020. To inform this study, this chapter has reviewed the
literature related to hospital readmissions for Medicare populations. This review has outlined the
key issues in hospital readmissions including the role of primary care and the existence of
disparities across lines of race and class. The review also explored aspects of care management
involved in achieving reductions in hospital readmissions for the target population. This
literature review process has informed the identification of the assumed knowledge, motivation,
and organizational influences specifically related to the achievement of the stakeholder goal. The
knowledge influences include conceptual and procedural knowledge about risk factors for
hospital readmission and the elements involved in reducing readmissions – both for particular
conditions and across the board. The motivation influences include the value placed on the
stakeholder goal and contributing tasks, as well as the collective efficacy of PACE leaders and
the IDTs in impacting factors that are outside of their direct control but which still have an
impact on whether a PACE participant is readmitted after an initial inpatient hospitalization.
Finally, the organizational influences include cultural models and settings that impact the
behavior of PACE, which functions as the only managed care unit operating in the larger fee-for-
service VHC context. Additionally, the role of leaders in creating a learning organization in
support of achieving the stakeholder goal is an important organizational influence. The next
chapter will discuss the methodology to capture data from PACE leaders in order to address the
research questions about knowledge, motivational, and organizational influences that impact
their ability to accomplish the goal of reducing readmissions in their patient population.
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CHAPTER THREE: METHODOLOGY
Introduction to the Methodology
This evaluation study sought to determine the current performance, relevant knowledge,
motivation, and organizational influencing factors, and potential recommendations relative to
Versa Health Corp’s (VHC) Program of All-Inclusive Care for the Elderly (PACE) leadership
group’s stakeholder goal of achieving an all-cause 30-day hospital readmission rate of 15%.
VHC PACE pursued this goal as part of a broader, enterprise level effort at VHC to attain a 4.5
star quality rating. This study utilized the Clark and Estes (2008) gap analysis framework with a
qualitative design that featured multiple methods of data collection. This chapter outlines the
research design and methodology, data collection and instrumentation and data analysis.
The research questions that guided this study were:
1. What are the knowledge, motivation, and organizational factors related to PACE
leaders’ ability to achieve their goals for reducing all-cause 30-day readmission rates?
2. What is the interaction between PACE organizational culture and stakeholder
knowledge and motivation that either enables or hinders PACE leaders in their pursuit
of reduced 30-day hospital readmission rates?
3. What are recommended interventions that would enable PACE leaders to accomplish
their performance goal of achieving an all-cause 30-day readmission rate of 15%?
Sampling and Recruitment
Participating Stakeholders
Though the collective efforts of all stakeholders at, and even outside of, PACE contribute
to the organization’s achievement of its goal to reduce hospital readmission rates, it was
important to evaluate where PACE leadership stood relative to their performance goal. Taken
47

together, the PACE leadership team had 15 leaders, including executives who provide
operational, strategic, and administrative oversight, directors over specific functions that span
multiple sites, and center leads for each of the eight sites. Of these, the 10 participants in this
study represented a variety of PACE leaders: administrative leaders (2), clinical leaders (1),
functional leaders (3), and site leadership (4). The staff had low turnover, with tenure ranging
from eighteen months to over twenty years.
Interview Sampling Criteria and Rationale
Criterion 1
Role. The sample was selected based on the primary criterion of leadership role within
PACE. Leaders were required to take ownership of the stakeholder performance goal within the
organization’s performance management system and results on this goal were factored into their
annual evaluation.
Criterion 2
Tenure. Because the job description of a PACE center leader required that the successful
candidate have significant prior experience in a managed care environment, the requirement for
tenure in role was only one year; this ensured that all participants had an understanding of the
culture of the organization and of PACE as a unit within the larger organizational context. At the
time of the study, all leaders interviewed had been employed for over one year.
Criterion 3
Responsibility. All PACE leaders had administrative responsibilities, budgetary
accountability, and were either measured in terms of their center’s performance or on PACE’s
overall performance on a variety of patient and population outcomes, including hospital
readmission rates.
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Interview Sampling Strategy and Rationale
In order to maintain confidence in the accuracy of assertions made and generalizations
drawn from the research based on the population studied, careful thought was given to the
participants in the study (Johnson & Christensen, 2015; Merriam & Tisdell, 2016). By taking a
purposeful or purposive sampling approach, whereby participation in the research study was
limited to individuals who possessed unique characteristics germane to the research questions,
the most relevant information was obtained (Johnson & Christensen, 2015; Merriam & Tisdell,
2016). Purposeful sampling was used because of the information-rich nature of the sample and
the potential for engaging in thick description to yield valuable insights about the influences at
play and the interrelationships between them (Merriam & Tisdell, 2016). Administrative leaders
were selected whose roles were either directly patient facing or carried responsibility for
operational decisions that directly impacted patient outcomes. For this reason, leaders whose
primary responsibility pertained exclusively to finance, technology, facilities, or transportation
were excluded from this study, as they were not expected to take ownership of this goal, nor was
their performance connected to the goal of reducing hospital readmissions. In addition to the six
administrative, clinical and functional leaders, leaders from all eight (8) PACE sites were invited
to participate, so as to give maximum variability to the voices included in the sample,
particularly in terms of size, location, and years in operation. Given the small size of the PACE
unit relative to the larger VHC organization, the sample was considered comprehensive.
However, because some leaders opted not to participate, the sample did not represent a census of
PACE site leaders (Johnson & Christensen, 2015). The conceptual framework rested on the
notion of PACE being a unique cultural setting that is located at the intersection of two distinct,
and in some ways conflicting, cultural models. By engaging the top levels of PACE leadership in
49

interviews, this comprehensive sampling revealed the gamut of leadership perspectives within
that organizational context.
Explanation for Choices
Because this was qualitative research, the researcher was the instrument of data
collection, collecting information on meanings attached to particular events or phenomena
(Creswell & Creswell, 2018). In light of the multitude of factors that influence hospital
readmissions, it was important for the researcher to allow space for the exploration of the
feelings, thoughts, and intentions related to the stakeholder performance goal—a task for which
interviews were particularly well-suited (Merriam and Tisdell, 2016).
Qualitative Data Collection and Instrumentation
Qualitative research serves the purpose of bringing to light and making meaning of the
internal and external experiences of those being studied (Weiss, 1994). Both qualitative
interviews and document review were used to explore the experiences of PACE leaders as they
pursued the goal of reducing hospital readmission rates for their population. These methods were
chosen for their open-ended, collaborative nature, and their ability to open unique windows into
the perspectives of others (Patton, 2002; Weiss, 1994). The document review shed light on
knowledge and organizational influences pertaining to the stakeholder goal, while interviews
explored the knowledge, motivational, and organizational influences operating in the stakeholder
context.
Documents and Artifacts
As artifacts that capture discrete aspects of the lived experience within the organization,
internal documents granted the researcher access to the "official perspective" (Bogdan & Biglen,
2007, p. 137), arming her with significant social and historical context for information that was
50

gathered from interviews. Leveraging both internal and external documents as data sources
provided deep grounding in the research content (Merriam & Tisdell, 2016) and enabled the
researcher to gain insight into the language of participants (Creswell & Creswell, 2018).
Documents such as organizational charts, internal performance dashboards, meeting minutes,
internal communications such as memos and operational guidance, marketing materials, and
reports produced for regulatory agencies external to the organization were reviewed as part of the
data gathering process. These documents were private but not confidential and were accessed by
the researcher after being granted permission by PACE leadership. Their authenticity and
accuracy were assessed by participants prior to being released to the researcher. Despite the fact
that these documents were not explicitly designed or developed for research purposes (Merriam
& Tisdell, 2016), and run the risk of painting an incomplete picture when considered in isolation,
the insight they could provide on department priorities, current performance, and what leadership
values (Bogdan & Biklen, 2007) was relevant to the research questions. The documents that were
included in the document review also offered insight into how a managed care function operates
within the broader organizational context of a volume-driven Federally Qualified Health Center
(FQHC), thus making this avenue of data collection central to the conceptual framework.
Interviews
Interview Protocol
Semi-structured interviews were conducted, leveraging an interview guide with open-
ended questions to gather comparable data across participants in a way that elicited responses
that are in their own words. The purpose of using this approach was to draw out not only
statements of fact and recounting of process, but also participants’ reflections, views, and
opinions (Creswell & Creswell, 2018). In order to build a multi-dimensional picture of the
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participants and their work context, the interview protocol contained a variety of question types.
Per Patton's (2002) categories, behavioral questions were balanced by knowledge and values
questions, with background questions setting the stage for the responses that followed. Staying
true to the intent of qualitative inquiry, questions were designed to be neutral, singular, clear, and
open-ended—allowing the participant to offer the reflections most salient to them (Patton, 2002).
The questions explored the knowledge, motivational, and organizational factors that influenced
readmission rates, including but not limited to risk factors for readmissions, teamwork,
leadership, and communication, in an effort to surface content that revealed their working
theories, models, and beliefs pertaining to the conceptual framework, thereby advancing the
research agenda.
Interview Procedures
To explore these research questions, the researcher utilized a purposeful sample of PACE
leaders, selected for maximum variation. Ten leaders from among the center manager, director,
and vice president roles at VHC PACE participated in this study, representing approximately
67% of the leadership population. The study was conducted over an eight-week timeframe,
between August 2019 and October 2019. Informed consent was obtained from all participants
prior to the interviews, and the interviews ranged from 55 to 90 minutes based on the interview
protocol (see appendix A), for a total of roughly 14 hours of interviews. Each participant was
interviewed only once; follow-up interviews were not conducted.
Purposeful sampling ensured that participants in this qualitative study were a rich source
of information for the topic of study. For the purposes of this research, interview participants
were drawn from the center manager and above at VHC PACE, purposefully sampled to cast the
widest possible net for meaningful perspectives related to hospital readmissions. Additionally,
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within this purposeful sample, the leaders of 50% of PACE sites were interviewed in order to
pursue maximum variation within the purposeful sample, which enhanced the credibility and
transferability of findings.
The aim of research was not only to capture meaning from the experiences of others, but
to “describe and explain the world as those in the world experience it” (Merriam & Tisdell, 2016,
p. 250). Maintaining fidelity to the perspectives of those studied is essential in qualitative
research (Maxwell, 2016), and the pursuit of fidelity in this study was reflected throughout the
data gathering process. To ensure that the data gathered was as close as possible to the actual
words spoken by the participants, interviews were recorded and transcribed to ensure verbatim
data collection. Recordings were supplemented by researcher fieldnotes, particularly with regard
to body language or other observable phenomena that could not be captured by a voice recorder.
Because the interviewer is the instrument of data gathering in qualitative research and the
largest determinant of the quality of data gathered from an interview (Merriam & Tisdell, 2016;
Patton, 2002), the researcher’s presentation had the potential to impact the data gathered. As
such, every effort was made to align the wording of the interview protocol with the language of
the participants. The interviewer also dressed in alignment with the settings in which participants
were interviewed, wearing more business casual attire at the corporate headquarters, and opting
for a slightly more formal look when visiting PACE centers. Formal interviews with center
managers were conducted at their respective PACE sites in a participant selected conference
room so as to minimize disruption to daily operations. Leaders who worked from the corporate
office were interviewed in their offices or in an available corporate conference room.

