Strategies to Improve Corporate Financial Investment in Care Coordination Programs.

Section 1: Foundation of the Study

Dual-eligible beneficiaries are those entitled to both federal and state health care

benefits (Eggbeer, Bowers, & Morris, 2013). The dual-eligible population accounts for a

disproportionate share of state and federal health care expenditures (Gimm, Blodgett, &

Zanwar, 2016). Moreover, dual-eligible beneficiaries have a greater likelihood of poor

health outcomes related to multiple chronic conditions, mental illness, and functional

limitations than beneficiaries with single coverage (Eggbeer et al., 2013). Policymakers

focused on reducing health care costs by improving the poor coordination of state and

federal health benefits (Gimm et al., 2016). Health care leaders describe the dual-eligible

market as a multibillion dollar opportunity to reduce health cost by using care

coordination programs (Eggbeer et al., 2013).

The triple aim model (TAM) of reducing per capita health care costs, improving

patient experience, and providing population health is a national framework to transform

health care at the social and business levels (Bodenheimer & Sinsky, 2014). Improving

coordination may require health care leaders to assess current processes to determine

appropriate resource allocation to realize the financial benefit of program

implementation. Providing financial justification for health care interventions is a

challenge for health care leaders (Wilf-Miron, Bolutin, Gordon, Porath, & Peled, 2014).

Some health care leaders struggle with reflecting the benefit of investing in care

coordination programs (Perry & Stevens, 2013). Wilf-Miron et al. (2014) indicated the

need for additional research on presenting the financial impact of implementing care

coordination programs. The aim of this study was to explore strategies health care leaders

use to improve corporate financial investment in care coordination programs that include

TAM objectives.

Background of the Problem

The older adult population with both federal and state health care benefits is

accountable for 39% of state expenditures and 31% of federal expenses (Gimm et al.,

2016). Eggbeer et al. (2013) indicated the total health care costs associated with the dual-

eligible population totaled $320 billion. The enrollment of dually eligible beneficiaries in

a managed care organization can save the public health care programs an estimated $13

billion in health care cost over a 5-year period (Frank, 2013). Therefore, policy leaders

authorized 3-year dual demonstration programs that outsourced the care coordination of

the dual-eligible beneficiaries to managed care plans (Eggbeer et al., 2013). Sixty

managed care plans in 10 states received a capitated, risk-adjusted payment to provide

services for dual-eligible beneficiaries (Craver, Cuellar, & Gimm, 2016). Managed care

leaders within a capitated payment model set care coordination program cost at $150 to

$195 per beneficiary per month (Eggbeer et al., 2013). The change in the regulatory

landscape challenged health care leaders to provide sustainable solutions to address the

$20 billion loss associated with the lack of care coordination for the dual population

(Eggbeer et al., 2013). According to Hendrikx et al. (2016), leaders pursue TAM

objectives to ensure a sustainable health care system. Moreover, TAM goals of achieving

population health, reducing per capita costs, and improving patient satisfaction are the

framework defining the systematic social and business changes required in the health care

industry (Bodenheimer & Sinsky, 2014). According to Miranda, Ferranti, Strauss,

Neelon, and Califf (2013), health care leaders use TAM objectives to define the

transformation of the health care system. Health care leaders must take an individualized

approach to developing a business strategy for care coordination programs based on the

drivers of profit margin and the mission of the organization (Perry & Stevens, 2013). The

results of this study may impact the field of business by providing strategies for health

care leaders in the position of manager, director, and vice president to improve corporate

financial investment in care coordination programs that include TAM objectives.

Problem Statement

Care coordination programs for dual-eligible beneficiaries cost between $150 and

$195 per enrollee per month (Eggbeer et al., 2013). Health care leaders must limit

allocation to care coordination programs to $125 to $150 per member per month to

realize net savings (Brown, Peikes, Peterson, Schore, & Razafindrakoto, 2012). The

general business problem was a lack of financial investment in care coordination

programs by managed care organizations, which results in loss of profitability for the

organization. The specific business problem was that some health care leaders in the

position of manager, director, or vice president lack strategies to improve corporate

financial investment in care coordination programs that include TAM objectives.

Purpose Statement

The purpose of this qualitative single-case study was to explore the strategies that

health care leaders use to improve corporate financial investment in care coordination

programs that include TAM objectives. The target population was health care leaders in

the role of vice president or higher from one health care organization with experience

implementing strategies to improve corporate financial investment for care coordination

programs that included TAM objectives. The geographical region was Southern

California. Health care executives may consider the findings from this study as a

contribution to social change if recommendations improve the quality of care for the

dual-eligible population.

Nature of the Study

I selected the qualitative method for this study. Qualitative researchers can use

interviews to seek an understanding of the uniqueness of events from the perspective of

the participants, which extends beyond a comparison of variables (Stake, 2010). The

qualitative method was appropriate because I used interviews for an in-depth exploration

of a distinct event. Conversely, quantitative researchers use numerical data to test

hypotheses (Hanson, Balmer, & Giardino, 2011). The quantitative approach was not

appropriate because I did not intend to test hypotheses or use an experimental setting for

the study. In mixed-methods research, researchers combine qualitative and quantitative

methods when a single method is insufficient to provide a comprehensive understanding

of the topic or results require additional clarification (Wisdom, Cavaleri, Onwuegbuzie,

& Green, 2012). The mixed-methods approach was not appropriate because the

integrative approach would have complicated the scope of the study beyond the

collection of descriptive data to reflect the insights of the participants.

I used a case study design. Researchers can use interviews in a case study design

to conduct in-depth research on a contemporary event within the bounds of the case study

site (Yin, 2014). The case study design was appropriate because the objective of the study

was to conduct in-depth research of current strategies used by health care leaders to

garner financial support within the bounds a single organization. The ethnographic,

phenomenological, and narrative designs were not suitable for this study. Researchers use

the ethnographic design to understand the culture of the environment by engaging in

extended relationships with research participants (Wolcott, 1999). The objective of this

study was not to engage in an extended relationship with participants to gauge the culture

of the organization. According to Moustakas (1994), phenomenological researchers study

lived experiences of participants and the perceptions of those experiences. In this study, I

did not seek to provide an understanding of the lived experiences of the participants.

Finally, researchers using the narrative design provide a sequential account of the

participant’s personal stories regarding his or her life experience (Hays & Woods, 2011).

The narrative design was not appropriate because I did not take an account of a sequence

of events to tell a story.

Research Question

The central research question was as follows: What strategies do health care

leaders use to improve corporate financial investment in care coordination programs that

include TAM objectives? The interview questions included the following:

Interview Questions

1. What successful strategies did you use to improve corporate financial

investment in care coordination programs?

2. What strategies did you find worked best to improve corporate financial

investment in care coordination programs?

3. How did you communicate the corporate financial investment strategies to

executive leaders?

4. How did you evaluate the cost effectiveness of care coordination programs?

5. What are your recommendations to health care leaders pursuing care

coordination investments?

6. What other information can you share regarding this study?

Conceptual Framework

TAM, which was developed by Berwick and the Institute for Healthcare

Improvement in 2008, is a framework that provides the social and business constructs

required for health care transformation (Vetter, Boudreaux, Jones, Hunter, & Pittet,

2014). The key tenets of TAM are population health, reducing per capita health care

costs, and improving patient satisfaction (Miranda et al., 2013). According to

Whittington, Nolan, Lewis, and Torres (2015), leaders are successful in deploying TAM

when there is investment capacity to integrate the key tenets and alignment in the

organizational governance structure. The development of business strategies requires

leaders to align with the key corporate metrics driving the decisions of senior leaders

(Harvard Business Press, 2011).

Anderson and Bjarnadóttir (2016) posited that health care leaders face difficulty

in defining the cost effectiveness of care coordination programs due to variations in

program models. Likewise, Katon and Unützer (2013) indicated that defining the

financial structure at the organizational level is a hindrance in the adoption of new care

coordination models. According to Ory et al. (2013), TAM objectives are the measures of

successful care coordination implementation. Therefore, TAM was applicable because I

explored the strategies health care leaders use to improve corporate financial investment

in care coordination programs that included TAM objectives.

Operational Definitions

Capitated payment: Capitated payments are payments fixed per enrollee per

month (Quinn, 2015).

Care coordination: Care coordination is a set of activities to manage the health

care needs of a population, resulting in a cost saving (Scholz, 2015).

Corporate financial investment: Corporate financial investment is money

attributed to an asset with the expectation of an increase in the future value of the asset

(Chaysin, Daengdej, & Tangjitprom, 2016).

Dual-eligible: Dual-eligible beneficiaries are beneficiaries receiving federal and

state-sponsored health care benefits from a single source that integrates the financing and

delivery of care (Prindiville, 2013).

Managed Care Organization for the Older Adult (MCOOA): MCOOA is a

capitated, risk-adjusted organization that provides services to a defined older adult

population (Morley, Walsh, & Wilkin, 2013).

Risk adjustment: Risk adjustment is the process of adjusting payment to the

MCOOA based on the severity of illness for a beneficiary qualified for the federally

sponsored health care program (Hellander, Himmelstein, & Woolhandler, 2013)

Star quality rating: Star quality rating is the federal quality rating system that

rates MCOOA on a 1 to 5 rating scale (Reid, Deb, Howell, & Shrank, 2013).

Transition: Transition is the process of changing from one health care level to

another (Cleave et al., 2013).

Transitional care: Transitional care includes services provided to support

continuity of care between care transitions during a specified time interval (Verhaegh et

al., 2014)

Assumptions, Limitations, and Delimitations

Assumptions

Assumptions are the components of the study that validate the relevance of the

research topic (Thomas, Nelson, & Silverman, 2010). The underlying assumption of this

study was that health care leaders in the position of manager, director, or vice president

consider care coordination programs a viable solution to impacting costs within an

MCOOA. There was an assumption that the MCOOA leaders consider TAM objectives

of reducing per health care capita cost, improving patient experience, and improving

population health as the foundation for health care transformation. The next assumption

was that the inclusion criteria would allow me to identify participants with the knowledge

base to provide in-depth answers to the interview questions. Finally, I assumed that

participants would provide honest responses during the interview process.

Limitations

The limitations are the weaknesses of the study that are outside the control of the

researcher (Thomas et al., 2010). The single case study design limitations included

sample size and generalizability. According to Yin (2014), the single case study design

limits the study to a single unit of analysis, which may not represent the activities of other

organizations. In addition, the sample size in a single unit of study was a limitation.

Finally, documentation as a source of evidence was a limitation based on retrievability,

biased selectivity, reporting bias, and access (Yin, 2014).

Delimitations

According to Thomas et al. (2010), the delimitations are within the capacity of the

researcher to control and are used to identify the bounds of the study. I delimited the

study to participants with the breadth of knowledge and willingness to participate in the

study. The participants included leaders within a bounded managed care system delimited

to a single eastern county of Southern California. In addition, the case study site

contracted to provide care for beneficiaries receiving federally sponsored health care

benefits, state-sponsored benefits, employer-based benefits, dual-eligible beneficiaries,

and the uninsured. The delimitation was to the beneficiaries dually eligible for federal-

and state-sponsored health care benefits.

Significance of the Study

A challenge to the health care system in the United States is to convert a

fragmented system into one that focuses on reducing costs through integrated service

delivery, enhanced population health, and improved quality (Enthoven, 2016). TAM is

the framework defining the health care systematic changes required to control costs

(Bodenheimer & Sinsky, 2014). The core objectives of TAM include improving

population health, reducing the cost of health care, and improving patient satisfaction

(Bodenheimer & Sinsky, 2014). According to Fuse-Brown (2015), cost containment is a

critical component of the Affordable Care Act (ACA). The transformation of the

provision of care for the 10.2 million beneficiaries of federal and state health care reflects

the social and economic influence of the ACA (Craver et al., 2016). Therefore, health

care executives have an interest in strategies to control the cost for the dual-eligible

population because the population has a higher incidence of chronic conditions, social

needs, and mental health disorders (Zainulbhai, Goldberg, Ng, & Montgomery, 2014).

According to Murphy and Neven (2014), the cost of inpatient utilization has led to

national attention to care activities designed to reduce costs. Senior executives can have

an awareness of the need to develop innovative programs; however, leaders must present

an evidence-based business strategy to support the use of scarce resources (de Waal,

Beaumont, & Mitchell, 2013). The study of strategies for health care leaders to improve

the corporate financial investment in care coordination programs that included TAM

objectives may be valuable in maintaining the financial solvency of MCOOA, reducing

fragmentation of health care, and improving the quality of care to the older adult.

Contribution to Business Practice

The dual-eligible population accounts for 20% of the U.S. federal program

enrollment and approximately 40% of the total expenditures (Frank, 2013). Moreover, the

dual-eligible population has a greater incidence of emergency hospitalizations, chronic

conditions, homelessness, and frailty (Ortega, 2016). In the capitated model, the MCOOA

will receive a prospected, blended payment to manage services for beneficiaries

(Rahman, Keohane, Trivedi, & Mor, 2015). According to Kennedy (2013), beneficiaries

of federal and state health care programs spend $300 billion annually. Reinhard (2013)

identified an opportunity to increase market share and profitability for those MCOOA

with the capacity to integrate and coordinate care for the high-risk dual population.

Furthermore, Zainulbhai et al. (2014) indicated that new strategies to improve access,

control costs, improve the quality of care, and reduce barriers are essential to managing

the financial burden of the dual-eligible population. Health care leaders, however, may

not have the competencies to develop a business case presentation to support the

implementation of new strategies (de Waal et al., 2013). The results of this study may

contribute to efficient business practices by identifying the strategies aligned with TAM

objectives of reducing per capita costs. The results may also influence business practices

by providing strategies for health care leaders in the position of manager, director, or vice

president to gain access to corporate resources for the implementation of care

coordination programs.

