Abstract

Structured Abstract Statement of the Problem/Significance. Many current proposals to investigate the quality and value of healthcare delivered to highly vulnerable populations focused on health equity with substantive reasoning. Clinically vulnerable and socially disadvantaged clients were given healthcare insurance access through the expansion of Medicaid via the healthcare reform. The provision of healthcare insurance to highly vulnerable Medicaid beneficiaries without sufficient navigation of managed care system or fully meeting the beneficiaries’ social determinants of health (SDH), obstructs the “Triple Aim” of population health. Failure begets failure. The focus of health improvement requires a shift from the physical determinants of health (PDH) model to a social and physical determinants of health model. The PDH model implies clients are the sole cause of their health status and bear the total responsibility for their fate. Without addressing the social structures that influence health choices and health outcomes of highly vulnerable populations a negative goal cycle will prevail. Study Design. A focused ethnographic study was conducted to explore, identify, and understand the transitional experience of a cultural group of 20 post-ACA Medicaid beneficiaries (adults with persistent asthma) who rely upon a faith-based DSH (Mercy Fitzgerald Hospital in Delaware County, Pennsylvania) for healthcare. Within the theoretical framework of Meleis’ Transitions theory, the challenges and obstacles of transition from the state of being uninsured to the complexities of Medicaid managed care were explored as well as the behaviors and attitudes adopted to overcome these challenges. Thematic analysis of ethnographic findings presented the voice of the Pennsylvania Medicaid beneficiaries and the future direction of nursing practice, nursing education, nursing research, and health policy. Constant comparison in data sources centered on the PAMB role changes as it affected their health beliefs, health practices, and personal health responsibility. Sampling Method.

Twenty study participants were purposively selected from the medical surgical floor of Mercy Fitzgerald Hospital (MFH) census to participate in the focused interviews. Fifteen of the twenty PAMB interview participants also participated in a structured interviewing method, free listing, to identify the PAMB’s extent of certain cultural, cognitive domains that required further investigation. Participant recruitment followed institutional review board approvals from the Catholic University of America and the Mercy Health System. Participant identification as a PAMB occurred through selfidentification to the primary investigator following the notification of the research study from an advertisement flyer, referral by MFH/SML Wellness Center HCP administration, or through PAMB word of mouth. Moderators and Mediators Study variables underscored the role of the participants as the moderators and mediators of their healthcare transition. Professional power and PAMB Powerlessness. Based on the HCP respect toward PAMB, and the communication between the two, found in the PAMB data suggests that HCP power was disproportionate to participant involvement in shared Advanced Nursing & Patient Care International Journal https://chembiopublishers.com/ANPCIJ/ Submit Manuscript @ https://chembiopublishers.com/submit-manuscript.php 2 clinical decision making and clinical discourse in general. Participants experienced powerlessness during hospitalizations due to illness, socioeconomic factors, and misalignment of HCP team goals.

At the time of discharge, participants felt confusion about treatment plan, medications to discard or retain, and an inability to meet the HCP goals for participant health outcomes. Lack of implementation of health behaviors due to participants’ competency issues caused loss of self-efficacy related to failure to perform recommended behaviors. Some participants (P 15, P10) felt abandoned by HCP after they returned home from hospitalization. Participants described a sense of disconnection with HCP stemming from the inability of HCP to relate to participants’ socioeconomic challenges. This disconnection led to PAMB-reports of unrealistic discharge goals. Failure to meet HCP treatment goals undermined the participants’ self-confidence and prompted disengagement from future adoption of positive health behaviors. Negative Goal Cycle. HCP and participant goals at discharge were often misaligned because of unclear or incomplete clinical discussion. The disconnect was based between HCP directions and what the participant knew he/she could realistically accomplish at home. An incomplete HCP understanding of PAMB ability to achieve the goals of the action plans was formed from the insufficient clinical discussion with PAMB. If PAMB did not express any difficulty in completing the clinical objectives of asthma/COPD therapy or describe socioeconomic status obstacles to prescribed medications, HCP presumably were unaware of them. The negative goal cycle encouraged low participant goal achievement, compliance with treatment plans, low self-confidence, and poor performance on Health care Effectiveness Data and Information Set (HEDIS) clinical indicators. Participants will not likely meet goals that are unknown or unachievable for them. Stigma. PAMB’s experience of internalized and externalized stigma related to Medicaid insurance negatively mediated their self-care integration and self-advocacy efforts. Some participants refrained from clinical decision-making and did not question the HCP-developed action plan. PAMB’s experience of stigmatization reflected a sense of shame and inequality, and correlated to their reliance on a historically stigma-associated public health insurance program.

The inability to procure private health insurance for oneself adversely affected PAMB sense of autonomy creating variance in the power distribution between HCP/case managers and PAMB. Most participants were in poor health at the time of data collection, which may have further added to their sense of stigma. PAMB with multiple chronic diseases often interpreted a HCP’s abrupt manner of speaking, or resistance to listen fully to their description of current illness, as negative. Nevertheless, only one PAMB self-identified illness as a source of stigma. Public insurance is associated with stigma-related experiences and assumed yet plays an important role in healthcare for low-income adults Allen (2014). Regardless of the source, these negative stances were perceptible to the PAMB while receiving care at both MFH and in the community. Evidence from the PAMB interviews and CCD free-listing suggested that externalized stigma was experienced more commonly than internalized stigma. This signals a need for behavioral changes in HCP and case managers’ approaches to PAMB in order to reduce stigmatization. PAMB stigma experiences influenced their decisionmaking ability, confidence levels, and health-seeking behaviors. Allen (2014) recommend a rebranding of Medicaid insurance to combat stigmatization and increase utilization of the proper levels of healthcare. The recent expansion of Medicaid initiated a normalization of Medicaid insurance to some extent through the allowance of beneficiary employment. The means to care for one’s health and contribute to society through taxation mitigated the effects of previous undesirable images of Medicaid beneficiaries to some extent. By increasing eligibility to individuals with lowpaid employment, new Medicaid enrollees have contributed to their own health plan via payroll deduction (taxes). A healthier individual increases the chances of a healthier society.