53

Credibility and Trustworthiness

As noted by Merriam and Tisdell (2016), “All research is concerned with producing valid
and reliable knowledge in an ethical manner” (p. 237). Throughout the course of this study,
various strategies were adopted to ensure that both the process and product of the research were
credible and trustworthy.
The use of an audio recorder to capture the interviews and enable verbatim transcription
of participant inputs was the first strategy used to promote credibility and trustworthiness. This
increased the accuracy of data capture and lessened the likelihood of errors that could have led to
misinterpretation. Triangulation, which involves exploring multiple perspectives or sources of
evidence (Creswell & Creswell, 2018; Merriam & Tisdell, 2016), was also employed as a
strategy to enhance credibility. Due to the scope of the study, triangulation of sources within the
PACE leadership team took the form of holding interviews with clinical leadership, operational
leadership, and wraparound support leaders. Validity of themes that emerged from the study was
increased by including these three distinct perspectives. The use of both document review and
interviews as data sources served as another form of triangulation to confirm emerging findings.
In order to ensure that the emergent findings captured by the researcher were an accurate
reflection of the participants’ input, member checking was used as a validation mechanism.
Interview questions were tested through the conduction of pilot interviews that tested for length,
appropriateness of language, and relevance of content. In order to not contaminate the data by
giving participants prior exposure to the questions, pilot interviews were carried out with leaders
who were not part of the sample. Peer debriefing was also used as a member-checking strategy to
check the researcher’s interpretation, test for alignment with the perspectives gathered in the
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data, and assess resonance of researcher’s takeaways so as to guard against potential
misinterpretation and mitigate researcher bias.
Ethical research practice is a sine qua non of credible research. It ensures that interactions
with the researcher, as the research instrument, are untainted by coercion or any other form of
harm to research participants. As such, the researcher’s commitment to integrity as demonstrated
through the adoption of ethical practices such as informed consent, reminding participants of the
voluntary nature of participation, and confidentiality of information shared also contributed to
the credibility and trustworthiness of the study. Finally, the researcher engaged in reflexive
practice by keeping a journal and regularly reflecting on the research in order to surface potential
biases that could have informed the course of inquiry. These strategies were combined across the
course of study design, execution, and data analysis to increase the believability and credibility
of the study.
Ethics
By choosing to employ the qualitative approach to explore the research questions at the
center of this study, the researcher acknowledged that she not only collects data, but becomes the
instrument of data collection. As the instrument of data collection, the researcher’s ethical
decisions formed the foundation upon which the trustworthiness, reliability, and credibility of the
study stood (Merriam & Tisdell, 2016). Additionally, the role of the researcher carried with it
responsibilities such as commitment to justice, integrity, and respect for both the privacy and
anonymity of participants, and the participants themselves (Creswell & Creswell, 2018). The
researcher’s ability to be guided by these standards directly impacted the degree of trust she was
able to build with participants and the trustworthiness of the research product. In light of the
importance of holding the highest standards of ethical practice as the basis for research, an
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information sheet (appendix B) was distributed to each participant at the beginning of the study.
In order to honor the primary obligation of the researcher to the human subjects being studied
(Rubin & Rubin, 2012), the purpose of the study and their rights as participants—including
confidentiality and the right to withdraw without penalty—were transparently explained to all
participants (Glesne, 2011). Participants were only included in the study after their review of the
information sheet and agreement to participate. Moreover, the researcher reiterated her
commitment to ensuring privacy and protection from harm by requesting that participants avoid
referencing any personally identifiable patient data in our conversations and following all
relevant guidelines, including but not limited to those set forth by the Health Insurance
Portability and Accountability Act (HIPAA) in any exchange of information, whether written or
verbal. Permission to record was requested before each interview, and data was stored on a
password protected drive to ensure security. To further ensure data security, pseudonyms were
used, names were wiped from transcripts and were not reported with the findings, and recordings
were destroyed upon completion of the study.
Managers and leaders within the PACE unit of VHC were the primary participants in this
study. While the researcher’s position is not located in that department, it was still important for
her to maintain awareness of her role as both a researcher and a member of the enterprise
strategy team. Because of the researcher’s positional proximity to the executive team, she
ensured that all participants were informed that nothing they shared would be used against them
in a punitive or evaluative way, whether individually or collectively. A small token ($10 gift
card) was offered as an incentive for participation. This incentive was offered as a gesture of
appreciation for the participants’ time, but was small enough to not be seen as a coercive
measure, thereby reinforcing the voluntary nature of participation. Because PACE was a
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completely separate unit from the researcher’s department with no overlap in reporting
structures, no other potential conflicts of interest were present.
It was important for the researcher to account for her biases (Merriam & Tisdell, 2016) so
as to ensure that they did not unduly impact the outcome of the research. As she undertook data
collection, analysis, and reporting activities, the researcher utilized reflexive practices and
strategies as a check on her potential biases as someone who has played the role of caregiver to
an aging relative who has had to interface with healthcare personnel across settings. Other
potential biases stemming from her role and team were addressed through reflexivity as well.
Limitations and Delimitations
Limitations—factors outside of the researcher’s control that impact the study’s
outcomes—were taken into consideration both upon initiating the study and in the interpretation
of results. Limitations applicable to this study included:
• Organizational changes within VHC that could impact perspectives on and
attitudes towards the goal being studied
• Technology changes in the organization that impact communication between
VHC and hospital partners
• Regulatory changes in the healthcare landscape that impact organizational
priorities
Additionally, due to the unforeseen and unforeseeable nature of the global COVID-19 pandemic,
this research was done on a model that has since experienced significant changes in its approach
to the model of care. Data collection for this project was completed roughly six months before
the COVID-19 pandemic would capture the attention of the globe. As such, a limitation of this
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project is its inability to account for these foundational shifts to the PACE model at the time that
the research was conducted.
Delimitations included the fact that this was a qualitative study, which limited
generalizability, and that data was collected only from the leadership level, which meant that
perspectives from frontline staff, patients, and other stakeholders were not considered.
Conclusion
This research study was performed using a qualitative design that included document
review and the completion of 10 qualitative interviews with various VHC PACE leaders. A
rigorous approach was taken in order to ensure that the highest ethical standards were upheld and
bias was mitigated while collecting data that addressed the research questions of the study.
Piloting and member-checking were used to increase the credibility and trustworthiness of
instruments and findings, and data was secured throughout the process to safeguard participant
confidentiality. The researcher maintained awareness of her biases through reflexive practices
and emphasized the voluntary nature of participation in the study through informed consent.
Chapter four will present the results of the interviews findings relative to the identified research
questions.

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CHAPTER FOUR: RESULTS AND FINDINGS
The purpose of this evaluation study was to ascertain the knowledge, motivational, and
organizational factors that influence how Program of All-Inclusive Care for the Elderly (PACE)
leaders understand and approach the issue of hospital readmissions among their patient
population, and impact the performance of PACE leaders in their pursuit of the stakeholder goal
of 15% all-cause 30-day readmission rates across all PACE sites. It was assumed that PACE
leaders need particular knowledge, motivation and organizational capabilities in order to lead
their teams in achieving this goal. The purpose of Chapter Four is to analyze the findings relative
to the assumed PACE leaders’ knowledge, motivation, and organizational influences on their
ability to positively impact the goal of reduced hospital readmissions. The findings presented in
this chapter encompass data from both interviews and document analysis. Data for this study was
collected through 10 qualitative interviews conducted over an eight-week period, in addition to
document analysis. Interviews were conducted with clinical, administrative, functional, and
operational (center level) leaders at Versa Health Corp (VHC) PACE locations and at the
corporate headquarters. This chapter presents the results and findings from those interviews. The
Clark and Estes (2008) Gap Analysis framework was used to assess and validate assumed needs.
The study also proposes recommendations to address the needs that are surfaced in these areas.
Recommendations to address the identified needs are discussed in Chapter Five.
The research was guided by three key questions:
1. What are the knowledge, motivation, and organizational factors related to PACE
leaders’ ability to achieve their goals for reducing all-cause 30-day readmission rates?
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2. What is the interaction between PACE organizational culture and stakeholder
knowledge and motivation that either enables or hinders PACE leaders in their pursuit
of reduced 30-day hospital readmission rates?
3. What are recommended interventions that would enable PACE leaders to accomplish
their performance goal of achieving an all-cause 30-day readmission rate of 15%?
Participants
Qualitative interviews were the primary mode of data collection in this study of the
PACE organization within VHC. Interview requests were sent to the full complement of 15
PACE leaders, of which 10 leaders elected to participate. Leadership was the primary selection
criterion for selecting study participants, based on the level of influence that leaders within the
organization are both assumed and expected to carry relative to the organization’s strategic goals.
The study targeted leaders who had over one year of tenure, functioned in a scope of leadership
that included either operational, administrative, functional, or clinical responsibility, and had
experience in a managed care setting. Table 5 shows the demographic composition of the leaders
interviewed for this study.
Table 5
Demographic Composition of Leaders Interviewed (N=10)
Leader Gender Tenure at PACE
A Female 1-5 years
B Male 1-5 years
C Female 16-20 years
D Female 1-5 years
E Male 6-10 years
F Female 6-10 years
G Female 1-5 years
H Female 1-5 years
I Female 11-15 years
J Female 16-20 years
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Document Analysis
In addition to interviews, document analysis was used to provide additional insight into
the leaders’ assumed knowledge, motivation and organizational influences pertaining to their
approach to the issue of hospital readmissions. Meeting minutes, regulatory submissions,
marketing materials, and quality dashboards were analyzed for plans, processes, messaging, and
approaches to readmissions. Review of these documents revealed that recognition and
appropriate management of high-risk patients is a key component of efforts to reduce hospital
readmissions. This provided validation for the declarative knowledge assumed influence, which
assumed that PACE leaders needed to be able to identify the risk factors that contributed to
hospital readmissions. The procedural knowledge assumed influence, knowledge of the steps
involved in effectively transitioning care from hospital to outpatient, was also identified as a
potential asset through the analysis of documents that detailed the processes used to measure and
monitor related metrics. A key finding with regard to the value placed on reducing hospital
readmissions by PACE leadership is the fact that readmissions and discharge planning was
mentioned, in one form or another, in 80% of meeting notes and agendas reviewed. Finally,
while the documents reviewed made mention of the Inter-Disciplinary Team (IDT), very few of
the documents obtained by the researcher gave adequate insight into the site level dynamics of
IDTs, yielding little useful data that spoke to the organizational assumed influences.
Findings for Assumed Knowledge Influences
In their revision of Bloom’s taxonomy, Anderson and Krathwohl (2001) organize
knowledge into four categories: factual, conceptual, procedural, and metacognitive, with factual
knowledge also being considered declarative in nature. Two primary assumed knowledge
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influences on the ability of leaders to reach their goals for reducing all-cause 30-day readmission
rates were identified based on the literature review. The first is knowledge of risk factors related
to readmissions (declarative knowledge) and the second is knowledge of how to effectively
transition patient care from an inpatient to an ambulatory setting (procedural knowledge).
Interview participants were asked six questions (four main questions and two follow-up
questions) related to their knowledge in these areas. Knowledge needs were considered
“validated” if a simple majority (60%) of participants demonstrated knowledge in the areas in
question; needs were considered “not validated” if responses fell below that majority threshold.
The validated knowledge needs are those which solutions will be focused on in Chapter 5. The
questions used to investigate the assumed knowledge needs of PACE leaders were:
1. Tell me about your population – who do you serve?
2. Would you say that readmission is a problem for the majority of your population? Why
or why not?
a. Which segments of your patient population would you say are at greatest risk for
readmission?
b. What makes these segments the ones that are at highest risk?
3. From what you have seen, what are the major reasons that patients are readmitted to the
hospital after discharge?
4. Can you list and explain the steps that are taken with PACE participants who have just
been discharged from the hospital?
Table 6 presents a summary of the assumed knowledge findings.
Table 6

Summary of Results and Explanation for Knowledge Needs
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Assumed
Knowledge Need
Category Result Current Asset or
Continuing Need?
Explanation
PACE leaders need
to know the risk
factors that
contribute to high
hospital readmission
Declarative
(Factual)
Not
Validated
Current Knowledge
Asset
90% of PACE leaders
were able to identify
multiple clinical risk
factors for
readmission. 60% of
PACE leaders were
able to identify
relevant social risk
factors that contribute
to readmissions.
PACE leaders need
to know how to
effectively transition
patient care from an
inpatient to an
ambulatory setting
Procedural Not
Validated
Current Knowledge
Asset
100% of PACE leaders
interviewed were able
to outline the steps
required to
successfully transition
a patient post-hospital.
Declarative Knowledge of Factors that Contribute to High Hospital Readmissions
According to Sun, Merrill, and Peterson (2001), declarative knowledge is essential to
both the learning and communication of skills and knowledge. Declarative knowledge related to
readmissions was assessed using three questions, designed to shed light on PACE leaders’
knowledge of the risk factors related to hospital readmissions. Table 7 clarifies that most PACE
leaders demonstrated declarative knowledge as they could identify risk factors from both clinical
and social categories.
Table 7

Summary of Declarative Knowledge Demonstration Results

Risk Factor Category Number of Interviewees that
Identified Issue
Percentage of Interviewees
that Identified Issue
Clinical 9 90%
Social determinants 6 60%