Implications for Social Change

MCOOA accounts for 25% of the enrollment for beneficiaries with federal- and

state-sponsored health care benefits (Reid et al., 2013). Therefore, MCOOA could have a

positive effect on the federal health care program by improving the quality of care

(Newhouse & McGuire, 2014). Deficient care coordination during transitions from the

hospital to the community can lead to adverse outcomes and readmissions (Feltner et al.,

2014). Hodin (2013) indicated that fragmented care for dual beneficiaries has an adverse

influence on their overall health outcomes. The results of the current study may

contribute to positive social change by supporting TAM objectives of population health

and improved patient experiences. Furthermore, the results may have a positive impact on

social change by providing insight into the strategies health care leaders positioned in the

role of manager, director, or vice president use for care coordination programs designed

to impact the adverse outcomes experienced by the dual-eligible population.

A Review of the Professional and Academic Literature

There is an increased focus on preserving federal and state funding by

encouraging innovative approaches to improving the quality of care for the dual-eligible

population. However, care models must align with new payment structures and quality

initiatives for MCOOA sustainability. Health care leaders strategize on how to create a

business case for coordinated care programs when the traditional business model is not

applicable (Perry & Stevens, 2013). The focus of the current study was to explore the

strategies health care leaders use to improve the corporate financial investment in care

coordination programs that include TAM objectives. The literature review reflected the

core business implications for MCOOA to implement care coordination programs for the

dual-eligible population and the position of industry leaders.

I employed a systematic approach using journal articles, scholarly books, and

dissertations to guide the literature review. A gap existed in the literature on strategies for

leaders to garner financial support for care coordination programs for the dual-eligible

population. The gap may be due to the July 2014 implementation of integrated benefits

for the dual-eligible population. As illustrated in Table 1, the literature review included

246 publications, 87% with publication dates between 2013 and 2017. Of the 246

publications, the peer-reviewed articles accounted for 90%. The electronic databases

were EBSCOHost, Academic Search Complete, Science Direct, Thoreau, and ProQuest. I

also used the Google Scholar search engine. My strategy to extract relevant literature

started with a broad search of terms narrowed to a specific term search. First, the search

included triple aim, dual-eligible, readmission, care coordination, patient-centered

medical home, accountable care organization, Medicare Advantage, health care reform,

health care cost, Medicare costs, corporate sustainability, corporate social

responsibility, stakeholder theory, shareholder theory, Star ratings, medical loss ratio,

risk-adjustment managed care, qualitative research care coordination, qualitative

research health care, health care leadership, and health care leaders. Next, the specific

terms included cost of dual-eligible, Affordable Care Act, Financial Alignment Initiative,

triple aim objectives, population health, transition of care, business case, business case

health care, business case care coordination, cost-effectiveness of care coordination,

cost-benefit analysis, and care coordination return on investment. The results of the term

search guided the inquiry. Additionally, the linked articles feature within the electronic

databases contained resources for the literature review. As I cataloged references, themes

emerged to define the seven sections of the literature review. I organized the literature

review into these sections to present the analysis and synthesis of the literature based on

the focus of discussion: (a) comparative theories, (b) MCOOA, (c) Affordable Care Act,

(d) care coordination, (e) dual-eligible population, (f) readmissions, (g) relationship of

study to previous research.

Table 1

Source of Literature for the Literature Review

Total

Percentage

Peer reviewed articles 197 90%

Publication between 2013 and 2017 214 89%

Seminal books 16 7%

Comparative Theories

The comparative theories for critical analysis included TAM, corporate social

responsibility theory (CSRT), corporate sustainability theory (CST), stakeholder theory,

and shareholder theory. Bodenheimer and Sinsky (2014) indicated that TAM represents

the interdependent business and social objectives required to re-engineer the health care

system. Similarly, Eccles, Ioannou, and Serrafeim (2014) noted CST has interrelated

dimensions of social, economic, and ecological activities. The fundamental principles of

CSRT are the organization’s socially responsible activities (Husted, Montiel, &

Christmann, 2016). According to Eccles et al., maintaining a positive profit margin for

the shareholders in an environment free of fraudulent practices is the central social

obligation of organizations grounded in the shareholder theory. Conversely, stakeholder

theorists extended corporate accountability to shareholders and multiple stakeholders due

to the interrelated aspects of business and society (Queen, 2015).

Triple aim model. The conceptual framework guiding this study was TAM.

Health care researchers at the Institute for Healthcare Improvement (IHI) proposed TAM

in 2008 as a concept to address health care deficiencies (Whittington et al., 2015). TAM

is the health care framework defining the systematic changes required to control health

care costs (Bodenheimer & Sinsky, 2014). Moreover, the core objectives of TAM include

achieving population health, reducing the cost of health care, and improving patient

satisfaction (Bodenheimer & Sinsky, 2014). The researchers at the IHI posited that

societal changes were necessary to realize global transformation in the health care

structure (Whittington et al., 2015). Similarly, Miranda et al. (2013) indicated that leaders

use the TAM objectives to define health care system transformation.

Policymakers structured the ACA programs to make systematic changes from

volume-based health care to a structure grounded in the value of health care (Cason,

2015). Strong, Hanson, Magnusson, and Neiger (2015) indicated that the ACA provisions

align with the goal of achieving TAM objectives. Therefore, health care leaders use the

TAM model to define the success of health care reform initiatives (Katon & Unützer,

2013). Strong et al. noted that the strategies of implementing TAM include isolating a

population, defining measures of success, achieving system-level outcomes, and

providing an expeditious evaluation of effectiveness. However, Hendrikx et al. (2016)

indicated that differences in the industry definitions of TAM objectives cause variation in

the means of measuring successful implementation. Eapen, Lauer, and Temple (2014)

posited that measuring the achievement of TAM objectives required clinical trials with

adequate sample sizes to measure clinical outcomes. According to Panzer et al. (2013),

measuring TAM objectives requires health care leaders to define the benchmark

performance for each measure.

Triple aim objectives. The components of TAM include reducing per capita

costs, achieving population health, and improving the patient experience (Bodenheimer &

Sinsky, 2014). Vetter et al. (2014) indicated the cost of health care in the United States

would represent 19.3% of the GDP by 2019. Similarly, Jackson et al. (2013) posited that

the United States spends a greater percentage of the GDP on health care than any other

country; however, this does not equate to higher quality outcomes. TAM is integral in

addressing health care waste and increasing costs (Coyne et al., 2014). However, provider

payment models lack incentives for lowering the per capita cost of health care

(Whittington et al., 2015). Gage and Albaroudi (2015) posited that the focus of

policymakers shifted from cost control to improving the value of health care.

Population health encompasses the clinical outcomes of a defined group of

individuals (Kindig & Isham, 2014). Whittington et al. (2015) pointed out that health care

leaders must engage in completing a population assessment and choose populations

whereby the three objectives of TAM apply. Furthermore, Hendrikx et al. (2016) noted

that measures of population health differ and result in various means of implementation

based on regional social needs. Moreover, Kindig and Isham (2014) indicated that

improving population health requires the collaboration of numerous organizations to

address the multiple social and physical determinants of health, and a single organization

cannot accomplish population health. Miranda et al. (2013) noted that health care

industries lack the analytical tools to support population management. Similarly, Phillips

et al. (2015) indicated that deficient data exchange at the level where patients access care

has an adverse influence on the capacity to achieve population health. George and

Shocksnider (2014) indicated nurse leaders require financial knowledge and access to key

business drivers to gain support for care coordination programs aimed at population

health.

Harder, Krulewitz, Jones, Wasserman, and Shaw (2016) indicated measuring

patient experience is a critical component when transforming the structure of the health

care system. Cook et al. (2015) described the patient experience as the patient’s

perception of care. Similarly, Bernabeo and Holmboe (2013) noted that patient

engagement and shared decision-making is a key system-level competency required to

achieve TAM objectives. Hibbard and Greene (2013) indicated that increasing patient

engagement improves the perceived patient experience. Hacker and Walker (2013) added

that the influence on patient experience is essential because patient behaviors account for

60% of health outcomes. According to Cook et al. (2015), improving health outcomes

involves utilizing patient experience feedback to guide patient engagement and quality

initiatives.

Hacker and Walker (2013) indicated that the accountable care organization

(ACO) and the patient-centered medical home (PCMH) are key concepts to

implementing TAM. The PCMH is a transformative concept of care aimed at re-

engineering the primary care practice (Jackson et al., 2013). The core tenets of the PCMH

include (a) team-driven care, (b) holistic care for the patient, (c) care coordination across

the continuum of care, (d) innovative methods of communication to improve access, and

(e) systematic approach to quality and safety (Jackson et al., 2013). According to Hahn,

Gonzalez, Etz, and Crabtree (2014), the National Committee for Quality Assurance

introduced the PCMH model to improve the quality of care within a primary care setting.

Health care organizations, however, may pursue the PCMH recognition as a label versus

a transformative process to improve the quality of care (Hahn et al., 2014). Similarly,

Howard et al. (2016) indicated that the pursuit of a PCMH extends beyond the verbiage

used to describe the practice to include the actions that support a transformation in the

culture of the organization.

The ACO is an ACA concept to transform the health care delivery system to meet

TAM objectives (Sandberg et al., 2014). In an ACO, there is a consortium of providers

contracted to reduce cost by creating a systematic, quality-based approach to managing a

population (Auerbach, Liu, Hussey, Lau, & Mehrotra, 2013). According to Kelleher et al.

(2015), the ACO success is in the ability to reduce cost and improve quality, thereby

improving the value of care. However, Rose, Zaslavsky, and McWilliams (2016) pointed

out that an ACO retaining a fee-for-service payment methodology for physicians and

specialists can cause conflicting priorities with volume versus value. Moreover, the

drivers of the ACO framework are the state and federal financial incentives for achieving

reductions in health care costs (Pham, Cohen, & Conway, 2014). Colla et al. (2014)

pointed out that the ACO framework allows for cost savings based on evidence-based

practice versus indiscriminate reductions in services.

Golden (2015) indicated there are more than 700 ACOs that provide health care

for an estimated 23 million people. According to Berkowitz and Pahira (2014), the core

elements of ACO development are as follows: leadership, governance, information

technology, analytical capacity, population health management, and care coordination.

Similarly, Hofler and Ortiz (2016) indicated that the two defining goals for an ACO are

enhancing the quality of care for a defined population and improving care coordination to

reduce the costs associated with hospitalizations and emergency room visits. However,

Golden indicated that policymakers will not realize the estimated $5 billion dollar saving

by 2019.

Corporate social responsibility theory. According to Carroll (2015), Bowen

initiated the CSRT body of literature to discuss the relationship between business and

society. Queen (2015) added that CSRT is an organization’s determination of the cost-

benefit of social initiatives. According to Husted et al. (2016), organizations grounded in

CSRT influence local communities by improving social benefits and decreasing social

problems. Scholars of the CSRT define the instrumental value of CSRT as the view of

societal issues based on the benefit to people (Husted et al., 2016). Theorists of CSRT

indicate the benefit of organizations engaging in socially responsible activities is a

positive reputation (Chernev & Blair, 2015). Additionally, Korschun, Bhattacharya, and

Swain (2016) pointed out that communicating CSRT initiatives to customers and

employees supports a high-performing work environment and positive reputation. There

is an economic value of maximizing on short- and long-term returns based on positive

public images (Tang, Gallagher, & Bie, 2015). Cheng, Ioannou, and Serafeim (2014)

posited that performance of CSRT philosophies affects business investments by lowering

capital constraints that could reduce the capacity to engage in strategic projects.

Likewise, Korschun et al. (2016) indicated that there are greater returns for organizations

with high CSRT activities. However, the CSRT was not the appropriate conceptual

framework for this study due to the emphasis on the social drivers of decision-making.

TAM was the most suitable framework based on the interrelated social and business

objectives driving systemic health care changes.

Corporate sustainability theory. In 1987, the World Commission on

Environment and Development introduced the CST to address environmental and social

problems that will impact future generations (Linnenluecke, Verreynne, Scheepers, &

Venter, 2017). Rego, Cunha, and Polónia (2015) posited that the definition of corporate

sustainability is diverse, resulting in the varied application of practice and theory.

Furthermore, Lozano (2015) indicated the organization’s leaders are the driving force for

implementing CST practices. The focus of corporate sustainability is on an organization’s

ability to meet the needs of internal and external stakeholders while maintaining

consideration for future stakeholder needs (Montiel & Delgado-Ceballos, 2014).

Similarly, Milne and Gray (2013) defined sustainability as a general concept about

consumption of natural resources and the impact of the consumption on future

generations. Hahn, Figge, Aragon-Correa, and Sharma (2015) noted a deficiency in

defining how organizations lessen the impact of activities on ecological systems.

Additionally, Milne and Gray stated the ecological component of the concept is

inconsistent among organizations, and business leaders debate the defining criteria for the

ecological contribution to society. Similarly, Whiteman, Walker, and Perego (2013)

indicated that scholars of the CST failed to provide a detailed account of how

organizations can operationalize CST interventions. The concept of sustainable

development is a blend of social, economic, justice, environmental, business, politics, and

legal activities to maintain future resources (Hahn, Pinkse, Preuss, & Figge, 2015). Hahn,

Figge, et al. (2015) noted that sustainable development is the fundamental principle

guiding CST.

Hahn, Pinkse, et al. (2015) describe the business implications for CST as a profit-

based strategic plan to address environmental and social pressures. Similarly, Eccles et al.

(2014) posited that there is a positive impact on the bottom line through economic

sustainability occurring in concert with ecological and social aspects of the business.

Moreover, the business considerations for CST require the integration of environmental

influences with the social and econimic factors (Whiteman et al., 2013). CST involves the

organization’s role in managing the ecological factors, social considerations, and external

perceptions (Eccles et al., 2014).

