STRATEGIES FOR ACHIEVING PATIENT-CENTERED HEALTHCARE AND COST CONTAINMENT

STRATEGIES FOR ACHIEVING PATIENT-CENTERED HEALTHCARE AND

COST CONTAINMENT

Section 1: Foundation of the Study

In 2001, the Institute of Medicine (IOM) established patient-centeredness as one

of six goals for refining the U.S. healthcare system (Zill, Scholl, Härter, & Dirmaier,

2015). In the United States and throughout many other industrialized nations,

patientcentered care (PCC) is one of several strategic goals pursued by healthcare

organizations (Price & Elliott, 2018). The cost shared by patients continues to increase,

while the medical insurance provided to most elderly patients in the form of Medicare

continues to decrease (Altman & Frist, 2015). As such, efforts by healthcare managers to

mitigate cost and increase quality as stipulated within the Patient Protection and

Affordable Care Act (PPACA) could necessitate requirements that healthcare managers

might find difficult to achieve (Delmatoff & Lazarus, 2015). Notwithstanding, costs

within the U.S. healthcare system continue to soar, while quality care spirals downward

for many Americans (Hosseini, 2015). To help mitigate the cost of healthcare, a growing

body of healthcare managers and scholars consider PCC as indispensable for reducing

cost and delivering an improved quality healthcare system (Rahul, Press, & Conway,

2015). I analyzed the strategies healthcare managers use to reduce the cost of elderly

patients’ healthcare without reducing the quality of patient care.

Background of the Problem

Bartels, Gill, and Naslund (2015) stated the PPACA signifies the most significant

legislative change in the U.S. healthcare system in nearly half a century. The PPACA

provides provisions designed to reduce costs and encourage the development of new

systems of healthcare delivery by monitoring outcomes and efficiency. Since the

inception of the Medicare and Medicaid programs in 1965, a substantial portion of

Americans benefited from a system that provides health and welfare benefits for aging

adults, disabled Americans, and others by reducing out of pocket medical expenses

(Blumenthal, Davis, & Guterman, 2015). In 1992, Medicare introduced the resourcebased

relative value scale to correlate the reimbursement with the actual cost of providing

service and to reward rational thinking rather than adherence to procedures (Diebel,

2015). Historically, the Medicare program is a defined-benefit program whereby the U.S.

Government subsidizes a portion of a patient’s health benefits. However, some legislators

are proposing the Medicare program become a defined-contribution system that would

greatly reduce the payment of services and medical goods passing the cost to

beneficiaries (Rivlin & Daniel, 2015). The impact of this action would directly affect

Medicare-dependent aging adults’ quality healthcare, which makes up more than 55% of

all Medicare cost (Tsai et al., 2016). Hence, the healthcare industry is struggling to

determine the best model to deliver quality-valued healthcare service for aging Medicare

patients in an era where time and service are principal cost factors. The desire to employ a

value-centered healthcare model should influence how medical facility managers develop

strategies to provide sustained medical services while implementing effective cost control

measures to meet shareholders’ expectations.

Problem Statement

In 2014, Americans spent $2.9 trillion or $9,255 per person on healthcare, the

highest per capita among developed nations. However, the World Health Organization

ranks the U.S healthcare system 37th among all nations in performance (McGinnis, Diaz,

& Halfon, 2016). Medicare spending grew 3.4% to $585.7 billion in 2013, reflecting both

the aging population and the increasing cost of healthcare (Martin, Hartman, Washington,

& Catlin, 2017). The general business problem is some medical facilities managers’ are

unable to mitigate rising individual medical costs for the elderly while maintaining or

improving healthcare service quality within the PCC model. The specific business

problem is some healthcare managers lack patient-centered strategies to reduce the cost of

elderly patient healthcare without reducing the quality of patient care.

Purpose Statement

The purpose of this qualitative descriptive multiple case study was to explore what

patient-centered strategies healthcare managers use to reduce the cost of elderly patient

healthcare without reducing the quality of patient care. The participants consisted of six

midlevel healthcare managers from several departments located at six full-service acute

care facilities in Virginia who reduced the cost of patient healthcare without reducing the

quality of patient care. Conducting this study may lead to positive social change for

elderly patients by improving the delivery and access of quality PCC while catalyzing,

developing, and implementing cost reduction strategies that healthcare managers can

employ to make healthcare more accessible.

Nature of the Study

I conducted this study using a qualitative descriptive case study approach. Sutton

and Austin (2015) recommended the use of a qualitative method for studying attitudes and

beliefs held by individuals to evaluate similar themes. The focus of this study was to

explore patient-centered strategies from the perspective of the healthcare manager, thus

making the qualitative method appropriate for this study. Ali and May (2017) stated the

phenomenon of PCC is complex and multidimensional. As such, a qualitative case study

was the most appropriate design for this study. I used open ended, semistructured

interview questions that explore strategies healthcare managers use as they deal with the

complexities of providing quality patient care. In contrast, quantitative research is

deductive, whereby the researcher formulates a set of hypotheses to test the relationships

of two or more variables or the differences between two or more groups (Hyett, Kenny, &

Dickson-Swift, 2014). Because I was not comparing variables, a quantitative method was

not appropriate. A mixed methods approach is beneficial for researchers seeking to

observe a situation in its natural state as well as provide a comprehensive understanding

of a phenomenon from a statistical perspective (Kaur, 2016). Without a quantitative

component, a mixed methods approach was also not appropriate.

Yin (2014) and Yazan (2015) stated researchers prefer the descriptive case study

method when conducting qualitative research by questioning how or what. The focus is on

an existing phenomenon within a real-life environment. I considered other qualitative

designs, for example, ethnography and narrative to conduct my study. Draper (2015)

stated a researcher would use an ethnographic design to explore the culture and

perspectives of a group in its natural setting. Because I did not explore culture, an

ethnographic design was not appropriate. A narrative method was not appropriate for this

study, as I did not focus on a participants’ biography or life story (Gill, 2014).

Research Question

The overarching research question driving this study was:

RQ: What patient-centered strategies do healthcare managers use to reduce the

cost of elderly patient healthcare without reducing the quality of patient care?

Interview Questions

1. How do you, as a healthcare manager, view patient-centered strategies, for

example, patient-centered medical homes, accountable care organizations,

person-centered care, person-focus care, and client-centered care, as a means

of reducing the cost of elderly patient healthcare?

2. What are the advantages of patient-centered strategies in reducing elderly

healthcare costs?

3. What patient-centered strategies have the board of directors supported to

improve healthcare delivery and operational cost?

4. How do you measure the effectiveness of patient-centered strategies?

5. How did your organization address key challenges to implement successful

patient-centered strategies without reducing the quality of elderly patient care?

6. How do you communicate patient-centered strategies with staff at all levels to

improve quality care and reduce the cost of elderly patient care?

7. How, if at all, has the PPACA affected your ability to implement

patientcentered strategies and maintain quality patient care?

8. How will your organization address the cost of delivering patient-centered

strategies for elderly patients if Congress restructures the Medicare Trust

Fund?

9. How will your patient-centered care strategies improve the quality of care and

fit into the healthcare reform movement?

10. What other information would you like to add that these questions might not

have addressed?

Conceptual Framework

The core principles of a value-centered healthcare model stems from Fayanju et

al.’s (2016) research on the foundation for defining patient-centeredness. The

patientcentered theory is an evolutionary development based on the psychologist Carl

Rogers’ person-centered approach in 1940 (Miller & Moyers, 2017). Crisp (2018) stated

Rogers’ theory focuses on a person’s trust of their innate tendency (known as the

actualizing tendency) of human beings to find the fulfillment of their potentials. Rogers

emphasized a client-centered therapy that supported empowering the patient as the central

focus for the delivery of care, for example, PCC (Crisp, 2018; Frankel, Johnson, & Polak,

2016).

The core principles of a value-centered healthcare model emphasizes the

following attributes of PCC: access, continuity, comprehensiveness, coordination and

communication, cultural competency, family and person focus, and payment alignment.

Locatelli, Hill et al. (2015) expanded on the conceptual framework of PCC by

synthesizing previous theoretical and empirical work on organizational change with an

emphasis on patient-centered innovations. Piña et al. (2015) noted healthcare organization

leaders have determined that developing innovation among their various staff

organizations is challenging. The view that full-service acute care hospitals are complex

adaptive systems that are ever changing, reactive, proactive, and distinctive within a

natural environment sets the conditions for the conceptual framework for this study.

Overall, the patient-centered model applies to multiple organizations and populations.

Also, using the patient-centered model enables researchers to focus on the value-centered

healthcare business model.

Operational Definitions

Acute care facility: An acute care facility is an inpatient medical facility where

patients receive constant medical care for periods of less than 25 days (Koenig, Demiralp,

Saavoss, & Zhang, 2015).

Ambulatory care facility: An ambulatory care facility is a medical facility that

provides outpatient care that includes diagnosis, observation, consultation, treatment,

intervention, and rehabilitation service (Martin-Misener et al., 2015).

Fee-for-service: Fee-for-service is where medical providers receive payment for

services rendered by unbundling services paid for separately. In healthcare, private

insurers and the government provide incentives to physicians based on treatments,

because payment is dependent on the quantity of care, rather than the quality of care.

(Zuvekas & Cohen, 2016).

Managed care: Managed care is a health insurance network that manages medical

care through established contractual agreements between providers and patients (Baicker

& Robbins, 2015).

Patient-centered care: PCC is a type of medical care respectful of, and responsive

to, an individual patient’s preferences, needs, and values, ensuring that patient values

guide all clinical decisions (Zill et al., 2015).

Patient- and family-centered care: Patient- and family-centered care is a model

focusing on partnerships among practitioners, patients, and their families or care partners

to ensure that decisions respect patients’ wants, needs, and preferences (Rawson &

Moretz, 2016).

Assumptions, Limitations, and Delimitations

Understanding the complexities healthcare managers encounter when meeting

their patients’ needs and those of their shareholders are challenging tasks complicated by

healthcare policies, cost, and the community they serve. Assumptions, limitations, and

delimitations support a researcher’s ability to focus their study on the participants’ lived

experience and gain insight from participants’ personal experience (Goldberg & Allen,

2015).

In the following subsections, I discuss facts assumed to be true, limitations that

might constrict the study, and delimitations that focus the scope of the study on what

patient-centered strategies healthcare managers use to reduce the cost of elderly patient

healthcare without reducing the quality of patient care.

Assumptions

Berssaneti and Carvalho (2015) stated an assumption is a variable independent of

the scope of a study as defined by the researcher. Assumptions are facts presumed true but

not confirmed. Goldberg and Allen (2015) stated the researcher should verify their

assumptions with the interviewee to confirm their validity. Likewise, Wright, Wahoush,

Ballantyne, Gabel, & Jack (2016) stated a researcher formulates their assumptions based

on perceptions derived from known truths. When I began this study, I developed several

assumptions. First, I assumed the participants would respond truthfully. Second, I

assumed that healthcare managers would strive to put patients’ care and needs first.

Third, I assumed a healthcare manager’s success is dependent on the quality of the actual

value-care delivered.

Limitations

Schulenkorf, Sherry, and Rowe (2016) stated limitations are constraints that occur

beyond the control of the researcher that could potentially affect the study. Hence, a

limitation existed because of the potential difficulty in understanding the expectations of

all healthcare leaders who support this study. Another potential limitation involved the

sample size, which might not have proven to be representative of the healthcare

leadership population of hospitals throughout all regions. Lastly, findings from the

geographical area of the study might not apply to other regions with different

socioeconomic challenges, access to employment, and opportunities for advancement.

Lewin et al. (2015) stated other limitations to a study could derive from the respondents’

level of trustworthiness and the probability of bias with the participants’ interviews.

Delimitations

Yazan (2015) stated delimitations are the restrictions the researcher sets for the

scope of the study to define the boundaries. Likewise, Rule and John (2015) discussed a

researcher’s initial theory of a case aids in providing the thematic emphases and design of

delimitations. Similarly, Nakrem (2015) indicated that understanding a hospital’s culture

can vary based on the facility. Hence, the selection of a healthcare facility management

team could have delimited this study. Marshall and Rossman (2016) stated delimitations

are boundaries chosen by the researcher. Rural Virginia was a boundary for this study.

Furthermore, the researcher’s scope of research questions could be a delimiting

factor. A study’s delimitation could affect the results and any conclusions drawn from the

researcher’s analysis. Baškarada (2014) stated choosing a case study design may be a

limitation of a study. I focused on nonmedical providers and not the abundance of medical

professionals who are direct providers of PCC delivery.

Significance of the Study

The significance of this study lies in the potential for identifying efficacious

patient-centered strategies that reduce cost without compromising the quality of care in

hospitals that provide services for patients located in rural Virginia. Administrators who

study business strategies may learn how to develop, deploy, and implement

patientcentered strategies to reduce ambulatory and acute cost (Galarraga & Pines, 2016).

The information from this study could add value to the healthcare field through

identifying and exploring successful strategies established by managers who use patient-

centered strategies developed and employed within a healthcare business model from the

healthcare manager’s perspective. As healthcare administrators adjust to providing

strategies that support ACA legislation through 2020 (Gaffney & McCormick, 2017), the

future effects of this reform may challenge medical facility managers to implement

strategies that mitigate costs. Moreover, hospital administrators with limited

patientcentered strategies may learn to develop and implement other patient-care

strategies to achieve lower costs for Medicare-dependent patients (Tsai et al., 2016).

Contribution to Business Practice

Healthcare leaders must understand that leadership is about teamwork and

building relationships (Allison, 2015). As well, healthcare leaders must understand the

importance of prioritizing the patient in all decisions. Consequently, as each generation

ages, chronic diseases and increasing comorbidities will continue to influence the costs of

care. Understanding how healthcare leaders develop plans and strategies to meet patients’

needs while mitigating cost will lead to improving efficiencies, preserving hospital

resources, and improving stakeholder engagement for their facility’s near-term and

longterm success (Pizzo & Cohen, 2016).

Implications for Social Change

From a social change viewpoint, results from this study may be valuable to assist

healthcare administrators to create and develop effective patient-centered strategies.

Elderly patients seeking healthcare could realize both economic and social gains through

improved patient-centered strategies that improve and support quality care (Pizzo &

Cohen, 2016). Several comprehensive models of care have emerged to limit long-term

healthcare support that have the potential to reduce costs and improve the quality of

healthcare for patients with complex needs (Bartels et al., 2017). Moreover, Castro, Van

Regenmortel, Vanhaecht, Sermeus, and Van Hecke (2016) advocated that collective

patient participation could shape patient-centered strategies through education, training,

and policy development in support of quality healthcare. Developing such strategies may

promote social change by increasing patient engagement and strengthening the ability of

medical providers to connect with patients (Franzen, 2017).

A Review of the Professional and Academic Literature

The goal of this multiple case study was to explore patient-centered strategies

from the perspective of six midlevel healthcare managers who work at a full-service acute

care facility that services patients from rural communities in Virginia. In this literature

review, I explored strategies that midlevel healthcare managers use to reduce the cost of

elderly patient healthcare without reducing the quality of patient care. A thorough

expositive literature review involves identifying, synthesizing, and encapsulating studies

inside an extensive body of research on a specific topic (Paré, Trudel, Jaana, & Kitsiou,

2015). By exploring literature covering PCC, cost improvements, healthcare policies,

PCC strategies, patient satisfaction, and other resources, useful strategies may emerge that

hospital managers can implement to reduce the cost of patient healthcare without a

reduction in a patient’s quality of care.

The resources used for this literature review were from the Walden University

Library research databases including (a) ProQuest Central, (b) Academic Search, (c)

American College of Healthcare Executives, (d) Google Scholar, (e) EBSCOhost, (f)

Science Direct (g) Emerald Management Journals, Management, and (h) government

websites. The totals for sources referred to in this study by category were as follows: (a)

six books, (b) 254 journal articles, and (c) seven reports. Of the 267 resources, 235 (88%)

had publication dates less than 5 years old.

Table 1

Details of Literature Review by Year of

Publication

Older

than 5

years

2014

2015

2016

2017

2018

Total

Books

Reports

Peer-reviewed

109

254

Totals

112

267

The body of knowledge on patient-centered healthcare and cost containment

strategies is constantly transforming to meet the needs of patients, healthcare leaders,

providers, healthcare organizations, insurers, and local and federal government agencies.