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Clinical Risk Factors
PACE leaders were interviewed to determine whether there were needs in the area of
knowledge of risk factors that contribute to hospital readmissions. The findings demonstrate that
nine out of the 10 participants interviewed were able to list and discuss the clinical risk factors
associated with increased readmissions, while six of the 10 participants were able to name the
social risk factors that raise the likelihood that a patient would be re-admitted after leaving the
hospital. Multiple PACE leaders identified congestive heart failure (CHF), pulmonary conditions
such as pneumonia and chronic obstructive pulmonary disease (COPD) and chronic conditions
that arise from or contribute to increased frailty as important potential contributors to
readmissions. CHF was a common starting point for interviewees, with participant H noting that,
“the patients who are highest risk are the patients with CHF… those who are on dialysis; patients
with uncontrolled diabetes that leads into other complications, hypertension, and other forms of
age-related health decline.” Similarly, participant A started with CHF, but also articulated why
frailty matters in the issue of hospital readmissions for seniors:
The top five are the big top five for us. So it's cardiovascular… they either have a cardiac
event, either a heart attack or something that causes heart arrhythmias, like CHF. Also
there are the pulmonary pieces – do they have pneumonia? How are their lungs doing?
Then there are the neurological pieces. They could have a stroke; they could have loss of
consciousness due to blood loss or an infection. There is sepsis, everything from a simple
infection to serious sepsis that can’t be handled outpatient. Frail seniors are susceptible to
the worst cases because they're already compromised from having been in the hospital.
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The interviewees’ ability to take a multi-system view of the clinical risk factors that are most
relevant for the PACE population suggests a level of knowledge that moves beyond awareness
and into the realm of expertise with handling patients who have complex needs and risk profiles.
This robust knowledge of clinical risk factors was widely observed across interviewees across all
leadership categories.
The Role of Family Support as a Clinical and Social Risk Factor
The majority of PACE leaders were able to articulate an understanding of clinical risk
factors in light of their responsibility to facilitate the transition between hospital and home.
Family support was identified as an important social risk factor that contributes to readmissions
for the seniors who make up the PACE population because of the role that family members play
in carrying out discharge instructions, ensuring adequate nutrition, and supporting the activities
of daily life. One critical area of this transition that is highly influenced by family members and
caregivers is support of dietary needs. Leaders acknowledged that the challenges families face in
“adapting to completely different dietary needs” was a key source of risk for their participants
who had just transitioned from hospital to home. For instance, participant D explained that:
Congestive heart failure is one of the reasons we do see people go back. They either go
back with shortness of breath due to congestion in their chest cavity due to backing up of
the heart. …. If it's CHF, then we have to look at fluid restrictions. We have to look at
dietary changes – all of the things that happen that change a person's point of view of
how they've taken care of themselves or how the family's taken care of them – so that the
family doesn’t feed grandma the complete wrong food for her now in her new state.
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More than half of all leaders mentioned the role that family members play in facilitating the
transition out of hospitalization, and their role in helping to define and enforce the new normal
after a patient has spent time in the hospital.
Family Member and Caregiver Integration as a Risk Factor
Multiple leaders spoke about the “partnership with the participants’ family members” that
was needed, as well as the “collaboration needed with the family … to ensure continuity of care
so that participants don’t end up back in the hospital” and the relationship that had evolved with
family members so that what they do at home “becomes an extension of what we do here at the
center.” Family members were therefore seen as vital extenders of the work that PACE leaders
and their teams did to manage the risk of hospital readmissions.
While some leaders were able to give specifics of the recognition programs for family
members and caregivers that they instituted in their centers to encourage partnership because
they saw family members as “our eyes and ears outside of the center,” others were more blunt in
their description that “they are more susceptible to readmissions for hospital just because of the
poor family support system that they have.” Reasons for limited family support ranged from
“families have to work so they have limited time to participate in the care of an elder relative” to
“family members are detaching from our elderly participants, especially the more difficult ones
with neuro-degenerative disorders like Alzheimer’s.” So much of perceived readmission risk
depended on what happened in the home that interviewee E highlighted that they “usually have
to do a little bit of extra work with assessing and educating the patient and the family… when
they get to the PACE center.” Leader D expressed a parallel thought when she shared that:
We provide a lot of patient education even to the family members and care givers. ...
we're able to prevent readmissions for the most part based upon patient education …
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because a key barrier to our goal is a family member who may not understand the
condition or who's not a part of the participant's care.
This underscored the idea that the participation of family members or caregivers in the transition
process and the degree to which they were educated and motivated to play an active and involved
role in the transition could be considered a risk, in and of itself.
Risk Factors from Social Determinants of Health
PACE leaders expressed near universal agreement with one interviewee’s assertion that
“our population’s medical conditions are easier to navigate when their social determinants are
more solid.” The responses given by PACE leaders to the issue of the risks of readmission posed
by social determinants of health all found their start in the presence and effectiveness of family
support, however they did not end there. Comments were premised on the idea that if the family
members or caregivers were better equipped to support the transition, then there would be a
lower likelihood of that person returning to the hospital for reasons that were preventable.
However, the families themselves also exist in a social context, hence issues such as housing and
safety consistently appeared throughout interviews with PACE leaders. It was widely accepted
by the PACE leaders interviewed that, “For us, we can't look at somebody or look at the
diagnosis and say, this is not really high risk for readmission because it's often all of the
surrounding things that happen that cause the readmission.” Interviewees shared at length their
thought processes and practices regarding “the surrounding things of family support,
homelessness, not having nutritious food—some of those social determinants that would impact
a person's … healing from an admission [to the hospital].” Leader G even outlined a thought
process that succinctly summarized a perspective that was shared by other leaders when she
shared that their concerns included:
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“what might keep someone from following the instructions post-discharge, getting their
medication, coming to the appointment. Do they have transportation? Do they have the
money? Can they read? Do they have someone that can give them the medication? Do
they have access to healthy meals? Is there substance abuse in the home?”
It was widely acknowledged that while participants were “going home and trying to heal …
they're coming back to an environment that may not be the best place for them.” Finally, leader F
illustrated the extent of the problem presented by housing insecurity by noting that the
participants who had the hardest time with transitioning after a hospital stay were the ones with:
the least family support system that I've witnessed. They live by themselves, either by
renting a room somewhere or are they in transitional housing because they had been
homeless for a long time. They live in trailer homes, mobile homes, little shacks, in
garages... in living situations that are not optimal for helping them to recover.
Family support assumes that family members are present in the physical space to which the
participants return post-hospitalization, and the collective social situation of the family—not just
the participant—impacts the healing process and therefore the risk of readmission. Across the
board, PACE leaders demonstrated intimate familiarity with the social risk factors that contribute
to hospital readmissions.
Procedural Knowledge of How to Effectively Transition Patient Care
Transitions of care are a crucial process that have immense influence on the risk of
readmission (Cope, Jonkman, Quach, Ahlborg & Connor, 2018). Transitions of care involve
many steps, four of which are highlighted below. Two key components of the handoffs included
in transitions of care are discharge planning and medication management. Once care has been
transitioned from inpatient into the community, assessments of the patient’s clinical state and
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home environment are required as best practices to manage readmission risk. Across the board,
PACE leaders of all levels demonstrated a strong ability to outline the steps involved in
transitioning patients from a hospital setting back to outpatient care. Therefore, the procedural
knowledge influence among this group is considered a current asset. Across levels, roles, and
locations, PACE leaders were able to consistently outline the process by which patients are
monitored in the hospital up to the moment of discharge and detail both the tasks for which the
PACE team is responsible upon discharge from the hospital, and the timelines within which
these ought to be completed.
Discharge Planning
Discharge planning was of utmost importance among PACE leaders when asked about
the steps taken with patients who have just been discharged from the hospital. For the PACE
leadership team, discharge planning began not at the moment at which a PACE participant is
released from the custody of the hospital in which they had been admitted, but rather at the time
that the procedure was complete. PACE clinical leadership maintains open lines of
communication in the form of daily hospital rounds with the hospitals to which their participants
are typically admitted to ensure that:
the PCP [primary care provider] teams in the clinics are aware of what's going on with
the hospitalization… they're aware of what is the issue, why they went to the hospital and
when they're discharged, what are the next steps, so that summary discharge instructions
are really given on nearly all of the patients that we have in the hospital.
This collaborative relationship with hospitalist providers at a partner hospital was a key feature
that was raised during seven out of 10 interviews. By collecting information on patients while
they were still in the hospital and pushing that information to the patients’ primary care
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providers, PACE leaders set up a transfer of factual knowledge that enabled the team to prepare
for execution of the processes that they use to manage the patient transition once the patient is
no longer inside the walls of the hospital.
Clinical Assessments by the Inter-Disciplinary Team
Once the participant is discharged, the imperative expressed by nearly all leaders was for
the PACE team to contact them and perform their own assessments of the participants’ condition
as soon as possible. Almost all leaders interviewed mentioned that “within 24 hours of being
discharged they're to be seen by their primary care doctor here at the center” and that “if the
participant is not able to come to the center … the provider or the disciplines go to the
participant's home.” Multiple interviewees spoke in consistent terms of the post-discharge
assessments by the primary care physician, as well as those conducted by the physical and
occupational therapists within the first 72 hours of discharge, and detailed how important it was
to “contact the family once a week for the first four weeks post-discharge in efforts to reduce
readmissions.” Participants discharged from the hospital were the subject of care coordination
meetings that happened daily at each site. Care coordination meetings are facilitated using the
care coordination log, which is a continually updated list of all patients in the hospital and those
being discharged. These meetings included members of all clinical disciplines, thereby ensuring
that the appropriate information is consistently being communicated to all parties that have a role
in assessing the participants’ status post-hospitalization in order to determine “whether there has
been a significant change in the participant’s function.” PACE leaders spoke uniformly about the
steps taken by the team after the initial assessment was complete. PACE leaders’ responses
echoed those of interviewee I:
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If it is determined that there's significant decline in their function that we do not foresee
improving, then that triggers each of the eight IDT disciplines to do a full assessment on
that participant because … it is very likely that the care plan approach for that participant
is going to change.
This response is representative of those given by interviewees and gives an indication of how
strong a command of the internal processes used to manage and monitor the participants PACE
leaders possessed.
Medication Management
Changes in pharmacological routines rank among the most significant changes that take
place after a hospital visit. PACE leaders were particularly sensitive to the needs of their
population in this area, and tended to highlight the management of medication—both inside and
outside the PACE center—as a critical risk factor that needed to be closely monitored in order to
reduce the risk of preventable readmissions. Leader F summarized both the issue and the impact
of this shift on the participant’s ability to resume normal functioning:
In the older population, it's very common to see that they don't really know how to
manage their medications well. And many times coming out of the hospital now their
medications might have changed. There might have been new medications added to their
routine. And so that really creates a little bit of chaos in their day to day routine.
This idea of new medications as a variable that needed to be closely managed was reinforced by
other leaders who shared thoughts along the lines of leader J, who mentioned that “coming out of
the hospital with new pills and a new routine really puts them at risk of being readmitted.”
Leader G was even more granular in her description of the issue when she stated that “They see
the bottles, but they don't understand what they're for… They don't understand that some of them
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they need to take in the morning, some are for night… they need us to manage their medications
for them.” In line with the theme of the PACE team’s role in supporting ongoing medication
management, leaders also noted that the primary care team was now responsible for adjusting
and managing medication levels – a task for which they had to “provide education to the patient
and family to make sure they understand the new way they’re supposed to take their meds.”
Education on new routines of medication administration included the mode, manner, timing, and
order of administration. PACE leaders were able to name the issues embedded in the new
medication routines that typically accompanied hospital discharge, where and how their
participants needed help in this area, and the role that they and their teams played in supporting
the reconciliation of medication routines for their participants during the post-discharge period.
Home Environment Assessment
Interviewees were able to articulate in their own words where the actions and decisions
embedded in the transition process would shift based on the safety of the home environment, and
what resources needed to be allocated to a newly discharged patient according to their status
relative to the pre-hospitalization baseline. Leader B noted that hospitals “don't do a detailed job
of defining what they need help with… so the purpose of our assessments is to exactly define do
they need moderate or maximum assistance because it makes a big difference.” Specifically, the
PACE team conducts assessments of the home environment to determine not only the level of
assistance required, but also what resources are needed to provide that assistance. Other leaders
spoke of the need to “do a home visit to determine the new DME—durable medical equipment—
that might be needed in the home” and leverage information from the hospital teams to guide
these decisions in support of patient care. Based on these responses, it was determined that
PACE leaders have a strong knowledge base in how to support the transition of care from the
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standpoint of adjustments that need to be made inside the participant’s lived environment in
order to minimize the risk of readmission.
Summary of Knowledge Findings
In summary, an overwhelming majority of PACE leaders were aware of the clinical risk
factors associated with readmissions and demonstrated a strong working knowledge of the steps
involved in executing transitions of care. Both declarative and procedural knowledge influences
are considered current assets based on the data gathered, as the assumed needs in these areas
were not validated.
Findings for Assumed Motivation Influences
The construct of motivation is comprised of three components: active choice, persistence,
and mental effort (Rueda, 2011). Motivational challenges therefore find their solutions in
interventions that either prompt a choice, facilitate persistence in the face of obstacles, or
stimulate the mental effort required to achieve the performance target. Value as a motivational
influence impacts both active choice and persistence (Rueda, 2011). In order to determine what
interventions would be appropriate in the context of PACE leaders relative to the stakeholder
goal of reduced hospital readmissions, motivation needs were analyzed using data from
interviews with limited input from the document analysis. Results for the evaluation of
motivation needs are grouped into two sections according to the assumed motivation influences.
The first section reviews findings for stakeholder utility value and the second section reviews
findings for stakeholder efficacy. These motivation assumed influences were explored through
the use of the following questions in the interview protocol:
1. Would you say that hospital readmission is a problem for the majority of your population
/ the PACE population? Why or why not?
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2. How would you describe the importance of the steps that you and your team take to
reduce readmissions for your patients?
3. How confident are you in your ability to impact the readmission goal in a positive way?
4. How would you characterize your team’s confidence in their collective ability to impact
the readmissions goal through their efforts? What skills or processes are they most / least
confident in?
a. Where have you seen evidence of this?
b. Can you remember a time when their confidence was not as high? What
contributed to that?
Table 8 presents a summary of the assumed motivation findings.
Table 8

Summary of Results and Explanation for Motivation Needs

Assumed
Motivation
Influence
Category Result Current Asset
or Continuing
Need
Explanation
PACE leaders
need to see the
value of their
efforts in reducing
hospital
readmission rates
Value Not
Validated
Current Asset A majority of PACE leaders
interviewed acknowledged the
importance of both the goal
and their efforts related to the
goal of reducing hospital
readmissions.
PACE leaders
need to believe
that they are
capable of making
changes that
positively impact
hospital
readmissions
Collective
and Self
Efficacy
Validated Continuing
Need
PACE leaders demonstrate
confidence in their teams’
ability to impact change,
however the leaders
interviewed consistently
exhibit greater confidence in
their own abilities than in their
teams’ abilities to positively
impact readmissions.