Hahn, Figge, et al. (2015) indicated the business considerations include the

potential for positive returns when investing in environmental and socially driven

initiatives. In this study, I did not focus on the ecological impact of business decisions on

future generations. Therefore, the CST was not the appropriate framework for this study.

TAM defines the objectives for systematic health care changes by implementing the

social and business tenets of improved population health, reducing per capita costs, and

improving the patient experience (Bodenheimer & Sinsky, 2014). Thus, TAM was the

more appropriate framework to study strategies health care leaders use to influence

decision making for care coordination program implementation.

Shareholder and stakeholder theory. Organizations grounded in shareholder

theory indicate the organization’s societal obligation is to maintain profitability for its

shareholders (Eccles et al., 2014). The morality of shareholder view is the right to

freedom of choice and ownership of personal property, without a violation of that right

for others (Mansell, 2013). In contrast, Friedman (1962) argued that only the individual

could possess social responsibility, not an organizational structure (Mansell, 2013).

Shareholders are owners that have the right to determine resource allocation (Mansell,

2013). The critique of the shareholder view is that resource allocation grounded in

maximizing owner profits is to the detriment of charity, employee morale efforts, and

other stakeholders (Queen, 2015). According to Mansell (2013), managerial staff is

contractually obligated to act based on the interests of the shareowners.

The stakeholder view expands the corporate relationship to multiple stakeholders

(Queen, 2015). Moreover, Kull, Mena, and Korschun (2016) posited that the outcome of

an organization depends on multiple stakeholder relationships. Critics hold that a focus

on broad stakeholder initiatives consumes managerial time in negotiations (Queen, 2015).

However, Kull et al. indicated that mutual trust developed with stakeholders provides a

competitive advantage. The critique of the stakeholder theory is the conflicting priorities

for managers to align with the separate agendas of owners versus stakeholders (Queen,

2015).

The stakeholder and shareholder theory are not mutually exclusive concepts, and

a balance between stakeholder costs and shareholder benefit is optimal (Queen, 2015).

Therefore, as individual conceptual frameworks, the stakeholder theory and shareholder

theory were not appropriate for this study. TAM was most suitable for this study to

determine how leaders make decisions that may influence social and business objectives

of health care.

Managed Care Organization for the Older Adult

The federal government contracts with risk-based managed care organizations to

provide services to federal health care beneficiaries (Newhouse & McGuire, 2014).

Newhouse and McGuire (2014) indicated that the intent of the managed care organization

for the older adult was to reduce costs and provide federal beneficiaries with an option

beyond federally sponsored health care. Twenty-seven percent of recipients of federally

sponsored health care enroll in one of the 3,300 managed care plans (Hellander et al.,

2013). MCOOA have the capacity to offer competitive benefit packages and care

coordination for beneficiaries (Landon et al., 2015). MCOOA receive a higher federal

reimbursement than traditional fee for service programs; however, the increase in

spending is not equivalent to a rise in quality (Hellander et al., 2013). Managed care plans

receive approximately $10, 123 per enrollee, which estimates to $136.2 billion a year

(Hellander et al., 2013).

Although the intent of MCOOA is to control health care expenditures, the federal

government spends $282.6 billion more for MCOOA than traditional fee for service

programs (Hellander et al., 2013). Baicker, Chernew, and Robbins (2013) pointed to a

shorter length of stay and reduction in hospital costs counterbalancing the additional

payments to MCOOA. Landon et al. (2015) support the assumption by indicating

MCOOA have lower utilization than the traditional federal health care program due to

network contracting and care management program implementation.

The federal government used the Star Rating system to determine MCOOA

performance based on the quality of care provided (Xu, Burgess, Cabral, Soria-Saucedo

& Kazis, 2015). Moreover, Reid et al. (2013) revealed the Star Ratings affect beneficiary

enrollment decisions; thus, influencing the MCOOA total enrollment and revenue. The

Star Ratings reflect Healthcare Effectiveness Data and Information Set (HEDIS)

measures, Consumer Assessment of Healthcare Providers and Systems surveys

(CAHPS), Health of Seniors surveys (HOS), and administrative data (Reid et al., 2013).

The provisions of the ACA reduced the higher payments to MCOOA and linked

payments to the quality of care through Star ratings (Xu et al., 2015). Landon et al.

(2015) stated the MCOOA could provide better quality than traditional federally

sponsored health care programs based on the use of flexible benefits and vast networks of

providers. The traditional federally sponsored health care program consists of benefits

determined by legislation and standard fee schedules (Baicker et al., 2013). According to

Reid et al. (2013), the Star Rating system is an essential business driver for MCOOA

because the federal government linked Star Ratings to the MCOOA’s financial

reimbursement in 2011. Additionally, state officials can enact quality payment withholds

based on the quality performance measures selected by the state (Morley et al., 2013;

Zainulbhai, et al., 2014).

The Obama Administration enactment of the PPACA modified the payment

structure of MCOOA requiring changes in business practices to ensure financial solvency

(Rak & Coffin, 2013). Moreover, the ACA changes in the health care reimbursement

structure include bonus payments and an increased capacity to enroll new members (Xu

et al., 2015). The current payment structure is that MCOOA receives capitated risk-

adjusted reimbursement from the federal government per enrollee for a given period

(Craver et al., 2016). According to Brown, Duggan, Kuziemko, and Woolston (2014), the

capitated risk-adjusted methodology is critical in eliminating the incentive to overutilize

services in a fee for service model. Morley et al. (2013) indicated that policymakers

reduced payments to MCOOA through the Financial Alignment Initiative.

The ACA included provisions to control costs and quality activities by regulating

the medical loss ratio for MCOOA (Harrington, 2013). Hall (2014) indicated tracking

medical expenditures is a key performance measure of the ACA. Conversely, Harrington

(2013) indicated a decreased focused on medical cost control would allow leaders to

increase spending on quality-based, clinical services. However, Harrington indicated

there was a decrease in the willingness to invest in innovative strategies without

measurable results. Harrington noted that the medical loss ratio regulation ensures the

health plans attribute the appropriate percentage of premium revenue for the medical care

and activities to improve the quality of care. Furthermore, the medical loss ratio of 80%

to 85% established by the ACA requires MCOOA to provide a rebate to insurers when

premium payments exceed the cost of providing medical care and specific quality-based

activities (Harrington, 2013). Health care economists suggested the ACA has decreased

the rate of health care spending (Hall, 2014). Proponents argue the recession and existing

downward trends may account for the deceleration of health care expenditure (Hall,

2014). However, those supporting the medical loss ratio indicate it is a solution to the

lack of transparency causing increased administrative costs (Harrington, 2013).

Affordable Care Act

The core components of the ACA include increasing health care coverage and

redefining the health care system (Berwick, Feeley, & Loehrer, 2015). On March 23,

2010, President Obama enacted the ACA into law and increased the insured population

by an estimated 16 million by 2015 (Hamel, Blumenthal, Abrams, & Nuzum, 2015).

However, Sommers, Buchmueller, Decker, Carey, and Kronick (2013) indicated the goal

of the legislators was for the ACA provisions to increase the insured population by 30

million. According to Orentlicher (2014), the ACA changes improved the health

insurance market by eliminating high premiums and coverage denials based on

preexisting conditions. Conversely, Hamel et al. (2015) indicated that increasing health

care coverage occurred by allowing the selection of affordable coverage through a health

plan marketplace, through federally sponsored expansion of the state-funded health

insurance program, extending dependent health coverage, and prohibiting discrimination

due to pre-existing conditions. Orentlicher indicated expanding state health care coverage

extends coverage to those previously uninsured, but does not equate to universal

coverage or better health outcomes.

Redefining the health care system is a complex component of the ACA provisions

(Hamel et al., 2015). Public and private organizational leaders focused on the

development of new care structures to transform the health care system (Berwick et al.,

2015). According to Hamel et al. (2015), redefining the health care system includes

changes in the payment structure, delivery models, workforce, and degree of innovation

for sustainability. Mery, Majumder, Brown, and Dobrow (2017) indicated that achieving

the objectives of TAM is the measure of transformation in the health care delivery

system. Likewise, Whittington et al. (2015) noted that TAM framework became a

national model to implement the health care redesign strategic objectives of the ACA.

Hamel et al. pointed out that systematic transformation of the payment structure included

readmission penalties, pay for performance strategies, reducing hospital-acquired

conditions through incentive payments, and bundled payment structures. Likewise,

Franklin and Busis (2016) indicated that the ACA provisions include investments in

billion dollar grants for care coordination and payment models aimed at achieving the

objectives of TAM.

Hirsch et al. (2014) indicated that ACA legislators introduced the, the

Independent Payment Advisory Board (IPAB) and the Patient-Centered Outcomes

Research Institute (PCORI) as the accountable agencies for redesigning the health care

infrastructure. The objective of the IPAB administrators is cost containment (Hirsch et

al., 2014). The IPAB commissioners evaluate payment methodologies for the federal

health care program based on changes in the per capita costs thresholds (Hirsch et al.,

2014). Frank, Basch, and Selby (2014) indicated that the role of the PCORI

administrators is to fund research that represents the voice of the community and supports

providing research to support informed health care decision-making. Moreover, the

PCORI aims to increase evidenced based health decision by funding clinical research

(Hirsch et al., 2014). According to Jain and Shrank (2014), legislators introduced the

Innovation Center to develop programs to improve care, advance system integration,

provide preventative initiatives, and improve state-based programs. Moreover, the

Innovation Center administrators are responsible for the evaluation of ideas to improve

the quality of care and reduce health care costs (Jain & Shrank, 2014)

The ACA legislators introduced the Federal Coordinated Healthcare Office

(FCHO) to ensure the integration of federal and state programs. In addition, the Financial

Alignment Initiative of 2011 is one of the Innovation Center programs to integrate the

payment and delivery of health care for the dual-eligible population (Prina, 2016).

According to Craver et al. (2016), the aim of the Financial Alignment Initiative is to

develop cost effective care models to minimize cost shifting between federal and state

health care programs and to reduce the fragmented approach to care delivery for the dual-

eligible population. The Financial Alignment Initiative presents opportunities to augment

service delivery models (Craver et al., 2016). Effective April 2014, 10 states signed a

capitated financial alignment memorandum of understanding with the federal government

to provide care to dual-eligible beneficiaries (Verdier, Streeter, Chelminsky, &

Nysenbaum, 2014). Verdier et al. indicated that the state and federal government officials

reduced the reimbursement to MCOOA based on the amount of savings expected for the

year. Moreover, the Welfare and Institution Code noted that MCOOA expected to

achieve savings through managing utilization patterns versus reducing reimbursement to

providers (Cutler, Rich, & Yee, 2013).

Care Coordination

Collaborative health care is a process recognized as a strategy to achieving TAM

(Katon & Unützer, 2013). Desjardins (2015) indicated care coordination is the

organization of patient care activities amongst multiple providers aimed at appropriate

health care utilization. According to Morton et al. (2015), coordination of care is

important in avoiding duplication of services, consistently delivering evidenced-based

guidance and improving access to care. Similarly, Xing, Goehring, and Mancuso (2015)

indicated that poor coordination of care and access issues are key drivers of increased

health care costs.

Care coordination is an essential component to addressing TAM objectives by

structuring payment models to promote physician involvement in care coordination

(Moreo, Moreo, Urbano, Weeks, & Greene, 2014). According to Aronson, Bautista, and

Covinsky (2015), the adjustment to the payment structure for clinicians represents a cost

efficient, evidenced-based change to the health care system. Similarly, Shaw, Asomugha,

Conway, and Rein (2014) indicated that the ACA legislators promote the advent of

innovative strategies to improve care coordination to reduce health care cost. Moreover,

the ACA provisions include contracts and grant opportunities for care coordination at

various levels of the care continuum (Desjardins, 2015). The ACA changes included the

FCHO to facilitate research of care coordination programs aimed at reducing cost and

integrating services for dual population (Frank, 2013).

Care coordination programs differ in approach, settings, provider, and population

(Marek et al., 2014). The variation and customization in programs present a challenge for

health care leaders to define successful implementation (Schultz, Pineda, Lonhart,

Davies, & McDonald, 2013). Schultz et al. (2013) noted that the industry lacks

consistency in defining care coordination, developing evidenced based practice, and

measuring coordination of care. Hong, Siegel, and Ferris (2014) revealed successful care

management models included: (a) customization, (b) qualitative and quantitative methods

for member identification, (c) a primary focus on care coordination, (d) relationship

building with patients and providers, (e) interdisciplinary team based on needs, (f)

training for team members, and (g) use technology to improve care. Tricco et al. (2014)

added that targeted interventions should include modifications with proven success such

as changes in the team, case management, and self-management strategies. Care

coordination becomes of increasing importance with an aging population with chronic

illness and comorbidities (Daveson et al., 2014). Similarly, Xing et al. (2015) noted that

targeting the care coordination intervention for the high-risk population is an effective

strategy for improving health care outcomes.

The return on investment for care coordination programs may vary. A review of

primary care-based care coordination programs revealed little to no benefit in utilization

outcomes (Marek et al., 2014). Similarly, McWilliams and Schwartz (2017) indicated

that care coordination programs did not influence cost savings for health care

organizations based on the need to expand resources and to increase the use of services.

In contrast, Marek et al. (2014) posited that transitional care was an effective care

coordination program feature to reduce inpatient utilization costs. Murphy and Neven

(2014) indicated that care coordination program assessments lacked a standardized

method of evaluating cost. Moreover, Murphy and Neven indicated that cost-

effectiveness was a fundamental element for leaders to determine an efficient allocation

of resources. The measure of success across programs was the ability to reduce inpatient

utilization outcomes. Kates, Shield, Behrend, and Noyes (2015) indicated that inpatient

cost would increase from $129.1 billion in 2008 to $234.9 billion in 2019.