The literature presented in this study contains current strategies managers are employing

within a patient care delivery structure. Effective healthcare managers are leading

healthcare organizations with the goal of improving the patient experience through proven

strategies that improve safety, efficiencies, and cost (Mohammed et al., 2016). PCC

strategies are essential for linking every aspect of a healthcare organization with the

objectives and goals of the organization’s leadership (Anderson, 2015).

I organized this literature review into the following 10 main subject categories: (a)

patient centered-care, (b) primary care team model, (c) assessing PCC, (d) PCC as a

measurement within healthcare, (e) PCC within the ACA, (f) how PCC emerged to its

relevance in today’s healthcare delivery, (g) PCC within a value-centered healthcare

model, (h) value-based purchasing, (i) patient-centered medical home (PCMH), and (j)

healthcare leadership and continuous quality improvement. In the first two subject

categories, I explored the theory related to this study as well as the theorist, tenets of the

theory, and evolution of the theory related to this study. Next, I explored several alternate

theories considered but not selected and the reasons for not selecting those theories. The

remaining categories expand on the topic of this study as they relate to PCC.

Patient-Centered Care

Zill et al. (2015) stated the IOM recognizes the term PCC as the vanguard of

healthcare. PCC is a strategy demonstrated when healthcare professionals freely interact

with the patient and the healthcare workers to effect a positive outcome for the patient

(Zill et al., 2015). However, various definitions of PCC exist resulting in multiple

interpretations of who or what should be the focus of a PCC strategy. Zill et al. (2015)

argued that PCC is one of six improvements used to enhance the quality of care in

healthcare systems. Additionally, PCC is a fundamental capability all healthcare

professionals must have to provide healthcare in this century (Bernabeo & Holmboe,

2013). Healthcare leaders should apply PCC strategies that emphasize respect, care for the

patient, value, a patient’s opinions, a desire to relieve pain and suffering, care

coordination, a focus on the population health, disease prevention, and a healthy lifestyle

(Zill et al., 2015).

Likewise, Jun and Oh (2017) noted the patient’s perspective of PCC is relevant

when the focus is the patient and not the desires of the provider. As such, healthcare

providers should seek to provide patients with a personal and customizable experience

(Locatelli, Turcios, & LaVela, 2015). Healthcare organizations that employed PCC

benefited from improved disease management, higher patient satisfaction and

engagement, reduced anxiety among patients, and an overall increase in patient perceived

quality of life (Jun & Oh, 2017). Among the elderly, implementing PCC is improving the

delivery of preventive care for patients suffering from chronic conditions (Liang et al.,

2017).

Krupic, Sayed-Noor, and Fatahi (2017) further sought to link PCC with a theory

based on caring that one J. Watson established in 1988 that addresses the basic tenets

applied in the field of nursing science. Millenson, Shapiro, Greenhouse, and DiGioia

(2016) stated the term patient-centered care emerged from the concept of

patientcenteredness mentioned in a Gerteis et al. (1987) article Through the Patient’s Eyes

that presented information gathered during the Picker/Commonwealth Program in 1987.

Carl Rogers, a noted psychologist and founder of psychotherapy, established the

term patient-centeredness in the 1940s (as cited in Lor, Croks, & Tluczek, 2016). Rogers

argued that every individual had inherent qualities that one could draw from to alleviate

challenges. In the 1960s, British psychoanalyst E. Balint created the term patient-centered

medicine (as cited in Tanenbaum, 2015). Balint’s term focused on one aspect of the

patient-care team, for example, the physician, which limited the value of the other care

providers.

In 1987, the Picker/Commonwealth Patient-Centered Care Program developed the

term patient-centered care. The Picker/Commonwealth Foundation was developed

through a partnership between Dr. Harvey Picker, his wife, Jean Picker, and the

Commonwealth Foundation, an independent, nonprofit, private, public policy

organization located in Pennsylvania (Rawson & Moretz, 2016). Their motivation to

explore patient care resulted from a lack of responsiveness they deemed lacking when a

patient received treatment for a life-threating medical condition in the 1980s (Byczkowski

et al., 2015). The partnership specifically sought to bring attention to realigning the

healthcare provider’s focus on medical care from the disease back to the patient for

improving the delivery of healthcare. Through the Picker’s philanthropic donation, the

Commonwealth Foundation directed their efforts to change the focus of healthcare

industry delivery of care toward the patient with an increased appreciation for the

importance of the patient’s participation in their care (Byczkowski et al., 2015).

As time progressed, the developers of the Picker/Commonwealth Program focused

patient delivery on the following: (a) valuing and respecting the patient preference and

verbalized needs; (b) coordinating and integrating care for the patient; (c) sharing

information, education, and open communication among providers, the patient and the

family; (d) the patient’s well-being; (e) supporting the patient and family’s emotional and

psychological well-being; (f) including the family and friends into the patient’s care plan;

and (g) transitioning and continuing aftercare until released

(Byczkowski et al., 2015).

In 2001, the IOM presented six improvements in their report entitled “Crossing

the Quality Chasm” examining the quality of healthcare in the United States and

strategies to improve PCC as aims for improvement (Berwick, Feeley, & Loehrer, 2015).

As the concept of PCC evolves, the medical community continues to reshape the

implementation of PCC to achieve improvements in patient care delivery based on current

practice procedures. Moreover, various forms of PCC emerged substituting one word for

the other with the focus remaining on the patient as specified in the IOM report. Some of

these terms were client-centered care, person-centered care, and family- and PCC that

ultimately mean the same thing and were often used interchangeably depending who

performed the research (Price & Elliott, 2018).

The Europeans use the term person-based with the goal to put a name to the

patient and not a number like many hospitals in the United States (Yardley, Morrison,

Bradbury, & Muller, 2015). Overall, implementing person-centered care versus a

physician-centric care delivery is producing increased positive outcomes for caregivers

(Flieger, 2017). The focus of person-centered care is supporting what is most important to

the patient and focusing all of the patient’s treatment team strategies toward those

goals (Yardley et al., 2015).

As PCC transforms the interaction among the patient, caregiver, and the family,

PCC evolved to include other providers beyond the healthcare personnel who provide

direct care. Locatelli, Turcios et al. (2015) stated the patient’s team includes patient

advocates, technological providers, communication supports, and various health

administration personnel. The expansion of the patient’s care team has improved the

delivery of care by enhancing awareness and responsiveness for the patient (Santana et

al., 2017). The healthcare community defines PCC as healthcare derived from a

partnership among the caregivers, patient, and their families that safeguards the patient’s

needs, desires, and preferences ensuring the patient’s values guide all clinical decisions

(Winn, Ozanne, & Sepucha, 2015).

Assessing Patient-Centered Care

While the healthcare community in the United States and globally focus on

providing PCC, researchers and those responsible for managing healthcare organizations

are assessing the quality of patients’ decisions to improve treatment planning, execution,

and the delivery of PCC. Kogan, Wilber, and Mosqueda (2016) stated physicians who

practice PCC could improve their patients’ results and their approval ratings. Researchers

determined that patients desire to be a part of their decisions regarding healthcare and

their treatment options (Bernabeo & Holmboe, 2013). Hence, caregivers who facilitate

patient participation in their care are reducing the use of extraneous diagnostic testing,

treatment, inpatient care, and referrals for specialty care (Schneider, Hill, & Blandford,

2016). Bernabeo and Holmboe (2013) called the process of involving patients in their

treatment based on their values, beliefs, preferences, and knowledge as shared decision

making. Likewise, Locatelli, Hill et al. (2015) described effective PCC as a process that

involves the patient rather than the physician making decisions independent of the

recipient receiving the healthcare. Bernabeo and Holmboe (2013) stated healthcare

policies should reflect the concept of shared decision making among providers and

patients to improve the delivery of PCC.

Winn et al. (2015) stated caregivers and healthcare managers want to know how

well the patient’s care-team is informing their patients based on previous treatment

received. Moreover, researchers seek the patient’s support to determine if clinicians are

providing the best medical options and outcomes to treat the patient (Winn et al., 2015).

Batalden et al. (2016) stressed that healthcare managers must ensure their healthcare

teams are communicating with patients, mutually developing treatment plans, and

thoroughly adhering to the treatment plans discussed with the patient and family to

implement PCC effectively.

Another measure researchers and healthcare managers are using to measure PCC

is the patient’s experience (Tzelepis, Sanson-Fisher, Zucca, & Fradgley, 2015). In

addition, researchers are assessing the value concordance or agreement to assess the

effectiveness of quality decisions in support of PCC (Winn et al., 2015). Winn et al.

(2015) defined value concordance as the relationship between the patients’ preferences

regarding medical treatment and treatment goals. Within PCC, the patient’s choice and

outcomes should correlate; however, when the patient’s outcome differs from the

expected, the patient may question the value of the treatment. Likewise, the associated

cost of delivering the patient’s care may exceed the standard cost, hence subjecting the

patient’s care for questioning (Winn et al., 2015).

Alternative Approaches

Primary care team. The primary care team model, also referred to as the practice

team, direct primary care team, and interprofessional collaborative practice model

(Selleck et al., 2017) was an alternate approach for this study. Körner et al. (2016) stated a

primary care team is a collaborative practice intervention consisting of various members

of interdisciplinary teams that include physicians, nurse practitioners, physician assistants,

registered nurses, and health assistants. The primary care team primary function is to meet

the healthcare needs of the patient (Doekhie, Buljac-Samardzic, Strating, & Paauwe,

2017). The primary care team model often includes monitoring and collaboration among

various paraprofessionals, for example, a nurse, health assistants, and other medical

professionals in support of the patient delivery of care (Coleman et al., 2017). The overall

goal of a primary care team is to improve the delivery of care for patients (Freund et al.,

2015). However, the primary care team model does not emphasize the patient or family as

a member of the team. Schottenfeld et al. (2017) stated medical facility leaders and

primary care teams will need to make profound changes in the following: (a) the culture

and organization of care, (b) the environment in which medical personnel interact with

patients, (c) education and training, and (d) the means by which primary care personnel

and patients understand their roles and responsibilities.

Physician-centered care. Similarly, physician-centered care involves a standard

of care focus around the direction, goals, and efficiency of the physician (Yurkiewicz,

2016). Lim and Kurniasanti (2015) defined physician-centered care as the evaluation and

treatment of diseases, which emphasized the clinical expertise of a physician. According

to Flieger (2017), physician-centered care delivery impeded effective team-based PCC.

Orom et al. (2018) argued that a trusting closed physician-centered relationship could

adversely reduce a patient’s willingness to participate and discuss their provider’s

treatment decision-making. Moreover, Islam et al. (2017) stated the introduction of the

PCMH model and other PCC models would necessitate physicians and other healthcare

professionals to work collaboratively to coordinate PCC. Orom et al. (2018) stated

patients that actively participate in their treatment decision within a PCC model,

statistically better adhere to their treatment plan than patients who participate in a

physician-centered patient relationship. Lim and Kurniasanti (2015) indicated that shared

decision-making is a critical process of PCC whereby the patient and clinician participate

jointly in making health decisions for treatment. However, Pollard, Bansback, and Bryan

(2015) stated the shift towards a patient-centered approach by physicians has been slower,

because of clinician’s limited willingness to exercise shared decision making with their

patients. Additionally, the traditional decision-making approach facilitated by the

proponents of the physician-centered model is a sharp contrast to the PCC model (Lim &

Kurniasanti, 2015). Moreover, the physician-centeredness model directly contradicts to

PCC. Therefore, I did not choose this model for use in this study.

Patient-Centered Care as a Measurement Within Healthcare

It is a challenge for healthcare leaders to reduce cost by servicing more patients

with fewer providers. Moreover, the maximum time a medical practitioner can provide

medical care ranges between 15 and 18 minutes (Bard et al., 2016). This time model used

in many medical facilities enables medical practitioners to serve as many patients as

possible with the most cost-effective treatment based on the patient’s medical benefit

(Tai-Seale et al., 2017). As such, PCC has emerged as a significant measurement for

internal organization leaders to assess standards and external evaluating organization

leaders, for example, the Joint Commission to measure one facility against other like

healthcare organizations.

The Joint Commission, established in 1951, is a nonprofit organization that

accredits and certifies healthcare organizations with the principal aim of improving the

quality of care provided to patients (Hirose, 2016). One aim of the Joint Commission is to

evaluate how acute care facilities integrate patient-centered communications along with

PCC into the organization strategic plan to improve the quality of patient care (Happ et

al., 2015). Hence, as of 2011, the U.S. Health and Human Services (HHS) directed

healthcare organizations to focus their strategies on improving the quality of healthcare by

making it more patient-centered (Burwell, 2015). However, implementing PCC is not a

one-size fit all concept. Based on various PCC models and strategies used by healthcare

organizations, a certain amount of uncertainty occurs when managers levy PCC with

diverse populations (Hawley & Morris, 2017). Consequently, the Joint Commission in

their assessment expects managers of healthcare organizations to establish standards that

advance communication, culture, and competence for PCC (Bucknall et al., 2016). A

measure, highlighted in the (ACA) in 2010, was to strengthen cultural competency,

ethnicity, and language among providers to meet the demands of a diverse population

(Abdus, Mistry, & Selden, 2015).

Healthcare leaders are leveraging feedback obtained from patients through

inservice surveys to meet the demands of patients and standards measured by the Joint

Commission, ACA, and stockholders. Manary et al. (2015) stated the healthcare

community through mandates established by the Centers for Medicare and Medicaid

Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) developed

a Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey

to address measures to improve the quality of patient care. The overall goal of this survey

was to improve the quality of care for patients by providing useful data to the consumer

and healthcare facility leadership could use to improve PCC.

Etkind et al. (2015) stated that many healthcare organizations are utilizing

patientcentered outcome measures (PCOMs) to improve PCC. PCOMs is a term focused

on measuring patient and proxy-reported outcome measures derived from internal surveys

to improve the delivery of PCC. Healthcare leaders of various organizations are using

surveys to connect their organization’s accomplishments with their values to improve the

patient’s experience (Manary et al., 2015). As such, Bishop and Macdonald (2017)

expressed that surveyed patients often highlighted the personal professionalism of the

ancillary staff, the facility maintenance, and feeling of safety are measures as important.

Acknowledging patient concerns through surveys is helping to improve the patient

experience and PCC (Etkind et al., 2015).

Healthcare leaders who value increasing their patients’ knowledge, leveraging

innovations in healthcare, mitigating cost, and reducing their competition to improve a

healthcare facility position among other facilities will improve their ability to retain

patients (Manary et al., 2015). Millar, Freeman, and Mannion (2015) stated researchers

have ascertained that safety and trust are quantifiable measures healthcare leaders should

emphasize to reduce patient attrition, improve customer value, and anticipate customer

responses to various situations. These measures can improve PCC for a facility. Etkind et

al. (2015) stated research has shown that many healthcare facilities are not able to

correlate the outcomes measured into increased value for patients.

Overall, long-term care Medicare-dependent patients have seen the greatest

improved value from measures gathered through surveys (Etkind et al., 2015). Chang et

al. (2013) emphasized the challenges healthcare managers endure to sustain PCC by

underscoring an increased reliance on interpersonal care and feedback from the patient or

their family. Furthermore, if family members are true participants in the patients’ care,

medical providers must provide sufficient information to ease their anxiety so they can

make knowledgeable decisions as advocates for their relatives (Mitchell et al., 2016).

Moreover, the HCAHPS provides healthcare facilities a standard survey to assess the

general needs of most full-service acute care facilities; however, many healthcare

administrators will require specific surveys to target special populations needs for

specialties, for example, pediatrics, geriatric, hospice, cardiology, and oncology patients

(Ranard et al., 2016). Overall, healthcare managers are using surveys as a principal tool to

improve the delivery of PCC.

Patient-Centered Care Within the Affordable Care Act

President Barack H. Obama signed the PPACA on March 23, 2010. President

Obama designed the PPACA or other appellations, for instance, Obamacare and ACA, to

increase access to patient healthcare and reduce an individual’s out-of-pocket expense

(Cunningham, 2015). Two benefits of PPACA for Americans are a reduction in

preexisting condition exclusions and the elimination of lifetime limits on insurance

coverage (Cheng, 2016).

Cunningham (2015) stated the PPACA requires all Americans to have access to

affordable healthcare at rates based on one’s income regardless of an individual’s health

status. Other benefits of PPACA for Americans are statutes that restrict health insurers

from discriminating the sale of insurance basis on a person’s health status and granting tax

credits to both individuals and families (Ogundipe et al., 2016). According to Blumenthal,

Abrams, and Nuzum (2015), 30 million of the 31 million Americans projected by the

writers of the PPACA gained health insurance and 10.8 million additional Americans have

enrolled in Medicaid since the enactment of the PPACA. As of 2016, the uninsured rate

for Americans has declined by 43%, from 16.0% in 2010 to 9.1% in 2015 (Obama, 2016).

Historically, President Obama was not the first President to argue for a comprehensive

healthcare plan that all Americans could access. In 1912, President Theodore Roosevelt

unsuccessfully attempted to campaign for a united healthcare plan (Doherty, 2017).

Roosevelt began his initiative based on a campaign promise to provide healthcare for all

industry workers who were experiencing an increase in chronic health issues during the

Second Industrial Revolution (Manchikanti, Helm, Benyamin, & Hirsch, 2017).

Consequently, Franklin D. Roosevelt (FDR), the 32nd President of the United

States, spearheaded several legislative efforts to include a national healthcare reform to

meet the needs of Americans after the Great Depression (Gaffney, 2015). FDR sought to

enact a national health insurance mandate; however, the political climate after the

depression would not support a standalone healthcare insurance mandate (Doherty, 2017).

Instead, FDR was able to establish the Social Security Act, which he signed into law in

1935. FDR continued to push for a healthcare provision. Through his Surgeon

General, Thomas Parran, FDR sought to have national health insurance support Social

Security beneficiaries as a means to assist some portion of Americans (Kim, 2017). FDR

was unable to establish a universal healthcare insurance program before his death in 1945.

President Truman, FDR’s successor, took up the pledge to establish a universal healthcare

reform. Like FDR, Truman attempted to establish a national healthcare program but failed

based on a heavy Republican Congress that did not support the idea (Manchikanti et al.,

2017). After Truman, Lyndon Johnson, the 36th President, took up the task to establish a

national healthcare program. Under Johnson’s administration, he signed the Medicare and

Medicaid Bill in 1965 (Doherty, 2017). Johnson’s signing was the greatest achievement

toward the concept of a national health program since the idea emerged during Theodore

Roosevelt’s presidency in 1912 (Doherty, 2017). President Johnson established Medicare

to support Americans 65 years and older (Manchikanti et al., 2017). However, as culture

evolves, the Medicare program signed into law by President Johnson is not the same

program Americans are using as of 2015 (Blumenthal, Davis, & Guterman, 2015).

In 1966, 19 million Americans benefited from the passing of Medicare (Falconi,

2015). As of 2015, 53 million Americans benefit from Medicare (Blumenthal, Davis, &

Guterman, 2015). In 1972, Medicare expanded to include individuals younger than 65

with long-term disabilities and patients diagnosed with end-stage renal disease (Altman &

Frist, 2015). This expansion of Medicare was another step toward providing healthcare to

a segment of the American population that otherwise could not afford healthcare

(Blumenthal, Abrams, & Nuzum, 2015).

In 1977, during the Carter administration, the Department of Health, Education,

and Welfare established the Health Care Financing Administration (HCFA) to administer

both the Medicare and Medicaid programs (Altman & Frist, 2015). Between the 1980s

through 2003, Medicare and Medicaid added measures to assist Americans and others. In

1988, Congress required all states to use Medicaid funds to pay Medicare premiums and

cost sharing for qualified Medicare beneficiaries (QMBs) with incomes below 100% of

the federal poverty level (FPL) (Altman & Frist, 2015). Later in 2003, President George

W. Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act,

which provided new outpatient prescription drug benefits beginning in 2006

(Viswanathan et al., 2015). The PPACA has the greatest impact and quantifiable effect on

U.S. citizens access to health insurance since the establishment of the Medicare and

Medicaid Act of 1965 (Blumenthal, Davis, & Guterman, 2015; Shaw, Asomugha,

Conway, & Rein, 2014).

The ACA is an act created through ad hoc legislation (Gaffney & McCormick,

2017). An ad hoc legislature differs from a traditional legislature model by the process

Congress will use to get the law they desire approved. A traditional legislature will focus

on implementing one law or act (Bishop, 2014). The ACA is two bills, the PPACA and the

Health Care and Education Reconciliation Act of 2010 (HCERA) passed almost

immediately after the PPACA to amend that legislation (Bishop, 2014).

Upon President Obama’s reelection in 2012, Congress composition changed from

a Democratic majority to a Republican-controlled Congress. This change of power lead to

a push by a Republican-led Congress in 2012 and beyond, as well as the principal promise

of Donald Trump, the 45th President of the United States, to dismantle the ACA as written

(Ogundipe et al., 2015). Bishop (2014) stated the ACA is the first time the U.S.

has preserved access for all Americans the basic right to healthcare that encompasses

improved delivery of care as well as a federal government overhaul of healthcare

insurances. The ACA focused more on the cost of insurance as opposed to the cost of

healthcare (Obama, 2016). Ericson and Kessler (2016) stated the debate, for example

health insurance mandates or tax, regarding the ACA pertain to the manner the

government discourages or encourages Americans with private, individual (nongroup)

insurance whose health plans may terminate due to higher premiums, coverage for fewer

services, and or denial of benefits to people with pre-existing medical conditions impacts

compliance among Americans.

Since the ACA became law in 2010, the uninsured rate has declined by 43%

(Obama, 2016). According to Blumenthal, Abrams, and Nuzum (2015), the number of

uninsured Americans declined from 49 million in 2010 to 30 million in 2015.

The remaining uninsured will have several options that follow:

• Pay a tax penalty 1% of their income in 2014 that will increase to 2.5% in

2016 if they do not obtain acceptable coverage

• Enroll in Medicaid or seek out an employer plan, if one qualifies

• Obtain subsidized private insurance on the exchange if they meet income

requirements between 133% and 400% of the poverty line as determine by the

U.S. Census Bureau

• One can purchase insurance on their own that will most likely incur a greater

cost based on the inability to qualify for an exemption (Gaffney &

McCormick, 2017).

Elderly Americans, who are a minimum of 65 years old, can use Medicare and

Medicaid to cover their healthcare expenses. Provisions embedded in the law set forth

measures to improve PCC as stipulated by the Patient-Centered Outcomes Research

Institute (Frank et al., 2015). To ensure patients had a voice in their delivery of care, the

authors of the ACA created the PCORI to examine measures for improving health and

healthcare management by patients and providers by analyzing the quantifiable efficiency

of current health treatments (Bishop, 2014). In 2014, the Supreme Court sustained the

constitutionality of the individual mandate of the PPACA, thereby ensuring the Act

remained intact as endorsed by President Obama as well as the goal of cost containment

and improved patient access (Ogundipe et al., 2015).

In particular, Title V of the PPACA outlines the strategy to expand access to care

to low-income, underserved, and uninsured, minority, health disparity, and rural

Americans (Islam et al., 2015). In Medicaid program expansion states, the proportion of

Medicaid enrollees reporting poor access to care declined from 8.5% before the expansion

to 7.3% after the expansion that resulted in a 1.2% change with 5.3% of patients reporting

no change in access (Ndumele et al., 2014).

How Patient-Centered Care Emerged to its Relevance in Today Healthcare Delivery

The terminology of PCC has evolved globally from healthcare policies identified

from the World Health Organization, the National Health Service, U.S. HHS, and the

Australian Commission on Safety and Quality in Health Care (Santana et al., 2017).

Healthcare managers, physicians, nurses, and other medical professionals embrace PCC

as a principle function for ascertaining a patient’s goals and use these goals to develop a

patient’s treatment plan (Tinetti, 2016). Bowen et al. (2017) advocated that a

patientcentered performance management system would provide a valuable platform for

all those involved with providing PCC by ensuring management incorporates the patient

preferences, as well as hold medical service providers accountable for a patient-centered

performance measurement model. Consequently, Pluut (2016) stated healthcare providers

are employing various models and methods of PCC to meet various patients’ needs.

Santana et al. (2017) surmised from various data sources that three principal themes of

PCC are (a) the patient participation and involvement, (b) the relationship between the

patient and the healthcare professional, and (c) the environment where the patients receive

care.

The delivery of PCC remains a challenge based on language, socioeconomic

status, education, and cultural incompatibilities among patients (Moore et al., 2016). To

deliver PCC, Blaum et al. (2017) acknowledged three universal phases as follows:

1. Ensure the family member or legal guardian and patient comprehend the

patient’s diagnostic health status.

2. The process of establishing and prearranging the goals of the patients with the

medical providers to plan the patients required a length of care.

3. The third phase requires the patient and provider to commit to an established

plan of care based on the goals established through dialogue with patient and

caregiver. A challenge many healthcare professionals encounter is converting a

patient’s goals into a methodology to determine the appropriate intervention.

Bowen et al. (2017) suggested using the patient-centered performance

management system to document recommendations for medical professionals and the

patient with the likelihood the recommendations received would benefit the patient or

provide indicators that a chosen goal could cause harm. Tanenbaum (2015) stated the goal

of PCC is to avoid utilizing a one-size-fits-all PCC model. By implementing the latter

strategy, healthcare professionals can establish a PCC plan that adjusts for various cultural

and regional dynamics. Similarly, Blaum et al. (2017) recommended caregivers receive

additional education to prepare them to care adequately for the elderly and those with

advanced-care illnesses.

Patient-Centered Care within a Value-Centered Healthcare Model

In 2007, the Institute for Healthcare Improvements (IHI) developed the Triple

Aims framework cited and used by healthcare organizations throughout the world

(Storkholm, Mazzocato, Savage, & Savage, 2017). Two benefit healthcare administrators

and providers have gained by implementing the Triple Aim are a focus on the patient and

an increased delivery of suitable care (Conrad & Alfredson, 2016). The three aims attempt

to (a) improve the patient care experience, (b) improve the health of a population, and (c)

reduce per capita healthcare costs. These became the cornerstone of the ACA

(Storkholm et al., 2017).

Porter and Kaplan (2016) identified value as the core function patients require and

providers and stakeholders must accomplish to improve outcomes. Additionally, a

function is to reduce the cost to organize healthcare around a patient-centered system.

Likewise, Subramaniam et al. (2017) identified the Joint Commission, a non-profit

organization responsible for accrediting over 21,000 healthcare organizations, as

encouraging healthcare leaders to create a culture that promotes safety and value

patientcentered communication. When the ACA became law in 2010, CMS executed

several programs to transition from a volume-based reimbursement to a value-based care

model (Bosko & Gulotta, 2016). Porter and Kaplan (2016) specified that value within a

healthcare delivery model is health outcomes that resonate with patients alongside the

expected cost required to achieve predictable outcomes.

At the national and state levels, healthcare and governmental leaders identified the

lack of value gained through physician’s fee-for-service plans that limit patient and

healthcare organizations’ ability to examine insurers; however, under managed care,

insurance companies could negotiate cost-effective contracts subject to review and

monitoring (Baicker & Robbins, 2015). Porter and Kaplan (2016) stated improving value

requires improving outcomes without raising costs, lowering costs without compromising

outcomes, or both. Price and Elliott (2018) determined that a lack of patient involvement

could create confusion among the patient, caregivers, and healthcare providers resulting

in the patient perceiving a lessening of value care. Elwyn et al. (2014) advocated that

healthcare providers have determined that PCC improves their patients’ outcomes, as well

as improve self-management, patient approval ratings, and improved medical outcomes.

When addressing elderly patients, particularly Medicare recipients, the medical treatment

team should work to ascertain what the patient values and prefers when designing a

treatment plan that supports results and outcomes the patient and caregivers desire (Cox,

White, & Abernethy, 2014).

Shared decision making, a method used by healthcare teams to gather information

that informs the patient of their treatment options and strategies while addressing the

patient’s preferences, assists in developing the patient treatment plan (Elwyn et al., 2014).

Medical personnel who utilize decision aids in support of decision making have seen

increasing support by patients and caregivers when developing treatment teams for those

with complex illnesses often seen in elderly patients (Cox, White, & Abernethy, 2014).

Elwyn et al. (2014) concluded that shared decision making in support of PCC is most

effective when clinical teams can adapt based on the patient’s situation, needs, and

projected outcomes. Notwithstanding, healthcare managers should be aware of the limits

any decision support system may have and develop strategies that help to mitigate issues

in providing the level of care expected from the patient and caregiver (Cox et al., 2014).

Porter and Lee (2016) proposed a value-based delivery model where healthcare

facilities organize care around the patient needs versus a model focus on enhancing the

financial performance of primary care practices under fee-for-service payments. Bosko

and Gulotta (2016) attested the need for organizations to convert to a value-based plan for

sustainability. A value-based plan would require a methodical change in the approach to

care across the healthcare continuum. For healthcare to improve, Bosko and Gulotta

(2016) stated the healthcare industry should utilize risk stratification models to manage

the population and identify high-risk patients. Risk stratification models enable medical

facilities managers to organize workflow and group patients based on needs.

Porter and Kaplan (2016) recommended analyzing primary healthcare as a

multitude of several patient subgroups that enable managers to measure outcomes and

cost, other payment models and strategies that support primary and specialty care

solutions. Healthcare managers and insurers are using big data, for example, large volume

of detailed electronic information accessible for the purpose of analyzing patient’s

medical history, inconsistency in healthcare quality, treatment strategies, hospital

readmission rates, and opportunities to reduce patient cost and manage overtaxed medical

resources for the purpose of improving value and efficiencies (Manogaran et al., 2017).

Subsequently, Rollow and Cucchiara (2016) indicated the establishment of PCMH is a

significant model for improving value, team-based care, outcomes, and costs containment.

The ACA will cover an additional 30 million Americans by 2020 with health

insurance who without the ACA would remain uninsured (Rice et al., 2014).

Notwithstanding, a core achievement of the ACA has been the requirement for all

Americans to have health insurance at rates based on the population averages regardless

of one’s health status (Obama, 2016). Sommers, Maylone, Blendon, Orav, and Epstein

(2017) stated one of the aims of the ACA was to provide healthcare coverage for low

income citizens. One group of high-risk citizens is the elderly. Chandra et al. (2015)

stated the following factors identify the elderly as a risk factor: sociodemographic,

environmental trends with outpatient care, repeated adverse drug incidences, and the

number of elderly patients using multiple prescriptions. In short, Rice et al. (2014)

indicated increased accessibility and affordability to health insurance regardless of a

person’s station would move the U.S. much closer to the concept of universal healthcare.

Value-Based Purchasing

The healthcare industry could not sustain the rate of increases in Medicare patients

incurred in the late 2000s. CMS established the Value-Based Purchasing (VBP) program

as a means to add value to healthcare services. Within the ACA, a statute is a means to

reduce cost. All funds for inpatient health services will correlate with value and measures

per (42 U.S.C. § 18001 (2010). The number of readmissions and catastrophic events

increased among Medicare-dependent patients costing over $30 billion in 2009, reflecting

poorly on the U.S. even though many non-U.S. citizens hailed the U.S.

healthcare system as the best in the world (Raso, 2015). Lipshy (2017) described a setting

that includes adverse events, for example, operations performed with foreign objects left

inside of patients due to poor safety and maintenance standards. However, Kronick (2016)

indicated the U.S. healthcare system saved $12 billion in Medicare and Medicaid costs

from 2010 to 2013 based on collaborations between U.S. Department of Health and

Human Services (HHS) agencies and other partners to achieve the goals of improving

care, greater efficiency of healthcare dollars, and healthier people.

In 2014, value-based payments emerged as requirements based on provisions

established by President Obama when he signed PPACA and the HCERA together known

as the ACA (Burwell, 2015). Raso (2015) stated VBP funds would come from reduced

hospital Medicare payments. Stein et al. (2015) recognized that VBP provides hospitals

with financial incentives based on a critical factor that the patient experience is a key

component of quality care.

Moreover, CMS would redistribute revenue as withheld-funds derived from

Medicare payments back to hospitals based on quality performance data based on its prior

year’s performance (Raso, 2015). Based on the success of the VBP, former HHS

Secretary Burwell announced that VBP would tie Medicare fees for service to value by

2018 (Lynn, McKethan, & Jha, 2015). Additionally, the CMS moved to expand VBP in

2015 by rewarding or penalizing hospitals with financial incentives based on their quality

of care delivery and spending (Das et al., 2016).

Bosko and Koenig (2016) stated CMS established programs that incentivized

hospitals for providing quality facility care and penalized those facilities that failed to

provide quality care as facilities transitioned to a value-based payment system. Bundled

arrangements are a focus for CMS. CMS is moving coverage of over 55 million Medicare

beneficiaries and 72 million Medicaid enrollees (Pizzo & Ryan, 2016). In 2014, Section

3001(a) of Public Law 111-148 outlined the inpatient value-based purchasing program

that referenced the criteria for value-based payments based on a hospital meeting

performance standard for the performance period of that year.

The overall success rating of a hospital correlates directly with that hospital’s

payfor-performance (P4P) strategy that supports the outcomes for increased efficiencies

and positive levels of patient experiences (Stanowski, Simpson, & White, 2015). Bosko

and Koenig (2016) defined a value-based program as a payment redistribution program

for qualified hospitals that subsidize a set percentage of the base operating payments to a

VBP payment group; the percentage for 2017 is 2.0%. Overall, VBP rewards hospitals

based on their performance. Furthermore, physicians must adhere to payments derived

from servicing Medicare and Medicaid-dependent patients based on value versus volume

(Ryan & Rodgers, 2018). The ACA identifies the payment as a value modifier that ties a

physician’s quality of care and those costs associated with Medicare Part B payments

(Bosko & Hawkins, 2016). Along with the payment plans listed within Medicare Part B,

physicians can take part in alternate reimbursement methods that include the PCMH

model and other approved payment methods (Bosko & Hawkins, 2016).

In addition to the VBP, two other programs make up the CMS programs, the

Hospital Readmissions Reduction Program (HRRP) and the Hospital-Acquired

Conditions (HAC) program. The HRRP and HAC are penalty programs designed for

hospitals that fail to transition to value-based reimbursement, hospitals with unnecessary,

avoidable readmissions, and hospitals whose performance is in the bottom quartile for all

hospitals (Bosko & Koenig, 2016). The CMS established bundled payments to motivate

providers to coordinate care, increase quality, and reduce cost based on a single payment

for a specified treatment over a definite period (Pizzo & Ryan, 2016).

Organizations striving to improve healthcare should align the quality components

of the CMS programs, which include the quality of payment, reimbursement structural

change, and provider’s compensation. Organizations must evolve to incentivize

behavioral change and promote adherence to quality and service metrics (Pizzo & Ryan,

2016). As such, many healthcare organizations leaders have taken steps to improve their

delivery of care based on constraints outlined in the ACA and demands from local, state,

and federal agencies, as well as insurance companies to provide sustainable quality

healthcare at a lower cost (Douthit, Kiv, Dwolatzky, & Biswas, 2015). In contrast,

hospitals located in regions where patients’incomes are higher and charitable

contributions to hospital are the norm have seen a steady increase in favorable patient

surveys. However, those patient’s surveyed with limited income and longer travel distance

to healthcare facilities have experienced difficulties accessing quality healthcare

(Stanowski, Simpson, & White, 2015).

The challenge in providing PCC to those disproportioned Americans entering the

healthcare market is that it is slow to see the gains established through the ACA as

highlighted through patient-reported experience surveys (Schlesinger, Grob, & Shaller,

2015). Healthcare managers of medical facilities will need to develop strategies and

processes to lower costs without diminishing safety and quality so that medical staffs can

accomplish quality healthcare while making a profit (Porter & Kaplan, 2016). Stanowski

et al. (2015) identified that hospitals could gain benefit by linking the patient experience

to financial incentives that coincide with increased safety, outcome care, and patient

satisfaction surveys. Similarly, Bowen et al. (2017) discussed that using the electronic

health record (EHR) system; (an existing digital system used by health facilities to

document a patient’s medical history) can improve a patient’s safety and minimize risk

from unnecessary medical treatment. Mohammed et al. (2016) suggested healthcare teams

that utilize patient experience data gathered from patient satisfaction surveys could

improve the patient experience and the delivery of health services to increase a patient’s

outcome.

The task of lowering cost, maintaining safety, and meeting stockholder goals

increases the challenge of making PCC a priority. As a larger portion of lower income and

vulnerable Americans receive their healthcare from Safe-Net hospitals (SNH) often

located in disenfranchised and rural communities, the complexities of managing a hospital

increase (Andrulis, Siddiqui, Reddy, Jahnke, & Cooper, 2015). French, Guzman, Rubio,

Frenzel, and Feeley (2016) stated time-driven activity-based costing (TDABC) is a tool

many hospitals are beginning to use to help healthcare providers and managers improve

processes within their organizations. Bhavnani et al. (2017) advocated the need for the

healthcare industry to develop new patient-centered, evidence-driven models that support

healthcare transformation and cost reductions. Bhavnani posited that healthcare providers

and managers could accomplish the shift in focus from serial treatment to sustainable

health outcomes based on ACA standards. Notwithstanding, Safe-Net hospitals have a

higher chance of failing without some institutional process improvement measures

implemented in support of healthcare transformation (Andrulis et al., 2015).

Bhavnani et al. (2017) emphasized that healthcare facilities should implement

alternate means to communicate that include telehealth, virtual health, email, phone, and

text to limit a patient’s time in a healthcare facility that in turn increases cost and impact

patient surveys, a principal indicator in VBP. Lipshy (2017) indicated that healthcare

organizational leadership should commit to zero defect concerning the patient’s safety and

employ tools that support gained efficiencies to meet sustainable healthcare delivery.

Lipshy (2017) indicated that an organization’s leadership requires resilience, such as the

competence to recognize errors efficiently and elicit strategies that deter and isolate them,

thereby averting any damage that may result if not mitigated. HHS is the U.S. agency

charged to improve and safeguard the health and well-being of all Americans. The agency

focuses are (a) to provide incentives to providers and healthcare facilities, (b) to increase

standards of care for Americans through improved integration of teamwork between

providers and patients, and (c) to place emphases on improving communication both

digital and through others forms of media between providers and patients (Burwell,

2015). According to Mamlin and Tierney (2016), other forms of communications, for

example, telemedicine and telehealth support the universal goal of expanding access to

healthcare to millions of additional Americans while reducing the cost to meet PCC

initiatives expected from CMS and HHS.

The Patient-Centered Medical Home

The PCMH is the single best strategic model to improve healthcare quality, reduce

cost, and most importantly improve the patient’s, caregiver’s, and treatment team’s

experience. Evidence supports PCMH as a tremendous model for delivering primary care

within patient-centered modality (Heisler, 2017). The PCMH concept originated in 1967

when the American Academy of Pediatrics (AAP) crafted the term medical home to

define the role of the pediatric practice for chronically ill homebound children (Lerner &

Klitzner, 2017). Moreover, PCMH population base consisted of children and adolescents

characterized as children with special health needs (Adepoju, Preston, & Gonzales, 2015).

This earlier model focused on coordinating care among specialists, thereby omitting the

patient’s primary care physician. The next significant

advancement to PCMH occurred between 1978 and 1990. During the World Health

Organization’s International Conference on Primary Health Care in 1978, the terms access

to care, continuity of care, comprehensiveness and integration of care, patient education

and participation, team-based care emerged along with accompanying public policy in

support of primary care goals (Bath & Wakerman, 2015). In 1990, reports emerged that

mention the terminology medical home.

Based on Ed Wagner’s chronic care model developed in the 1990s, the IOM

medical home concepts, and joint principles developed by several medical professional

organizations that included the American Academy of Family Physicians (AAFP) and the

American College of Physicians (ACP), establish the current criteria developed for

PCMH (Johnson et al., 2015). As PCMH took root, professional journals and other

literature, scholars, and practitioners began to incorporate lean processes to improve the

PCMH model within various organizations (McGough, Kline, & Simpson, 2017). The

earliest definition of PCMH as it related to care for adults emerged in 2007 when a study

conducted by the AAFP focused on interventions and outcomes linked with several large

initiatives known as medical homes (Lerner & Klitzner, 2017). In 2007 the AAP, AAFP,

ACP, and the American Osteopathic Association collaborated to refine the medical home

concept with patient-centeredness, in their Joint Principles of the patient-centered medical

home (McHugh, Harvey, Hamil, & Scanlon, 2016).

To that end, the current model of PCMH emerged when it formalized in 2007.

Coleman, Wagner, Schaefer, and Reid (2016) stated the National Committee for Quality

Assurance (NCQA), a privately own organization, helped to propel the PCMH model

through its recognition and accreditation for many healthcare initiatives and models used

throughout the U.S. government. Over the next 3 years, PCMH would become a principal

model within the ACA. Notwithstanding, interface within the ACA is the concept PCMHs

as defined in Section 3502 of the ACA to advance healthcare advantages for populations,

preventive health, persistent chronic illnesses as well as other healthcare needs (Nowinski

Konchak, Moran, O’Brien, Kandula, & Ackermann, 2016). Miller et al. (2017) stated the

United States’ depleting economic resources and decreasing healthcare budgets provide

the perfect setting for healthcare providers to implement the PCMH model as an

innovative approach to improving healthcare quality while reducing costs.

The Agency for Healthcare Research and Quality (2017) defined the patient-care

medical home model as the standard of primary care that delivers the central functions of

primary healthcare. Nevertheless, the writers of the ACA include provisions that assist

and endorse the PCMH model as a financial incentive for Medicaid programs to transition

patients from an inpatient model to a home-based model that supports technology

advancements, safety, outcomes, and cost reductions (Nielsen et al., 2016).

Based on the literature, the PCMH consists of five functions and attributes that

include (a) comprehensive care, (b) patient-centered, (c) coordinated care, (d) accessible

service, and (e) quality and safety. These five elements aim to place the patient in the

center of their care and streamline the care across the continuum of healthcare (AHRQ,

2017). Van Hasselt et al. (2015) stated scientific data supports the claim that the PCMH

model is less resource intensive than traditional standards of medical delivery and

positively improves disease management and effective preventative health.

Overall, the establishment of PCMHs involves (a) transforming physician-centric

care processes by incorporating all members of a healthcare team, (b) placing the patient

at the center of care to improve quality, and (c) increasing healthcare team’s access to

their patient. Since the enactment of the ACA, scholars generally support the following:

(a) treating chronic illnesses, (b) promoting preventive care and mitigating acute care

needs, (c) employing multidisciplinary healthcare teams, (d) coordinating care transitions,

(e) developing strategies that leverage multiple communication and technological

systems, (f) monitoring risk mitigation, safety, and clinical based treatment care, and (g)

improving electronic health records management as strategies to institute PCMH

(McGough et al., 2017). Current studies support PCMH as the best model to mitigate a

patient’s total cost, meet patient satisfaction, and improve hospitalization rates across

multiple diverse populations (Nielsen et al., 2016). Bilello et al. (2018) supported

evidence that the PCMH model is a capable model that underscores all levels of

healthcare delivery while decreasing cost. PCMH has been the fastest growing model for

managing patients with chronic health issues (Conrad & Alfredson, 2016). Overall,

healthcare facility administrators that have implemented the PCMH model are seeing cost

reductions based on a decrease of chronically ill patients utilizing emergency room

services (David et al., 2015).

Healthcare Leadership and Continuous Quality Improvement

Healthcare leaders today continue to struggle with the goal of delivering quality

healthcare to all patients. The PCMH model helped close the gap for most Americans

despite the deficiency of effective communication and coordination of PCC across the

wide range of healthcare delivery systems (Cantiello, Kitsantas, Moncada, & Abdul,

2016). Moreover, the relationship between the patient and the medical team providing the

service is the core function that supports customer’s support for or against various

modalities associated with PCC (Chang et al., 2013). Consequently, Balbale, Turcios, and

LaVela (2015) stressed that the evidence supports healthcare workers are transitioning

from the physician-centric care model to a PCC model that supports tailoring treatment

centered on the patient and family needs. However, at the core of the delivery of

healthcare is the healthcare leader. These leaders vary among hospital managers,

physicians, treatment teams, and other administrative personnel. Bradbury and Lifvergren

(2016) suggested that effective leaders understand and embrace the needs of their patients

through a PCC strategy that strengthens and promotes innovative ideas to enhance the

overall patient’s experience and quality care.

Transition

The purpose of this qualitative descriptive case study was to understand what

patient-centered strategies healthcare managers use to reduce the cost of elderly patients’

healthcare without reducing the quality of patient care. In this literature review, I provided

a historical perspective and discussion of PCC, assessing PCC, patient centeredcare as a

measurement within healthcare, PCC within ACA, PCC relevance in today’s healthcare

delivery systems, PCC within a value-based healthcare model, value-based purchasing,

PCMH, healthcare leadership and continuous quality improvement in healthcare. In the

next section, I will describe the validation for the use of a qualitative descriptive multiple

case study to explore patient-centered strategies healthcare managers use to reduce the

cost of elderly patients’ healthcare without reducing the quality patient care. In Section 3,

I will provide my presentations of the findings with a description of the finding’s

application to professional practice and implications for social change.

Section 2: The Project

The purpose of this qualitative descriptive multiple case study was to explore and

present an enhanced understanding of how healthcare managers strategically apply

patient-centered strategies to reduce the cost of elderly patients’ healthcare without

decreasing the quality of a patient’s care. Using a multiple case study enabled me to

address the principal research question based on feedback from multiple viewpoints

within a healthcare setting.

Purpose Statement

The purpose of this qualitative descriptive multiple case study was to explore what

patient-centered strategies healthcare managers use to reduce the cost of elderly patient

healthcare without reducing the quality of patient care. The participants consisted of six

midlevel healthcare managers from several departments located at six full-service acute

care healthcare facilities that employ 150 people or more in Virginia, who have reduced

the cost of elderly patients’ healthcare without reducing the quality of patient care.

Conducting this study may lead to positive social change for elderly patients by

improving the delivery and access of quality PCC while catalyzing, developing, and

implementing cost reduction strategies that healthcare managers can employ to make

healthcare more accessible.

Role of the Researcher

The role of the researcher in this study was to collect, analyze, and interpret data

and results garnered from participants’ interviews and archival data. Hyett et al. (2014)

suggested a researcher seek out generalities and uniqueness about a case by considering

cautiously and thoroughly the environment, historical background, physical setting, and

other institutional and relative regulatory factors. Noble and Smith (2015) noted that the

role of the researcher is to facilitate participants’ sharing of perspectives and experiences

regarding the phenomena. Houghton, Murphy, Shaw, and Casey (2015) stated that a role

for a researcher is to gather material from observations and attempt to comprehend the

phenomenon of interest based on the meanings that participants provide. I did not have a

personal or professional relationship with the participants. I do not work in the healthcare

field; therefore, my career experience should not have affected research outcomes.

I sought to maintain all ethical standards during this study by adhering to the

protocols outlined in the Belmont Report (National Commission for the Protection of

Human Subjects of Biomedical and Behavioral Research, 1979). I stressed the adherence

to protecting the rights and welfare of participants as well as their autonomy as stipulated

in the Belmont Report. I adhered to Walden University’s Institutional Review Board (IRB)

process by conforming to ethical standards compliance requirements before conducting

research. To meet this objective, I submitted an electronic submission of the IRB form

with the inclusion of the research proposal description, data collection tools, research

participants, and informed consent. To meet the ethical standards of Walden University

and U.S. federal regulations, I did not collect data until I received approval from the

Walden IRB.

Ponelis (2015) stated using a qualitative exploratory multiple case study allows

the researcher to explore the strategies in a real-life setting. As the study proceeds, the

researcher should work to include shared experiences among participants through

interview questions, data collection, and data analysis. I sought to mitigate bias by

identifying and engaging in a process that exposed and eliminated predispositions. A

researcher can reduce bias through a self-assessment, which connotes reflexivity while

increasing dependability through the transparency of the study’s development (Moon

Brewer, Januchowski-Hartley, Adams, & Blackman, 2016). Sorsa, Kiikkala, and

ÅstedtKurki (2015) indicated bracketing provides researchers the means to mitigate

predetermined experiences, attitudes, and beliefs during the extent of the study to avoid

tainting the process with bias. According to Antwi and Hanza (2015), the researcher

should remain neutral during the data collection process. A lack of a relationship with the

participants should improve the researcher’s ability to mitigate personal bias in a study

(Fusch & Ness, 2015). Also, I used peer debriefing as well as new information to help

clarify bias when I analyze themes and outcomes.

This case study data included interview transcripts, researcher notes, and

associated documented evidence. Yin (2014) suggested interviewing participants with

different views throughout the organization as a value-added method. Goldberg and Allen

(2015) suggested researchers prepare for future discussions from readers by presenting

preliminary results to participants while incorporating their feedback throughout the

study. I reviewed my case study results with my participants to garner feedback for

validating transcripts to verify their responses.

Participants

Robinson (2014) stated identifying the participants who can best enlighten the

research question and understanding of the phenomenon for a qualitative study is

purposive sampling. Elo et al. (2014) indicated convenience, theoretical, and snowballing

are other types of qualitative sampling for identifying participants’ knowledge of the

research topic. Elo et al. (2014) stated researchers could improve the reliability of a study

by specifying the sampling method and the participants for their study. As such, the

participants a researcher selects should be those individuals capable of supporting the

researcher’s questions and able to enhance the understanding of the study (Sutton &

Austin, 2015).

The target population included six midlevel healthcare managers from six acute

care facilities in Virginia that execute strategies to reduce the cost of elderly ambulatory

and acute patients’ healthcare without reducing the quality of patient care. I solicited these

participants through the hospital’s human resources department and the American College

of Healthcare Executives national and local chapters, where I am a member. Palinkas et

al. (2015) stated participants who meet a precise standard by having a higher knowledge

of the phenomenon of interest through their capabilities are desirable participants. Yin

(2014) stated the participants of a case study should be knowledgeable about the

phenomenon of the researcher's study. Palinkas et al. (2015) recommended selecting

individuals or groups that are knowledgeable of the phenomenon. Antwi and Hamza

(2015) recommended the researcher encourage participants under study to speak freely on

the phenomenon with which they have experience.

According to Merriam and Tisdell (2015), it is important for researchers to

establish relationships with potential participants. Lowther et al. (2016) recommended

researchers develop relationships with their participants by (a) employing compassion, (b)

using open and nonjudgmental conversations, (c) communicating trust and support, and

(d) reiterating to participants the importance of their contribution to society. I instituted

honest and mutual relationships with participants, abided by the ethical principles of

nonmaleficence, and ensured participants’ privacy to enhance a successful working

relationship with participants (Petrova, Dewing, & Camilleri, 2016). Palinkas et al. (2015)

indicated a researcher using a qualitative method often relies on specific rules for defining

the number of participants. Palinkas et al. (2015) stated the type of analysis stipulates the

level of detail required for homogeneity, for example, a small sample size of 3-6

participants versus a large sample group.

I garnered interviewees through purposeful sampling via the American College of

Healthcare Executives membership database, telephone, and e-mail to solicit and

communicate with participants. Palinkas et al. (2015) defined purposeful sampling as a

technique for identifying and selecting information-rich cases based on limited resources.

Palinkas et al. (2015) specified that purposeful sampling involves selecting individuals or

groups of people specifically who may provide an in-depth understanding of the research

phenomenon. I followed up with an email before data collection to confirm the

volunteers’ participation in the study. Participants used e-mail to specify their preference

for a face-to-face interview or Skype that explains the ethical and privacy protection of

participants. Yin (2014) recommended researchers use an open-ended question when

engaging participants by e-mail, telephone, and face-to-face. Johnston et al. (2016) stated

interviews should last a maximum of 60 minutes so the researcher can capture the voice

of the participants. Researchers should use a semistructured process when conducting an

interview (McIntosh & Morse, 2015).

Research Method and Design

Hyett et al. (2014) stated a research method includes an established set of specific

processes, tools, and techniques to gather and analyze data. Healthcare researchers can

use qualitative analysis to develop effective strategies for exploring healthcare managers’

experiences in providing the delivery of PCC strategies that reduce the cost of elderly

patient healthcare without reducing the quality of patient care (Lewis, 2015).

Research Method

Three research methods used by healthcare researchers are qualitative,

quantitative, and mixed methods (McCusker & Gunaydin, 2015). I used a qualitative

research method. Leung (2015) defined qualitative research as a systematic collection and

interpretation of documented material obtained through conversations and observations

within a natural setting. Sutton and Austin (2015) asserted healthcare researchers should

seek an increased understanding of their study participants’ or group’s natural experiences

to gain a fuller description of the phenomenon. Kalu (2017) stated a qualitative research

method signifies an orderly and objective means of labeling and measuring phenomena.

Healthcare researchers can use qualitative research to understand and experience the

actual phenomenon in its natural setting (Sutton & Austin, 2015). Tayabas, León, and

Espino (2014) concluded researchers who pursue qualitative research for healthcare

research would benefit by identifying areas and programs that need improving and

processes required to create change within an organization. According to Marwick (2014),

most researchers who use quantitative studies use observation and ex post facto designs

within a controlled environment based on statistics and numbers. Barnham (2015) stated

researchers use quantitative methods to examine social phenomenon, test theories, and

establish a problem based on variables consisting of statistics to determine if their theory

explains or predicts phenomena of interest. A quantitative approach would not have

provided the means to examine the participants’ perceptions and experiences.

Although researchers support the use of a mixed methods approach to study a

phenomenon, it was not an appropriate method for this study. A mixed methods study is a

combination of qualitative and quantitative methods. However, the quantitative method

cannot account for the experiences and assumptions of healthcare managers concerning

the impacts of healthcare for Medicare-dependent patients. A mixed methods design

supports a researcher’s aim to extend and validate qualitative and quantitative methods,

hence detailing a comprehensive meaning of the phenomenon (Palinkas et al., 2015).

However, the goal of this study was to explore strategies of a phenomenon based on

personal experiences of healthcare leaders; a qualitative inquiry was beneficial for

studying those strategies used to reduce the cost of elderly patient healthcare without

reducing the quality of a patient’s care. French, Luo, and Bose (2017) suggested that

mixed methods is a holistic approach for researchers to pursue new initiatives. Through

face-to-face interviews and data collecting, a mixed methods researcher can assess the

demands of caregivers and the logistics to analyze their business processes. The rationale

used to employ a qualitative case study over a quantitative or mixed methods study was

the ability to attain a deeper universal view of the research problem that can assist

understanding of the problem and situation (Yin, 2014). The goal of this study was to

explore patient-centered strategies from the perspective of the healthcare manager. A

qualitative method was advantageous for studying the experiences of healthcare

managers.

Research Design

To evaluate patient-centered strategies used by managers to reduce cost and

maintain quality patient care, I chose the case study design to explore this phenomenon.

Yazan (2015) stated a case study design provides the researcher with the means to assess

the complexities and comprehensive study of a phenomenon. According to Moeyaert,

Maggin, and Verkuilen (2016), the case study design provides researchers the means to

focus on one or more subjects via observation repeatedly over a defined period until one

achieves their desired outcomes.

Houghton et al. (2015) suggested healthcare researchers require qualitative

research skills to interpret data collection, the nature of a healthcare system, and the

organizational structure. A qualitative case study approach can provide the means to

explore what patient-centered strategies healthcare managers use to reduce the cost of

elderly patient healthcare without reducing the quality of patient care. By exploring and

analyzing a multiple case study, a researcher can fully understand and communicate the

significance of conducting a study into a single problem (Morse & McEvoy, 2014).

Additional study designs considered included phenomenology and ethnography

(Maggio, 2016). Gill (2014) summarized phenomenology was both a philosophical

movement and a family of qualitative research designs subdivided as either descriptive or

interpretive. Van Manen (2017) emphasized a phenomenology study includes exploring

the quintessence of a participant’s knowledge through interviews and observation.

Furthermore, Yin (2014) stated the phenomenological design focuses on how the

experience of a phenomenon affects participants. Howlett (2014) noted an ethnographic

design is for developing a description and interpretation of culture, social system, or

group. Researchers who implement an ethnographic design seek to explore the culture of

individuals possessing shared behavior patterns and beliefs (Balyer, Karatas, & Alci,

2015). Baskerville and Myers (2015) argued that ethnography addresses conceptual issues

of human behavior from actual accounts of field experiences.

Zill et al. (2015) explained the differences between a phenomenon and perspective

referring to the different manner healthcare managers and medical professionals define

and implement PCC. While PCC may delineate the constraints of the study, healthcare

managers, and medical professionals may apply various strategies to accomplish

improved patient care. As such, Yin (2014) stated the boundaries between the

phenomenon and context might not be transparent. The study’s limitations provide the

parameters of the case. A multiple case study design was beneficial for exploring the

delivery of PCC strategies that reduce the cost of elderly patient’s healthcare without

reducing the quality of patient care. Multiple design constraints include a researcher’s

budget, time, and access to quality participants. Constraints can influence a researcher

study; however, small groups of participants who are resourceful and informative are

more often better suited to achieve data saturation when the study’s scope is narrow

(Malterud, Siersma, & Guassora, 2016; Power & Gendron, 2015).

Population and Sampling

I used purposeful sampling to select participants who have the prerequisite

experiences and skills necessary to address the study interview questions. Gentles,

Charles, Ploeg, and McKibbon (2015) stated purposeful sampling provides criteria for

researchers to select participants with specific skills, expertise, and education. A sample

size of six midlevel healthcare managers should offer the breadth of experiences,

knowledge, and perceptions of strategies for reducing the cost of patient care without

reducing the quality of patient care. According to Fusch and Ness (2015), a qualitative

researcher study can limit the number of participants to between three and six

participants.

Cridland, Jones, Caputi, and Magee (2015) stated the semistructured interview is

the most common type of interview that researchers can adjust to meet the needs of

various interviewees. Semistructured interviews are value-added for increasing the

reliability and validity of data collection based on the interviewee ’s knowledge and

understanding of the questions (Yin, 2014). I used semistructured interviews composed of

10 questions to facilitate with two to four subquestions to enable the participants to

address the main research question.

Morse, Lowery, and Steury (2014) stated the number of participants in a study

should enable the researcher to gather enough data to sustain researching the problem. A

sample size of six midlevel healthcare managers should provide suitable data and

saturation for this study (Yin, 2014). Morse et al. (2014) stated data saturation is the

means by which a researcher determines when there are sufficient data for exploring the

phenomenon. The target population consisted of six midlevel healthcare managers from

six acute care facilities in Virginia who developed and implemented strategies to reduce

the cost of patients’ care without reducing the quality of patient care. I solicited six

participants for this study based on input from the hospital’s human resources department

and the American College of Healthcare Executives national and local chapters, where I

am a member. I attained data saturation by gathering critical and substantial data through

interviews and focus groups. According to Fusch and Ness (2015), researchers will reach

data saturation when they have attained enough information to reproduce the study.

Morse et al. (2014) stated a researcher’s study achieves saturation when data collection

meets a threshold where no new information or themes emerge from study participants

and other types of data. According to Malterud et al. (2016), the selection of six

participants in a study should be an adequate sample size to achieve saturation when I no

longer receive information that adds to the development of my study.

Fusch and Ness (2015) asserted conducting interviews is a method a researcher

can use to obtain data saturation. Fusch and Ness (2015) stated there is no one-size-fitsall

method for a researcher to obtain data saturation; however, more is not essentially

superior than less. Qualitative researchers aim to explore and detect the key issues

associated with the phenomena; hence, no one-size-fits-all method for a researcher to

obtain data saturation; however, more is not essentially superior than less (Roy et al.,

2015).

The following five factors affect attaining data saturation within a qualitative

study: the scope of the investigation, characteristics of the target audience, expertise of the

research, resources, and research audience. Malterud et al. (2016) suggested the more

information a population of interviews presents relevant to the actual study, the fewer

participants the study will need to explore the phenomena. As the researcher, I reached

data saturation by focusing on controlling the scope of this study through established

restrictions that support a thorough exploration of participants’ feedback throughout the

case study (Fusch & Ness, 2015). The characteristics of my study participants were

homogenous. For example, participants sharing similar traits; hence, the target

interviewees will enable saturation for the reason individual interviews will share similar

responses to research questions (Condon et al., 2015). Roy et al. (2015) stated proficient

researchers rarely need a large group of interviews to acquire data saturation.

The sample size for this study was appropriate for this study because healthcare

managers are leading complex organizations with the responsibility for ensuring safety,

patient-care, cost management, and information-rich data regarding the phenomenon (Roy

et al., 2015). Fusch and Ness (2015) stated researchers must ensure data saturation within

their study to guarantee quality research and achieve validity. A researcher’s saturation of

themes determines the point at which one has sampled sufficient participants (Morse et

al., 2014). Robinson (2014) stated a researcher achieves theoretical saturation when

continued data collection results in no new emerging themes. At this point, the researcher

has gathered enough data to justify claiming to achieve data saturation (Fusch

& Ness 2015).

Ethical Research

Ethical issues and challenges vary across cultural sans regions; henceforth, respect

for participants, consent, and integrity are mandatory for any study (Vitak et al., 2016).

According to Bromley, Mikesell, Jones, and Khodyakov (2015), the researcher should

ensure one’s study is ethically acceptable by the participants, the studied organization, and

the institute the researcher seeks to gain approval. I took every measure to ensure

conducting this study complies with the highest level of ethical standards. I completed a

National Institute of Health (NIH) Protecting Human Research Participants course to

meet the basic requirements to conduct a study.

Ali and May (2017) stressed that researchers seek out voluntary participants by

determining if they satisfactorily understand the nature of the study and the consequences

of participating in the study. Vitak et al. (2016) recommended that the informed consent

document involves the researcher providing identified participants pertinent information

about the research while engaging the participants in writing to confirm their willingness

to be a participant in the study. I requested each participant to sign the informed consent

document. I informed the participants before and during the study that they could

withdraw from this study based on their desire, with no penalty. If they decided to

withdraw from the study, I would have asked the participant to send an email to

quincy[email protected] or call to inform me of their intent not to participate.

However, if participants neither called nor sent an email, I followed up with each

participant that had not confirmed their participation by phone, email, or certified mail.

The IRB board provides the researcher with the best opportunity to ensure the

study meets the prerequisites to conduct a successful study (Hudson & Collins, 2015). I

did not identify my study participants by name; however, I identified the geographical

location of the facilities where I conducted my study. I submitted my IRB application for

approval before seeking support from participants. I met with each participant before

engaging him or her for a signature in support of my study. I exercised characteristics

based on the Belmont Report three guiding principles that are (a) respect for the

participants, (b) beneficence, and (c) fairness in participant selection (Vitak et al., 2016).

As the researcher, I exercised professionalism throughout the entire study by

emphasizing timeliness, patience, adhering to defined protocol measures, and conditions

established within the participant’s consent form (Kass et al., 2015). Belmonte and

Opotow (2017) defined data archiving as the transfer of records from the participant to a

repository authorized to assess, preserve, and offer access to the participants’ records.

Data archiving is a process for storing, securing, and preserving research data and

resources for future research and continuations of similar studies (Wang, Kung, & Byrd,

2018).

I took every precaution to safeguard my participants’ information from loss and

damage. All data collected both electronically and manually will reside in a secure,

fireproof safe for 5 years. After 5 years, I will destroy all stored data.

Data Collection Instruments

Throughout this study, I was the primary instrument for data collection, using

open-ended, semistructured questions in face-to-face interviews with healthcare managers

or by Skype. McIntosh and Morse (2015) stated researchers should use semistructured

interviews to discover participants’ viewpoints about a phenomenon or situation relating

to the study topic. Kallio, Pietilä, Johnson, and Kangasniemimi (2016) stated

semistructured questions provide the researcher flexibility and the chance to address

issues that arise extemporaneously during the interview. I used Yin’s (2014) protocol

framework to structure my interview and improve the reliability of my case study. Yin’s

(2014) protocol consists of four sections: (a) an overview of the case study, (b) protocol

purpose, (c) data collection procedures, and (d) a guide for the case study report (see

Appendix A).

I aimed to conduct my interviews by asking semistructured questions in a logical

order. I decided to change the order each participant receives the interview questions if

the conversation flow of exchange stimulates the need to alter the order of the interview

questions (Crocker et al., 2014). As the researcher, I used open-ended semistructured

questions and additional questions as needed. Yin (2015) stated the researcher should

administer the same interview protocol to all participants to maintain consistency

throughout the study. The semistructured interview consisted of ten open-ended questions

to inspire participants to provide an in-depth understanding of the research question (see

Appendix B).

Yin (2014) stated the interview is one of the best techniques for conducting

qualitative research. Researchers can employ several methods to conduct an interview.

Three of these methods are face-to-face interviews, group interviews, and telephonic, for

example, Skype interviews. Based on Carter and Baghurst (2014), the researcher becomes

the instrument of data collection because they provide a means for participants to discuss

their experiences. Barnham (2015) stated the interview is a method distinguishable in

various research methodologies. Sutton and Austin (2015) recommended the researcher

audio record all interviews and analyze the findings by transcripts. As well, researchers

should use Skype when participants are difficult to garner a face-to-face interview. Data

obtained through Skype can provide an increased account of participant viewpoints on

patient-centered strategies an important theme of this paper (McIntosh & Morse, 2015).

As the researcher, I used a coding system to identify study participants and minimize

ethical concerns, confidentiality, and privacy. Sutton and Austin (2015) stated a researcher

should methodically read each line of the transcript and apply the code to ensure one

captures the participant’s conversation. Yin (2014) emphasizes that researchers establish a

protocol when conducting a qualitative study. I defined my interview protocol (see

Appendix A) with four sections: an overview, data collection procedures, data collection

questions, and a guide for the case study report. Before initiating this study, I restated to

the participants that their participation is voluntary; they had the right to withdraw at any

time, and that confidentiality would remain in effect throughout this study.

I safeguarded each participant’s data to ensure I adhere to Walden University

institutional review board (IRB) processes. As the researcher, I electronically submitted

my IRB form along with a description of the research proposal, data collection

instruments, research participants, and Federal Regulations applicable to this study. I did

not collect any data until receipt of approval from the Walden IRB committee.

As the principal data collection instrument, I coded participants’ experiences from

face-to-face, group, telephonic interviews, and Skype interviews. Participants’ perceptions

included discussion regarding reducing the cost of elderly care for patients and the

viability of patient-centered strategies to maintain quality patient care. Three issues

explored in the interviews include (a) use of midlevel healthcare managers, (b) patient-

centered strategies, and (c) elderly-dependent patients. Cypress (2017) stated the

reliability and validity of a data collection instrument are critical measures that extend

interviews’ answers by summarizing questions, goals, and objectives of the study.

Dependability is the qualitative equivalent of reliability within a quantitative design

(Hays, Wood, Dahl, & Kirk-Jenkins, 2016). Researchers can achieve reliability in a

qualitative study through consistency from using original sourced form and context

(Leung, 2015). Evaluating the reliability and truthfulness of a study aids in authenticating

the research findings (Elo et al., 2014). To achieve the reliability of the data collection

instrument, the researcher should explain to the participants the process and a list of

identical interview questions for each participant. To help ensure reliability in

interviewing, McIntosh and Morse (2015) recommended researchers request clarification

and follow-up information if the researcher is unclear about the meaning of the

information.

A quality control technique important for conducting a study that I used is member

checking. Member checking is a process of validating the credibility of participants’

results (Birt, Scott, Cavers, Campbell, & Walter, 2016). According to Birt et al. (2016),

participants can review the data they provided to the researcher for accuracy.

Member checking provides the researcher with the ability to reduce risk and

misunderstanding (Lub, 2015).

Data Collection Technique

The multitude of data collection techniques requires researchers to center their

techniques on a few versus the variety of techniques available to researchers. According

to O’Cathain et al. (2015), qualitative researchers should select from the following range

of data collection techniques to conduct their research telephone, face-to-face interviews,

focus groups, nonparticipant observation, case notes, paper, audio, video, diaries,

discussions in online chat rooms, and social media. Elo et al. (2014) stated a researcher

should select a data collection technique and analysis that support the framework of the

data collection and the overarching research question.

Snowball sampling is a method whereby researchers seek out additional

participants for their study based on their acquaintances and peers (Robert, 2015).

Snowball sampling provides a means for researchers to acquire participants that may

respond unlikely to a volunteer request due to the nature of the study (Robinson, 2014). A

disadvantage of snowballing is some of the participants may lack the mixture of

experiences and knowledge necessary to expand on the study (Palinkas et al., 2015).

Purposeful sampling is a method used by researchers when their study has a

clearly defined theoretical or conceptual framework (Leung, 2015). Additionally,

researchers who use purposeful sampling seek participants who provide relevant and

productive data about the questions developed for their study to provide a definite

explanation of the phenomenon (Cleary, Horsfall, & Hayter, 2014; Gentles et al., 2015).

Robinson (2014) noted snowball and purposeful sampling are both instrumental for

conducting qualitative research. Both of these sampling methods are useful for

maximizing efficiency and validity (Palinkas et al., 2015). I selected my participants

through purposeful sampling. A weakness of purposeful sampling is that the researcher’s

own bias with choosing the participants can impede one’s ability to draw inferences from

the participant pool (Etikan, Musa, & Alkassim, 2016). Baškarada (2014) asserted

researchers must guard against influencing the participants of the study that could skew

the data collection and analyses.

The primary data collection technique used throughout this study was

semistructured interviewing. Utilizing semistructured interviews provides the researcher

with the ability to conduct in-depth conversations with the interviewee based on

experiences expressed, perceptions and opinions garnered from the interviewee (Cridland

et al., 2015). Semistructured interviews provide the researcher freedom to ask additional

questions, adjust the order questions are given and adjust the intent of the questions to

gain a greater understanding of the subject discussed (Kallio et al., 2016). Cridland et al.

(2015) stated the researcher should encourage participants throughout their interview to

emphasize portions of the discussion they indicate important to the discussion.

The participants for this study received an estimate of the time I would spend with

each person and a list of predetermined questions. I used the interview questions to

conduct face-to-face interviews with each participant based on the combination of

literature reviewed and my personal experience and education. I used an alphanumerical

code to ensure I maintained confidentiality for all participants. A data analysis technique

I employed is member checking. Elo et al. (2014) stated member checking is a continuous

process researcher’s use during data analysis where participants can check the findings to

ensure they accurately reflect their experiences. Morse (2015) stated using member

checking improves the credibility of a researcher’s findings through increased

engagement and enabling observations of participants. Member checking can help ensure

the credibility of a researcher’s findings from recorded interviews of participants (Cope,

2014).

I developed follow-up questions to explore themes and ideas to help increase

clarity and stimulate discussion from interviewees while ensuring I maintained

participants’ privacy. Using a case study requires secondary data that can include archival

data, financial reports, and internal transcripts as provided by participants along with

participant interviews to accomplish methodological triangulation for this study

(Whitmore, Baxter, Kaasalainen, & Ploeg, 2018). I sought secondary data, for example,

internal publications and Joint Commission reports from participants.

Data Organization Technique

Employing data organization helps to ensure the researcher can prevent and

mitigate errors, and that the instruments and material used during the interviews are valid

and reliable (McIntosh, Kamei, Adams, & Hassan, 2016; Dikko, 2016). I collected data

via semistructured interviews to better recognize the participant's experiences and my

observations. The researcher who uses semistructured interviews can garner flexibility

with issues that are important to the participants (Cridland et al., 2015). Based on

Whitmore, Baxter, Kaasalainen, and Ploeg (2018), I employed semistructured interviews

supported through audio recordings and laptop for manual transcribing. Also, I established

a file system coordinated with labels where I will store each type of data, for example,

recordings, e-mail, and consent forms. I will secure all data collected via password-

encryption on a computer file and secure data within a fingerprint secure file container for

a minimum of 5 years. After 5 years, I will destroy all data collected to ensure participants’

confidentially,

Data Analysis

Qualitative data analysis requires the researcher to identify, sort, integrate, and

synthesize information gathered through observations, interviews, and other methods;

determine patterns and themes to answer the research question. Bengtsson (2016)

suggested that data analysis in qualitative research encompasses working with data,

organizing it, synthesizing it, and searching for themes and patterns. Yin (2014) suggested

that data analysis consists of five steps: collecting the data, coding the data into groups,

regrouping the data into themes, evaluating the information, and developing conclusions

or findings. Twining, Heller, Nussbaum, and Tsai (2017) agreed with Yin that data

analysis involves examining, categorizing, tabulating, testing, or combining evidence for

empirically constructed conclusions. Based on the nature of this study, my data analysis

followed the abovementioned Yin’s (2014) five steps.

Noble and Smith (2015) stated a researcher could improve credibility through

triangulation, which one can use to study a phenomenon. Morse (2015) stated

triangulation assures validity through verification for clarifying the phenomenon the

researcher is studying. The main purpose of triangulation is to confirm data and ensure the

data collected are complete and valid (Morse, 2015). Researchers can attain triangulation

of their case study by comparing various paradigms simultaneously and comparatively

(Lub, 2015). Researchers use methodological triangulation to assure the validity and

reliability of emergent themes through cross-checking, comparing, and contrasting

professional journals and previously studied data (Morse, 2015). I used methodological

triangulation to check and recheck, compare, and contrast the consistency of the findings

to ensure the validity and reliability of the results. I obtained the data and information for

this study by conducting semistructured interviews with six midlevel healthcare managers

from six acute care facilities located in Virginia. I also utilized archival documents and

online secondary data that includes financial reports, annual reports, mission statements,

and other working papers. Dun et al. (2015) stated the secondary data requires less cost to

obtain and is readily available eliminating the need to incentivize research participants.

Whitmore, Baxter, Kaasalainen, and Ploeg (2018) stated one could collect data during the

interviews with a digital recorder and via manual transcription to analyze the data.

Likewise, Hays et al. (2016) stated researchers involved with analysis use data to discern

significant themes, patterns, and descriptions that support the critical research questions

of one’s study. Scholars determined that data software tools are critical assets for

researchers when conducting analyses to finalize data captured from interviews and

manual transcripts (McIntosh et al., 2014).

Moreover, computer-assisted qualitative data analysis software (CAQDAS) is a

critical tool that provides researchers the capability to manage multiple tasks, organize

data sources, consolidate information according to themes, and identify patterns for data

(Talanquer, 2014). I used NVivo 12 software to support analyzing my data. NVivo is

software that specifically supports qualitative analyses as well as provides the researcher

immediate access to data results after input. Zamawe (2015) stated using NVivo enables a

researcher to code transcripts and audio files effectively and efficiently. I uploaded all

recorded data and manually-transcribed information into NVivo to organize, to code data,

analyze, and validate data.

Carter and Baghurst (2014) stated coding is a process that requires the researcher

to tag category data with type names or descriptive words and then group that data into

themes. I maintained the participants’ confidentiality throughout this study by using

standard initials that represent a title with a two letter and number combination. Chief

Patient Health Experience Officer (CPHEO A-1) Chief Population Health Officer (CPHO

A-2) and Chief Transformation Officer (CTO A-3) are examples of hospital

representatives. As such, coding of data is for identifying patterns and themes (Sturges et

al., 2015). Gale (2014) stated one should classify all of the data and link it methodically

with other parts and types of data. Once the transcription phase was complete, I

transcribed the participants’ interviews and uploaded it into NVivo 12 to facilitate

analyzing the data.

Reliability and Validity

Quality is a goal researchers’ aim to achieve within their study by assuring studies’

reliability and validity (Cypress, 2017). According to Hays et al. (2016), reliability

reflects the dependability of measures while validity is a concept concern with being

justifiable, accurate, and truthful. Failure to obtain saturation in case studies can

negatively affect the studies’ validity and reliability (Fusch & Ness, 2015). Transferability

resembles external validity, dependability mirrors reliability, and confirmability reflects

objectivity within a qualitative study (Hays et al., 2016).

Reliability

Morse (2015) described reliability as dependability, consistency, or repeatability of

a researcher’s data collection, interpretation, and analysis. Objective researchers seek to

enable other researchers to repeat their results using the same or similar methods. Noble

and Smith (2015) stated reliability describes the consistency of the analytical processes,

as well as accounting for participants and research method biases that might influence a

researchers’ findings. Noble and Smith (2015) stated the researcher could assess the

reliability of their study findings by making a judgment about the soundness in relation to

the application and appropriateness of methods accepted and the integrity of the

conclusion. According to Twining et al. (2017), a researcher establishes reliability for

their study when the data collection procedures replicate the same results. Cypress (2017)

stated researchers assert rigor in qualitative research through reliability and validity that

are essential components of quality. Hence, I assured reliability by checking this study for

repeat patterns, checking for processes’ consistency with response to the methods and

scored results of data, auditing interviews, and analyzing notes and data collected

throughout this study.

Dependability. Connelly (2016) stated dependability occurs when the researcher

establishes an audit trail to log research notes of all activities that occurred during the

study to review data captured during interviews and observations. A researcher achieves

dependability by using overlapping methods such as triangulation to ensure

trustworthiness (Morse, 2015). Cypress (2017) stated a researcher could enhance

dependability by having a doctoral committee review a researcher’s acquired themes and

descriptors for validity. Likewise, member checking provides the data for review by

participants to improve the dependability and credibility of data gathered during the study

(Pashaki et al., 2015). I employed member checking techniques to increase the

dependability of my study.

Validity

Noble and Smith (2015) stated validity refers to the truthfulness and application of

the methods used by researchers and how well the results of their study can be accurately

reproduce. Equally, the researcher should consider the validity of their study by framing

the discussion regarding conscientiousness, empathy, sensitivity, and respect (Lub, 2015).

Kern (2018) stated triangulation increases the assurance of validity and enhances the

researcher’s understanding of the studied phenomena. Kern (2018) concluded that

methodological triangulation results from the convergence of different data collected from

multiple sources on the same phenomenon, which assures the validity of the study. I

observed my participants and collected secondary material from the acute care facilities to

study the phenomenon through methodological triangulation. Hays et al.

(2016) described the validity of a qualitative study as credibility and transferability.

Credibility. Credibility is the qualitative equivalent to quantitative studies’

internal validity (Hays et al., 2016). Elo et al. (2014) stated that a central tenant of validity

is trustfulness. A researcher can meet the goal of truthfulness by approaching the analysis

phase of the study through preparation, organizing, and reporting on results. Researchers

who select a method suitable for others to understand their study design will help to

ensure the credibility of the study analyze (Elo et al., 2014). Baroudi, Chileshe, Hosseini,

Zuo, and Baroudi (2015) suggested achieving credibility in qualitative studies through

peer-debriefings conducted in face-to-face meetings and analytical memos to improve

findings. As such, a researcher can achieve credibility throughout their study for

similarities and consistencies. Triangulation is a means used to reveal as much depth as

possible in a study (Hyett et al., 2014). Hays et al. (2016) recommended researchers

employ triangulation to collect more data from additional sources as well as cross-check

their data for reliability to assure the validity of qualitative research. Henceforth,

triangulation enhances the credibility of a researcher's findings. I used NVivo 12 software

program to help facilitate finding themes and verbatim transcription from participants’

interviews with healthcare managers and administers.

Transferability. Transferability denotes the extent a researchers’ qualitative study

findings are transferable to other contexts and individuals which in quantitative studies

compares to generalizability (Morse, 2015). Transferability within a qualitative study

infers the findings of a study will enable others to advance or extend the original study or

provide research material that another individual can generalize for their research (Cope,

2014). Cypress (2016) stated purposive sampling enhances the transferability of the study

results. I positioned this study to meet the basic tenets for transferability by establishing

case study protocols and databases, for example, a protocol guide for case studies, data

collection procedures, and interview questions (Yazan, 2015;

Yin, 2014).

Confirmability. Qualitative researchers acknowledge that dependability,

credibility, transferability, and confirmability are analogous criteria to achieve

trustworthiness and ensure the rigor of qualitative findings (Anney, 2014). Cope (2014)

stated a researcher achieves confirmability in a qualitative study when the data represent

the participants’ responses and not the researcher’s biases or viewpoints. Connelly (2016)

stated confirmability is the neutrality or the degree researchers can repeat consistent

results. I ensured confirmability by conducting an audit trail to confirm findings,

interpretations, and recommendations supported by data (Chellan & Sibiya, 2018). I

utilized an audit trail to review and study all procedures, themes or categories identified,

and interpretations by implementing a running account of the process (Cypress, 2017). I

also used a reflexive journal to achieve conformability by recording all events, data

collection, analysis, and personal reflections (Anney, 2014). I retained a reflexive journal

to capture participants’ views to bracket observations and bias (Cope, 2014).

Data Saturation. Sutton and Austin (2015) stated a researcher achieves data

saturation after interviews with the new participant’s experience with the phenomenon in

question reveal redundancy among data set. Saturation occurs when a researcher can no

longer obtain new data and when further coding is no longer practical (Fusch & Ness,

2015). Palinkas et al. (2015) recommended researchers employ an iterative methodology

of sampling and resampling to ensure theoretical saturation occurs. I ensured data

saturation while achieving the goal of confirmability for this study. I utilized in-depth

interviews and field notes as a strategy for collecting data. According to Palinkas et al.

(2015), researchers use purposeful sampling in a qualitative study to help identify and

choose information-rich cases linked to the phenomenon of the research. Furthermore,

Robinson (2014) stated the sample size helps to ensure rigor and the appropriateness of

the sampling strategy. According to Yin (2014), a case study with 10 or few participants

could obtain data saturation essential for establishing credibility. Hence, I chose a sample

size of 6 participants for my study. Anney (2014) stressed that member checks are critical

processes for researchers; as the researcher must test all the data to alleviate internal

conflict in their quest for credibility and data saturation.

Transition and Summary

The purpose of this qualitative multiple case study was to understand what patient-

centered strategies healthcare managers use to reduce the cost of elderly patients’

healthcare without reducing the quality of patient care. I employed semistructured

interviews through audio recordings, a laptop, and publicly available documents to

explore the strategies and participants’ experiences. I used methodological triangulation to

assure credibility. I selected participants at the mid to upper levels of management who

work for a healthcare system that has implemented patient-centered strategies to reduce

the cost of elderly patient healthcare without reducing the quality of patient care.

The objective for this section was to describe the role of the researcher, the

participants for the study, the research methods and design, population sampling, ethical

research, data collection techniques, and analysis for assuring reliability, validity, and

transferability of the research instrument and data collection process. In Section 3, I will

complete the following: (a) the presentation of findings, (b) applications to professional

practice, (c) implications for social change, (d) recommendations for action, (e)

recommendation for future study, and (f) my principal conclusions.

Section 3: Application to Professional Practice and Implications for Change

Introduction

The purpose of this qualitative multiple case study was to explore what

patientcentered strategies healthcare managers use to reduce the cost of elderly patient

healthcare without reducing the quality of patient care. In Section 3, I provide a detailed

review of the data collected, the conceptual framework, and the findings related to the

research question. The data analysis findings provide awareness of strategies healthcare

managers employ that support PCC while ensuring a profit for their stakeholders. I

conclude Section 3 with recommendations for further studies, thoughts on my experience

while conducting this study process, and a summation of the study conclusions.

Presentation of the Findings

I conducted semistructured interviews with six midlevel healthcare managers who

have the responsibility for leading, developing, implementing, and monitoring PCC

strategies within their medical facilities located throughout Virginia. All of these

fullservice acute care facilities are complex adaptive systems that are ever-changing,

reactive, proactive, and distinctive within a natural environment. I collected the following

hospitals’ opened-sourced reported performance information as secondary data: the Joint

Commission Gold Seal of Approval Quality Report, The CMS Compare Datasets reports,

mission and vision statements, and list of the hospitals’ websites-leadership structure. I

coded all documents to maintain confidentiality and concealed each participant and their

facilities with the following codes: P1H1, P2H2, P3H3, P4H4, P5H5, and P6H6. The

codes H1–H6 denoted hospitals and P1–P6 denoted participants. The conceptual

framework that grounded this study included PCC and the valued-centered healthcare

model. I conducted data triangulation based on analysis of interview data, secondary data,

and the literature review. I used member checking and methodological triangulation to

ensure credibility, data saturation, and confirmability of data outcomes.

In this study, I explored the perceptions of healthcare managers concerning the

effects of the patient-centered model within their business model. The main research

question for this study was the following: What patient-centered strategies do healthcare

managers use to reduce the cost of Medicare patient healthcare without reducing the

quality of patient care? Throughout this study, I served as the primary instrument for data

collection using open-ended, semistructured questions in face-to-face interviews with

healthcare managers. The four themes that emerged from my data analysis were PCC

matters, management leadership strategies, control methods for monitoring cost, and

maximizing community healthcare services. I used NVivo 12 analysis software to

organize and evaluate my data and link comparable coding categories together for the data

analysis. The data analysis process I used comprised compiling, disassembling, and

reassembling data to arrive at my four major key themes. In summary, Section 3 covers

the following topics: (a) an introduction (b) a detailed presentation of the findings, (c)

applications to professional practice, (d) implications for social change, (e)

recommendations for action, (f) recommendations for further research, (g) personal

reflections of the study, and (h) a conclusion.

The primary research question for this study was: What patient-centered strategies

do healthcare managers use to reduce the cost of elderly patient healthcare without

reducing the quality of patient care? Effective strategies within a healthcare organization

are about making choices necessary to differentiate one organization from another to meet

their customers, for example, patients and stakeholders, needs (Porter & Lee, 2015).

According to Lee et al. (2016), value-based payment models stimulate the delivery of

efficient, high quality, PCC through financial penalties and rewards. The frequency of the

codes and the resultant four themes aligned with the conceptual framework of this study.

Table 2 shows the frequency of references to the key themes that I derived from the data

triangulation process, which included documents reviewed, interviews, personal notes,

and peer-reviewed literature.

Table 2

Frequency of Themes and Number of Participants

Description of themes

Frequency of

theme

reference

Occurrences

Patient-centered care matters

P1, P2, P3,

P4, P5, P6

Leadership strategies

P1, P2, P3,

P4, P5, P6

Cost reduction strategies

P1, P2, P3,

P4, P5, P6

Maximizing community healthcare services

P1, P2, P3,

P4, P5, P6

Theme 1: Patient-Centered Care Matters

All six participants in this study identified the importance of implementing a PCC

model within a system that emphasized value-based health services, cost reduction, and

value for the patient. Participants’ responses revealed the importance of training and

monitoring staff to evaluate their ability to provide and communicate effective PCC. P5

noted H5 staff annually participate in training to meet regional and state regulations per

the CMS. P2 noted the treatment team has the responsibility to educate the patient and

family to ensure they understand the treatment plan and who will be delivering the

treatment. P2 further stated, “A good treatment plan would eliminate wasted time the

medical treatment team spends with the patient that in turn will reduce labor cost and

employee burnout.” P4 noted that as an executive director, all staff members including

medical, support services, and administration personnel receive training on customer

service and the importance of using multiple forms of communications in support of

enhancing the patient’s experience. P5’s responses confirmed participants 1, 2, and 4’s

reactions by stating, “When you have a well-trained staff, and everybody is doing what

they are supposed to do based on their training, you find that patient-centered care quality

goes up.” P1 stated,

Across all specialties, patient-centered care not only reduces costs but also

through good communications, the care team can keep that patient at the center of

their care, which helps to ensure the patient buys into the proposed treatment plan

that the care team wants to provide the patient.

October et al. (2016) denoted a similar finding and underscored that good communication

decreases conflict between the medical team and families as well as increased family and

patient trust and satisfaction with care. P4 stated, “We have been looking at asking the

patient what we can do better for you.” According to Castro et al. (2016), several

initiatives healthcare organizations have implemented are patient participation to help

improve quality of care, increase patient safety, and increase patient satisfaction. To help

meet this challenge, all of the participants noted their use of morning huddles to address

the needs of patients and set goals for the patient and team members. Ghorob and

Bodenheimer (2015) confirmed that high performing facilities that employ huddles are

associated with improved care, better patient experience, and considerable staff

satisfaction. P4 noted the executive team also conducts a daily huddle to synchronize

activities, identify gaps, and fill those gaps to ensure they are meeting the needs of their

patients.

P1 explained the benefits of using huddles within the PCMH model to ensure the

patient’s needs are communicated and synchronized among the care team, the patient, and

family. P1 stated,

The patient-centered medical home model has been around for a while having the

patient receive treatment for their recovery/aliment at home by a care team that

communicates to each other and the patient regarding the management of services

and care.

P1 noted that PCMH was instrumental for reducing cost and keeping the patient at

the center of that care, making sure they buy into their care. According to Ehrenberg et al.

(2016), healthcare leaders who support patient-centeredness in their delivery of care models

have shown increased functional capacity and decreases in the mortality rate of elderly

patients. Shi et al. (2017) surmised that PCMH has been a critical model for servicing low-

income, racial, and ethnic minority patients in medically underserved and rural areas. P6

noted that H6 routinely incorporates PCMH as a strategy to step down the patient’s level of

care from an inpatient acute care setting to a home healthcare setting. P6 added, “We utilize

PCMH to help reduce the cost of patient’s healthcare, emergency department visits, and

readmission rates.” P3 noted H3 aims to focus their teams, led by providers along with

paraprofessionals and nurses to engage routinely with their patients. P3 further stated, “H3

leadership will often employ their paraprofessionals and nurses to the extent of their license

so that they can meet the patient's needs potentially without even engaging the provider

with routine management.” Participants 1, 2, and 4 noted the value of PCMH as a model

for keeping patient-centered, enhancing quality improvement processes, and supporting the

implementation of preventive care programs. According to Bilello et al. (2018), the PCC

model advocates within a PCMH setting that the patient remains central to their care

delivery, which is essential for ensuring high-quality care and better patient outcomes.

Building well-trained staffs, supporting good communications among care teams

and patients, communicating patient’s concerns through huddles, and leveraging PCMH

to improve patient access and value are components of the patient-centered theory and

value-centered healthcare model. The findings align with the conceptual framework of the

patient-centered theory and a value-centered healthcare model. The participants explained

the importance of implementing a PCC model within a system that emphasized value-

based health services, cost reduction, and value for the patient. This study demonstrated

(a) communication, (b) access to care, (c) continuity of care, (d) comprehensiveness, (e)

coordination and communication, (f) cultural competency, (g) safety, (h) family and

person focus; and (i) educating the patient and family contributed to PCC matters

(Chumbler, Otani, Desai, Herrmann, & Kurz, 2016; Lim & Kurniasanti, 2015).

Additionally, all six participants discussed and concurred on the value of implementing a

PCC model through their perceptions based on the primary research question. The

participants’ responses, documents, literature review, and current research provided

information that helped to identify the key theme PCC matters.

Theme 2: Leadership Strategies

P3 stated, “A key leadership strategy H3 staff has implemented in support of

patient-centered strategies is to make the organization fit the patient flow.” According to

DiGioia Lorenz, Greenhouse, Bertoty, & Rocks (2010), a critical leadership step in

improving patient-centeredness is care flow mapping that leadership can use to

understand patients’ desires through the lens of the patient and family. P4 noted H4’s

management uses continuous quality improvement strategies to address areas in which

their performance fails to meet the patient’s needs. The participant’s statement aligned

with the evidence presented by Henke et al. (2018) that healthcare leadership and

stakeholders are investing in infrastructure and technology to improve patient flow, share

transfer information and collaborate across care settings to meet patients’ needs and

quality of care based on clinical best practices.

P3 stated, “H3 leadership continuously looks to leveraging their staff, for example,

case managers to take on complex cases to reduce the volume and care for those

individuals categorized as chronic high utilize patient (CHUP) that are considered high

prescribers.” Participants 1, 6, 3, and 4 noted their facilities’ leaders rely of various data to

measure the effectiveness their staffs are meeting PCC goals and value. P1 stated, “H1

leaders consistently review emergency department (ED) trends to determine if patients are

seeking routine care at ED’s vs. seeking service with their primary care team.” P6, noted

H6 leadership considers multiple key performance indicators like length of stay,

readmissions rates, percentage of our patients discharged to community, and their function

independent measure scores, to develop strategies to improve PCC, quality, and cost

reductions. P6 further noted H6 leadership utilizes benchmarks data to compare their

performance against their competition to develop strategies to improve areas they are

underperforming. Participants 6, 5, and 2, noted a leadership strategy used within their

organizations focuses on retaining and recruiting experience and trained labor. All

participants expressed challenges in retaining nurses and other staffs to meet the needs of

their patients. P4 noted H4’s leadership is beginning to employ strategies that address

changing the culture among teams and management to improve communication to

improve patient-centered delivery of care. P4 added, “H4 leadership is leveraging

continuous quality improvement committees (CQIC) to improve training sessions by

communicating daily email messaging delivered periodically throughout the day to keep

staff abreast of trends and safety concerns.” P6 noted H6’s board of directors are sharing

data gathered from their quality improvement committee or Council with management to

ensure actions implemented reflex the concerns of patients and directors who participate

in those committees. This finding is in alignment with Pomey et al. (2015) who concluded

that healthcare leaders are increasingly integrating patients as members of their

organization’s continuous quality improvement committees to aid with improving PCC by

incorporating their experiences to redesign health and healthcare services.

Healthcare leaders are employing strategies to improve patients-centered care to

address better patient’s needs, values, and concerns through increase care practices

garnered through data that align with the conceptual framework value-centered healthcare

model and patient-centeredness theory. All six participants elaborated their use of data

collected through various modalities that include patient flow mapping, continuous

quality improvement committees, and benchmarking to improve the continuum of care

and develop strategies to reduce patient’s cost. The data derived from semistructured

interviews, documentation collected, and the literature view directly correlate to the

importance of effective leadership strategies. Additionally, the participants’ leadership

strategy aligns with complex adaptive systems that are ever-changing, reactive, proactive,

and distinctive within a natural environment correlates with the conceptual framework for

this study.

Theme 3: Cost Reduction Strategies

All participants agreed that lowering the cost of care was critical to their success

as healthcare managers. Honaganahalli, Melissa-Gateley, and Neufeld (2017) summarized

those healthcare organizations that support PCC could reduce patient’s short-term and

long-term morbidity, that in turn, positively impacts lower long-term healthcare costs.

According to Huang (2016), patient access and long waits continue to impact staff

productivity, quality, and increase healthcare cost. P1 noted maximizing patient access,

and scheduling have reduced cost for H1. P1 indicated even across specialties; reduced

cost occurred because of improved communications between patients and case

management. Bard et al. (2017) stated healthcare manager’s current challenges to provide

quality care while reducing cost increases in complexity when leadership must also

consider competition, problematic scheduling, and an elderly population with recurring

chronic illnesses. Participants 1, 2, 4, and 6 noted their facilities leadership supports

primary and post-acute care throughout their hospital to coordinate on behalf of the

patient to provide the best care, reduce duplication of services, and alleviate unnecessary

cost to the patient. P2 stated, “Leadership goals at H2 are to leverage the right labor based

on the patient's needs.” P2 further noted, “Paraprofessionals perform treatments under the

directions of the provider. Hence, you want your more expensive labor (physicians, etc.)

doing things that only they can do like assessment and complex treatment. All follow-up

treatment, routine activities, you want to make sure your cheaper labor pool (para-

professionals, nurses, etc.) conduct those tasks, which is a cost-effective approach to

treating patients.”

Participants 3, 4, and 6 noted educating their patients on the cost of pursuing care

from their primary care team versus seeking care at the emergency room is a strategy their

facilities senior leadership are employing to help reduce patient’s cost. Cosgrove et al.

(2013) denoted similar findings that healthcare leaders should use patient-centered

communication to aid with achieving faster recovery, improved clinical outcomes, better

care experience, and fewer diagnostic tests and referrals. Pourat et al. (2015) noted the

cost of care decreased and the continuity of patient’s care increase when patients sought

care with their primary care provider instead of visits to emergency rooms.

Another strategy all participants noted was the use of Hospital Consumer

Assessment of Healthcare Providers and Systems (HCAHPS) to measure consumer’s

satisfaction. Farley et al. (2014) indicated a hospitals performance is one of the most

critical measures for obtaining the CMS financial incentives as stated in the PPACA (P.L.

111-148, Section 3001) that authorized the establishment of the Hospital Value-Based

Purchasing Program. According to Chumbler et al. (2016), patients’ satisfaction correlates

with the frequent use of health services and influences both patient compliance and the

continuity of care. P2 stated, “Our leadership receive HCAHPS Surveys on a week to

week basis from Press Ganey Associates, an HCAHPS administrator. HCAHPS surveys

give us feedback via a scoring process based on percentages that provides this facility a

ranking in comparison to the other healthcare facilities.” P1 noted H1 leadership makes

ever attempt to meet their patients’ needs by reviewing HCAHPS, compliance officer

feedback, and feedback from Joint Commission surveys. All participants indicated that

HCAHPS surveys are effective tools management uses to develop strategies necessary to

focus resources on improve PCC that support optimize future payments.

According to Elf et al. (2017), an essential criterion for value-based healthcare is

an organizations strategy to transition towards reimbursement for patient’s complete care

cycle as oppose to a single care provider. P2 and P3 noted their leadership must ensure the

medical staff present are capable of supporting all patients seeking care. This issue

continues to be a problem as efficiency of care and crowding affect disproportionately

patient satisfaction that, in turn, negatively influences HCAHPS surveys (Farley et al.,

2014). P6 stated, “Maintaining a sufficient nursing staff is a big challenge for many

organizations that can compromise safety and care for patients.” P6 noted that H6’s

human resources department have developed programs focus on boosting employee

morale, training as well as external recruitment strategies to attract more nurses to their

hospital.

Moreover, healthcare managers that employ and recruit well-trained staff

sufficiently to meet the patient population they serve will improve their opportunities to

secure positive HCAHPS surveys. Crilly et al. (2015) indicated that crowding has

negatively impact patient delivery of quality care in the areas of safety, timeliness,

patient-centeredness, efficiency, effectiveness, and equity. Schreyer and Martin (2017)

noted crowding has influenced staff stress, retention, prolonged inpatient lengthen of stay,

and increased cost across the patient’s continuum of care.

Healthcare leaders are employing cost reduction strategies that expand on the

conceptual framework of PCC and the value-centered healthcare model by reviewing

HCAHPS and Joint Commission surveys, leveraging labor based on patient needs, and

educating patients to utilize their primary care team versus seeking treatment through an

emergency room. All six participant concurred that HCAHPS surveys are useful tool that

improve PCC and optimize future payments that correlates with the conceptual

framework of PCC and the value-centered healthcare model. In analyzing the

openedsourced reported performance information retrieved from all participants’ facilities

and the literature review, cost reduction strategies seemed to be an accurate assessment of

what healthcare leaders are implementing to accomplish value-centered healthcare.

Korenstein et al. (2016) expanded on the conceptual framework of value-centered

healthcare by noting that value equates to the balance between care quality (in terms of

patient satisfaction and health outcomes) and costs, though specific delineations as

defined by various healthcare organizations business models.

Theme 4: Maximizing Community Healthcare Services

Many healthcare facilities have not accounted for the total cost patients sustain

related to the price for quality (Lee et al., 2016). According to Bernhardt et al. (2016), the

expenses related to many elderly patients’ care includes substantial medical,

pharmaceutical, and surgical services, adapted housing, and extensive support from

family and other community based supportive services makes 65 years old and older the

most expensive phase of life for most Americans. A strategy many hospitals that support

rural and under-deserved populations have used are collaborations with community-based

healthcare centers. The ACA implemented the extension of health centers as a vital part of

its strategy for ensuring that rural, under-deserved populations, for example, elderly and

low-income, would gain access to quality healthcare (Shin et al., 2015). P5 noted one of

H5 goals is to return patients identified from rural communities with resources established

through healthcare centers to ensure a continuum of care. P6 stated, “Our job is to make

sure the patient continues to get care and are progressing fast enough that they can live

independently in their community and home performing daily living activities.”

According to Shi et al. (2017), an emphasis on using healthcare centers has improved

accessible, cost-effective, and high-quality primary care and has helped to reduce health

disparities. P1 stated, “We collaborates with the patient’s community healthcare center to

provide a continuum of care which is another way the community has embraced,

providing care not just for the elderly, but to the entire population of patients that

otherwise would not get their care and would be an emergency room.” Community

healthcare centers have been a crucial component of the U.S. safety net system.

According Nguyen, Makam, and Halm (2016), the safety-net system is a mix of public

hospitals, clinics, community health centers, and other healthcare organizations

distinguished by their shared mission to provide care to individuals regardless if the

patient uses Medicaid, Medicare, private insurance, or no ability to pay for healthcare. P2

noted, “Providing quality healthcare in the community of the patient is value-added

because when a patient does not like the care at one hospital vs. the next, they will choose

to seek care in another community if they feel the services for certain care is of a lesser

quality in their healthcare service area.” Leveraging community collaboration to meet the

needs of patients can help to establish stability in their lives and improve their health and

quality of life as well as considerably reduce cost (McCulloch, 2017).

Other strategy healthcare leaders are using to deliver and promote the continuum

of healthcare within the community for patients is telehealth. Neville (2018) defined

telehealth as a collection of electronic communication methods used to provide enhanced

patient care and education for the patient and family. According to Doarn (2016),

telehealth has increased access to healthcare for patients living in remote and underserved

areas. P1 stated, “Our organization and several other organizations in the community are

going to clinical video telehealth where the patient receives care in their home, and the

providers and or specialists can remain at the Medical Center to treat the patient.

Participants 2, 3, 4, and 5 discussed similar strategies for utilizing telehealth to improve

outcomes and patient access to care to reduce emergency room visits, chronic diseases,

post-acute care, and readmission rates from long term care. Participants 1, 2, 3, 4, and 5

acknowledged telehealth has improved patient access to high-quality healthcare particular

when great distances separate the provider and patient. P1 noted that PCC remains a

critical function within telehealth. P1 stated, “If the patient agrees, we will set them up

with home telehealth and follow and track the patient with a registered nurse and other

members of the patient’s care team for post-acute care.” According to Neville (2018),

telehealth is changing the daily delivery of care by reducing outpatient visits, increasing

medical staff capacity to focus on diagnosing and treating patients sooner, considerably

reducing trauma center cost, and closing the spatial distance for patient’s access to quality

healthcare who reside in rural areas.

By using the conceptual framework for this study, both patient-centeredness and

value-centered healthcare models serve to recognize the need for healthcare managers to

implement strategies that support and maximize community healthcare organizations. All

six participants elaborated their organizations are using telehealth to help meet the needs

of patients in the most restrictive environment which correlates with the conceptual

framework of value-based healthcare by using innovations that support the elements of

PCC: access, continuity, comprehensiveness, coordination and communication, cultural,

and person focused. The semistructured interview process and organization documents

further confirmed valued-based care in the theme maximizing community healthcare

services. The documentation collected outlining the strategy of collaborating with

community-based healthcare centers used by healthcare leaders in their organization,

supported the importance of PCC strategies. The findings of this study support the

conceptual framework that healthcare managers are embracing PCC and a value-based

healthcare model based on their organizations strategies to reduce patient cost by serving

patients in their community as authorized through the ACA.

Applications to Professional Practice

The findings of this study illuminate patient-centered strategies healthcare

managers can use to reduce the cost of elderly patient healthcare without reducing the

quality of patient care. The four themes that emerged from the data analysis were PCC

matters, management leadership strategies, control methods for monitoring cost, and

maximizing community healthcare services. While this research offers meaningful

information for healthcare managers that support a rural population, these strategies are

applicable across all populations. According to Shin et al. (2015), the largest population of

low-income patients receiving healthcare from federally-funded community centers are

working adults at 61% and children at 32%, and elderly adults at 7%. However, the 7%

served are costing the most to treat based on their individual needs. An aging population

of people living with chronic illnesses today have increased the demand for complex care

and social services and add to rising healthcare cost (Williams-Roberts, Abonyi, &

Kryzanowski, 2018). Healthcare managers can apply the findings of this research to their

business practices of managing and leading healthcare facilities, continuous process

improvement teams, and stakeholders to enhance their implementation of PCC to meet

the needs of patients, their families, and staffs. The findings of this study could assist

healthcare managers to develop other processes to meet the needs of patients that live in a

rural area by combining patient’s HCAHPS surveys and community healthcare. The

findings show that healthcare leaders are utilizing various strategies to help reduce elderly

patient cost without diminishing the quality of a patient care. The results support the need

for managers to continue developing strategies that meet the various desires of patients.

The findings of this study advocate the importance of communication between the patient,

family, and care team. In addition, the lines of communication between healthcare

manager, healthcare providers, and other stakeholders should maximize feedback received

from patient’s surveys and turned into actionable strategic objectives that help to meet the

needs of patients. The results from this study could help improve patient safety and care

coordination, which the CMS track to measure the delivery of quality healthcare service.

CMS reports patients discharged to post-acute care facilities have seen a reduction in

readmission rates based on improve communication, medication safety, innovated care

planning, and improve emphases in training staff at medical facilities that treat Medicare

and Medicaid patients (Kripalani, Theobald, Anctil, & Vasilevskis, 2014). The results

from this study may enable healthcare managers to consider keeping the patient and

integral member of the patient’s treatment and proactively implementing measures to

improve patient satisfaction. Also, the results support acknowledging that the voice of the

patient is credible and that promoting health literacy through multiple mediums for

patients, caregivers, and family members supports strategies to reduce out of pocket

medical cost.

Implications for Social Change

Healthcare managers with the responsibility to develop strategies that help reduce

the cost of patient healthcare while ensuring the quality of care remains are value added in

today’s healthcare industry. According to Bauer et al. (2014), healthcare leaders are

accountable for the delivery of care and the payment models that incentivize providers for

delivering quality care and achieving good metric outcomes. Conversely, experienced

healthcare leaders that implement strategies to improve healthcare efficiencies and the

delivery of PCC are critical within a modern healthcare environment. Similarly, Sfantou

et al. (2017) stated PCC matters when quality of care is a vital component for attaining

superior productivity within a healthcare facility for patients.

The implications for positive social change for this study embrace the importance

of including the patient, the patient’s family, and caregiver among the critical stakeholders

in developing the patient’s treatment plan. Another positive social change from this study

may benefit the development of leadership strategies that support care team and

physicians actively engaging their patients to participate in their treatment planning.

Educating the patient, their family, and caregiver on the importance of their participation

in their care through correspondence when entering a healthcare facility may improve

HCAHPS surveys. According to Delany (2018), Australia has seen a great deal of success

actively engaging patients through correspondence on the standards of PCC that they can

expect from their care team, which has enhanced the safety and quality of care provided.

Other implications for positive social change are the development of cost

reduction strategies to improve use of resources through improved communication

between the patient, care team, and other ancillary support staff. Conversely, healthcare

facility leaders that fail to address the amount of waste in their facilities will eventually

find their bottom-line disappear. According to JAMA, researchers have determined that

healthcare spending accounts for 20 percent of the U.S gross domestic product with 2.5

percent accounting for as waste (Carroll, 2017).

Recommendations for Action

I recommend several actions for all healthcare managers charged with delivering

and managing healthcare regardless of the demographics being service. Novice and

experienced healthcare leaders should embrace lifelong learning, as such; the

recommendations from this study apply to promoting PCC strategies in all healthcare

environments. The key themes expressed in this study included: (a) PCC matters, (b)

management leadership strategies, (c) control methods for monitoring cost, and (d)

maximizing community healthcare services. Addressing the themes present opportunities

for healthcare leaders and those charged with developing policies to continue promoting

the importance of patient-centeredness when structuring cost models and strategies that

support value-based incentive payments.

Conversely, this will shape increase discussion for the delivery of healthcare as

healthcare leaders continue to look within their ranks to structure strategies and staffs to

meet the needs of patients, families, caregivers, and stakeholder objectives. Action from

this study may encourage an increase in dialogue between C-suite leaders and middle

management where staffs are providing services to patients. According to Vaughn et al.

(2014), C-suite leaders in higher-performing hospitals have shown to be more effective at

communicating and modeling their vision of quality care by fashioning a culture that

supports an expectation that staff and leadership will work across traditional boundaries to

improve quality. Further, according to several participant’s feedback, middle managers

would embrace more interface with C-suite leaders where the continuum of care takes

place. The implementation of successful leadership strategies could contribute to a

healthcare facility by improving C-suite and management commitment to monitor

performance based on predetermine patient-centered goals that ensures shared feedback

and accountability to key stakeholders, staff, and the community they serve.

Recommendations for Further Research

The subject matter of exploring patient-centered strategies healthcare managers

use to reduce the cost of elderly patient healthcare without reducing the quality of patient

care merits further research given the lack of studies that focus on elderly patient care.

Below are three limitations to this study that may provide transparency for future

research.

1. The analysis for this study only included hospitals that served a large

population of rural patients. This focus was justified to get an account of

patients receiving care from acute care facilities; however, this excluded

patient care centers and other community-based treatment centers that serve

elderly patents.

2. A second limitation, beyond the design of this study, was the lack of additional

measures and methods in the evaluation set; these methods include survey

instruments, PCC meta-measures, patient outcomes, quality measures,

participant observation, and process evaluation. The results of this study may

100

have varied if the researcher examined the problem using all the methods

above to develop a comprehensive methodology that support understanding of

how healthcare managers apply PCC in different medical locations.

3. Third, all the participants were non-medical degreed healthcare managers with

multiple years of experience leading teams and staffs, which may limit the

generalizability of the findings.

Reflections

As a student and facilitator of healthcare policies and strategy development, I was

knowledgeable of the various models employed by healthcare administrator. I took every

effort to minimize bias throughout this research process by remaining neutral and

objective during the interview and secondary data research process. Throughout the

interview process, I was able to gain a greater understanding of the challenges healthcare

managers’ experience in their employment of patient-centered strategies to provide the

highest quality of care while keeping an eye on the costs associated with the delivery of

care. I had no prior knowledge of or relationship with the participants; henceforth, the

task of gathering participants willing to participate in this study was not easy. However,

the participants selected were experts based on their years of experiences and knowledge

of PCC and openness to support my research. Each participant felt comfortable with my

interview techniques, questions presented, and length of time spent during their interview

session. I gave all participants a chance to add or change their interview transcription to

ensure reliability and validity throughout the interview and data collection process. Using

101

triangulation, secondary data, literature reviews, and member-checking immensely aided

in developing the findings presented for this study.

Conclusion

The focus of this study from its conception has been to explore what

patientcentered strategies healthcare managers use to reduce the cost of elderly patient

healthcare without reducing the quality of patient care. According to Norman (2019),

fifty-five percent of Americans consider the affordability of healthcare the number one

concern for the past five Gallup listing of problems facing the United States.

Notwithstanding, healthcare spending in the US accounts for 18% of the gross domestic

product, which continues to strain the federal, state, and individual budgets (Johnson et

al., 2015). Because healthcare leaders are a significant driver for a healthcare facilities

financial success, they must demonstrate an ability to develop and monitor cost-reducing

strategies that promote CMS value-based incentives, while remaining vigilant of what

strategies work and those processes to improve those strategies considered ineffective.

According to Elwyn et al. (2014), healthcare managers must institute PCC at its core

values and continuously monitor and assess the outcomes of PCC to ensure the care team

collaborates with the patient in their delivery of care.

The findings from this case study showed that healthcare managers are using

multiple strategies to reduce patient cost while ensured their patients receive quality PCC.

Healthcare managers who exercise excellent communication skills with providers, staff,

and patients are seeing improved CMS surveys that in turn are increasing value-based

102

incentive payments for their healthcare facility. Several areas all participants have seen

improvements based on communication among their stakeholders are improve safety

outcomes, enhanced patient experiences, a reduction in waste as determine through

continuous improvement committees, and greater patient-care team satisfaction.

Moreover, the findings of this study provide strategies managers have found effective to

deliver quality cost-effective PCC as well as an opportunity for others to look within their

organizations to assess the viability to implement some of the strategies identified in this

study.

I recommend healthcare leaders continue to build relationships with other

community-based facilities in their communities. The least amount of risk a large hospital

facility could consider is an affiliation with a community partner. As the uncertainty of

healthcare delivery and the complexities of adjusting payment models that support

patient-centeredness, out of pocket cost containment and reduction, and a continuum of

quality care remains a concern for Americans, healthcare leaders may benefit their

organizations footprint and bottom line through community based strategic partnerships

and telehealth.

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