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Value of Their Efforts in Reducing Readmission Rates
Value is defined as the importance that one has for a task (Eccles & Wigfield, 2002).The
specific construct under investigation for the purposes of this study is utility value, which is
defined as the connection between accomplishing the task and achieving a future goal (Rueda,
2011). In order for them to be motivated to make the active choice to take steps towards reducing
hospital readmissions, persist through each unique case over time, and exert the mental effort
required to positively impact the readmissions goal, it was assumed that PACE leaders need to
have high utility value for the actions that they take relative to the stakeholder goal of achieving
a 15% 30-day hospital readmission rate. Based on the document analysis, it can be inferred that
there is high value for reducing readmissions among PACE leaders, as evidenced by the central
position that readmission discussions take in care coordination and other meetings, as well as the
level of resources dedicated to readmissions in the form of staff and meeting time. This is
reinforced by interview data, which shows that 60% of leaders agree that hospital readmissions is
an important issue at PACE. Figure 3 illustrates the distribution of views on the importance of
readmissions.
Figure 3

Summary of Results to the Question: Would you say that hospital readmission is a problem for
the majority of your population / the PACE population?

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Despite the majority of leaders expressing some value for the issue of readmissions,
different levels of leadership had different levels of value for the topic. Center managers were
generally highly focused on the readmissions goal and considered it “one of the most important
goals ... one of the highest priorities” and “super important … a daily commitment.”
Additionally, center managers were able to articulate the rationale behind their value of the
readmissions goal. Their comments in this regard mirrored one another, as they spoke of the
need to “be proactive in keeping participants out of the hospital as much as possible” and
expressed that “we don’t want participants in the hospital because we don’t want them to
suffer… [and at the hospital] they do unnecessary testing.”
In parallel, one administrative leader noted that “readmissions ... literally has been on my
radar for almost four years.” This leader then went further to situate the stakeholder goal in the
context of PACE’s role as both the provider of care and payer for services offered to participants,
making the observation that “readmissions are incredibly expensive and ... from the perspective
of outcomes, folks who get readmitted fare much worse.” This response anchored the focus on
Yes No No response
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hospital readmissions within PACE’s model of managed care, with its dual aims of cost
management and quality optimization. Furthermore, value for the goal is also derived from its
position as a key metric that is tracked by external regulators. Leader A clarified that “there's
some critical key metrics and readmission is one of them… it's high on our regulatory dashboard.
It is also a predictor of increased frailty and of potential for death.” This majority viewpoint
captured the internal and external reasons why the readmissions goal carries importance among
PACE leaders, as well as the value that is anchored in both costs of readmissions and the poorer
outcomes that result.
Contrasting perspectives, while in the minority, did exist. Some functional leaders
reflected an undercurrent of skepticism regarding the value placed on the goal, particularly in
how the goal, or the importance of the goal, was translated beyond the leadership level to staff on
the front lines. Of the leaders who responded that readmissions were not a problem at PACE, the
reasoning put forward was either that the performance against the goal was satisfactory, which
meant that the issue should not be considered as a ‘problem,’ or that the relative prioritization of
the goal in that person’s lived experience was so low that it never received adequate attention.
One leader remarked that “If we have 10, it's number nine. We never talk about it.” This leader
went on to argue that “half the members of the IDT don't even understand why readmission rates
hurt them,” making the point that because there wasn’t a common understanding of the cost of
readmissions, there wasn’t broad recognition among frontline staff of the reasons “why we
should prioritize doing the post-discharge process well or reduce readmissions.” His position was
supported by another functional leader who proffered that frontline staff:
don't see the big picture. They are so focused on, ‘oh, I have so many assessments to do, I
have so many patients to see, I'm attending three hours of meetings, I don't have time.’
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But they don't see the importance of seeing this patient status post-hospital. They don’t
ask why are we seeing this patient? What are we trying to achieve?
The perspectives of functional leaders provided an important balance to the dominant narrative
regarding the importance of readmissions. While the functional leaders tended to be more
removed from the IDTs and admitted that they spoke from a distance, their contributions to this
question elevated the possibility that there was neither a uniformly accepted understanding of the
implications of hospital readmissions for PACE nor of the importance of the steps taken to
reduce them. Despite this evidence that value isn’t being translated beyond and across leadership
levels in a way that informs actual work priorities of frontline staff, the assumed motivational
need of value for the readmissions goal is considered validated only for functional leaders, as
value for readmissions presents as a current asset for all other categories of PACE leaders.
Efficacy in Their Ability to Make Changes That Positively Impact Hospital Readmissions
In general terms, efficacy is defined as the ability to produce a desired or intended result
(Cetin & Askun, 2018). Self-efficacy speaks to individual beliefs about one’s own confidence for
a task, while collective efficacy refers to beliefs about the ability of the group to achieve the
desired objective and produce results through collective action (Bandura, 2000; Pajares, 2006).
PACE leaders’ efficacy beliefs were proposed as an assumed influence because there are
multiple factors of both a clinical and non-clinical nature that impact whether a PACE participant
is readmitted to the hospital within 30 days of an index admission. Some of those factors are
within the PACE leaders’ control, but many are not. As a result, it is plausible that beliefs about
their ability to impact the goal would factor into how PACE leaders approach planning related to
the readmissions goal, and how motivated they are to execute these plans.
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One key finding in the area of efficacy is that PACE leaders had greater self-efficacy than
collective efficacy related to tasks associated with minimizing readmissions. PACE leaders’ self-
reported levels of self and collective efficacy, on a scale of 1-10 with 10 indicating highest
efficacy and 1 being the lowest, are outlined in table 9.
Table 9

Summary of Self Efficacy and Collective Efficacy Results

Leader Self-Efficacy Self-Rating Collective Efficacy Self-Rating
A 8 No response
B No response 2.5
C 9 3
D 9 7
E 9 6
F 3 No response
G 10 8
H 10 9
I 9 7.5
J 10 10
Self-Efficacy
Center level operational PACE leaders (also called center managers) tended to rate
themselves highly when it came to their confidence in their abilities to forestall readmissions for
their populations. Their high level of belief in their ability to positively impact the hospital
readmissions rate came from two sources – their own depth of knowledge on the PACE
requirements, expectations, and best practices in controlling hospital readmissions, and the
strength of individual team members who provided them with targeted support.
Multiple center managers and administrative leaders credited their high self-efficacy to
their years of experience and strong command of the rules, regulations, and practices required to
keep seniors out of the hospital. One leader shared that “my confidence comes from my history
with PACE, knowing how the program works, knowing how corporate works, how the system
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works.” Others frequently made mention of how “well-versed on the expectations for
readmission” they were, and recounted their years of experience to underscore the point that their
tenure in the role had given them confidence that they could solve the problems that would arise
as they took steps to keep their participants out of the hospital.
Another source of confidence that was consistent across center managers and
administrative leaders was their strong team members on their bench. Center managers expressed
that having strong supervisors who could fill in for them at IDT meetings was critical to keeping
them abreast of changes and updated when they were unable to attend the meetings themselves.
Echoing responses from other center managers, one leader called out her nurse manager as the
primary source of her personal confidence, noting that the strong support from this individual
meant that she could do more because that person effectively acted as an extender of the center
manager role. In parallel, administrative leaders expressed confidence in specific leaders they
had developed to become “the best leaders they can be” as extensions of themselves.
Functional leaders, however, were less confident in their abilities to positively impact the
readmissions goal because of the indirect management relationships in which they existed and
the lack of formal authority they exercised over the members of the interdisciplinary teams at the
center level. One functional leader reflected that she was “not very confident” that she could
“make an impact in [her] current role” and that she “really [didn’t] know what [she] could do
outside of guiding or supporting efforts, or making recommendations … because it's all about the
IDT.” Leader C expressed a similar sentiment, noting that:
If we’re talking about me, I don’t think I can impact readmissions… Why? Because the
disciplines don't report to me. The disciplines report to the center manager or supervisor
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at the site level. If the center managers or supervisors at the site don't understand what
we're implementing and there's no buy in, then it's not going to happen.
These leaders lamented the siloed way in which they had experienced the PACE organization.
Despite the presence of interdisciplinary teams to guide patient care, that model of cross-
functional collaboration and mutual sharing did not carry over beyond the immediate context of
the IDT, in the estimation of functional managers. In the same breath, these functional leaders
also expressed a frustration that they were being underutilized. For example, one leader
remarked that “I feel that we have an important role. I don't know that it's really seen that way or
utilized that way in all honesty.” Functional leaders opined that the value that their disciplines
brought to the table were not being recognized as clinical and center-level operational leaders did
not invest the effort in helping to communicate and build support for their initiatives to IDTs or
to the broader team.
Collective Efficacy
Findings in the assumed motivational influence of collective efficacy parallel the findings
for self-efficacy at the level of center managers. This level of operational leader has higher belief
in the capacity of their teams to effect positive change on the stakeholder goal through collective
action than do functional leaders. There was a recurrent theme that “every member of the team –
from transportation to the nurses on the floor – has a role to play in keeping the participants out
of the hospital,” which was echoed across the responses of 75% of center managers interviewed.
One leader remarked that her team’s “confidence comes from knowing they have a team they
can lean on. If something goes wrong, its not on one person. When we have low scores, its not a
personal failure; it’s an opportunity to do better.” Additionally, leaders with more established
teams – those who had worked together for longer and themselves had significant tenure in their
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roles – tended to express greater confidence in the ability of the team to positively impact the
readmissions goal.
Conversely, functional leaders expressed that the confidence among their teams was “not
very high” because, as one leader put it “they’ve never been included as potentially successful
players in the whole process across the board in every site.” They noted that the teams that they
led were “doubting their skills” in the absence of full buy-in at the center level. This uncertainty
and lack of clarity that underlies the low collective efficacy at the functional team level stands in
contrast to the high confidence of center-specific teams and presents a potential motivational
need. The data collected at least partially validates the assumed motivational need of collective
efficacy as an area for intervention so as to improve performance against the stakeholder goal.
Summary of Motivation Findings
Over the course of 10 interviews with PACE leaders, it became clear that there is high
value for the readmissions goal across the PACE leadership. The results for efficacy are mixed,
with a majority of leaders indicating high self-efficacy, with the exception of functional leaders,
and with interviewees expressing higher self-efficacy than collective efficacy.
Findings for Assumed Organizational Influences
Schein (2017) observed that organizational cultures are usually a composite of sub-
cultures, each of which carries its own language, beliefs, and assumptions. The importance of
culture and leadership to an organization cannot be overstated. Because culture is not directly
visible or subject to direct manipulation (Schneider, Brief & Guzzo, 1996), culture in the context
of this study was examined through the lens of cultural models and cultural settings. Cultural
models are the invisible assumptions and shared schema that govern individual and group level
values and behaviors; cultural settings, on the other hand, are the contexts in which culture plays
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out (Gallimore & Goldenberg, 2001). The governing idea behind leadership as an assumed
influence had less to do with the (well established) roles that leaders play in setting and
stewarding culture. Instead this influence was grounded in Senge’s (1990) argument that in
learning organizations, the leader takes on a number of new roles, one of which is the designer of
learning processes. This study sought to determine the cultural and leadership influences that
informed how PACE leaders approached their hospital readmissions goal. The questions used to
explore the assumed organizational influences included:
1. How would you describe yourself as a leader?
a. What attributes of your own leadership have been most useful in the role of…?
b. What is required of you as a leader in a managed care setting?
c. How much of your role would you say is dedicated to facilitating learning?
d. What, if any, rewards, policies, or structures are in place to support team
learning?
2. If I were to join an interdisciplinary team (IDT) meeting about a patient who had just
been discharged from the hospital, what would I see team members doing? What would I
hear them talking about?
a. Which IDT structures or practices would you say are most supportive of the
readmissions goal?
b. Which structures are least supportive? Which have less of an impact on the goal?
Table 10 presents a summary of findings related to the assumed organizational influences.
Table 10