Dual-Eligible Population

According to Whittington et al. (2015), choosing a population to implement the

three dimensions of the Triple Aim is a core competency for health care transformation.

Rittenhouse et al. (2015) indicated that the older adult population would account for 19%

of the total population by 2030. Moreover, the dual population requires coordination to

integrate the financial and medical components of the federal and state health care

programs (Prindiville, 2013). The Duals Office ensures the dual-eligible beneficiary

receives integrated benefits (Justice & Holladay, 2013). In addition, the provisions of the

ACA created regulatory groups to monitor activities for the dual-eligible population

savings (Brown et al., 2012). Eggbeer et al. (2013) pointed out that the dual-eligible

population is increasing at a rate double that of single-program beneficiaries. In addition,

the dual population has a higher incidence of social issues influencing the ability to

access health benefits (Ortega, 2016). Zainulbhai et al. (2014) added that medical and

behavioral complexities complicate care for the dual-eligible. Joynt, Gawande, Orav, and

Jha (2013) indicated that 10% of the older adult population consumes 50% of the federal

health care resources. Moreover, Powers, Chaguturu, and Ferris (2015) revealed that care

coordination programs could improve quality of life and reduce health care expenditures.

Eggbeer et al. indicated the system of managed care is appropriate for dual-eligible

beneficiaries because of the following: 40% of the population is younger than 65, 75% of

the dual-eligible population has not experienced a hospital admission, and 87% of the

dual-eligible reside at home. However, the dual-eligible population presents a challenge

when coordinating care amongst multiple providers and services (Eggbeer et al., 2013).

Kennedy (2013) indicated the dual-eligible population is at risk for fragmented care due

to the coordination required between multiple programs with varied benefits, ID cards,

appeal and grievance processes, and documentation.

Jung, Trivedi, Grabowski, and Mor (2015) indicated the dual-eligible population

account for 15% of state-sponsored health care enrollment and 39% of the expenses.

Eggbeer et al. (2013) posited that care coordination programs for dual-eligible

beneficiaries cost between $150 and $195 per enrollee. However, Brown et al. (2012)

concluded that programs could cost no more than $125 to $150 to realize savings.

MCOOA must reduce hospitalizations for the dual-eligible beneficiary by 15 per 100

enrollees to realize net savings (Brown et al., 2012). Additionally, the dual-eligible

population has 25% more chronic conditions than single-program recipients (Segal,

Rollins, Hodges, & Roozeboom, 2014). Cleave et al. (2013) indicated multiple chronic

conditions cause 98% of the federal health care expense. Moreover, the high incidence of

medical, social, and mental health needs complicates care coordination for the dual

eligible population. (Zainulbhai et al., 2014). Eggbeer et al. proposed that coordinating

and integrating care for the dual-eligible could improve the quality of care and save $20

billion in expenditures.

The Coordinated Care Initiative (CCI) in California consists of participation from

8 counties: Alameda, Los Angeles, Riverside, San Bernardino, Orange, Santa Clara, San

Diego and San Mateo (Cutler et al., 2013). Cutler et al. (2013) indicated that the CCI is

limited to a 3-year demonstration project to determine the statewide implementation of

unified state and federal health care benefits. Statistics reflects that 76% of dual-eligible

beneficiaries are 65 and older, and 37% are people with disabilities (Cutler et al., 2013).

The total dual population is approximately 1 million in California, of which, 223,084 are

in the eastern county of Southern California (Cutler et al., 2013). There is a 200,000 cap

on enrollment in the county (Cuter et al., 2013).

Fifteen states received a $1 million grant for the development of care management

programs for beneficiaries enrolled in federal and state-sponsored health care programs

(Lindeblad, 2013). The purpose of a care management program is to reduce expenditures

for the federal government and improve health outcomes for the dual population

(Lindeblad, 2013). The dual-eligible rate of hospitalization is 26% compared to 20% for

the single-program beneficiaries (Segal et al., 2014). Although hospitalizations are

necessary to regain optimal functions, hospitalizations for conditions identified as an

outpatient service are potentially avoidable hospitalizations (Wysocki et al., 2014).

Zainulbhai et al. (2014) determined that 44% of the dual-eligible population require long

term support services to address co-occurring conditions and social issues. Wysocki et al.

(2014) indicated improved transitions and community services can reduce avoidable

hospitalizations for the duals. Wysocki et al. explained the interconnectivity of medical

and long-term care services requires payment reform to encourage providers to improve

coordination of care and transition of care. Nevertheless, Segal et al. (2014) indicated

26% of the hospitalizations for the dual population were potentially preventable.

Zainulbhai et al. (2014) indicated that new strategies developed through the federal

demonstration projects are necessary to improve the quality of care, enhance access, and

reduce administrative barriers for the dual-eligible population. However, Prindiville

(2013) voiced a concern related to consumer protections to avoid new strategies that limit

care for the vulnerable dual-eligible population.

Readmissions

Ouslander and Maslow (2012) indicated reducing preventable hospitalizations is a

key initiative in achieving the objectives of TAM. Similarly, Hitch et al. (2016) stated

that the capacity to control high readmission rates is where health care systems are

deficient in meeting TAM objectives. However, care coordination is a consistent theme in

reducing the costs associated with readmissions (Carter, Bryant-Lukosius, DiCenso,

Blythe, & Neville, 2014). Gohil et al. (2015) indicated that readmissions occur within one

year for approximately 30% of hospitalized patients. Moreover, Hitch et al. noted that 1

in 5 beneficiaries enrolled in the traditional federal health care program readmit to an

inpatient level of care, costing the federal program 26 billion dollars annually.

Readmission is one of the key indicators of quality health care delivery (Hao et al., 2016).

Hao et al. (2016) indicated that preventative measures for readmission include focusing

on high-risk factors, strategic prevention strategies, and timely interventions for

vulnerable populations. The readmission rate for beneficiaries enrolled in the traditional

federal health care program is 20% and cost an estimated $17 billion (Fischer et al.,

2014).

According to Vipperla et al. (2014), identifying the risk and reason for

readmissions can reduce health care costs. Jiang et al. (2016) posited that readmissions

are the result of lack of primary care incentive to reduce readmissions, fragmented health

care, and poor access to care. Gohil et al. (2015) indicated that social determinants such

as education and income level have a direct impact on the probability of readmission.

Moreover, Dharmarajan et al. (2013) indicated that readmissions occur from generalized

vulnerabilities post hospitalization that include new disabilities, nutritional deficits, sleep

disturbance, and new medications. According to Picker et al. (2015), there is not a

standard preventative method to deter readmission due to the complexity of identifying

patients with a high risk of readmission. Likewise, Kahlon et al. (2015) indicated that

researchers and clinicians are unsuccessful in developing an algorithm to predict

readmissions. However, Mittler et al. (2013) noted that improved care coordination

during the transition from the hospital to an alternative level of care can prevent

readmissions.

There is limited evidence-based literature to determine a particular methodology

for transitional care interventions or identification of populations at greatest risk of

readmission (Kripalani, Theobald, Anctil, & Vasilevskis, 2014). However, poor

communication at the point of transition endangers the lives of older adults (King et al.,

2013). The older adult is at greater risk for medication discrepancies at the point of care

transition related to chronic conditions, comorbidities, functional impairments, and

complex medication regimens (Coughlin, Waidmann, & Phadera, 2012). Kripalani et al.

revealed there are various complexities to identifying specific interventions that affect

readmission. Similarly, Johnson et al. (2013) reported the transitional care program

elements include scheduling follow-up care, educating on the disease condition, and

training on warning signs that could result in readmission. Feltner et al. (2014) indicated

the focus on transitional care interventions improve readmissions by preventing adverse

events related to poor care coordination. Moreover, McWilliams and Schwartz (2017)

proposed that transitional care strategies include information technology, staff trained for

transitional care, interventions delivered in a home environment, and action planning for

inpatient and outpatient settings.

Although readmission is a significant portion of health care costs, health care

leaders may debate the value of readmissions as an indicator of health care quality.

Additionally, Fischer et al. (2014) indicated there is a lack of evidence to support using

readmission rates to measure the quality of hospital care. With the same vein, Parina,

Chang, Rose, and Talamini (2015) indicated readmission is not an independent measure

of quality based on the weak correlation to mortality rates. Gulati (2013) discovered 28%

of readmission are based on individual behavioral factors; therefore, negating the use of

readmissions as an indicator of hospital performance. Gu et al. (2014) determined the

dual-eligible status of patients has an adverse impact on the readmission rates. Therefore,

hospitals with high dual populations will receive a disproportionate share of readmission

penalties (Gu et al., 2014).

Relationship to Previous Leadership Research

Leaders require education in cost-benefit analysis and developing models that can

measure quality and cost (George & Shocksnider, 2014). In addition, leaders strategically

plan the development of a business case to influence stakeholders to invest in new

initiatives (Harvard Business Press, 2011). In the health care environment, a business

case manages clinical and financial performance expectations and provides an analysis of

the resources required for implementation (Song, McAlearney, Robbins, & McCullough,

2011). Health care leaders struggle with creating a business case for care coordination

because the standard business model does not apply (Perry & Stevens, 2013). According

to Wilf-Miron et al. (2014), health care leaders have difficulty determining the cost and

savings associated with health care interventions to improve the quality of care. Perry and

Stevens (2013) stated the organization’s mission and drivers of profit margin are

considerations when creating a business case. Creating the business case is necessary to

establish the value add for the proposed new initiative or for requesting resources for

existing projects (Perry & Stevens, 2013). A business case provides documentation of the

cost and benefits of potential investments (Maes, van Grembergen, & de Haes, 2013).

The business case provides a critical, formalized document for evaluating the allocation

of resources. The content of the business case can include an investment description,

investment objectives, investment requirements, investment impact, investment risk,

investment assumptions, and investment governance.

Health care leaders may lack strategies to garner support for care coordination

programs for the dual-eligible population. In addition, leaders may lack strategies to

reflect the effectiveness of care coordination programs. Kripalani et al. (2014) concluded

there is a lack of evidence-based literature to support a particular method for leaders to

reflect the benefits of implementing care coordination interventions. In addition, Wilf-

Miron et al. (2014) indicated that there is a variation in the delivery of care coordination

programs limiting the ability to do a cost analysis of the effectiveness. Similarly,

Schuller, Kash, Edwardson, and Gamm (2013) indicated there is a gap in the literature

defining how health care leaders enact organizational change. According to Wilf-Miron

et al. , there is an abundance of research to support implementing quality initiatives based

on performance indicators; however, there is a gap in the literature for leaders to use

when reflecting the associated financial implications. Similarly, Marek et al. (2014)

revealed a deficiency in the literature to defining how leaders reflect the cost-

effectiveness of care coordination programs. Likewise, Wilf-Miron et al. pointed out the

need for additional research on how leaders present a business case for implementation of

programs designed to address care for the complex population. Hong et al. (2014) noted

that there is little evidence of the ability of care coordination programs to reduce net costs

and demonstrate cost savings. According to Teut and Linde (2013), case study design is

an effective approach to study a field where there is a deficiency of existing research.

Researchers may use qualitative strategies to extract information from leaders as

key informants. Kash, Spaulding, Johnson, and Gamm (2014) employed qualitative

strategies to research success factors used by health care leaders to implement change

initiatives. Kash et al. used an open-ended interview process to engage participants in

describing critical success factors and offered insight into the process of successful

change implementation. In addition, Schuller et al. (2013) used qualitative strategies to

explore factors that can enable or disable implementation of change initiatives amongst

health care leaders and managers. Schuller et al. identified the use of a case study design

to provide a deeper understanding of the factors for leaders to implement change

successfully. Additionally, Brown et al. (2012) gave an analysis of four care coordination

programs that produced neutral cost results for the federal health care program for the

older adult. Brown et al. pointed out the need for health care leaders to control the cost of

interventions to realize savings when developing new care coordination programs.

According to de Waal et al. (2013), health care executives require evidenced based

business strategies to support the use of scarce resources for quality improvement in

health care.

Health care leaders in the position of manager, director, or vice president may use

TAM framework to define transformational changes within the organizational structure.

Findley, Matos, Hicks, Chang, and Reich (2014) suggested TAM framework as a

measure for leaders to determine the successful integration of community health workers

into the care coordination team. Likewise, Ory et al. (2013) used TAM objectives for

leaders to define the success of implementation of a care coordination program designed

to support self-management of chronic conditions. Lucatorto, Watts, Kresevic, Burant,

and Carney (2016) used TAM as the framework to determine the impact of the advanced

practice registered nurses in the care coordination program. In this study, TAM is the

conceptual framework to explore the strategies health care leaders positioned in the role

of manager, director, or vice president use to increase the resource allocation for care

coordination programs within a managed care setting.

I used a systematic approach to reviewing relevant journal articles and scholarly

books to guide the literature review process. Moreover, I provided a comprehensive

review of the literature on TAM, MCOOA, the Affordable Care Act, dual-eligible

population, care coordination programs, and readmissions. The literature review supports

the use of the qualitative research method to explore the strategies health care leaders use

to improve corporate financial investment in care coordination programs that include

TAM objectives.

Transition

In Section 1, I provided the foundation of the study to support the exploratory,

single case study design. Additionally, the section included (a) the background of the

problem, (b) the problem statement, (c) the purpose statement, (d) nature of the study, (e)

research question, (f) interview questions, (g) conceptual framework, (h) operational

definitions, (i) assumptions, limitations, and delimitations, (j) significance of the study,

and (k) the literature review. Section 2 is the detailed underpinnings of the qualitative,

case study. The objective was to provide the reader with the case study protocol driving

the research process. Section 2 contains a detailed account of the research process and

includes (a) purpose of the research, (b) the role of the researcher, (c) eligibility criteria

for participants, (d) research methodology, (e) research design, (f) population and

sampling, (g) ethical research, (h) data collection instruments and technique, (i)data

organization and analysis, and (j) reliability and validity. To conclude in Section 3, I

discussed the research findings, recommendations, and reflections.

