Predictors of Patient Activation Among Underserved Patients in a Nurse-managed Health Center: A Pilot Study

The concept of patient activation has gained traction as the term referring to patients who understand their role in the care process and have “the knowledge, skills and confidence” necessary to manage their illness over time (Hibbard & Mahoney, 2010). Improving health outcomes for vulnerable and underserved populations who bear a disproportionate burden of health disparities presents unique challenges for nurse practitioners who provide primary care in nurse-managed health centers. Evidence that activation improves patient self-management is prompting the search for theory-based self-management support interventions to activate patients for self-management, improve health outcomes, and sustain long-term gains. Yet, no previous studies investigated the relationship between Self-determination Theory (SDT; Deci & Ryan, 2000) and activation. The major purpose of this study, guided by the Triple Aim (Berwick, Nolan, & Whittington, 2008) and nested in the Chronic Care Model (Wagner et al., 2001), was to examine the degree to which two constructs– Autonomy Support and Autonomous Motivation– independently predicted Patient Activation, controlling for covariates. For this study, 130 nurse-managed health center patients completed an on-line 38-item survey onsite. The two independent measures were the 6-item Modified Health Care Climate Questionnaire (mHCCQ; Williams, McGregor, King, Nelson, & Glasgow, 2005; Cronbach’s alpha =0.89) and the 8-item adapted Treatment Self-Regulation Questionnaire (TSRQ; Williams, Freedman, & Deci, 1998; Cronbach’s alpha = 0.80). The Patient Activation Measure (PAM-13; Hibbard, Mahoney, Stock, & Tusler, 2005; Cronbach’s alpha = 0.89) was the dependent measure. Autonomy Support was the only significant predictor, explaining 19.1% of the variance in patient activation. Five of six autonomy support survey items regressed on activation were significant, illustrating autonomy supportive communication styles contributing to activation. These results suggest theory-based patient, provider, and system level interventions to enhance self-management in primary care and educational and professional development curricula. Future investigations should examine additional sources of autonomy support and different measurements of autonomous motivation to improve the predictive power of the model. Longitudinal analyses should be conducted to further understand the relationship between autonomy support and autonomous motivation with patient activation, based on the premise that patient activation will sustain behavior change.

EXISTENCE OF UNUSED MANAGED CAPACITY ON DEDICATED LANES AND AN ALTERNATIVE ON HOW TO SELL IT VIA AUCTIONS

This dissertation verifies whether the following two hypotheses are true: (1) High-occupancy/toll lanes (and therefore other dedicated lanes) have capacity that could still be used; (2) such unused capacity (or more precisely, “unused managed capacity”) can be sold successfully through a real-time auction. To show that the second statement is true, this dissertation proposes an auction-based metering (ABM) system, that is, a mechanism that regulates traffic that enters the dedicated lanes. Participation in the auction is voluntary and can be skipped by paying the toll or by not registering to the new system. This dissertation comprises the following four components: a measurement of unused managed capacity on an existing HOT facility, a game-theoretic model of an ABM system, an operational description of the ABM system, and a simulation-based evaluation of the system. Some other and more specific contributions of this dissertation include the following: (1) It provides a definition and a methodology for measuring unused managed capacity and another important variable referred as “potential volume increase”. (2) It proves that the game-theoretic model has a unique Bayesian Nash equilibrium. (3) And it provides a specific road design that can be applied or extended to other facilities. The results provide evidence that the hypotheses are true and suggest that the ABM system would benefit a public operator interested in reducing traffic congestion significantly, would benefit drivers when making low-reliability trips (such as work-to-home trips), and would potentially benefit a private operator interested in raising revenue.