Summary of Results and Explanation for Organizational Needs

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Assumed
Organizational
Influence
Category Result Current Asset
or Need?
Explanation
The organization
needs to empower
leaders as
designers of
effective learning
processes
Leadership Partially
Validated
Current Asset
overall

Need for
functional
managers
only
Most PACE leaders
demonstrated evidence of
being effective designers and
leaders of learning processes,
however functional leaders
displayed gaps in their level of
empowerment.
The organization
needs to assess
IDT alignment in
relation to the
stakeholder goal of
achieving 15%
readmission rate
Cultural
Settings
Validated Continuing
Need
Gaps in critical thinking and
communication dynamics at
the IDT staff level point to a
need for continued assessment
and alignment.
The organization
needs to assess
alignment of site-
level cultural
norms with the
tenets of managed
care
Cultural
Models
Not
Validated
Current Asset The organization demonstrates
integration of managed care
mindsets, norms, and practices
at the site level.
Leaders as Designers of Effective Learning Processes
PACE leaders demonstrated their empowerment as designers of effective learning
processes and investment in professional development of their teams by prioritizing team
learning, taking a hands-on approach, facilitating the flow of information across settings, and
leveraging their position to elevate voices within the IDT.
Across the board, PACE leaders from all categories were clear that a significant
proportion of their time was dedicated to facilitating learning in one form or another. Table 11
presents PACE leaders’ self-report of the proportion of their time spent facilitating team
learning. PACE leaders considered their participation in and leadership of learning opportunities
for their staff “one of the highest roles that [they] play,” whether that leadership was done
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formally or informally. Interviewees spoke of their roles as facilitators of learning with
enthusiasm and gravitas, and almost all made the connection between taking this role seriously
and increasing the capabilities of their staff to meet organizational performance goals. For
example, leader H noted that “making sure that my staff have the tools, that they have the skills
needed to navigate” the new electronic health record (EHR) that was being implemented was her
‘main thing’ for the two months prior to the interview—a viewpoint that was echoed across other
leaders’ responses. Similarly, leader A shared that her orientation in supporting both formal and
informal learning for her team was to “make them confident that they can do the right thing.”
Table 11

Proportion of leader time dedicated to team learning

Leader Time Spent on Team Learning
A 33%
B 60%
C 60%
D 80%
E No response
F 50%
G 75%
H 60%
I 90%
J 100%
In addition to prioritizing team learning by the time spent on it, PACE leaders take a
hands-on approach to facilitating team learning, leveraging various techniques such as modeling
and elevating the voices of team members to promote robustness in the team’s collective
learning. Leader E highlighted that it was not only important for him to give guidance on
processes, but also to “create structure” and “model by example the importance” of what was
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being taught. In like fashion, other center level and administrative leaders described taking a
tailored, hands-on approach as indispensable to success in this aspect of their roles. Reflections
such as “my role with my supervisors is ensuring that they can guide their team members and…
develop their direct line staff” and “I am not a hands-off leader… I like to remove barriers and to
allow my staff to really shine” serve to reinforce this point. Some leaders conceptualized their
roles in this regard as coaches who would “ask provocative questions,” “foster conversations to
increase awareness of performance,” and support team members to “paint an excellent picture of
success” so that they would be motivated to move towards it and would know when they
accomplished it.
Leaders acknowledged that this requires patience, and more than one expressed a
commitment to using their voice to raise up other voices so as to enhance the quality of group
discussion and thereby promote learning. One example of this is leader B’s comment that:
If someone is bulldozing over the rest of the individuals, and we can't collectively find a
voice then I'll be the one who pushes back. Even if I agree with what they're saying, I
recognize if only one person is saying it, soon none of us are going to have a voice.
Noteworthy too is leader H’s reflection on how to promote equity of voice within her team:
With one team, the meetings are smooth. Everybody has their input and I don't find
myself having to call on people like, "Hey, what do you think OT, or what do you think,
PT, or transportation" It just flows. Whereas with one team, I find myself always inviting
people to join, calling on people to join the conversation.
These leaders see the shared forums in which the work takes place as a key site of learning, and
demonstrate empowerment as leaders to promote equity of voice in the spaces where practice is
shaped and dynamic learning takes place.
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Leaders see facilitating the flow of information across multiple settings as part of how
they facilitate learning. Whether from the larger VHC organization into PACE, or between the
inpatient hospital rounds, PACE grievance process, and IDT - ensuring that opportunities for
improvement are surfaced is a priority for PACE leaders at the center manager level and above.
One center-level leader put it best when she said:
there's plenty of opportunities for learning, where we might learn of something outside of
the IDT meeting, because of maybe a grievance that has been filed … those are
opportunities for retraining and reeducation … we welcome the grievances because those
are opportunities for us to really learn about what we're doing and some of the gaps that
we need to improve on.
Other leaders also acknowledged that though care coordination meetings were not considered
formal training, the forum was one in which group learning took place, and that drew on
information from different sources inside and outside of the organization.
Leaders maintained a cadence of daily, weekly, monthly, and quarterly meetings in which
learning took place. While monthly meetings were the most frequently reported forum for
intentional learning and development, multiple operational leaders mentioned that they linked
performance expectations during the annual evaluation process to learning expectations:
If they're just meeting expectations and we want them to move to [a higher level of
performance], we will embed courses on the competencies or skills that are gaps into
what is expected throughout this next year and ensure that completion of those courses is
part of their evaluation.
To do this, leaders leveraged the enterprise learning management system to promote formal
learning among their staff through a self-directed, online platform. One leader even requested
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that new modules be created for her staff based on new challenges that arose in the work
environment. This center manager saw it as her responsibility to ensure availability of training
for all levels of staff—including food service staff—in order to enhance their performance by
equipping them to handle the challenges that arose on a day-to-day basis, thereby increasing their
confidence. Her rationale was that “they'll be able to understand the person better, learn new
techniques and new skills on how to approach those unique situations, so that they can be more
successful in their job.”
While this influence was not validated as a need among the majority of PACE leaders,
functional managers were the exception. Leader G shared that she attempts to support team
learning by monitoring changes in the landscape for her discipline and sending practice alerts.
These alerts, which are “written guidance and mini-trainings” that contain information about
updated regulations and compliance requirements, are distributed to the entire PACE
community. However, she is unsure of the impact of her efforts:
I send these practice alerts for example, when policies change… I always wonder, is
anybody really looking at these? I can put the information out there, but I don't know if
it's actually going to be utilized or implemented.
This viewpoint was echoed by at least one other functional manager, who saw the lack of uptake
or feedback on these training opportunities and policy updates as the result of “lack of follow-
through and inconsistency in discussion.” Therefore, the assumed organizational need around
leader empowerment as designers of effective learning processes applies only to functional
leaders within PACE and is validated for this leadership sub-group.
Cultural Models: Assess Alignment of Site-Level Cultural Norms with the Tenets of
Managed Care
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This study assumes that in order to make progress towards controlling the hospital
readmission rate and achieve the 15% stakeholder goal, PACE needs to operate as an effective
managed care organization (MCO). Therefore, this organizational assumed influence
hypothesizes that the PACE organization needs to assess alignment of site-level cultural norms
with the tenets of managed care. Based on interview data, it was determined that the tenets of
managed care are well incorporated into each PACE site; as such, this assumed need is not
validated. In fact, as the data below reflect, the presence of a managed care informed culture is a
current asset across PACE.
Gallimore and Goldenberg (2001) define cultural models as “shared mental schema or
normative understandings of how the world works, or ought to work” (p. 47). These shared
mental schema exist at different levels – the team, department, and so on – and change within
one level has the power to affect the culture of another level (Erez & Gati, 2004). In the context
of PACE, the culture of administrative leadership exists at a different level than the culture of the
individual sites. Therefore, alignment of site-level cultural norms with the espoused tenets of
managed care would mean that both upper leadership and center managers would have a set of
shared beliefs, meanings and assumptions about what constitutes managed care (Erez & Gati,
2004; Schein, 2017). The two major themes in this regard were the uniqueness of PACE as a
managed care model and the centrality of cost and quality as the north star for monitoring,
managing, and achieving performance. For both themes, alignment was observed between center
leadership, functional leadership, and administrative leadership.
PACE as a Unique Model
Leaders at all levels acknowledged that while PACE is a managed care organization, it is
not the typical MCO, and that its operating model is distinct from the broader VHC organization.
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One leader deftly summarized the role that PACE plays in bridging the gap between hospitals
and primary care when he said:
Most other entities don't have the ability to do what PACE does. Regular PCPs don't have
the capacity to deal with another case because they can’t change their schedules …
They're not thinking about the actual care in the hospital; they're going to defer to the
hospitalist teams. Our hospital team and PACE is trying to bridge both worlds so we get
the discharge plan right while also overseeing the inpatient care itself.
Multiple leaders built on this theme by commenting on the degree of “flexibility that PACE has
that's different from your traditional managed care,” underscoring that its distinction from other
MCOs was based on more than just the older demographic difference to whom the program
caters. Furthermore, leaders were careful to establish that the PACE framework was inherently
relational, which stood in opposition to both the highly transactional operating model at VHC
and the world of tertiary care. One leader shared in stark terms that despite PACE being highly
regulated, “we are a relational model, not a transactional model” and another provided an
overview on the implications of this distinctness from the parent organization:
The beauty of PACE is that we don't try to monetize everything that we do because we
are capitated. We don't get reimbursed for each transaction: we look at the whole
relationship with the participant. In a managed care environment you have to switch your
thinking from a transactional fee for service into ‘this is the pool of money and how well
did we manage that money?’
The freedom to build relationships with patients long term, and exercise control over their care
pathways even outside PACE locations, and make spending decisions related to care all
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contributed to the flexibility that was a hallmark of PACE’s perceived uniqueness among leaders
interviewed.
Balancing Cost and Quality
Flowing from this relational model is a set of beliefs around putting the patient first
which, at PACE, has come to mean more than just knowing patients and their families, but also
“being accountable for the whole cycle of care.” In the context of monitoring hospitalization, it
means taking responsibility for patient outcomes—and related expenses—before, during, and
after the hospital encounter.
This focus on cost and quality is a defining feature of managed care environments, and
PACE is no exception. However, at PACE, leaders across levels and settings demonstrate
commitment to the idea that the pool of dollars allotted should be managed not to minimize
expenses, but rather to optimize patient outcomes. Leaders were of the mindset that “I have to
take care of dollars, but at the same time I can't compromise quality … if they truly need it, even
if it's thousands of dollars.” This idea of the right expenses being worth it was elaborated by
another leader who explained that:
As a leader in a managed care environment, there is a lot of pressure on cost. Are we
making good decisions, even if they're expensive decisions, are they the right decisions?
Is there any waste? Unlike other managed care environments, the goal here isn't always
the bottom line. Us being on the hook for all of the bills puts the onus on us to make sure
we're making the right decisions at the right time. For example, if this medication is
going to keep this person out of the hospital, then it's not too expensive. It may be the
right expense to do that.
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There was broad consensus that anything that prolonged a patient’s life in a high quality way and
enabled them to continue to live independently was preferable to the alternative, and this weight
factored into spending decisions at every level of leadership – from center managers to vice
presidents.
Cultural Settings: Assess IDT Alignment in Relation to the Stakeholder Goal
The assumed organization influence in the area of cultural settings is the idea that the
organization needs to assess IDT alignment in relation to the stakeholder goal of attaining a 15%
hospital readmission rate. The IDT is put forward as a cultural setting – a forum in which culture
plays out as “people come together to carry out joint activity that accomplishes something they
value” (Gallimore & Goldenberg, 2001, p.48). The assumption is that if IDTs, which operate at
the center level, show evidence of alignment with the key norms and practices of managed care,
then this would contribute positively to the achievement of the stakeholder goal. This assumed
need was validated, as the data suggests that a gap exists in the capability of IDT members to
consistently engage in the critical thinking and communication necessary to execute against the
dual aims of managed care. The themes of critical thinking and communication dynamics are
presented below.
Critical Thinking
Data collected from PACE leaders suggest that in the contest between cost and quality,
quality is given a higher weight. Because there is a fixed pool of dollars, however, leaders must
have mastery of critical thinking skills in order to succeed in a managed care model that is
premised on the optimization of resources at the organization level and the maximization of
outcomes for each patient. They must constantly engage in cost-benefit analyses in order to
determine what is worth the spend in each case and creatively problem-solve different issues that
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arise to conserve resources where possible. These skills appear to be lacking among team
members below the managerial level.
In relating the challenges connected to the critical thinking gaps among staff, leader F
related a vignette about a nurse who did not escalate a medication availability issue with the
urgency required, leaving a participant without the appropriate prescription for three days and
causing a medication error that had to be reported to the state:
challenges that we encountered ... have been staff not immediately identifying that there's
things that they should bring up to the next level… Sometimes that additional thought
process doesn't happen. And so we're trying to really work with the staff to ensure that
they are taking things to the next step, really thinking about what is the outcome if this
doesn't happen, and who do I need to talk to, to help me with this, to troubleshoot and
assess options that we have.
This and other examples were shared of staff being unable to “see the bigger picture,” and
therefore not being able to carry the accountability required in order for the ideals of managed
care to be realized. Leaders also mentioned the “fear around making decisions” and identified
that some staff seemed to “just want to be told what to do” even when a situation called for
creative thinking and answers were not readily available.
Communication Dynamics
The IDT is comprised of 11 members, eight of which represent clinical disciplines.
Among the disciplines is a medical doctor, usually referred to as a ‘provider.’ Leaders described
a difference that existed between physicians who were used to operating within the PACE
model, and those who were not. As one leader put it:
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When a doctor comes from the [VHC] clinic, they feel like they have power over
everybody - even over me. I have seen that. Then we have to have a conversation with
them that says ‘we don’t work this way, I encourage teamwork.’ I don’t know how they
work in the clinics, but in PACE we don’t do that.
The degree to which physicians were bought into the idea of the IDT and integrated as part of the
team impacted the communication dynamics of the entire team. Leaders discussed how the status
of physicians as “king of the ship … the person who’s going to keep somebody from going to
the hospital” and their perceptions as “gods in healthcare… always at the head of the table” has
had a chilling effect on the variety of perspectives brought to the table because the
representatives of the other disciplines defer to the doctor. They described how nurses and social
workers had to be coached in order to feel permission to “challenge a doctor, respectfully and
professionally.” Leaders consistently spoke of the need to manage that dynamic carefully in
order to reap the full benefit of PACE’s interdisciplinary model, as demonstrated by one leader’s
response:
The regulations identify that the IDT is an equitable milieu. Meaning an MD is on the
same level as an activities coordinator. They have the same voice, or the same amount of
authority within the IDT discussions and the creation of care plans. What I know as a
clinician is that's just not true. Most people have some level of transference towards
doctors.
While it was true that in some teams “providers are humble enough to be part of the team,” the
preponderance of responses implies that the teams in which providers “see themselves as part of
the team, not as the doctor because in IDT, there is no doctor” are fewer and further between. As
long as this power dynamic impacts the ability of individual team members to contribute and the
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capacity of the team to make the most informed decisions, beyond just a medical perspective, the
organization will need to continue to assess IDT effectiveness.
Summary of Organizational Findings
Based on interviewed conducted with PACE leaders, there are organizational needs in the
areas of leadership for functional managers, and cultural settings. Culturally, PACE’s alignment
with the tenets and practices of managed care despite the uniqueness of the program were
brought forward as an asset. However, these tenets and norms need to continue to be translated
from the site leader level to the IDT level, where barriers currently prevent IDTs from fully
operating in the promise that is managed care.
Conclusion
The results demonstrate that the assumed influences in the areas of declarative and
procedural knowledge are current assets for the organization. In the area of motivation, PACE
leaders displayed strong value for the issue of readmissions, making that an asset as well.
Continuing needs were found in the areas of cultural settings and leadership for one category of
leaders interviewed. Table 12 summarizes the results across all assumed influences.
Table 12
Summary of Findings
Knowledge Assumed Knowledge Influence Result
Declarative Knowledge of risk factors that contribute to high
hospital readmission
Current Asset
Procedural