Section 2: The Project

Policymakers increased efforts to reduce state and federal health care

expenditures by improving care coordination for the dual-eligible population (Gimm et

al., 2016). The provisions of the ACA included opportunities to refine the delivery of

services for the dually eligible. The challenge is in the ability of health care leaders to

define the business strategies for new service models aimed at cost reduction (Song et al.,

2011). Wilf-Miron et al. (2014) indicated the health care industry is inept in the

development of strategies to support business initiatives. In Section 2, I describe the

research purpose and provide a detailed account of the processes governing the

framework of the study.

Purpose Statement

The purpose of this qualitative single-case study was to explore the strategies that

health care leaders use to improve corporate financial investment in care coordination

programs that include TAM objectives. The target population was health care leaders in

the role of vice president or higher from one health care organization with experience

implementing strategies to improve corporate financial investment for care coordination

programs that included TAM objectives. The geographical region was Southern

California. Health care executives may consider the data from this study as a contribution

to social change if recommendations improve the quality of care for the dual-eligible

population.

Role of the Researcher

As the researcher, my role was as the primary instrument for data collection.

According to Hanson et al. (2011), the qualitative researcher is the primary instrument of

study when collecting interview data. My relationship with the topic, participants, and

area of study was that of an inside researcher. The inside researcher is a member of the

organization of study (Greene, 2014). I chose the inside researcher role to have direct

participant access and for a comprehensive understanding of the case study site. Greene

(2014) noted that inside researchers benefit from knowledge of the environment,

familiarity with participants, and access.

As the vice president of medical management, I possessed the knowledge of TAM

principles, care coordination, and the managed care environment. In addition, I had an

increased understanding of the business problem guiding the central research question

and a direct, established working relationship with the participants. However, the

participants were not subordinates. I interviewed leaders with accountability for work

processes and allocation of resources. According to McDermid, Peters, Jackson, and Daly

(2014), the advantage of a researcher employed by the research site is the understanding

of the organization and preexisting relationship with the participants. Similarly, Blythe,

Wikles, Jackson, and Halcomb (2013) indicated that inside researchers have an increased

depth of understanding, access, and rapport.

The three guiding principles of ethical research identified in the Belmont Report

provided the ethical foundation for the study. The role of the researcher is to ensure

respect for persons, beneficence, and justice (McDermid et al., 2014). Researchers

preserve the respect of persons by communicating the voluntary nature of the study and

providing information for informed decision-making (McDermid et al., 2014). The

ethical considerations include obtaining informed consent, providing honest dialog

regarding the study, and ensuring privacy and confidentiality (McDermid et al., 2014;

Yin, 2014). In addition, researchers maintain beneficence by maximizing benefits and

reducing harm (McDermid et al., 2014). Seidman (2012) indicated informed consent

minimizes participant risks. I used the informed consent process to guide ethical research

practices. To protect the confidentiality of the participants and reduce harm, I provided

them with unique identifiers rather than using their names or initials.

As an inside researcher, my role in this study was to mitigate bias through the

preservation of reflexivity. I mitigated bias and preserved reflexivity by using an

interview protocol and avoiding leading questions in the interview process. Collins and

Cooper (2014) indicated reflexivity is the initial process to determine how the view of the

researcher may influence the research process and findings. Similarly, Blythe et al.

(2013) indicated reflexivity is essential for inside researchers to reduce subjectivity and

bias. I used an interview protocol to establish uniformity and avoid deviation in the line

of questioning between participants (Appendix A). According to Jacob and Furgerson

(2012), an interview protocol preserves the focus of the study and ensures consistency in

the verbal exchange of information.

Participants

According to Barratt, Choi, and Li (2011), the experience of participants is critical

in determining the practicality of the research findings. Song et al. (2011) used a case

study design with organizational leaders as the key informants to extract qualitative data.

Likewise, Nicol, Mohanna, and Cowpe (2014) extracted information from senior health

care leaders to determine their views on the skills of clinical leaders. Cohen et al. (2014)

interviewed health care leaders to explore their understanding of the subject. In the

current study, the participant selection criteria included health care leaders at the level of

a vice president or above who used strategies to improve corporate financial investment

in care coordination programs that included TAM objectives.

According to Greene (2014), an inside researcher has direct access to the

organization of study as a member of the organization. Likewise, McDermid et al. (2014)

indicated the inside researcher has access to the organization and an understanding of the

site. Blythe et al. (2013) added that an advantage of inside research is the ability to gain

access as a member of the community of study. I gained access to the organization as an

inside researcher. I sent the letter of cooperation (Appendix B) that included a brief

description of the study to the chief medical officer via e-mail and scheduled a meeting to

obtain the signed letter of cooperation. After gaining the support of the chief medical

officer, I e-mailed the potential participants the informed consent with a voting option to

signify an agreement or disagreement with participation. The e-mail contained my direct

e-mail and telephone contact for potential participant questions prior to giving consent.

The informed consent included a description of the study and the disclosure information

identified in the Belmont report.

The participants did not have a reporting relationship with me or any employee

who reports to me. The participants were health care leaders in the position of vice

president or above who make or influence decisions about work practices and resource

allocation within the organization. According to McDermid et al. (2014), a researcher

employed by the research site develops an understanding of the organization and

establishes a preexisting relationship with the participants. In addition, Greene (2014)

noted that inside researchers benefit from the familiarity with participants and access.

Likewise, Blythe et al. (2013) added that inside researchers take advantage of access,

rapport, and depth of understanding.

Research Method and Design

I used the qualitative case study design to explore strategies for health care

leaders to improve corporate financial investment in care coordination programs that

included the TAM. According Bradley, Curry, and Devers (2007), qualitative researchers

provide an understanding of the complexity and breadth of a phenomenon. The

organizational phenomenon was the strategic processes health care leaders engage in to

procure funding for care coordination programs for the dual-eligible population. Yin

(2014) posited that a case study design can expand knowledge of organizational

phenomena.

Research Method

Researchers apply a qualitative, quantitative, or mixed-methods approach based

on the line of inquiry grounding the study. Moustakas (1994) indicated qualitative

researchers seek to obtain meaning from the core of the human experience. Likewise,

Denzin and Lincoln (2011) indicated qualitative researchers take an account of the

participant’s perspective through observations and interviews. Qualitative research

methods are ideal for identifying concepts and understanding phenomena (Bradley et al.,

2007). According to Myers (2013), qualitative research methods are appropriate for

exploratory, in-depth research on a topic that has limited existing research. Moreover,

Myers indicated the qualitative method allows the researcher to reveal the context in

which leaders generate decisions. I chose the qualitative method to explore strategies for

health care leaders in the position of manager, director, or vice president to improve

corporate financial investment for care coordination programs that included TAM

objectives. I conducted face-to-face interviews at the case study site, free of experimental

controls. The purpose of conducting the semi-structured interviews was to gauge the

participants’ experience and perspectives related to increasing resource allocation.

Qualitative strategies were appropriate for this study because the method allowed for

exploration of the decision-making process of health care leaders from the perspective of

the participants.

Quantitative researchers use numerical data to test hypotheses (Yilmaz, 2013).

Hanson et al. (2011) indicated quantitative researchers count occurrences and test

hypotheses. Quantitative researchers disregard context to focus on statistical techniques

to generalize findings (Myers, 2013). Because I focused on contextual content rather than

statistical numbers to test hypotheses, the quantitative method was not appropriate.

Investigators use mixed methods when the complexity of the research renders one

method insufficient (Wisdom et al., 2012). According to Yin (2014), researchers employ

mixed methods to address diverse research questions and to strengthen the data collected.

Likewise, Palinkas et al. (2015) indicated researchers use mixed methods to explore a

research topic using qualitative methods and to test a hypothesis using quantitative

methods. The qualitative method was appropriate for this study to extract the

participant’s insights and answer the central research question.

Research Design

The research designs prevalent in the literature include ethnography,

phenomenology, and case study (Hays & Wood, 2011). Additionally, Barratt et al. (2011)

indicated that researchers using the case study design to explore a phenomenon within the

bounds of the case. Moreover, the researcher using a case study design outlines the

questions and problems before conducting the study (Halaweh, 2012). Yin (2014)

described three conditions for choosing case study methods: research questions that use

how or why questions to explore operational connections, an environment free of

behavioral control, and the use of current events. I constructed the research question to

address an operational understanding of how health care leaders in the position of

manager, director, or vice president within a managed care environment gain funding for

care coordination programs. Research within a real-world context bounded by the

managed care site supported the application of a case study design. Researchers using an

ethnographic design focus on the culture of a group (Wolcott, 1999). Additionally,

Hanson et al. (2011) indicated ethnography requires the researcher to interact with

participants over an extended period in a setting where participants live. Moreover, in

ethnography the researcher uses participant observations and develops ongoing

relationships with the participants within a cultural framework (Watson, 2012). The

ethnographic design was not suitable because the study did not occur over an extended

period to gain knowledge of a culture. I did not employ extended periods of participant

observations as a data collection method, and I did not seek to develop continuous

relationships with the participants.

Phenomenological researchers aim to understand the lived or perceived

experiences of research participants (Tuohy, Cooney, Dowling, Murphy, & Sixsmith,

2013). Hays and Woods (2011) indicated phenomenological researchers aim to extract

meaning from understanding the individual’s conscious thoughts about a phenomenon.

Moreover, Moustakas (1994) reported that phenomenological researchers approach the

study of a phenomenon naively and without supposition. In this study, the focus was on

the strategies employed by health care leaders to gain financial support rather than the

subjective lived experiences of the participants. Therefore, the phenomenological design

was not appropriate.

Hanson et al. (2011) indicated qualitative researchers collect and analyze data

simultaneously to determine the point of saturation. According to Marshall, Cardon,

Poddar, and Fontenot, (2013), saturation occurs when there is a lack of new information

from the analysis of the interview data. Researchers achieve data saturation when there

are consistent themes noted in the data analysis process (Burda, van den Akker, van der

Horst, Lemmens, & Knottnerus, 2016). I achieved data saturation by interviewing

participants until there were no new themes identified in the analysis.

Population and Sampling

The purposeful sampling method supports the selection of information-rich cases

(Palinkas et al., 2015). Duan, Bhaumik, Palinkas, and Hoagwood (2015) indicated that

purposeful sampling is beneficial in capitalizing on scarce resources by identifying

participants who can provide information to support the purpose of the study. Nicol et al.

(2014) used purposeful sampling to gain insight from leaders involved in the key

leadership agenda. Kash et al. (2014) conducted a qualitative single case study using

purposeful sampling to extract the perceptions of health care leaders on evidence-based

leadership. Likewise, Cohen et al. (2014) implemented purposeful sampling to gain

information from health care leaders implementing population health strategies. I used

purposeful sampling to identify the participants in this study. The participant selection

criteria included health care leaders at the level of vice president or above who used

strategies to improve corporate financial investment in care coordination programs. The

sample size for the study was a minimum of six participants. Kelly (2010) noted that a

sample size of six to 10 participants could be appropriate for qualitative research.

Similarly, Barratt et al. (2011) indicated a sample of four to 10 is appropriate to capture

the essence of the phenomenon. Robinson (2013) indicated an estimated three to 16

interviews is appropriate in qualitative research. However, there is no predetermined

sample size for qualitative research methods (O’Reilly & Parker, 2013). Kelly posited

that the depth of information determines the sample size for a qualitative study as

opposed to a number based on a statistical calculation. Holloway and Wheeler (2013)

indicated a large sample size is uncommon and can jeopardize the depth and specificity

of qualitative research. Furthermore, the lack of new data determine the sample size

(Marshall et al., 2013). I selected a sample size of six participants to gain the depth of

information within a defined case study site. Data saturation occurs when no new

information emerges from the data analysis (O’Reilly & Parker, 2013). Marshall et al.

(2013) indicated data saturation is the point when the data extracted become redundant.

According to Burda et al. (2016), data saturation occurs when no new data emerge during

data collection and analysis. I completed parallel processes of conducting interviews and

analyzing the interview data to determine the point of saturation.

The participant selection criteria included health care leaders at the level of a vice

president or above who used strategies to improve corporate financial investment in care

coordination programs that included TAM objectives. The individual participant

interviews occurred in a closed environment to reduce interruptions, ensure privacy,

confidentiality, and accuracy of recordings. Moreover, I conducted the interview in a

closed environment onsite based on the preference of the participant. Consideration of the

actual setting is an essential step in the process of conducting interviews (Rabionet,

2011). According to Doody and Noonan (2013), an interview site without interruptions is

integral to the data collection process. Furthermore, Kelly (2010) indicated the interview

setting should be a mutually agreed upon location that is convenient for the participant.

Ethical Research

According to Seidman (2012), informed consent is the grounding principle of

ethically based research practices. The participants received and return the informed

consent form via email. I emailed the potential participants the informed consent with the

voting option to elect either an agreement or disagreement with participation in the study.

The email contained my direct email and telephone contact for participant questions prior

to the giving consent. Schrems (2014) indicated that researchers use the informed consent

process to provide the participant information to make a determination on involvement

(Schrems, 2014). Likewise, Wright (2012) indicated informed consent protects the rights

of the participant and provides information on the research project. Seidman outlined the

components of informed consent: (a) the invitation and explanation of the research study,

(b) potential risks and benefits involved with participation, (c) rights of the participants,

(d) confidentiality and privacy protections, and (e) Institutional Review Board (IRB) and

researcher contact information.