Knowledge of how to effectively transition patient
care from an inpatient to an ambulatory setting
Current Asset
Motivation Assumed Leader Motivation Influences Result
Value PACE leaders need to see the value of their efforts
in reducing hospital readmission rates
Current Asset
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Efficacy

PACE leaders need to believe that they are
capable of making changes that positively impact
hospital readmissions
Continuing Need
Organization Assumed Organizational Influences Result
Leadership The organization needs to empower leaders as
designers of effective learning processes
Continuing Need for
Functional Leaders only
Cultural Models The organization needs to assess alignment of site-
level cultural norms with the tenets of managed
care
Current Asset
Cultural Setting The organization needs to assess IDT alignment in
relation to the stakeholder goal of achieving 15%
readmission rate
Continuing Need

Chapter 5 will present recommendations to address the continuing needs identified.

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CHAPTER FIVE: SOLUTIONS, IMPLEMENTATION AND EVALUATION
This study sought to understand the factors influencing hospital readmissions in a
geriatric managed care program situated within a large Federally Qualified Health Center
(FQHC). Clark and Estes’ (2008) Gap Analysis framework was used to determine the
performance gaps impacting the Program of All-Inclusive Care for the Elderly (PACE) leaders’
stakeholder goal of achieving a 15% 30-day all-cause hospital readmissions rate and determine
evidence-based solutions to the gaps. To understand the PACE leaders’ knowledge, motivation
and organizational capabilities in the area of hospital readmissions, the study was anchored in
three research questions: 1) What are the knowledge, motivation, and organizational factors
related to PACE leaders’ ability to achieve their goals for reducing all-cause 30-day readmission
rates? 2) What is the interaction between PACE organizational culture and stakeholder
knowledge and motivation that either enables or hinders PACE leaders in their pursuit of reduced
30-day hospital readmission rates? 3) What are recommended interventions that would enable
PACE leaders to accomplish their performance goal of achieving an all-cause 30-day
readmission rate of 15%? The third question is the focus of this chapter, where continuing needs
will be examined and evidence-based recommendations to address them proposed, together with
implementation and evaluation plans.
The study’s “current assets” represent the areas where stakeholders demonstrated relative
strength in light of the readmissions goal, while the “continuing needs” are the areas where gaps
in the PACE leadership approach to readmissions were observed. The continuing needs are the
focus of the recommendations presented in this chapter. The chapter is organized into three main
sections. The first section highlights the PACE leaders’ continuing needs related to hospital
readmissions; the second section puts forward evidence-based solutions for the identified
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continuing needs, and the third section outlines a plan to implement and evaluate the
recommended solutions.
PACE Leader Continuing Needs
The findings revealed challenges that PACE leaders need to mitigate if they are to
achieve the goal of 15% all-cause 30-day hospital readmissions. These include one continuing
motivation and two continuing organizational needs. Table 13 reflects the continuing needs that
will be the focus of discussion in this chapter.
Table 13
Continuing Needs
Motivation Assumed Leader Motivation Influences Result
Collective
Efficacy

PACE leaders need to believe that they are
capable of making changes that positively impact
hospital readmissions
Continuing Need
Organization Assumed Organizational Influences Result
Leadership The organization needs to empower leaders as
designers of effective learning processes
Continuing Need for
Functional Leaders only
Cultural Setting The organization needs to assess IDT alignment in
relation to the stakeholder goal of achieving 15%
readmission rate
Continuing Need
In terms of motivation needs, PACE leaders need to believe that their teams are capable
of making changes that positively impact hospital readmissions through collective action. For
organizational needs, Versa Health Corp (VHC) needs to empower PACE functional leaders are
designers of effective learning processes and assess Inter-Disciplinary Team (IDT) alignment in
relation to the stakeholder goal, particularly in the areas of IDT members’ critical thinking skills
and team dynamics within IDTs. Below are recommendations for how these continuing needs
may be addressed.
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Proposed Recommendations
The purpose of this project was to evaluate PACE leadership’s knowledge, motivation,
and organizational needs to reduce the 30-day readmission rate and help VHC reach its
performance goal of being a 4.5 star rated healthcare provider in service of its mission to provide
quality care without exception to underserved communities in Southern California. In order for
the goals of the organization to be accomplished, continuing needs must be examined and
addressed using evidence-based solutions (Clark & Estes, 2008). These recommendations focus
on the motivation and organizational factors that impact the PACE team’s ability to meet its
goal. There are four main recommendations that will enable PACE leaders and the broader
organization to improve their performance in the area of hospital readmissions. These are: 1)
create spaces and structures for cross-disciplinary training and the development of teamwork
competencies; 2) invest in training to support the development of critical thinking skills; 3)
develop and deploy a mentorship program for providers as a component of new provider
onboarding, and 4) support the development of annualized functional training regimen.
Recommendation 1: VHC will create spaces and structures for cross-disciplinary training
and the development of teamwork competencies
The need for collective efficacy among PACE leader was validated as an influence that
impacts their ability to make progress on the stakeholder goal of achieving a 15% hospital
readmission rate. PACE leaders were found to have high self-efficacy, but comparatively lower
collective efficacy relative to the teams they led. Research suggests that teamwork behaviors--
activities that enhance teams' coordination, cooperation, and overall quality of interactions--
facilitate the formation and growth of collective efficacy (Chou, Lin & Chou, 2012; Tasa, Sears
& Schat, 2010). Chou, Lin and Chou (2012) also argue that building shared vocabularies and
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shared beliefs contributed to the evolution of team cognition, a central feature of which is the
transactive memory system (TMS). A TMS is a set of communication connections within a
group (Gibson, 2001) that comprise a "cooperative cognitive system that enables team members
to know which team members have expertise on a particular issue" (Chou, Lin & Chou, 2012, p.
385). Having an effective TMS enables teams to build trust in each other's abilities. Since
teamwork behaviors and an effective TMS have been found to promote both collective efficacy
and team performance, it is recommended that PACE leaders create structures that provide
training across disciplines and impart teamwork behaviors. By having dedicated spaces in which
members from each clinical and non-clinical discipline can inform and educate other disciplines
in their work and gain teaming skills, VHC can support the development of TMS within PACE
IDTs, thereby engendering greater collective efficacy among their teams.
Recommendation 2: VHC will invest in training to support the development of critical
thinking skills among IDT members
The results of this study point to a continuing need for alignment of IDTs with overall
managed care principles and practices. Two specific barriers to alignment that were identified are
critical thinking and communication dynamics. Research suggests that building the capacity for
critical reflection and providing instruction in metacognitive strategies are effective ways to
facilitate the development of critical thinking skills (Hoyrup, 2004; Ku & Ho, 2010). According
to Hoyrup (2004), critical reflection is built around a central core of problem solving and is a
practice meant to surface the rationale, driving factors, and consequences of actions taken.
Reflection allows for organizational learning in a bottom-up way through the unearthing and
questioning of assumptions that opens the door to improved work practice (Knipfer, Kump,
Wessel, & Cress, 2013). Hu and Ko (2010) found that critical thinkers gained control over their
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processes through planning, monitoring, and evaluation of both thoughts and tasks. Therefore, it
is recommended that the organization invest in training for IDT members to build skill in the
areas of critical reflection and metacognitive strategies such as self-checking their understanding
of both the problem and the task at hand.
Recommendation 3: VHC will develop and deploy a mentorship program for providers as
a component of new provider onboarding
Research from Brusoni and Rosenkranz (2014) and Gibson (2001) found that individuals
in a group setting are assigned roles and some of those roles come with a higher status, which
can bias group cognitions. These findings provide validation for the data point that doctors' high
status within the IDT impacts the communication and learning of the group. However, this same
dynamic can be used to provide balance because tenure within PACE was put forward as a key
success factor for providers, leaders, and staff, and providers with high tenure and significant
social capital carry even higher status than the typical doctor. In light of this organizational
reality, it is proposed that the organization update provider onboarding to include a program that
provides mentorship of less experienced providers by more seasoned physicians who are
considered effective communicators and team players within their IDTs. Pairing providers in this
way enables the modeling of optimal behaviors in the areas of teamwork and communication,
which will serve to remove this barrier to IDT alignment and enhance team performance.
Recommendation 4: VHC will support the development of annualized functional training
regimen for functional disciplines
The findings of this study suggest that PACE leaders spend significant portions of their
time facilitating team learning. Moreover, they consider the facilitation of individual and
collective learning a core function of their roles as leaders. However, the study also found that
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functional leaders within PACE need to be empowered as designers of effective learning
processes. Senge (1990) argued that leaders in learning organizations are responsible not only for
setting vision, giving direction and holding those they lead accountable for results; they are also
responsible for taking on new roles that enable them to prepare and support their followers to
tackle the problems of the future. Gibson's (2001) research found that clearly defined roles
enable the sharing of domain-specific expertise. Therefore it is important that the organization
clarify the role of functional managers relative to other functions within PACE so as to a)
establish mutual accountability and b) facilitate the sharing of their domain-specific knowledge
through the training regimen. Brusoni and Rosenkranz (2014) argue that leader success is linked
to the institutionalization of their decisions through organizational routines. Required trainings
that follow a set cadence are one example of impactful organizational routines (Becker, 2004).
As such, it is recommended that the organization empower PACE functional leaders as designers
of effective learning processes by defining their roles clearly and collaborating with them to
design, develop, and deploy a mandatory annualized training regimen that is focused on
functional discipline content for the entire IDT.
Implementation and Evaluation Plan
The model that informed this implementation and evaluation plan is the New World
Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016), based on the original Kirkpatrick Four
Level Model of Evaluation (Kirkpatrick & Kirkpatrick, 2006). According to Kirkpatrick and
Kirkpatrick (2016), the purpose of evaluation is to measure the effectiveness of interventions on
the intended results, in alignment with the goals of the organization. The process of evaluation
according to this model starts with the end in mind, then plans backward to ensure that both
proposed solutions are aligned with the goals of the organization, and that the connection
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between solutions and goals is readily apparent. Ultimately, this model provides a pathway to
identify the leading indicators that signal the implementation of behaviors that are expected to
yield the desired results.
VHC's mission is to reduce disparities in healthcare access and outcomes by providing
high quality primary care services to medically underserved populations in Southern California.
The PACE program within VHC is committed to improving outcomes for seniors by providing
high quality care combined with necessary wraparound services within a full risk, managed care
model. The prevention of unnecessary hospital readmissions is a reflection of the quality of care
provided and a core measure of program effectiveness. This project examined the knowledge and
skills, motivational, and organizational barriers that impact PACE leaders’ ability to achieve
their goal with regard to hospital readmissions rates. It is expected that by implementing the
proposed solution, a multi-faceted training program that begins with assessment and is supported
by activation of the training through coaching and modeling, PACE leaders should become more
effective at coordinating patient care across settings, monitoring patients during the immediate
post discharge window, and decrease the number of patients who are readmitted to the hospital
within 30 days of an initial admission, regardless of the cause.
Level 4: Results and Leading Indicators
Table 14 shows the proposed Level 4: Results and Leading Indicators in the form of
outcomes, metrics and methods for both external and internal outcomes for PACE. If the
internal outcomes are met as expected as a result of the training, assessment, coaching and
modeling, then the external outcomes should also be realized.
Table 14
Outcomes, Metrics, and Methods for External and Internal Outcomes
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Outcome Metric(s) Method(s)
External Outcomes
1. Reduced number of
patients who are
readmitted to the hospital
within 30 days of an initial
hospital visit
The number of 30 day hospital
readmissions within a month / quarter
Extract data from claims reports and
hospital discharge reports
2. Increased number of
patients discharged from
the hospital who have a
primary care visit within 3
days of discharge
Number of appointments with a
primary care physician within 3 days
of discharge
Aggregate data from EHR and
compare with hospital discharge report
Internal Outcomes
3. Decreased cost of care Length of stay as measured by average
bed days for readmitted patients
Extract data from claims reports,
hospital discharge notes, and EHR
4. Reduced missed
opportunities
The number of care touchpoints where
post-discharge issues could have been
addressed
Aggregate data (Level 3.1) from the
EPIC EHR missed opportunities report
5. Faster time to appointment 5a. The number of days between
hospital discharge and completion of
appointment with primary care
physician
Compare dates between hospital
discharge notes / report and EHR to
get a sense of the efficiency of the
scheduling and access processes
5b. Time to first post-discharge home
environment assessment
Compare dates between hospital
discharge notes and rounding log
5c. Time to schedule vs time to
appointment completion
Compare access report with EHR data
Level 3: Behavior
Critical Behaviors
The stakeholders of focus are the PACE leaders, including administrators and center
managers. The first critical behavior is that PACE leaders must ensure outreach to schedule post-
discharge appointments within 24 hours of patients being discharged from the hospital. The
second critical behavior is that they must hold the nursing and social work team members
accountable to ensuring that a home environment evaluation takes place within 48 hours of being
notified of patient discharge. The third critical behavior is that they must work with the
transportation team to ensure that newly discharged patients are given priority space on the
schedule to promote the completion of primary care appointments within 72 hours of discharge.
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The specific metrics, methods, and timing for each of these outcome behaviors appears in Table
15.
Table 15

Critical Behaviors, Metrics, Methods, and Timing for PACE Leaders

Critical Behavior Metric(s)
Method(s)
Timing
1. Oversee outreach
process to ensure that post-
discharge appointments
are scheduled within 24
hours of discharge
Time to schedule first
post-discharge
appointment
The PACE leader shall track
the hospital discharge list,
checking in daily with the
front office team to get status
updates on scheduling
Weekly, following each
IDT meeting
2. Hold the nursing and
social work team members
accountable to ensuring
that a home environment
evaluation takes place
within 48 hours of
discharge
Time to completion of in-
home environment
evaluation
The PACE leader shall hold
joint meetings with the
nursing and social work
functional managers, using
time to completion as a key
measure of success
Biweekly
3. Work with the
transportation team to
ensure that newly
discharged patients are
given priority space on the
schedule to promote the
completion of primary
care appointments within
72 hours of discharge
Availability of spaces and
rides for newly discharged
patients
The PACE leader shall meet
twice each week with the
transportation lead to assess
availability and provide
guidance on priority patients
Twice weekly
Required Drivers
PACE leaders require the support of their administrative and clinical leadership and the
organization to reinforce what they learn in the training and to encourage them to apply what
they have learned to ensure that patients are being adequately followed post discharge. Rewards
should be established for achievement of performance goals to enhance the organizational
support of PACE leaders. Table 16 shows the recommended drivers to support critical behaviors
of new reviewers.
Table 16
Required Drivers to Support PACE Leaders’ Critical Behaviors
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Method(s) Timing
Critical Behaviors
Supported (1, 2, 3 Etc.)
Reinforcing
Job Aid including checklist for home environment
evaluation.
Ongoing 2
Publish new guidance to aid in the prioritization of
newly discharged patients across team workflows
Ongoing 1
Encouraging
Collaboration and peer modeling during team
meetings.
Weekly 1, 2, 3
Feedback and coaching from functional managers Ongoing 1, 2, 3
Rewarding
Performance incentive for internal process measures
around appointment scheduling and completion
Quarterly 1, 2, 3
Acknowledgement during meetings and in weekly
newsletter when team performance hits benchmark
Quarterly 1, 2, 3
Operational Support
In order for PACE leaders to perform at the level that is required of them, there needs to
be funding dedicated to developing and deploying the trainings required, as well as additional
time built into functional manager schedules to travel to the various PACE sites to observe,
coach, model, and give feedback. Also, funding would have to be allocated for the related
performance incentives.
Level 2: Learning
Learning Goals
Following completion of the recommended solutions, the stakeholders will be able to:
1. Recognize the risk factors that contribute to readmission in terms of social
determinants of health, (Declarative knowledge)
2. Indicate confidence that they can work together across disciplines to support patients in
the care transition process, (Collective efficacy)
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3. Indicate confidence that they can identify clinical risk factors for readmission, (Self-
efficacy)
4. Value the timeliness of the appointment scheduling process, (Value)
5. Value the planning and monitoring of their work, (Value)

Program
The goals listed in the previous section will be achieved with a training program that
addresses teamwork competencies, critical thinking, mentorship and the technical elements of
managing the transitions of patient care from the hospital to outpatient setting in such a way that
the risk of re-hospitalization is minimized. The learners, healthcare professionals practicing in a
multi-disciplinary model of geriatric care, will study a variety of topics pertaining to both
transitions of care and coordination of care, as well as teamwork topics that enable them to hold
teams accountable to patient outcomes. The program is blended, comprised of e-learning
modules hosted on the internal learning management system (VHC-U) for nurses and social
workers, in-person learning sessions, coaching across disciplines, and real-time modeling of key
skills and behaviors for leaders, providers, nursing and social work staff. Time for completion
will vary by participant type.
During the asynchronous e-learning modules, nurses and social workers will be provided
with procedural and declarative knowledge on the principles, practices, and regulations
governing the PACE program in the areas of hospitalizations and transitions of care. Job aids
will be provided, as well as opportunities to practice in assigned pairs during the offline training.
To ensure transfer into their work setting, pairs of nurses and social workers will be assigned to
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conduct joint home environment evaluations and complete a unified protocol that enables more
flexibility in which staff are assigned to these duties.
During the synchronous face-to-face portion for leaders, the focus will be on the
teamwork and leadership behaviors required to make progress on the stakeholder goal, including:
crucial conversations, identifying teachable moments, critical thinking, problem-solving,
challenging groupthink, giving and receiving feedback, using dialogue to promote learning, and
empowering patients and families as agents in the transition from hospital to home. These
trainings will leverage multiple modes of interaction to promote adult learning such as case
studies, role-playing, teach-backs, and flipped instruction. Leaders will be sorted into cohorts
that complete the course of the training together over a twelve-month period.
Components of Learning
Various evaluations will be employed to allow learners to demonstrate their command of
the declarative and procedural knowledge being taught through this training program, as well as
the self-efficacy and value elements required for learning. Evaluating declarative knowledge is
fundamental, as this gives indications of the learner's ability to recall the facts required for the
implementation of new skills, practices, or processes. Procedural knowledge must be evaluated
in light of the process-oriented nature of the performance goal, and the requirement that learners
align on steps required to successfully complete the important processes involved in transitioning
and coordinating care. Lastly, learners must view these facts, concepts, and procedural steps as
both important and within their power to grasp and master what is being asked of them. As such,
table 17 lists the evaluation methods and timing for these components of learning.
Table 17
Components of Learning for the Program.
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Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”
Knowledge checks using multiple choice. In the asynchronous portions of the
course during and after video
demonstrations.
Knowledge checks through discussions, “think, pair,
share” and other individual/group activities.

Periodically during the in-person
workshop
Procedural Skills “I can do it right now.”
During the asynchronous portions of the course using
case-based questions with multiple-choice items.
In the asynchronous portions of the
course at the end of each
module/lesson/unit
Demonstration in groups and individually of using the
job aids to successfully perform the procedural steps.

During the workshops.
Retrospective post-test assessment survey asking
participants about their level of proficiency before and
after the training.

At the end of the workshop.
Attitude “I believe this is worthwhile.”
Instructor’s observation of participants’ verbal and non-
verbal responses (i.e., statements, enthusiasm, etc.)
demonstrating whether they see the value of what they
are being asked to relative to their day to day work.

During the workshop.
Discussions of the benefits of what they are being
asked to do on the job.

During the workshop.
Confidence “I think I can do it on the job.”
Survey items using Likert scale-type items Following each module/lesson/unit in
the asynchronous portions of the
course.
Reflections following practice and feedback. During the workshop.
Retrospective pre- and post-test assessment item. After the course.
Commitment “I will do it on the job.”
Discussions following practice and feedback.

During the workshop.
Create an individual action plan.

During the workshop.
Retrospective pre- and post-test assessment item. After the course.
Level 1: Reaction
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The Kirkpatrick New World Model defines level 1 as the degree to which learners find
the training experience enjoyable, engaging, relevant and satisfying. The more engaged learners
are, the more likely they are to learn the knowledge and skills needed to apply their learnings,
and display attitudes that are in alignment with the overall goal being sought. It is therefore a
worthwhile effort to plan for the components of level 1 in advance, so as to enhance the
likelihood of success of the training program. Table 18 below lists the methods and timing of
evaluation methods used to capture reactions to the program.
Table 18
Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Course activity analytics in the learning management
system
Ongoing during asynchronous portion
of the course.
Completion of online modules/lessons/units Ongoing during asynchronous portion
of the course.
Observation by instructor/facilitator During the workshop
Attendance During the workshop
Course evaluation Five days after the course
Relevance
Pulse-check with participants via anonymous survey
(online) and discussion (in-person)
After every module / unit and at pre-
determined points during training
Course evaluation Five days after the course
Customer Satisfaction
Pulse-check with participants via anonymous survey
(online) and discussion (in-person)
After every module / unit and at pre-
determined points during training
Course evaluation Five days after the course.
Evaluation Tools
Immediately Following the Program Implementation
The asynchronous portions of the course will take place through the learning
management system, called VHC-U. Learner activity in VHC-U will be tracked, including status
of each unit and module, time to completion for each unit and for entire modules, and grades on
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formative and summative assessments. Also, brief surveys that focus on the relevance of the
material will be built in at key milestones to gather feedback on the applicability of the material
and solicit learner input on course design and delivery.
During the face-to-face training sessions, level 1 evaluation will include both observation
by the facilitator and periodic pulse checks that specifically ask about relevance, for example by
asking in what situations participants could have employed the learnings in the past and where
they would anticipate using the knowledge from the course in the future. Level 2 will include
checks for understanding using case-based assessment items pulled from actual examples in the
work environment, using pair or group discussion and practice.
Delayed for a Period After the Program Implementation
Approximately four weeks post-training, and then again at eight and 12 weeks, surveys
containing rating scales and open-ended items will be administered to participants to gather their
reflections on relevance of and satisfaction with the training (Level 1), confidence in ability to
apply new skills gained (Level 2), application of the training to the care transition and care
coordination processes and the supports provided (Level 3), and the degree to which
performance on effective care transitions and coordination has led to decreased readmissions
among their populations (Level 4).
Data Analysis and Reporting
The Level 4 goal of PACE leaders is to achieve a 15% hospital readmission rate by
focusing on care coordination and effective transitions of care from the hospital setting. This will
be measured by the timeliness of appointment scheduling, the time to completion of post-
discharge appointments, and how quickly a home environment evaluation can be conducted to
ensure that patients are fully equipped and supported to readjust to life at home following a stay
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in the hospital. Each week, leaders will track how many patients have been discharged, how
many have had their appointments scheduled, how long it took to get the appointment scheduled,
what proportion of post-discharge primary care appointments were completed within a three-day
window, how long it took for a home environment evaluation to be conducted, and how many
patients were re-admitted to the hospital within 30 days of initial discharge. This information
will be included on an internal dashboard for leaders to review as a monitoring and
accountability tool.
Figure 4
Readmissions dashboard