To ensure compliance with ethical standards and principles, I aligned the

informed consent with the components identified by Seidman (2012). The first element of

the informed consent for this study included the invitation and details of the research

study to provide participants material to make an informed determination on

participation. There were no incentives offered to research participants. The next

component contained verbiage to indicate potential risks and benefits to participation in

the research study. The third component of the informed consent for this study included

the rights of the participants and the voluntary nature of the study, including the right to

withdraw at any point in the research process. Participants could withdraw via email at

any point in the study. In the privacy and confidentiality section, I documented the

process of de-identifying the organization, providing unique identifiers for participants,

storing research documents in a steel, fire resistant locked lateral file cabinet for 5 years

and storing electronic data in a password protected electronic database. The final section

of the informed consent included my contact information.

The primary tools for establishing ethical research practices are the values and

ethics of the researcher (Merriam, 2014). To ensure the ethical protection of participants,

I adhered to the principles guiding ethical research practices and obtained approval from

Walden University’s IRB before conducting the research study. Furthermore, Morse and

Coulehan (2015) indicated researchers protect participants by limiting information and

avoiding demographic data. Therefore, I did not use participants’ name, but a unique

identifier that consisted of an alphanumeric combination. The participant data excluded

the demographic data, department, and title of participants to maintain confidentiality.

Data Collection Instruments

I was the primary data collection instrument in the research study. Peredaryenko

and Krauss (2013) indicated that the researcher is the primary data collection instrument

in qualitative research. Likewise, Chan, Fung, and Chien (2013) noted qualitative

researchers are the primary instrument in data collection, data analysis, and the

interpretation of findings. Hanson et al. (2011) noted that qualitative researchers are the

primary instrument of the study, in that, the researcher takes note of verbal and nonverbal

communication during the interview process and explores emerging thoughts.

The semistructured interviews and company documents were the data collection

instruments for this study. The semistructured interview allows for flexibility in the order

of questions to ensure sufficient exploration of the research question (Rowley, 2012). The

flexibility applied to semistructured interviews enables the researcher to engage the

participant to elicit a complete response (Saleem et al., 2014). Furthermore, researchers

using semistructured interviews can guide the participant through the participant’s

experience (Kelly, 2010). The next data collection instrument was company documents.

The documentary evidence will consist of minutes from managed care meetings, financial

performance meetings, business operations meetings, utilization management meetings,

and strategic planning meetings. Yin (2014) indicated document evidence can

substantiate or expand on other lines of evidence in the case study design. Myer (2013)

indicated meeting minutes from the organization of study provides documents relevant to

the research topic. Moreover, Ritchie, Lewis, Nicholls, and Ormston (2013) noted that

meeting minutes are pre-existing documentary evidence that will have pre-established

topic-based sorting to support data analysis.

I used an interview protocol as a guide to provide uniformity when conducting the

interview (Appendix A). Jacob and Furgerson (2012) indicated the interview protocol

describes the pre-interview statements, post-interview statements, and provides written

cues and prompts to remain on topic and ensure participants clearly define abbreviated

terms. According to Rowley (2012), the interview questions within the interview protocol

may contain 2 to 4 prompts to ensure sufficient response. Prompting within the interview

protocol allows the participant to expound on answers and provide the researcher with an

increased understanding (Doody & Noonan, 2013).

I included the interview protocol elements identified by Jacob and Furgerson

(2012). The pre-interview section of my interview protocol contained prompts for

establishing the appropriate setting for the interview, rapport building, informed consent,

and recording devices. The interview section of the protocol included scripting prompts

for an introduction to the research study. Moreover, the interview section included the

interview questions. I entered prompts to document verbal and non-verbal notes within

the interview protocol. Next, the interview protocol for this study included a post-

interview section to ensure participants received an explanation of subsequent

communication and my email contact information. The final section of the interview

protocol was the member check process. According to Jacob and Furgerson, researchers

use the interview protocol as a procedural guide when conducting the interview.

The interview protocol contained the member check section, which included the

interview questions, synthesized responses, verification of the accuracy of responses,

additional information from the participant, and a section for follow-up questions

(Appendix A). I used the member checking process to increase the reliability and validity

of the interview data. According to Burda et al. (2016), member checking can increase

the trustworthiness of the research by allowing participants to check for accuracy of the

researcher’s interpretations. Similarly, Harper and Cole (2012) pointed out that the

member checking process reduces errors in the data and the interpretation of the data.

According to Caretta (2015), member checking promotes mutual respect with participants

and preserves the authenticity of the research. After conducting the initial interviews, I

conducted the member check process by completing my transcript interpretations and

conducting second interviews to validate the responses. In addition, the participants will

receive a printed copy of the interview questions and my synthesized responses.

Data Collection Technique

I used a paper-based interview protocol to collect the interview data (Appendix

A). According to Jacob and Furgerson (2012), researchers use the interview protocol as a

procedural guide to collect interview data. Likewise, Rowley (2012) indicated that the

prompts within the interview protocol guide the researchers through the data collection

process. Doody and Noonan (2013) noted that the interview protocol supports the depth

of understanding by providing prompting to expand on interview questions. The

interview protocol contained the pre-interview, interview, post-interview, and member

checking sections (Appendix A).

The interviews occurred in a closed environment to promote privacy and

confidentiality. In addition, the participant received a unique identifier to maintain

confidentiality. I recorded each interview using a digital voice-recording device. The

participant received a written copy of the interview questions to provide a visual review

of the questions. I allowed a minimum of one hour for the interview and ample time for

the participant to answer each interview question, adhering to the protocol prompts and

time management. During the interview, I documented nonverbal cues on the interview

protocol and recorded post-interview thoughts for reflexive journaling. Additionally, the

participant received an explanation of subsequent interview requirements and my contact

information following the interview.

Yin (2014) indicates using multiple sources of evidence is an advantage of the

case study design. The main advantage of interview data is that interviewing allows the

participant to vocalize experiences (Rowley, 2012). Moreover, interviews allow the

researcher to increase the complexity of questions, probe for details, provide clarification

of questions, and ask open-ended questions about the emergence of data (Doody &

Noonan, 2013). Doody and Noonan (2013) indicated the disadvantage of collecting

interview data is that interviews are time-consuming and susceptible to bias due to the

participant’s desire to answer questions to appease the researcher. Similarly, Rowley

(2012) indicated the time constraints require researchers to collect data from a small

participant base reducing the generalization of the research findings.

The next data source included the collection of company documents. The

documents consisted of minutes from meetings relevant to the research topic. I developed

a list of meetings pertinent to the study based on past meeting minutes. In addition, I

reviewed relevant data extracted from meeting minutes during the interview to allow

participants the opportunity to expand on the company documents. The document data

consisted of paper documents and online documents.

Documents as an additional source of data are advantageous and allow for an

economical and accessible means of discovering emerging themes (Merriam, 2014). In

addition, documentary evidence serves as a means of validating data retrieved from other

sources (Yin, 2014). Ritchie et al. (2013) indicated documentary evidence allows for ease

of sorting by topic. However, Merriam (2014) indicated a limitation of documents is the

potential for misalignment and difficulty in authentication. Ritchie et al. noted

documentary evidence potentially limit the application to research due to preexisting

purposes. Yin (2014) added that although documentary evidence is pertinent to the case

study design, author bias is a potential disadvantage.

Burda et al. (2016) noted that researchers use member checking to provide an

accurate account of the participant’s meaning. Likewise, Harper and Cole (2012)

indicated member checking is a means to reduce the probability of inaccurate data

interpretations. Moreover, member checking increases the credibility of the data by

having the participant validate the accuracy of the researcher’s interpretation (Caretta,

2015). I conducted an additional interview for the member checking process. The

participants received the interview questions and my synthesized responses to validate

the accuracy of the data interpretation. I audio recorded the interview and asked that the

participant clearly state if the interpretation is correct. In addition, the participant had

approximately one hour to provide additional information and to ask follow-up questions.

I clarified discrepancies identified and validated the accuracy of the changes during the

member check interview.

Data Organization Technique

In this study, the principal organization tool is the interview protocol. According

to Doody and Noonan (2013), researchers use the interview protocol to organize data for

the interview process to assist in extracting pertinent information from participants

(Doody & Noonan, 2013). Likewise, Jacob and Furgerson (2012) indicated that the

interview protocol is a procedural document that organizes the interview process and data

collected. In addition, researchers use an interview protocol to organize data in

preparation for the analytical phase of the research process (Rabionet, 2011).

As the primary instrument of the research study, the additional data organization

processes included reflexive journaling and a research log. Researchers use a reflexive

journaling to document preconceptions that may influence the research process (Tufford

& Newman, 2012). Furthermore, reflexive journaling documents the personal

experiences and beliefs of the researcher (Berger, 2015). According to Ward, Furber,

Tierney, and Swallow (2013), researchers use reflexive journaling to record ideas and

decision-making. I employed the use of reflexive journaling to document thoughts and

perceptions prior to and during the research process. According to Merriam (2014),

qualitative researchers use research logs to make note of obstacles and ideas stemming

from the data collected. Likewise, Yin (2014) indicated that researchers use notes to

document preliminary data interpretations. Ritchie et al. (2013) indicated that researchers

use a log to keep track of emerging analytical thoughts. I used a research log to document

emerging conclusions from the data. In addition, I labeled and categorize the research log

entries based on notes documented from interview and company documents. I stored the

data in a steel, fire resistant locked lateral file cabinet for 5 years.

Data Analysis

Yin (2014) identified multiple sources of evidence as a core principle of data

collection in the case study design. Therefore, I used methodological triangulation to

analyze data using multiple data collection methods. According to Hussein (2015),

triangulation entails analyzing the research question from multiple vantage points to

establish research validity. Moreover, triangulation is a strength in the application of a

case study design (Houghton, Casey, Shaw & Murphy, 2013). According to Carter et al.

(2014), researchers establish methodological triangulation by using multiple data

collection methods to research a phenomenon. Furthermore, Bekhet and Zauszniewski

(2012) indicated that methodological triangulation allows the researcher to explore the

phenomenon by using multiple qualitative strategies or multiple quantitative strategies,

not a combination of the two. The data collection techniques for methodological

triangulation included interview data and company documents. The documentary

evidence consisted of minutes from managed care meetings, financial performance

meetings, business operations meetings, utilization management meetings, and strategic

planning meetings.

Data analysis is the process of transforming data from the descriptive process to a

level of interpretation (Vaismoradi, Turunen, & Bondas, 2013). Moreover, researchers

separate text data and make logical connections to make inferences from raw data during

the data analysis phase (Wahyuni, 2012). Thematic analysis requires the researcher to

become familiar with data by transcribing, reviewing data multiple times, and noting

ideas (Vaismoradi et al., 2013). In addition, Bradley et al. (2007) indicated reviewing the

overall data without coding is the initial step in comprehending data. First, I reviewed the

data multiple times to familiarize myself with the information. Following the data review,

I employed the use of NVivo11 memo links to journal my thoughts and ideas.

I used NVivo11 as the software to guide the sequential process for data analysis

using coding, mind-mapping, and identification of themes. NVivo11 is the most

recognized Computer-Assisted Qualitative Data Analysis Software tool (Zamawe, 2015).

Houghton et al. (2013) supported the use of NVivo11 to analyze observation, interview,

and documentary evidence in a case study research design. In addition, Bernauer,

Lichtman, Jacobs and Robinson (2013) indicated that researchers could use NVivo11 to

support the critical thought processes involved in analyzing data. In addition, I used

NVivo11 to determine commonalities by linking the key themes from the data with the

conceptual framework, existing literature, and literature published after the proposal

approval date. According to Zamawe (2015), NVivo software can organize data based on

the purpose. In addition, Bernauer et al. (2013) indicated NVivo software aids in the

analysis process by organizing data based on themes and relationships. Moreover,

Houghton et al. noted NVivo is a data management tool that researchers use to provide a

comprehensive audit trail. First, I imported the text from the reflexive journal to the

source folder. Then, I organized the reflexive journaling according to the assigned

participant or assigned company document. I imported the company document files into

the source folder titled Company Documents. I labeled the company documents based on

the type of meeting. The meeting types included managed care meetings, financial

performance meetings, business operations meetings, utilization management meetings,

and strategic planning meetings. Next, I imported the audio files from the initial

interviews into the source folder titled Interviews. I listened to audio files and transcribed

the data within NVivo11. I added a node to assign the unique identifier to the participant

interview to capture the response by participant. I reviewed the transcriptions three times

prior to coding.

Yin (2014) indicated that the coding process is an essential phase of data

interpretation for qualitative research. Moreover, Elo et al. (2014) indicated that

qualitative researchers must code and interpret data using a structured approach.

Thematic analysis is a structured data analysis strategy of using codes, themes, and

theory (Bradley et al, 2007). I queried the data based on the 100 most frequent words

with four characters or more for open coding and thematic analysis. Bohren et al. (2014)

indicated that researchers use open coding to establish broad codes from the research

data. Likewise, Wolfswinkel, Furtsmueller, and Wilderom (2013) noted that researchers

apply open coding strategies to extract concepts from the data. Kolb (2012) posited that

researchers use open coding to identify different categories within the data. The analysis

process included the use of the NVivo11 coding stripes to provide documentation of the

coded sections of the interview and document data. The next process included the

NVivo11 tag cloud visual diagram feature to illustrate the themes based on the word

frequency for axial coding. Axial coding is the process of using the categories identified

in open coding to identify the main themes of a research study (Wolfswinkel, et al.,

2013). Kolb indicated that researchers use axial coding to establish connections between

the codes revealed during the open coding phase. Similarly, Bohren et al. (2014)

indicated that qualitative researchers use axial coding to separate data into themes. The

final step was to use the interview data and document data to create a visual chart of the

themes identified for methodological triangulation and selective coding. According to

Wolfswinkel et al. (2013), selective coding is the process of refining themes identified in

the axial coding phase. Likewise, Kolb indicated that researchers use selective coding to

further identify, connect, and validate core themes. King et al. (2013) noted that

researchers validate conclusions using selective coding to verify patterns. The data

collection and data analysis process occurred simultaneously to establish the point of data

saturation.

Reliability and Validity

Reliability

Dependability is the quality indicator used to establish reliability (Houghton et al.,

2013). The measure of quality in qualitative research depends on the documentation of

research processes, the analytical procedures, and the thought processes of the researcher

(Mertens, 2014). Dependability reflects the stability and accuracy of the research data

(Houghton et al., 2013). Furthermore, Thomas and Magilvy (2011) noted dependability

as the extent to which other researchers can follow the decision-making processes.

According to Houghton et al. (2013), NVivo11 software reflects the thematic

analysis process and provides an internal audit of findings. Although changes can occur

in the qualitative research method, researchers establish dependability by documenting

the changes for public auditing (Mertens, 2014). Moreover, researchers use a structured

audit trail to create dependability (Houghton et al., 2013). I provided a detailed account

of the research purpose, participants, research method, research design, population and

sampling, consents, data collection, data organization, and data analysis to establish

dependability and provide an audit trail. I used NVivo11 software to reflect the data

analysis and path of decisions used to reveal themes. Additionally, I documented in the

member checking section of the interview protocol the changes to participant responses

to provide an audit trail of the response verification process and establish dependability.

Validity

The specific quality indicators used to establish validity include creditability,

transferability, and confirmability (Wahyuni, 2012). Establishing credibility involves

processes that supports the researchers in ensuring interpretations are accurate and easily

recognized by those within the industry of study (Lohle & Terrell, 2014). I used

member checking of the interview responses to establish credibility. Member checking

increases credibility by allowing the participant to verify the accuracy of the researcher’s

interpretations of the interview data (Caretta, 2015). Likewise, Burda et al. (2016)

indicated researchers use member checking to ensure accurate conveyance of the

participant’s meaning. Additionally, Harper and Cole (2012) indicated member checking

is a means to reduce the likelihood of inaccurate data or erroneous data interpretations.

The member checking section of the interview protocol included the participant’s

validation of my synthesized responses. To further establish credibility, I used interviews

and company documents for methodological triangulation. The advantage of using

methodological triangulation is in the confirmation of research findings, the expansion of

data available for analysis, and the increased validity of the study (Bekhet &

Zauszniewski, 2012). Carter et al. (2014) indicated that researchers use methodological

triangulation to establish the credibility of findings by confirming findings between

sources of evidence. Likewise, Bekhet and Zauszniewski (2012) noted that

methodological triangulation augments validity and supports the confirmation of

findings. According to Hussein (2015), researchers use methodological triangulation to

improve credibility. I compared themes identified in the documentary data and the

interview data collected to discern methodological triangulation.

Black, Palombaro, and Dole (2013) indicated that investigators use transferability

to establish the trustworthiness of research. Moreover, transferability is the extent to

which the research findings of a research study can apply to different settings (Elo et al.,

2014). Houghton et al. (2013) indicated the overarching aim of establishing

transferability is for the reader to determine the applicability of research findings and

methods to different settings (Houghton et al., 2013). Moreover, Wahyuni (2012) noted

that researchers use detailed descriptions of the case study site to improve transferability

of research processes to other settings. Thomas and Magilvy (2011) specified that

researchers establish transferability by providing rich descriptions of the population. To

achieve transferability, I used a research log and provided thick descriptions of the

phenomenon, case study site, participant criteria, research processes, and findings to

allow readers to determine the applicability to different settings. In addition, I used an

interview protocol and ensured adherence to the data collection and data analysis

techniques for the case study design.

The predominant role of creating confirmability is to establish the reliability of

the findings by ensuring the findings do not represent the views of the researcher (Tong

& Dew, 2016). The confirmability process reduces bias by providing transparency

through reflexivity (Thomas & Magilvy, 2011). Furthermore, Wayhuni (2012) indicated

that confirmability allows others to confirm that research findings are an accurate

conveyance of participant views versus the opinion of the researcher. I used NVivo11

software to demonstrate confirmability through query searches to demonstrate findings

are beyond the investigator’s determination. According to Collins and Cooper (2014),

researchers use emotional reflexivity to reveal the predispositions of the researcher and to

reflect self-awareness. I documented preconceived thoughts using reflexive journaling.

Moreover, Thomas and Magilvy (2011) added that self-awareness of potential bias and

documenting preconceptions establishes trust and confirmability. Likewise, Houghton et

al. (2013) indicated documenting any personal thoughts or insights establishes reflexivity.

I used reflexive journaling following each interview to document personal thoughts or

feelings.

Data saturation occurs when no new concepts emerge from data analysis

(Marshall et al., 2013). According to O’Reilly and Parker (2013), data saturation

determines the adequacy of the sample selected. Data saturation is the point where

researchers note uniformity in codes and themes (Burda et al., 2016). Data saturation

occurred following the fifth interview. There was no new information emerging from the

interviews and company documents.

Transition and Summary

In Section 2, I presented the rich description of the research purpose and

processes. The section includes the role of the researcher, the participant selection

process, and justification for the population and sampling. Section 2 included a detailed

account of the ethical principles guiding the research. There is an expansion of the

rationale and scholarly justification for using the qualitative research method and case

study design. I included thick descriptions of the data collection instruments, data

collection techniques, data organization, and data analysis to support the external auditing

of processes. The final components of Section 2 consisted of the methods to achieve

reliability and validity through establishing dependability, creditability, transferability,

and confirmability. In Section 3, I included the research findings, recommendation for

action, and future research considerations.

Section 3: Application to Professional Practice and Implications for Change

Introduction

The purpose of this qualitative single case study was to explore the strategies that

health care leaders use to improve corporate financial investment in care coordination

programs that include TAM objectives. Section 3 consists of the (a) presentation of

findings, (b) application to professional practice, (c) implications for social change, (d)

recommendations for action, (e) recommendations for future research, and (f) reflections.

The data extracted from the semistructured interviews revealed the overall strategies to

garner support for care coordination programs. According to Wilf-Miron et al. (2014),

decision-makers expect leaders to present a return on investment for improvement in

health care. The health care leaders interviewed noted the importance of using data to

demonstrate a decrease in health care costs of care coordination programs. Health care

leaders also indicated that the structure of the care coordination program must align with

the organization’s strategic mission. Whittington et al. (2015) indicated that the success

of deploying the TAM depends on the integration of the key tenets with the

organizational structure. Participants in the current study also indicated that leaders must

focus on the high-needs, high-cost populations. Whittington et al. pointed out that health

care leaders must complete a population assessment to select populations in which the

three objectives of TAM apply. Finally, participants in the current study indicated that

leaders must work in partnership with primary care practices for interprofessional

collaborative practice.

Presentation of the Findings

The central research question for this study was as follows: What strategies can

health care leaders use to improve corporate financial investment in care coordination

programs that include the TAM objectives? I used semistructured interviews and archival

documents to collect data for this study. I analyzed the data using NVivo 11. The four

themes that emerged from my analysis included (a) reflecting a reduction in health care

cost, (b) focusing on high-need, high-cost populations, (c) partnering with primary care

practices, and (d) patient-centered care.

Theme 1: Reducing Health Care Costs

The key tenets of the TAM include reducing per capita health care costs,

improving patient experience, and providing population health (Bodenheimer & Sinsky,

2014). Although there are evidence-based care coordination methods that provide high

value, health care leaders lack the funding source for implementation (Rowe, Fulmer, &

Fried, 2016). The most common strategy to obtain financial support was indicating how

investing in care coordination programs can reduce the overall costs for the organization.

Six (100%) participants indicated that cost reduction is a critical strategy to improve

investment in care coordination programs. However, the specific cost reduction strategy

differed among participants. As depicted in Figure 1, participants with more than 20

years of experience recommended specific measures for cost reduction at a higher

frequency than participants with less experience. The data indicated that participants with

less than 20 years of experience referenced generalized cost savings with greater

frequency than participants with more than 20 years.

Figure 1. Cost reduction strategy coding by participant.

All participants indicated the capacity of the care coordination program to reflect

a cost saving is a critical strategy. Six (100%) participants identified hospital utilization

as a cost driver that warrants data analysis and strategic planning for the structure of care

coordination programs. According to Brown et al. (2012), MCOOA must reduce

hospitalizations by 15 per 100 participants to realize net savings. Likewise, Ouslander

and Maslow (2012) noted that reducing hospitalization is a key initiative in achieving the

TAM. One participant in the current study pointed out that leaders should resist the urge

to cite the TAM, but should clearly define the organizational measures that will affect the

TAM objectives. The specific hospital utilization data identified were bed days,

admissions, readmissions, emergency visits, and inpatient risk pool performance. All

participants in this study referenced bed days as a measure for consideration when

developing strategies for care coordination supports. Five (83%) participants referenced

inpatient risk pool data as an element to reflect the performance of a care coordination

program. Hitch et al. (2016) stated that controlling readmissions is a key element of

achieving the TAM objectives. Similarly, 67% of the participants in the current study

referenced readmissions as a key cost consideration. In the table below, I indicate the

frequency of principle metrics and the weighted percentages.

Table 2

Principle Metric Reference

Metric

Total number of references Weighted percentage

Risk pool performance 15 .95

Bed days 20 .90

Readmission 11 .50

Emergency visit 6 .27

Admissions 6 .27

Song et al. (2011) indicated that the business case for care coordination defines

the clinical and financial performance expectations for program implementation. Five

(83%) of the participants indicated that leaders should understand financial data from

health plan risk pools to use as a strategy to garner fiscal support. According to 33% of

the participants, leaders seeking to present a strong case for monetary support must use

financial trends to reflect gains versus depending solely on clinical benchmark metrics.

However, de Waal et al. (2013) revealed that health care leaders might not have the

competencies to develop a business case presentation to support the implementation of

new strategies. The participants in the current study revealed two strategies to address

gaps in competency. Four (67%) of the participants indicated that leaders could use

external consultants as a strategy to garner support and capture data on care coordination

practices within the industry. One (17%) of the participants noted that leaders could

capitalize on internal business units that focus on workforce strategic planning to provide

data on cost considerations and return on investment for program implementation.

McGinley and Gabbay (2016) identified the total cost per member per month as a

measure used to determine cost savings when transforming health care delivery models.

McWilliams and Schwartz (2017) pointed out that services and cost of care increase with

care coordination programs. Four (67%) of the participants in the current study identified

per member per month costs as a relative indicator to determine cost savings. One

participant indicated that per member per month data should be reflective of the financial

risk model of the MCOOA. According to 33% of the participants, executive leadership

understands the per member per month payment methodology, and health care leaders

should present cost analysis in a format familiar to the intended audience. Four (67%) of

the participants indicated that ensuring senior leadership understands the key metrics and

the managed care environment is a key strategy to garner financial support.

Theme 2: High-Need, High-Cost Population Focus

Blumenthal, Chernof, Fulmer, Lumpkin, and Selberg (2016) indicated that health

care leaders improve the system of health care by concentrating on the high-need, high-

cost (HNHC) population. Four participants (67%) in the current study noted that

strategies to garner support should include how health care leaders intend to influence the

HNHC population and reduce cost. Blumenthal et al. posited that the HNHC individuals

are 5% of the population and account for 50% of the expenditures. Four (67%) of my

participants concurred that there is a disproportionate share of the cost attributed to a

small population. In addition, the participants revealed that a focus on the HNHC patients

allows leaders to track and trend data to present the return on investment for a small

population. Care coordination programs that focus on the HNHC populations have the

capacity to meet the TAM objectives (Larson, Hoffman, & Artman, 2017). Four (66%) of

the current study participants reported that a successful business practice to garner

financial support and to address the overall TAM is to present strategies to address the

HNHC population, further confirming findings from the existing literature on HNHC

populations.

As shown in Figure 2, participants at the level of vice president with fewer than

20 years of experience referenced HNHC at a greater frequency than other participants.

All participants considered the dual-eligible population as a HNHC population. I

confirmed the findings related to the dual-eligible population reflecting a HNHC

population through recent literature. According to Ortega (2016), the dual-eligible

population has a higher incidence of chronic illness and higher costs. Similarly, Doyle,

Emmett, Crist, Robinson, and Grome (2016) indicated that the dual-eligible population

has a greater frequency of being poor, disabled, sick, and mentally ill compared to

beneficiaries of a single health care program.

Figure 2. High-needs, high-cost frequency by participant.

The care delivery model for the HNHC population should include a

multidisciplinary approach to providing services (Hochman & Asch, 2016), confirming

the finding for 83% of the participants in the current study. Specifically, 5 (83%) of the

participants stated that health care leaders should specify that the HNHC population

requires interprofessional collaboration to impact cost. Jette (2016) indicated that the

characteristics of the HNHC population include three or more chronic conditions and

functional deficits. Moreover, Jiang et al. (2016) posited that the economically

disadvantaged populations have multiple factors beyond medical conditions that

influence health. Factors such as housing, access to food, transportation, and health

literacy affect readmission rates (Alvarez, Ginsberg, Grabowski, Post, & Rosenberg,

2016). Aligned with the TAM objectives, Taylor et al. (2016) noted that social

determinants of health are integral in influencing population health and improving quality

outcomes. Five (83%) of the participants in the current study identified a partnership with

primary care as a strategy for fostering support for care coordination programs aimed at

the HNHC population.

Theme 3: Partnership With Primary Care

Capital spending has an impact on the operating budget of health care

organizations, requiring health care leaders to make investments that reflect value and

improve population outcomes (Klein, Brown, & Detsky, 2016). Transforming the health

care delivery system to focus on cost and quality requires concentration on the role of

primary care providers (Miller et al., 2017). A strategy shared by 83% of the participants

in the current study included a partnership with primary care practices due to the ability

of primary care to lead cost containment strategies. Mostashari (2016) confirmed this

strategy by indicating that the decisions of the primary care physician impact 85% of the

cost of care; however, independent primary care providers may lack the financial

resources to invest in the technological advances, analytics, and human resources

required to provide value-based care. When reviewing the recent literature, I was able to

confirm that there is an opportunity to garner financial support for care coordination

programs through the partnership with primary care. Three (50%) of the participants in

the current study indicated that health care leaders should use innovative strategies to

integrate with primary care to meet the TAM objectives. Maciosek (2017) indicated that

primary care providers could align with value-based preventative measures to meet the

TAM objectives.

Theme 4: Patient-Centered Care

According to McWilliams and Schwartz (2017), care coordination programs have

a positive impact on patient experience. Farmanova et al. (2016) noted that care

coordination is a critical factor in providing patient-centered care. Likewise, Rowe et al.

(2016) posited that outcomes-based performance metrics centered on the patient and

family are necessary to define effective care management programs. When reviewing the

literature, I confirmed the findings that patient experience is a defining strategy when

garnering financial support for care coordination programs. Five (83%) participants in the

current study agreed that the perception of the patient population is a critical factor when

gaining support for care coordination programs. However, Farmanova et al. noted that

presenting patient experience data for a population is more difficult that collecting data at

a project level. According to one participant in the current study, patient-centered care

requires a comprehensive training process to develop care coordination practices among

team members.

Findings Related to the Triple Aim Model

The research findings were consistent with the TAM. The TAM objectives

include reducing per capita costs, achieving population health, and improving the patient

experience (Bodenheimer & Sinsky, 2014). According to Ryan, Brown, Glazier, and

Hutchison (2016), the predominant goal of the TAM is to accomplish the three objectives

simultaneously. The themes identified in the current study indicated successful

approaches used to populate the TAM framework. The findings reflect that the tenets of

the TAM are key in presenting strategies to garner support for care coordination

programs.

The TAM is essential in identifying strategies to reduce health care waste and

decrease costs (Coyne et al., 2016). Although medical care accounts for 10% to 20% of

the factors driving heath status, health care leaders attribute 88% of health care spending

to providing medical care (Zangerle, Harris, Rimmasch, & Randazzo, 2016). All

participants in the current study identified a reduction in health care cost as the most

successful strategy used to foster support for care coordination resources. Also, the

participants in this study identified medical care based measures to populate the TAM

objective of reducing health care cost. Therefore, based on the research findings,

successful strategies for garnering support for care coordination programs address the

component of health care that accounts for the largest percent of spending. On the other

hand, Zangerle et al. (2016) indicated that effective programs must address the upstream

social factors that have the greatest impact on health outcomes.

Defining the needs of the population is a core requirement for achieving the TAM

objectives (Farmanova et. al, 2016). According to Farmanova et al., health care leaders

define the population by a common need within a geographical region or by a distinct

population driven by business requirements. Whittington et al. (2015) noted that health

care leaders must choose populations whereby the three objectives of TAM apply. The

participants in the current study revealed the HNHC population as the population health

care leaders should address when appealing for financial support. Also, Kindig and Isham

(2014) posited that population health requires the collaboration of numerous

organizations to influence the social and physical determinants of health. Farmanova et

al. posited that organizational leaders must form cross-sector partnerships to implement

programs designed at meeting the TAM objectives. The research findings included the

partnership with primary care practice as a successful strategy to gain resource allocation

for care coordination program. The participants confirmed that health care leaders should

seek alliances with organizations to impact the TAM objectives.

According to Harder et al. (2016), measuring the TAM objective of patient

experience is a critical component in efforts to change the delivery of health care. Cook et

al. (2015) revealed that efforts to improve health outcomes must take account of patient

experience feedback to guide quality initiatives. Moreover, Ryan et al. (2016) indicated

that health care leaders could use patient surveys to establish a quantitative measure of

the patient experience TAM objective. The participants revealed an opportunity to use

patient experience surveys to provide feedback to senior executives regarding the

effectiveness of care coordination programs. The participants indicated that a strong

alignment with the patient-centered mission of the organization is

Applications to Professional Practice

The most prevalent finding relevant to the professional practice of business was

defining the ability of care coordination programs to reduce health care cost. The finding

is important to the practice of business because it provides a mechanism to garner

financial support for care coordination grounded in cost control strategies. In review of

recent literature, cost control was a critical factor in the development of care coordination

programs and aligns with the TAM. Miller et al. (2017) indicated that reducing cost and

improving the quality of care require health care leaders to invest in the transformation of

the health care delivery system.

Ellner and Phillips (2017) noted that health care leaders have the capacity to lead

the effort to transform the health care industry to provide high quality care at a

sustainable cost by focusing on the transformation of primary care practices. Similarly,

Cross, Cohen, Lemak, Adler-Mil-Stein (2017) indicated that policy leaders focused on

primary care to impact the cost and quality of health care. However, transitioning the

primary care model requires human resource investment and defined interprofessional

practices to reduce fragmentation and influence cost (Zink, Kralewski, & Dowd, 2017).

Mostashari (2016) added that primary care providers may lack the resources to invest in

value based care. Moreover, Whittington et al. (2015) posited that provider payments

lack incentives for providers to decrease the cost of health care. The findings are relevant

to the professional business practices, in that, the participants revealed that a strategic

alliance with primary care has the capacity influence investment in care coordination and

impact health care costs. Moreover, the research participants revealed an opportunity to

align with primary care practices and support incentives that encourage primary care

physicians to reduce costs associated with hospitalizations and emergency room

utilization.

Reinhard (2013) posited that managed care leaders with the capacity to coordinate

care for high-risk populations would increase profitability and market share. Therefore,

health care leaders could develop strategies to garner support for care coordination based

on methods to improve profitability. Cross et al. (2017) indicated that health care leaders

focus on improving health care cost by targeting the HNHC population that consume a

disproportionate share of health care services. Similarly, Jette (2016) indicated that the

HNHC population account for an approximate 50% of the total health care cost. In

relation to the applicability to the professional practice of business, the research

participants revealed that health care leaders should focus on the HNHC population when

presenting strategies for care coordination. In addition, the participants revealed that a

focus on the HNHC population provides a targeted approach to reveal a return on

investment for care coordination for a high cost group. Also, the research participants

indicated that the cost control data varies based on the maturity of the organization. Less

mature organizations might require health care consultants to conduct an environmental

scan to provide cost-effective strategies for care coordination. Health care leaders may

consider this finding critical to the professional practice of business because the maturity

of the managed care organization may influence the strategies required to garner financial

support. According to recent literature, the strategies health care leaders deploy are highly

dependent upon the organizational structures and processes (Aveling, Martin, Herbert, &

Armstrong, 2017).

According to Miller et al. (2017), the United States health care costs are

approximately $2.9 trillion and are not tantamount to an increase in quality. Health care

leaders use TAM to describe the health care agenda for systematic changes for cost

control (Bodenheimer & Sinsky, 2014). However, recent literature reflects that health

care leaders struggle with the practical application of the TAM objectives due to the

diverse comprehension of the relationship between quality and cost (Storkholm,

Mazzocato, Savage, & Savage, 2017). The findings are relevant to the professional

practice of business, in that, the participants in the current study provided health care

leaders a method to align the request for resource allocation with the TAM objective of

reducing cost.

Implications for Social Change

Health care leaders define population health as the clinical outcomes of a defined

group of individuals (Kindig & Isham, 2014). Population health is one of the three goals

of the TAM (Bodenheimer & Sinsky, 2014). In addition, a driver of population health is

transforming the medical culture from providing sick care to the provision of wellness

services to prevent illness (McGough, Kline, & Simpson, 2017). According to Shrank

(2017), the mission of primary care practices is to improve population health through the

provision of high-quality care. Health care leaders may consider the findings of this study

important to impact social change because garnering support for care coordination

programs grounded in the TAM objective of population health allows leaders to impact

the health of communities.

According to Zangerle et al. (2016), social determinants of health influence 80%

to 90% of the population’s health outcomes. Bridger, Smith, and Saunders (2017) posited

that the drivers of health status include social components that require a collective

approach to population health. Moreover, Taylor et al. (2016) indicated that

policymakers should take note of care coordination strategies that focus on social

determinants that impact overall population health and impact cost. Therefore, health care

leaders seeking to influence social change could use the results of this study to affect the

quality of care for the HNHC populations through care coordination programs.

MCOOA accounts for 25% of the enrollment for beneficiaries with federal and

state sponsored health care benefits (Reid et al., 2013). In addition, the dual-eligible

population is increasing at a rate that is double the beneficiaries of a single program

(Eggbeer et al., 2013). Moreover, the dual-eligible population is at greater risk for

fragmented care related to the need to coordinate between multiple programs with varied

benefits (Kennedy, 2013). Ortega (2016) posited that the dual-eligible have complex

social issues influencing access to health benefits. Powers et al. (2015) revealed that care

coordination programs could improve the quality of life and reduce health care

expenditures. The data from this study may affect social change by providing an avenue

through care coordination programs to reduce care fragmentation and address the social

determinants of health for a targeted high needs population.

Recommendations for Action

Rowe et al. (2016) indicated that evidence-based literature supports the need for

care coordination programs; however, health care leaders may lack the budget for

program implementation. The research findings provide strategies to garner support for

programs grounded in the TAM objectives. Based on the research findings, I recommend

the following actions:

• Leaders should define the measures used to populate the tenets of the TAM.

• Health care leaders should understand the mission of the organization and

focus on the patient driven elements when developing strategies for financial

support.

• Health care leaders should identify the hospital-based utilization measures that

support the mission of the organization.

• Leaders should focus on the high-need, high-cost population and consider the

dual-eligible as a priority population.

• Health care leaders should identify stakeholders within primary care to create

an interprofessional practice environment to support medical and social

determinants of health.

• Health care leaders should gauge the maturity of the organization and shape

discussions to ensure a comprehensive understanding of managed care and

care coordination.

The findings are broadly applicable to health care organizations that are

accountable for care coordination programs. I will seek to disseminate findings through

academic journals and professional conferences. Moreover, health care leaders could use

the results of the study to provide leadership development training for leaders responsible

for care coordination programs.

Recommendations for Further Research

There is a limit in literature defining a specific methodology to communicate the

financial benefits of care coordination program (Kripalani et al., 2014). The findings

from my study may contribute to limitations in research on business practices that health

care leaders can use to support financial allocations to care coordination programs.

Variability exists amongst program infrastructure and maturity of the organization.

Therefore, the recommendation for future research is to determine if there is a correlation

between the maturity of the managed care organization and the strategies used to garner

support. I utilized a single-case study design, which limits the research. I would

recommend that future research includes a multiple-case study design to increase the

sample size and improve generalizability. Also, I would recommend further research on

the care coordination program infrastructure and the impact on investment potential.

Reflections

I explored the strategies health care leaders use to garner financial support for

care coordination programs. I used reflexive journaling to document preconceptions and

personal bias. As an inside researcher, I was aware of my obligation to mitigate bias

through the preservation of reflexivity. I maintained the use of the interview protocol and

wad careful not to lead the participant during interview process. There were four

preconceived ideas discovered in the journaling process. Through the journaling process,

I revealed a preconceived idea that using external consultants reflected a lack of trust in

the experience of the internal leadership. After completing the study, my thoughts on the

value of external consultants changed to view the use of external consultants as a

reflection of the maturity of the organization and the commitment to identify best

practices beyond the walls of the organization. Second, I had a preconceived idea that the

strategies used in an integrated delivery system for the older adult with less than 2,000

members would differ from those used in a managed care environment with greater than

200,000 members. The health care leaders (50%) provided confirmation that the capacity

to provide care in an integrated model is significantly different. However, developing

programs with similar infrastructure and management strategies can prove beneficial and

applicable in settings focused on the HNHC population. Therefore, my thoughts

expanded to realizing the value of an analysis of best practices and the capacity to

replicate. The next preconceived idea was that primary care practice is a customer of the

managed care organization’s care coordination program. The study participants revealed

a partnership that required sharing goals, shared strategies, and shared knowledge to

achieve the TAM versus a customer-based relationship. The final preconceived idea was

that strategies for investment in care coordination programs required changing patient

behaviors; therefore, requiring a long-term commitment to realize savings. The study

participants revealed that strategies should focus on short-term savings realized through

risk pool savings and hospital utilization for the high cost population.

Summary and Study Conclusions

The purpose of this qualitative single-case study was to explore the strategies that

health care leaders use to improve corporate financial investment in care coordination

programs that include TAM objectives. The target population was health care leaders in

the role of vice president or higher who have implemented strategies to improve

corporate financial investment for care coordination programs. I conducted semi-

structured interviews and used open-ended questions to extract interview data. In

addition, I used archival documents (meeting minutes) for triangulation of the data to

address the research question. The five themes that emerged included (a) reflecting a

reduction in health care cost, (b) focusing on high-need, high-cost populations, (c)

partnering with primary care practices, and (d) providing patient satisfaction data. The

research participants revealed that defining the measures used to populate the key tenets

of the TAM objectives is of greater importance than citing the TAM. As a priority, health

care leaders seeking investment in care coordination must have a concise presentation

that reflects the cost considerations based on the level of risk assumed by the managed

care organization. Next, leaders should seek out alliances with primary care practices to

influence the population with the highest needs and highest cost. Finally, the research

reflected that there should be clear patient experience data to reflect the impact on the

population.

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