Summary
The New World Kirkpatrick model of evaluation served as the foundation for planning,
implementing, and evaluating recommendations regarding the stakeholder goal of achieving 15%
hospital readmissions within VHC PACE. By providing a framework for planning for
implementation of the training program, from the reactions to the learning event, to the
knowledge, skills, attitudes, confidence and commitment, through the critical behaviors
necessary for results, the New World Kirkpatrick model enabled the creation of a thorough,
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grounded, and realistic training implementation and evaluation plan that will ultimately produce
a return on expectations by serving the organizational goal of closing healthcare disparities by
achieving the stakeholder goal of reduced hospital readmissions for frail and elderly patients in
the PACE program.
Future Research
Hospital readmissions among the elderly and underserved is an issue with profound
implications for the field of healthcare more broadly (Virapongse & Misky, 2018). This study
focused on the impact of an interdisciplinary approach on transitions of care in the context of
clinical and social risk factors in a managed care model. Future studies on the subject of
readmissions could address different managed care models, and the impact of other team
structures and approaches on hospital readmission rates. New research on the topic can leverage
longitudinal designs to investigate the impact of family and caregiver support on the risk of
hospital readmissions. Finally, the impact of technology—such as virtual patient engagement and
remote patient monitoring—on the transition from hospital to home is an exciting direction in
which future research can extend the body of knowledge on the subject, particularly in the
context of COVID-19, where teams have already begun to function in a more distributed manner.
Conclusion
The current study used a qualitative, mixed methods approach to investigate the
knowledge, motivation, and organization factors that influenced the VHC PACE leadership
group in their pursuit of a 30-day all-cause hospital readmission rate of 15%. This goal was
selected because it is a component that factors into VHC’s attainment of a 4.5-star quality rating.
The study found that while knowledge influences were not validated, and PACE leaders
113

demonstrated value for the issue of readmissions, there were gaps present in the areas of
collective efficacy, leadership, and the cultural setting of the interdisciplinary team.
Interdisciplinary approaches to care hold great promise, but also face challenges such as
role boundary conflicts and hierarchical power dynamics that inhibit teamwork (Rosen, et al.,
2018). Because healthcare is a complex adaptive system (Lipsitz, 2012; McDaniel, Driebe &
Langham, 2013), it requires effective interactions among various stakeholders, including
patients, families, and diverse groups of healthcare personnel (Lipsitz, 2012). The effectiveness
of these interactions can either enhance or decrease the level of trust present in these
relationships (Sturmberg & Lanham, 2014).
Trust is the fulcrum on which the findings and recommendations in this study turn. As
teams triumph over power dynamics that negatively affect communication, build critical thinking
skills, and develop teamwork competencies in a cross-disciplinary way, it is assumed that they
will be more effective, at least in part, due to greater trust among team members (Casimiro, et al.,
2014). As mentorship programs for providers and annual training regimens for IDT members are
deployed, it is assumed that individual team members will gain skills and expand their mental
models in a way that facilitates organizational learning (Kim, 1998; McDaniel, Driebe &
Langham, 2013). Team improvement is heavily dependent on the culture changes enabled by
leadership (Rosen, et al., 2018). Therefore as leaders become more effective designers of
learning processes, they have the opportunity to shape culture in ways that impact collective
efficacy through mechanisms of cooperative cognition that rely on trust (Chou, Lin & Chou,
2012; Gibson, 2001). Given the importance of variables like transitions of care and care
coordination—both of which entail multiple actors engaged in handoffs across different
processes—in determining whether a patient is readmitted to the hospital (Kripalani, Jackson,
114

Schnipper & Coleman, 2007; Long, Genao & Horwitz, 2013), it is not surprising that a relational
factor such as trust would be an underlying theme.
As community healthcare institutions, PACE and VHC were significantly impacted by
the COVID-19 pandemic. Given the shifts away from high-density settings that were initiated by
the pandemic, it is recommended that future research examine the effectiveness of distributed
work models for interdisciplinary teams, as well as the impact of remote patient monitoring and
other forms of technological innovations on the issue of readmissions. Future studies that
examine other settings, structures, or technologies that impact readmissions have the potential to
uncover innovative new dimensions of trust within the complex adaptive system of healthcare,
and in the area of hospital readmissions, specifically.

115

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133

Appendix A

Interview Protocol
Good morning / afternoon, [participant name]. Thanks again for taking the time to speak
with me today. As we talked about, I am in the process of interviewing PACE site leaders as part
of my dissertation for the Organizational Change and Leadership program at USC. I am
specifically looking at different aspects of the PACE model of managed care for this population,
especially as it relates to the issue of hospital readmission rates. I appreciate your willingness to
participate in this study, and want to remind you that you are free to withdraw at any time, your
information and what we discuss will be kept completely confidential, and you may decline to
answer a question or withdraw from the study at any point. In the final report, no personally
identifiable information will be used, and a pseudonym will be used to safeguard the identity of
the organization. I’m going to try my best to keep us on time and within the hour that we agreed
to. Does the allotted time still work for you? Before we begin, however, I would like to know if
you have any questions about the study itself or the interview today? [Wait for response]. May I
have your permission to record the interview? [Wait for response]. Great, now we can get
started.
I would like to start off by learning a bit more about you, your role, and your time at
VHC and PACE.
1. First, can I have you state your title and tenure at PACE to get us started?
a. How would you describe your responsibilities in this position?
b. What roles do you play?
c. What are the challenges in these roles?
5. Tell me about your population – who do you serve?
134

6. Would you say that readmission is a problem for the majority of your population? Why
or why not?
a. Which segments of your patient population would you say are at greatest risk for
readmission?
b. What makes these segments the ones that are at highest risk?
c. In your estimation, where does the readmissions goal rank in relation to the other
goals for the year?
7. From what you have seen, what are the major reasons that patients are readmitted to the
hospital after discharge?
8. Can you list and explain the steps that are taken with PACE participants who have just
been discharged from the hospital?
a. What is the PACE approach to care coordination for a recently discharged
patient? Can you share a recent example of how this played out?
b. What, if any, supports are in place to help limit readmissions?
c. What, if any, barriers can you think of that may limit the effectiveness of efforts
related to readmissions?
d. What is or is not working based on the current approach? How would you rate the
effectiveness of the processes and procedures currently in place?
e. How do you handle the parts that are outside of your control? Can you share an
example of this?
f. How is this knowledge shared and maintained at the team level?
9. How would you describe the importance of the steps that you and your team take to
reduce readmissions for your patients?
135

10. How confident are you in your ability to impact the readmission goal in a positive way?
11. How would you characterize your team’s confidence in their collective ability to impact
the readmissions goal through their efforts? What skills or processes are they most / least
confident in?
a. Where have you seen evidence of this?
b. Can you remember a time when their confidence was not as high? What
contributed to that?
I’d like to explore your role as a leader and what leadership is like at PACE.
12. How would you describe yourself as a leader?
a. What attributes of your own leadership have been most useful in the role of…?
b. What is required of you as a leader in a managed care setting?
c. How much of your role would you say is dedicated to facilitating learning?
d. What, if any, rewards, policies, or structures are in place to support team
learning?
I’ve heard about the IDT and how central it is to the PACE model. At this point I want to
transition us to exploring that space a bit more.
13. If I were to join an interdisciplinary team (IDT) meeting about a patient who had just
been discharged from the hospital, what would I see team members doing? What would I
hear them talking about?
a. Which IDT structures or practices would you say are most supportive of the
readmissions goal?
b. Which structures are least supportive? Which have less of an impact on the goal?
136

Thanks so much, again, for taking the time to share with me. I want to remind you that
everything you shared is confidential. I have one final question for you before we go:
14. Is there anything I didn’t cover, or anything that I should have asked but didn’t?

137

Appendix B

University of Southern California
Rossier School of Education
3470 Trousdale Parkway
Waite Phillips Hall
Los Angeles, CA 90089-4034

INFORMATION/FACTS SHEET FOR EXEMPT NON-MEDICAL RESEARCH

Addressing Hospital Readmissions as a Managed Care Model within a Federally Qualified
Health Center: An Evaluation Study

You are invited to participate in a research study. Research studies include only people who
voluntarily choose to take part. This document explains information about this study. You should
ask questions about anything that is unclear to you.

PURPOSE OF THE STUDY
This research study aims to understand how the PACE program manages hospital readmissions
among its patient population and what factors influence the program’s ability to achieve its
hospital readmission rate goals. This study is being conducted as part of a doctoral dissertation to
surface new knowledge and potential recommendations about the management of hospital
readmissions for underserved populations. The findings of this study are of potential benefit to
not only similar programs—like other PACE and Federally Qualified Health Centers (FQHCs)—
but also all primary care providers who operate under a managed care model.

PARTICIPANT INVOLVEMENT
If you agree to take part in this study, you’ll be asked to participate in a roughly 60-minute
audio-taped interview. You do not have to answer any questions you don’t want to. You can also
choose to not have the interview be recorded. If you don’t want to be taped, notes will be taken.
You have the right to withdraw from the study at any time.

PAYMENT/COMPENSATION FOR PARTICIPATION
You will receive $10 gift card for your time. You do not have to answer all of the questions in
order to receive the card. The card will be given to you when you complete the interview.

ALTERNATIVES TO PARTICIPATION
Your alternative is to not participate. Your relationship with your employer will not be affected
whether you participate or not in this study.

CONFIDENTIALITY
138

Keeping your data confidential is very important. Recordings of interviews will only be accessed
by the interviewer and transcribers. If you choose to participate, you will have the right to review
any notes taken during the interview. Any identifiable information obtained in connection with
this study will remain confidential. Your responses will be coded with a false name (pseudonym)
and maintained separately. Recordings will be kept for up to one year, at which point they will
be destroyed. No information will be released to any other party for any reason.

Required language:
The members of the research team, the funding agency and the University of Southern
California’s Human Subjects Protection Program (HSPP) may access the data. The HSPP
reviews and monitors research studies to protect the rights and welfare of research subjects.

When the results of the research are published or discussed in conferences, no identifiable
information will be used.

INVESTIGATOR CONTACT INFORMATION

Principal Investigator Samere Reid via email at samerere@usc.edu or phone at (323) 313-5903
or Faculty Advisor Cathy Krop at krop@usc.edu or (310) 890-7943.

IRB CONTACT INFORMATION
University of Southern California Institutional Review Board, 1640 Marengo Street, Suite 700,
Los Angeles, CA 90033-9269. Phone (323) 442-0114 or email irb@usc.edu.

139

Appendix C
Training Post-Survey – Immediate
Please rate your agreement with the following statements on a scale of 1-5, with 5 being strongly
agree and 1 being strongly disagree.
Level 1
1. The training content was relevant to my job duties.
2. The training was structured effectively.
3. The concepts presented made sense to me.
4. I received the right information to help me solve a problem in my role.
Level 2
5. I gained new knowledge that will help me to be more effective at my job.
6. I was able to practice skills necessary to doing my job well.
7. I am confident in my ability to apply what I learned in this training to my regular duties.
Level 3
8. I understand why this training was necessary.
9. This training was a valuable use of time.
10. I am very likely to apply what I’ve learned in this training to my job duties.
Free response:
11. If there are topic areas that you think should have been addressed in this training, but
weren’t, please list them here: __________________________________________.

140

Appendix D
Training Post-Survey – Delayed
1. Please share your thoughts on how well the implementation is working.
2. What, if any, positive results have you seen as a result of the training?
3. What evidence are you observing that the implementation is working?
4. What, if any, issues have you encountered that raise the need for further support?

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Asset Metadata

Creator Reid, Samere (author)

Core Title Addressing hospital readmissions as a managed care model within a federally qualified health center: an evaluation study

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 12/12/2020

Defense Date 12/10/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Federally Qualified Health Center,FQHC,Hospital Readmissions Reduction Program,hospitalization,HRRP,OAI-PMH Harvest,pace,Program of All-Inclusive Care for the Elderly,readmissions

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Krop, Cathy Sloane (committee chair), Hausner, Larry (committee member), Phillips, Jennifer (committee member)

Creator Email samerere@usc.edu,sareid@post.harvard.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-408685

Unique identifier UC11668081

Identifier etd-ReidSamere-9205.pdf (filename),usctheses-c89-408685 (legacy record id)

Legacy Identifier etd-ReidSamere-9205.pdf

Dmrecord 408685

Document Type Dissertation

Rights Reid, Samere

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA