Reseerchin Nursing & Health, 1992, 15, 285-294
The Organizational Environments and Services of VNAs and Hospital-Based Home Health Care Agencies Mary E. Burman
Visiting Nurse Associations (VNAs) and hospital-based home health care agencies (HBHHAs) were used to explore the impact of organizational environments on agency services. Disproportionate stratified random sampling, based on type and region of agency, was used to select the agencies. Seventy-three percent (120 HBHHAs and 156 VNAs) responded to the mail survey. Differences were found in the environments of the two types of agencies in funding and referral sources, amount of competition, accreditation by external bodies, and involvement in professional organizations. In terms of services, HBHHAs provided more types of high-tech services and were more likely to use external arrangements to provide services than VNAs. The organizational environment did have an impact on agency services. Medicare funding and referral sources, as environmental factors, had an impact on agency services. 0 1992 John Wiley & Sons, Inc.
Home health care agencies operate in a turbulent environment: competition has increased due to a greater number of providers, funding sources have altered reimbursement policies, and consumers have made demands for more quality services (Harrington, 1988; Pesznecker, Horn, Werner, & Kenyon, 1987; kttigrew, h e r , & Shaughnessy, 1988; Spiegel, 1987; Spohn, Bergthold, & Estes, 1988). Home health care agencies range from institutional-based to free-standing community agencies and differences have been found in the organizational environment of these types of agencies (Balinsky & Rehman, 1984). However, the nature of the organizational environment in home health care has not been clearly documented. Moreover, the impact of the organizational environment on services provided by home health care agencies has not been systematically investigated. Therefore, the purposes of this study were to (a) compare the organizational environments of
home health care agencies, specifically visiting nurse associations (VNAs) and hospital-basedhome health care agencies (HBHHAs); (b) compare the services provided by the agencies; and (c) investigate the impact of the environment on agency services. VNAs and HBHHAs are two specific types of home health care agencies that illustrate differences in organizational environments and services. A clear understanding of the organizational environments of home health care agencies and the impact on agency services is imperative for nurses, particularly at this time when there are growing concerns about quality of care from policy-makers, professionals, and clients (Hanington, 1988). The effectiveness of nursing care is the result of a dynamic interaction and if nurses are to clearly document the effectiveness of home health care services, knowledge of the services provided by home health care agencies and the environmental factors that impinge upon agency services is critical.
Mary E. Burman, RN, PhD, is an assistant professor in the School of Nursing at University of Wyoming. This article is based on dissertation research done at the University of Michigan and funded by a National Research Service Award from the National Center for Nursing Research, National Institutes of Health. The author acknowledges the contributions of Cecilia Dawkins, PhD, RN; Lauren Aaronson, PhD, RN; Violet Barkauskas, PhD, RN; Thomas D’Aunno, PhD; and Carol Loveland-Cherry, PhD, RN. This article was received on April 1 , 1991, was revised, and accepted for publication February 10, 1992. Requests for reprints can be addressed to Dr. Mary Burman, University of Wyoming, School of Nursing, Laramie, WY 82070.
0 1992 John Wiley & Sons, Inc. CCC 0160-6891/92/040285-10 $04.00
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RESEARCH IN NURSING 8 HEALTH
This study is based on institutional theory of organizational behavior, which focuses on the taken-for-granted aspects of structure and functioning of organizations(Scott, 1987). According to institutional theory, organizational survival is a function of the conformity to social norms of acceptable practices and not just efficient production. Organizations must conform to a variety of rules and regulations that are a part of environment (Meyer & Rowan, 1983; Scott, 1987). The concept of organizational environment is fundamental to institutional theory although it has been conceptualized in a variety of ways. It has been defined narrowly in terms of sources of inputs and markets for outputs (Pfeffer & Salanci, 1978) or more broadly as social, cultural, legal, and economic processes (Hasenfeld, 1983; Scott, 1983). In this study, the organizationalenvironment was examined at the social sector level, which incoprates an interactingnetwork of organizations for a specific social function. The environment is defined as factors that contribute to or regulate the activities of home health care agencies. These factors include funding and referral sources, accrediting bodies, professional organizations, clients or consumers, and competing agencies. Aspects of the organizational environment of VNAs and HBHHAs have been examined. Hospital-based agencies have been found to have a higher proportion of funding from Medicare than community-based agencies (Balinsky & Rehman, 1984; Pettigrew et al., 1988). Hospital-based agencies in New York received more of their referrals from hospitals, while community-based agencies in the same area had a higher portion of referrals coming from other types of community organizations (Balinsky & Rehman, 1984). There are conflicting findings on the type of clients served by VNAs and HBHHAs. In one study, hospital-based programs tended to have older patients with primary diagnoses of cancer or circulatorydisorders who were more functionally limited and received more intensive services than clients served by community-based agencies. Moreover, the clients of hospital-based programs were more likely than those of community-based agencies to have been institutionalized prior to the initiation of home health care (Balinsky & Rehman, 1984). However, the Balinsky and Rehman study was limited to New York state and the category of community-based agencies included VNAs plus other types of agencies. In a more recent study, there were no differences in the types of clients seen by hospital-based and community-based agencies (Pettigrewet al., 1988). In this study, there were no differences between
the two types of agencies for clients’ age, sex, admitting diagnoses, functional ability, or prevalence and seventy of chronic problems. The authors did note a tendency for freestanding agencies to care for individuals requiring longer cafe because of chronic problems while hospital-based programs treated patients with acute problems. Institutional theory posits that organizational structure is a function of the environment. Organizational structure in institutional theory has not always been clearly defined and has been defined variously as administrative complexity (Meyer, Scott, & Strang, 1987) and termination policies and benefits (Sheets & Ting, 1988). In this study, the structure of organizations is defined narrowly as the services undertaken by the organization to fulfill its mission. There is evidence suggesting that the services of VNAs and HBHHAs differ. In one study, hospital-based programs focused on casefinding, case management, and coordination of services (Balinsky, 1985). Hospital-based agencies were found to contract with other community organizations to provide direct clinical services while VNAs provided the vast majority of direct services to home care clients (Balinsky, 1985). In another study by the American Hospital Association, home intravenous (IV) therapy, private duty, and durable medical equipment were the services most frequently provided by hospital-based agencies (Lerman, 1987). There is little research on the impact of the environment on structure in home health care. However, in other aspects of health care (Gay, Kronenfeld, Baker, & Amidon, 1989) and in other fields, such as business (Dobbin, Edelrnan, Meyer, Scott, & Swidler, 1988; Sheets & Ting, 1988), education (Meyer et al., 1987), and communications (Powell, 1988), environmental factors have been found to influence organizational structure. In summary, differences have been found between community-based agencies, such as VNAs, and hospital-based agencies in terms of environment and services. However, studies have been regional and have not differentiated types of community agencies. Moreover, there is little empirical evidence of the impact of organizational environments on agency services in home health care. Therefore, many gaps remain in understanding the interrelationships among environmental factors and agency services.
METHOD A cross-sectional, national survey employing mailed questionnaires was used in this study.
ORGANIZATIONAL ENVIRONMENTS / BURMAN
Sample The agencies for the study were selected using disproportionate stratified random sampling to allow for comparisons between VNAs and HBHHAs. The strata for the study were the type of agency and region. For type of agency, VNAs and HBHHAs were sampled. Home health care agencies have been assigned to 10 regional fiscal intermediaries; these regions were used as the other stratum for sample selection. There were approximately 514 VNAs in 1986 (Spiegel, 1987) and approximately 1,990 hospitalbased agencies in 1987 (Home Care in U.S. Hospitals, 1989). To allow comparisons between the two types of agencies, VNAs were sampled in a greater number than their proportion. VNAs and HBHHAs were selected in proportion to the percent of each type of agency in each region. For example, 37% of VNAs are in the New England region and 37% of the selected VNAs were from this region. However, W A S were sampled disproportionately to the HBHHAs: 10% of the population of HBHHAs were selected, while 45% of the population of VNAs were selected. The VNAs were obtained from the mailing list of the VNA of America which lists all currently operating VNAs in the U.S. and had over 500 listings at the time of the study. The HBHHAs were selected from the list produced by the American Hospital Association of all hospitals that provide home health care services. Three hundred sixteen (73%) of the 431 agencies originally selected for the study returned questionnaires. Some of the returned questionnaires were not usable and some were from agencies that were not either a VNA or a HBHHA, resulting in a final sample of 276 agencies including 120 VNAs and 156 HBHHAs. The sample of VNAs and HBHHAs was representative of the population of VNAs and HBHHAs. Discrepancies between the population distributions and sample distributions, in terms of percent of agencies per region by type of agency, ranged from 0% to 7%, with a mean discrepancy between sample and population of 2.3%. The VNAs were larger than the HBHHAs with higher revenues, more full-time equivalent employees ( R E s ) , and greater numbers of home visits per year (see Table I). In addition, the VNAs were older. The vast majority of the agencies were nonprofit. Only 3% of the agencies (n = 7) were for-profit and these were HBHHAs. The typical respondent was a white female between 41 and 50 years of age with a master’s degree and between 1 1 and 20 years experience in home health care. The VNA respondents had
287
been in home care longer, employed by the agency longer, and in their present director’s position longer than the HBHHA respondents. Finally, more VNA respondents (61%) than HBHHA respondents (33%) had graduate degrees.
Measures A self-administered questionnaire was developed for this study by the investigator. Self-administered questionnaires were deemed an appropriate method of data collection for several reasons. First, the population of home health care agencies is fairly large and geographically diverse. Second, the information sought is considered sensitive in the competitive home health care industry and mailed, self-administered questionnaires can be used successfully to collect anonymous data (Dillman, 1978). Several approaches were taken during instrument development to facilitate reliability and validity. First, prior to development, input was obtained from seven individuals with experience in home health care administration in VNAs and HBHHAs using a focus group format. These discussions provided insight into current issues in service patterns and key environmental factors in home health care. Second, following development of the questionnaire, additional evaluation of the items was done by five individuals with theoretical and methodological expertise; one individual had an extensive background in organizational theory including institutional theory, three individuals were experienced community health nurses, and all had experience with survey methodology. This was followed by a pretest of the questionnaire with individuals experienced in home health care administration in both VNAs and HBHHAs. These individuals had been involved in administration, education and/or consultation in home health care at least 5 years. The pretest allowed an evaluation of the availability of the information sought, length of time for completion, and readability of the instructions and questions. The questionnaireaddressed the following areas. Environment: The organizational environment is composed of factors that contribute to or regulate the services of the home health care agencies. The specific environmental factors and their measurement are described in Table 2. Services: The type of services provided as well as the method of service provision were examined. Description of the service measures also are included in Table 2.
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Table 1. Agency Characterlatlco VNA
HBHHA
No.
Characteristic
(%)
No.
Chi-square ~~
Revenue Less than $500,000 $500.000 to 999,999 $1,000,000 to 4,999,999 $5,000,000 to 9,999,999 $10,000,000 to 20,000,000 Greater than $20,000,000 Home visits for last year Less than 10,000 10,000 to 49,999 50,000 to 99,999 100,000 to 150,000 Greater than 150,000 Number of FTEs Less than 5 5 to 14 15 to 30 31 to50 51 to 100 101 to 500 SO0 Years of operation Less than 2 2 to 5 6 10 10 11 to20 21 to40 >40
31 28 64 18 8 1
(20.7) (18.7) (42.7) (12.0) (5.3) (0.7)
62 27 15 3 0 0
(57.9) (25.2) (14.0) (2.8) (0.0)
30 81 21 10 6
(20.3) (54.7) (14.2) (6.8) (4.1
72 38 2 1 0
(63.7) (33.6) (14 (0.9)
6 26 35 22 30 32 3
(3.9) (16.9) (22.7) (14.3) (19.5) (20.8) (1.9)
26 47 30 9 6 2 0
(21.7) (39.2) (25.0) (7.5) (5.0) (1.7)
1 6 8 15 25 101
(0.6) (3.8) (5.1 (9.6) (16.0) (64.7)
3 56 28 22 10 1
(2.5) (46.7) (23.3) (18.3) (8.3) (0.8)
(0.0)
(0.0)
(0.0)
54.8'**'
58.7b"'
66.1'"'
155.8d"'
'df= 4.n = 257. bdf = 3 , n = 261. cdf = 5 , n = 274. ddf = 4 , n *** p < ,001
= 276.
Procedure
zational variables to be controlled. These covariates were included for theoretical reasons, such as including size (revenue or ~ E s ) because , in organizational research they have been found to be related to organizational structure. In addition, covariates were included for empirical reasons because they were identified in preliminary correlational analyses to be related to the dependent variables. Moreover, the VNAs and HBHHAs differed significantly on a number of these organizational variables. The control variables are defined in Table 2. Adjusted means, controlling for the effects of the covariates on the dependent variable, are provided with the ANCOVA findings.
Human subjects approval was obtained prior to initiation of the study. Following agency selection, the questionnaires were mailed to the directors or department heads with instructions on completion and return of the questionnaires. Two follow-up reminders were sent. The first, mailed 2 weeks after the initial mailing, was a postcard. The second reminder was mailed 4 weeks after the initial mailing and included a letter as well as another copy of the questionnaire. Completion and return of the anonymous questionnaireswere considered consent.
RESULTS Differencesbetween the W A S and HBHHAs were examined using t tests and chi-squares plus analysis of covariance techniques to allow other organi-
Organizational Environments The environmental factors are discussed separately in the following section. In terms of funding sources, both types of agencies received the largest
ORGANIZATIONAL ENVIRONMENTS I BURMAN
percent of funding from Medicare (M = 56.8%; = 26.4) followed by other governmental sources (M = 18.7%; SD = 18.4), private sources (M = 9.9%; SD = 8.4), and clients themselves (M = 5.2%; SD = 9.6). The smallest amount of funding came from “other” sources (M = 0.3%; SD = 0.9). HBHHAs (adj. M = 63.8) had a significantly higher percent of funding from Medicare than VNAs (adj. M = 52.1) (see Table 3). Alternatively, VNAs (adj. M = 22.0) had a significantly higher percent of funding from other governmental sources than hospital-based agencies (adj. M = 13.7). There were no significant differences in the amount of funding for VNAs and HBHHAs from private sources, clients, and “other” sources. Home health care agencies can be accredited by a variety of organizations. HBHHAs (71%) were significantly more likely than VNAs (24%)
SD
289
x2
(1 ,n = 275) = 18.18, p < .001. Specifically, HBHHAs were more likely to be accredited by the Joint Commission on Ac-
to be accredited,
creditation of Healthcare Organizations under the Home Care Program while W A S were more likely to be accredited by the National League for Nursing and/or the National Homecaring Council. VNAs (97%) were significantly more likely to be members of a professional organization than the HBHHAs (82%), xz (1,n = 265) = 55.72, p < .001. Specifically, VNAs were more likely to be members of the National Association for Home Care, the National Homecaring Council, VNA of America, and/or the National League for Nursing while HBHHAs were more likely to be involved with the American Hospital Association. In terms of referral sources, for both types of agencies, the largest percent of referrals was received from hospitals and physicians (M = 81.2;
Table 2. Major Study Constructs and Organlzatlonal Control Varlables Construct
Organizational environment 1) Funding sources
2) Accrediting bodies
3) Professional organizations 4) Referral sources
5) Competing agencies
6) Clients
§awices 1) Type of service
2) Method of service provision
Organlzatlonal control variables 1) Revenue 2) Number of FTEs
3) Agencyage 4) Director’s degree 5) Extent of service area 6) Parent organization
Measurement Percent of funding from typical payment sources including Medicare, other government sources, private sources, clients, and others Whether agency accredited (yes or no) and by whom Whether agency involved with professional organizations (yes or no) and which ones Percent of referrals from typical sources including hospitals and physicians, nursing homes, community agencies, and families, and clients. Extent of competition with different types of home health care agencies using 5-point scales. Total competition was calculated by summing the individual scores for the five types of agencies. Ranking of frequency of clients by primary medical diagnosis, racial background, and age. Number of high-tech services (pharmacy, radiology, IV services, parenteraVenteral therapy, laboratory, and respiratory services). Number of long-term services (homemaker/housekeeping, home delivered meals, personal contact services, transportation, and respite care). Percent of services provided through parent organization, formal contract with another organization, informal arrangement, and other arrangement. Total revenue for agency for last year Total number of full time equivalent employees in direct service and support services currently employed Years of operation for agency Highest degree: 1) BSN, AD or diploma 2) MS or PhD Extent of rural, urban, and suburban service area based on 5-point scales Whether the agency has a parent organization (yes or no)
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Table 3. Differences In Funding Sources between VNAs and HBHHAs Controlling for OrganlzatlonalVariables Source Medicare Covariates Director's degree Agency age Type of agency Residual Total Other governmental sources Covariates Suburban Agency revenue Agency age Type of agency Residual Total
ss
df
MS
F
7712.13 12223.94 4058.05 150164.17 183621.42
1 1 1 258 261
7712.13 12223.94 4058.05 582.03 703.53
13.25"' 21 .OO"' 6.97"
4937.31 1081.21 8077.86 1510.18 601 12.68 77130.48
1 1 1 1 21 7 221
4937.31 1081.21 8077.86 1510.18 277.02 349.02
17.82"* 3.90' 29.16"' 5.45'
SD = 14.4). The percent of referrals from nursing homes (M= 4.2; SD = 4.9), community agencies (M = 4.4; SD = 7.0), and families and clients (M = 10.3; SD = 11.1) was quite low for both types of agencies. HBHHAs (adj. M = 87.0) had a higher percent of referrals from acute medical care sources (MDs and hospitals) than VNAs (adj. M = 76.5) (see Table 4). VNAs (adj. M = 5.4) had a higher percent of referrals from community sources, such as community centers, than HBHHAs (adj. M = 3.1). Moreover, VNAs (adj. M = 13.4) had a higher percent of referrals from families and clients than HBHHAs (adj. M = 6.5). Although the difference was small, HBHHAs (adj. M = 4.8) had a higher percent from nursing homes than VNAs (adj. M = 3.5). For both types of agencies, the extent of competition was greatest with for-profit agencies (M = 3.3, SD = 1.3 for the VNAs and M = 2.4, SD = 1.3 for the HBHHAs, using a 5-point scale). Official agencies were not perceived to be a major source of competition for either type of agency (M = 1.7, SD = 0.9 andM = 1.7, SD = 1.0 for VNAs and HBHHAs, respectively). VNAs perceived higher Competitionfrom other hospitalbased agencies (M = 3.0, SD = 1.5)than HBHHAs (M = 2.0, SD = 1.2). This was also the case for private, nonprofit agencies (M = 2.4, SD = 1.3 for VNAs; M = 2.0, SD = 1.1 for HBHHAs) and other Visiting Nurse Associations (M = 2.1, SD = 1.2 for VNAs; M = 1.8, SD = 1.0 for HBHHAs). Consistently, VNA respondents reported more competition from each of the competing agencies than HBHHA respondents. This was true for total competition. VNAs (M = 12.3,
SD
= 4.4) had higher total competition scores than HBHHAs (M = 9.8; SD = 3.7), t(258) = 4.78, p < .001. The last aspect of the organizational environment examined in this study was the clients or consumers of the agency's services. The typical client for both the HBHHAs and the VNAs was a white person between the ages of 75 and 84 with a diagnosis of either circulatory disease or cancer. There were no significant differences between the two types of agencies in the clients served.
Services Two aspects of services were examined: the number of services provided by type and the methods of service provision. Three-quarters of the agencies provided the following services: homemaker, laboratory, IV therapy, parenteraventera1 therapy, and pediatric care. Less than 25% of the sample provided mental health services, radiology, and transportation. HBHHAs (adj. M = 3.9) were more likely to provide a higher number of high-tech services than VNAs (adj. M = 3.2) (see Table 5). In addition, agencies that had higher revenues and were part of a larger organization (i.e.. had a parent organization) provided more high-tech services. On the other hand, there were no significant differences between VNAs and HBHHAs on the number of long-term services (M = 2.6; SD = 1.5). In general, HBHHAs (adj. M = 51.0%) had a significantly higher percent of their services provided through an outside arrangement than VNAs
291
ORGANIZATIONAL ENVIRONMENTS I BURMAN
Table 4. Dlfferences In Referral Sources between VNAs and HBHHAs Controlling for Organizational Variables Source Physicians and hospitals Covariates Age of agency Number of FTEs Type of agency Residual Total Community Covariate Director's degree Type of agency Residual Total Family and self Covariate Director's degree Type of agency Residual Total Nursing homes Covariate Number of FTEs Type of agency Residual Total
ss
df
MS
F
798.1 1 733.44 3037.31 45801.50 51826.82
1 1 1 247 250
798.1 1 733.44 3037.31 185.44 207.31
4.30' 3.96' 16.38"'
1003.04 289.70 10792.71 12085.46
1 1 243 245
1003.04 289.70 44.41 49.33
22.58"' 6.52"
308.26 2373.25 27565.04 30546.54
1 1 245 247
308.26 2673.25 112.51 123.67
2.74 23.76"'
113.64 89.52 5474.92 5678.08
1 1 246 248
113.64 89.52 22.26 22.90
5.11' 4.02'
(adj. M = 41.9%) (see Table 6). However, there were no differences between the two types of agencies for any of the specific methods of external service provision: provided by parent organization, through an external contract, using informal arrangements, or "other" arrangements.
Impact of Organizational Environment on Services The number of each type of service, high-tech or long-term, was regressed on environmental factors
and control variables in a series of hierarchical multiple regressions with control variables entered first followed by environmental factors. The most explanatory model for the number of high-tech services is shown in Table 7. The number of hightech services was positively associated with the percent of referrals from nursing homes and the amount of services provided by outside arrangements. These environmental factors explained a significant amount of variance in the number of high-tech services even after controlling for type of agency and agency revenue. The number of
Table 5. Differences In Number of High-Tech Services Between VNAs and HBHHAs Controlling for Organizational Variables
Covariates Agency revenue Presence of parent organizationa Type of agency Residual Total .dummy coded: No = 0; Yes = 1. ' p < .05. " p < .01. " ' p < ,001.
ss
df
MS
F
7.26 45.87 15.02 466.02 531.36
1 1 1 250 253
7.25 45.87 15.02 1.86 2.10
3.89' 24.61 *** 8.06"
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Table 6. D W VNAa and HBHHAs
In Percent of Total Servlces Provlded by Outslde Arrangements Between
Covariate Extent of rural service area Type of agency Residual Total
ss
df
MS
F
0.33 0.53 20.58 21.44
1 1 262 264
0.33 0.53
4.25' 6.70"
.08
.08
' p < .05. * * p < .01.
long-term services was positively associated with the percent of funding from "other" sources and the percent of referrals from family and self and community sources (see Table 7). In the case of long-term services, agency revenue or size explained 11% of the variance and the environmental factors accounted for an additional 4% of the variance.
DISCUSSION One of the major aims of this study was to examine the organizational environments and services of home health care agencies. Although only VNAs and HBHHAs were examined, the intent of this study was to gain insight into the broader field of home health care. The study documented differences between VNAs and HBHHAs in their en-
Table 7. E
vironments and services. VNAs and HBHHAs differed in the key environmental factors. Specifically, differences were found between the HBHHAs and VNAs on funding sources, competing agencies, referral sources, involvement in professional organizations, and accrediting bodies. HBHHAs had a higher percent of funding from Medicare, were more likely to be accredited, and had a higher percent of referrals from physicians and hospitals than VNAs. VNAs had a greater number of funding sources, a higher percent of funding from other governmental sources such as Medicaid, were more likely to be involved in professional organizations, and received a higher percent of referrals from families and clients than HBHHAs. These findings are consistent with other recent studies (Balinsky & Rehman, 1984; Pettigrew et al., 1988) and the differing origins of the two types of agencies. VNAs developed in the public health tradition as independent agencies
M of EnvlronmentalFactors on Hlgh-Tech and LongTerm Services
Service High-tech Control variables Type of agency' Agency revenue Environmental factors Percent referrals from nursing homes Percent services provided by outside sources Long-term Control variables Agency revenue Environmental factors Percent referrals from family and self Percent referrals from community sources Percent funding from "other" sources 'dummy coded: HBHHAs = 0; VNAs ' p < .05. " p < .01. " ' p < .001.
beta
t
-.78 .23
-..27
.19
-4.01 *** 2.78"
.06
.20
3.29"'
1.29
.25
4.23*"
.1 8b'
.42
.32
5.23"'
.11***
.02
.13
2.20'
.03
.14
2.30'
.16
.11
1.75
b
=
1. ' F = 13.40(4,227). ' F
=
11.11(4,229).
R2
R2 Change
.08"
15c***
.lo"
.04"
ORGANIZATIONAL ENVIRONMENTS / BURMAN
serving community needs. On the other hand, HBHHAs originated within the medical care system connected with hospitals as a means to facilitate continuity of care. The differences between the two types of agencies in services were relatively minor. VNAs provided more long-term care services than HBHHAs, but this finding was related to the larger revenue of the VNAs. HBHHAs provided significantly more high-tech services than VNAs when revenue was controlled for in the analyses. Therefore, agency services were not greatly different once size (or revenue) was taken into account. HBHHAs in general had more services provided by some external mechanism; however, there were no differences between the two types of agencies in the specific methods of service provision. Although there were some differences, the similarities between the two types of agencies also must be emphasized. In regard to the organizational environment, there were no differences between the VNAs and the HBHHAs in the types of clients being served. Both received the largest percent of their funding from Medicare and referrals from hospitals and physicians. The changes in home health care, such as joint ventures, have led to a blurring of the distinctions between types of agencies. New classifications may be necessary for the type of agencies delivering home health care based on factors such as size, age, or corporate structure. Another purpose of this study was to examine the impact of the organizational environment on agency services. The organizational environment was found to have an impact upon agency services. Funding and referral sources were related to the number of high-tech and long-term services. Overall, these findings are plausible. Funding sources have become increasingly involved with the delivery of health care, defining what services will be reimbursed and what staff can provide c e h n services. In the acute care setting, hospitals have been found to alter their services in response to fiscal changes (Gay et al., 1989). Therefore, it is not surprising that agency services are influenced by funding sources. On the other hand, referral sources make it possible for agencies to provide services by making available necessary resources, for example, clients. It also is illuminating to examine the environmental factors that did not influence agency services. The client characteristics of those served did not have an impact. This may be due in part to the relatively unrefined nature of the measure. Examining the technological needs of clients might lead to different results. However, clients, re-
293
gardless of need, are generally viewed as having less power in the health care field (Hasenfeld, 1983). Neither accrediting bodies nor professional organizations had any influence in agency services. Perhaps these organizations are taken for granted in home health care because their influence is ongoing and less apt to change dramatically as in the case of funding sources. Finally, the amount of competition from other agencies was not related to agency services. This may be because some of the current high demand services, such as hightech services, were provided by a majority of the agencies in the study. However, further investigation and refinement of the measurement of competition is needed. Although this was not a specific aim of this study, examination of the organizational factors that were related to both the organizational environment and agency services is interesting. Size (as measured by revenue or FTEs)was a significant covariate in many of the analyses and this is consistent with other organizational research (Sutton & D’Aunno, 1989). Agency age was also a significant covariate. According to institutional theory, organizational structure is “imprinted at the time of founding and certain organizational characteristics remain throughout the life of the organization (Scott, 1987). Director’s degree was found to be correlated with environmental factors and services. The educational preparation of the director could influence herhis preference for funding and referral sources. However, these findings are confounded because of the differences between VNAs and HBHHAs in directors’ degrees and further study is warranted. There are several implications of this study for future research. First, differences were found in organizational environments of VNAs and HBHHAs. Therefore, it would be useful to include other types of home health care agencies, such as freestanding private agencies, in further research to examine differences in environments. Second, additional research is needed examining the impact of organizational and environmental factors on agency services. There were only minor differences between VNAs and HBHHAs in agency services; however, size of agency, as measured by revenue, did have an impact. Moreover, funding and r e f e d sources influenced services, while client characteristics, accrediting bodies, and competition did not. Incorporating all types of home health care agencies and refining measures of environmental factors such as competition, would be beneficial in more clearly identifying the influence of organizational and environmental factors. Finally, it would be useful to extend this research. Do
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agencies with different service patterns have different client outcomes? Do agencies in different environmentshave different outcomes? How does the environment influence agency services in terms of patient outcomes? What effect do agencies have on the environment? How can agencies influence the environment to bring about more positive outcomes for their clients? There are several implications of this study for nursing practice. The impact of the organizational environment, which is the context of nursing practice, must be considered. Nursing personnel need to identify environmental factors, such as the mix of funding and referral sources, that influence the provision of services in their agencies. Key environmental factors may have positive and negative and intended and unintended effects upon the practice of nursing and their influenceon agency structure must be recognized. Consequently, evaluation of the agency should include identification of environmental factors that influence care. Focusing on just the home health care agency, in terms of services and staffing, ignores key aspects of the organizational environment that can have an impact on services.
Balinsky, W. (1985). A comparative analysis of agencies providing home health services. Home Health Care Services Quarterly, 6 , 45-64. Balinsky, W., & Rehman, S. (1984). Home health care: A comparative analysis of hospital-based and community-based agency patients. Home Health Care Services Quarterly, 5 , 45-60. Dillman, D. (1978). Mail and telephone surveys: The total design method. New York: Wiley. Dobbin, F.R., Edelman, L., Meyer, J. W., Scott, W.R., & Swindler, A. (1988). The expansion of due process in organization. In L.G. Zucker (Ed.), institutional patterns and organizations, culture and environment (pp. 71-98). Cambridge, MA: Ballinger Publishing Co. Gay, E . G . , Kronenfeld, J.J., Baker, S . L . , & Amidon, R.L. (1989). An appraisal of organizational response to fiscally constraining regulation: The case of hospitals and DRGs. Health and Social Behavior, 30, 56-76. Harrington, C. (1988). Quality, access and costs: Public policy and home health care. Nursing
Outlook, 3 6 , 164-166. Hasenfeld, Y. (1983). Human service organizations. Englewood Cliffs, NJ: Prentice-Hall, Inc. Home care in U.S.Hospitals (1989). Hospitals, 63, 46-54.
Lerman, D. (1987). Room to expand home care business in 1987. Hospitals, 6 1 , 51-52. Meyer, J.W., & Rowan, B. (1983). Institutionalized organizations: Formal structure as myth and ceremony. In J.W. Meyer & W.R. Scott (Eds.), Organizational environments: Ritual and rationality (pp. 21 -44). Beverly Hills: Sage. Meyer, J., Scott, W.R., & Strang, D. (1987). Centralization, fragmentation, and school district complexity. Administrative Science Quarterly, 32, 186- 201.
Pesznecker, B., Horn, B., Werner, J . , & Kenyon, V. (1987). Home health services in a climate of cost containment. Home Health Care Services Quarterly, 8 , 5-21. Pettigrew, M.L., Kramer, A.M., & Shaughnessy, P. W. (1988). Hospital-based and freestanding home health care case mix: Implications for Medicare reimbursement policy. Home Health Care Services Quarterly, 8 , 75-88. Pfeffer, J., & Salancik, G.R. (1978). The external control of organizations. A resource dependence perspective. New York: Harper & Row. Powell, W.W. (1988). Institutional effects on organizational structure and performance. In L.G. Zucker (Ed.), institutional patterns and organizations, culture and environment (pp. 115136). Cambridge, MA: Ballinger Publishing Co. Scott, W.R. (1983). The organization of environments: Network, culture, and historical elements. In J.W. Meyer & W.R. Scott (Eds.), Organizational environments: Ritual and rationality (pp. 155-175). Beverly Hills: Sage. Scott, W.R. (1987). The adolescence of institutional theory. Administrative Science Quarterly, 32, 493-5 1 1.
Sheets, R.G., & Ting, Y.(1988). Determinants of employee-termination benefits in organizations. Administrative Science Quarterly, 33, 607-624. Spiegel, A.D. (1987). Home health care (2nd ed.). Owings Mills, MD: National Health Publishing. Spohn, P.H., Bergthold, L . , & Estes, C.L. ( 1 988). From cottages to condos: The expansion of the home health care industry under Medicare. Home Health Care Services Quarterly, 8 , 25-55. Sutton, R.I., & D’Aunno, T. (1989). Decreasing organizational size: Untangling the effects of money and people. Academy of Management Review, 14, 194-212.
The Organizational Environments and Services of VNAs and Hospital-Based Home Health Care Agencies Mary E. Burman
Visiting Nurse Associations (VNAs) and hospital-based home health care agencies (HBHHAs) were used to explore the impact of organizational environments on agency services. Disproportionate stratified random sampling, based on type and region of agency, was used to select the agencies. Seventy-three percent (120 HBHHAs and 156 VNAs) responded to the mail survey. Differences were found in the environments of the two types of agencies in funding and referral sources, amount of competition, accreditation by external bodies, and involvement in professional organizations. In terms of services, HBHHAs provided more types of high-tech services and were more likely to use external arrangements to provide services than VNAs. The organizational environment did have an impact on agency services. Medicare funding and referral sources, as environmental factors, had an impact on agency services. 0 1992 John Wiley & Sons, Inc.
Home health care agencies operate in a turbulent environment: competition has increased due to a greater number of providers, funding sources have altered reimbursement policies, and consumers have made demands for more quality services (Harrington, 1988; Pesznecker, Horn, Werner, & Kenyon, 1987; kttigrew, h e r , & Shaughnessy, 1988; Spiegel, 1987; Spohn, Bergthold, & Estes, 1988). Home health care agencies range from institutional-based to free-standing community agencies and differences have been found in the organizational environment of these types of agencies (Balinsky & Rehman, 1984). However, the nature of the organizational environment in home health care has not been clearly documented. Moreover, the impact of the organizational environment on services provided by home health care agencies has not been systematically investigated. Therefore, the purposes of this study were to (a) compare the organizational environments of
home health care agencies, specifically visiting nurse associations (VNAs) and hospital-basedhome health care agencies (HBHHAs); (b) compare the services provided by the agencies; and (c) investigate the impact of the environment on agency services. VNAs and HBHHAs are two specific types of home health care agencies that illustrate differences in organizational environments and services. A clear understanding of the organizational environments of home health care agencies and the impact on agency services is imperative for nurses, particularly at this time when there are growing concerns about quality of care from policy-makers, professionals, and clients (Hanington, 1988). The effectiveness of nursing care is the result of a dynamic interaction and if nurses are to clearly document the effectiveness of home health care services, knowledge of the services provided by home health care agencies and the environmental factors that impinge upon agency services is critical.
Mary E. Burman, RN, PhD, is an assistant professor in the School of Nursing at University of Wyoming. This article is based on dissertation research done at the University of Michigan and funded by a National Research Service Award from the National Center for Nursing Research, National Institutes of Health. The author acknowledges the contributions of Cecilia Dawkins, PhD, RN; Lauren Aaronson, PhD, RN; Violet Barkauskas, PhD, RN; Thomas D’Aunno, PhD; and Carol Loveland-Cherry, PhD, RN. This article was received on April 1 , 1991, was revised, and accepted for publication February 10, 1992. Requests for reprints can be addressed to Dr. Mary Burman, University of Wyoming, School of Nursing, Laramie, WY 82070.
0 1992 John Wiley & Sons, Inc. CCC 0160-6891/92/040285-10 $04.00
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This study is based on institutional theory of organizational behavior, which focuses on the taken-for-granted aspects of structure and functioning of organizations(Scott, 1987). According to institutional theory, organizational survival is a function of the conformity to social norms of acceptable practices and not just efficient production. Organizations must conform to a variety of rules and regulations that are a part of environment (Meyer & Rowan, 1983; Scott, 1987). The concept of organizational environment is fundamental to institutional theory although it has been conceptualized in a variety of ways. It has been defined narrowly in terms of sources of inputs and markets for outputs (Pfeffer & Salanci, 1978) or more broadly as social, cultural, legal, and economic processes (Hasenfeld, 1983; Scott, 1983). In this study, the organizationalenvironment was examined at the social sector level, which incoprates an interactingnetwork of organizations for a specific social function. The environment is defined as factors that contribute to or regulate the activities of home health care agencies. These factors include funding and referral sources, accrediting bodies, professional organizations, clients or consumers, and competing agencies. Aspects of the organizational environment of VNAs and HBHHAs have been examined. Hospital-based agencies have been found to have a higher proportion of funding from Medicare than community-based agencies (Balinsky & Rehman, 1984; Pettigrew et al., 1988). Hospital-based agencies in New York received more of their referrals from hospitals, while community-based agencies in the same area had a higher portion of referrals coming from other types of community organizations (Balinsky & Rehman, 1984). There are conflicting findings on the type of clients served by VNAs and HBHHAs. In one study, hospital-based programs tended to have older patients with primary diagnoses of cancer or circulatorydisorders who were more functionally limited and received more intensive services than clients served by community-based agencies. Moreover, the clients of hospital-based programs were more likely than those of community-based agencies to have been institutionalized prior to the initiation of home health care (Balinsky & Rehman, 1984). However, the Balinsky and Rehman study was limited to New York state and the category of community-based agencies included VNAs plus other types of agencies. In a more recent study, there were no differences in the types of clients seen by hospital-based and community-based agencies (Pettigrewet al., 1988). In this study, there were no differences between
the two types of agencies for clients’ age, sex, admitting diagnoses, functional ability, or prevalence and seventy of chronic problems. The authors did note a tendency for freestanding agencies to care for individuals requiring longer cafe because of chronic problems while hospital-based programs treated patients with acute problems. Institutional theory posits that organizational structure is a function of the environment. Organizational structure in institutional theory has not always been clearly defined and has been defined variously as administrative complexity (Meyer, Scott, & Strang, 1987) and termination policies and benefits (Sheets & Ting, 1988). In this study, the structure of organizations is defined narrowly as the services undertaken by the organization to fulfill its mission. There is evidence suggesting that the services of VNAs and HBHHAs differ. In one study, hospital-based programs focused on casefinding, case management, and coordination of services (Balinsky, 1985). Hospital-based agencies were found to contract with other community organizations to provide direct clinical services while VNAs provided the vast majority of direct services to home care clients (Balinsky, 1985). In another study by the American Hospital Association, home intravenous (IV) therapy, private duty, and durable medical equipment were the services most frequently provided by hospital-based agencies (Lerman, 1987). There is little research on the impact of the environment on structure in home health care. However, in other aspects of health care (Gay, Kronenfeld, Baker, & Amidon, 1989) and in other fields, such as business (Dobbin, Edelrnan, Meyer, Scott, & Swidler, 1988; Sheets & Ting, 1988), education (Meyer et al., 1987), and communications (Powell, 1988), environmental factors have been found to influence organizational structure. In summary, differences have been found between community-based agencies, such as VNAs, and hospital-based agencies in terms of environment and services. However, studies have been regional and have not differentiated types of community agencies. Moreover, there is little empirical evidence of the impact of organizational environments on agency services in home health care. Therefore, many gaps remain in understanding the interrelationships among environmental factors and agency services.
METHOD A cross-sectional, national survey employing mailed questionnaires was used in this study.
ORGANIZATIONAL ENVIRONMENTS / BURMAN
Sample The agencies for the study were selected using disproportionate stratified random sampling to allow for comparisons between VNAs and HBHHAs. The strata for the study were the type of agency and region. For type of agency, VNAs and HBHHAs were sampled. Home health care agencies have been assigned to 10 regional fiscal intermediaries; these regions were used as the other stratum for sample selection. There were approximately 514 VNAs in 1986 (Spiegel, 1987) and approximately 1,990 hospitalbased agencies in 1987 (Home Care in U.S. Hospitals, 1989). To allow comparisons between the two types of agencies, VNAs were sampled in a greater number than their proportion. VNAs and HBHHAs were selected in proportion to the percent of each type of agency in each region. For example, 37% of VNAs are in the New England region and 37% of the selected VNAs were from this region. However, W A S were sampled disproportionately to the HBHHAs: 10% of the population of HBHHAs were selected, while 45% of the population of VNAs were selected. The VNAs were obtained from the mailing list of the VNA of America which lists all currently operating VNAs in the U.S. and had over 500 listings at the time of the study. The HBHHAs were selected from the list produced by the American Hospital Association of all hospitals that provide home health care services. Three hundred sixteen (73%) of the 431 agencies originally selected for the study returned questionnaires. Some of the returned questionnaires were not usable and some were from agencies that were not either a VNA or a HBHHA, resulting in a final sample of 276 agencies including 120 VNAs and 156 HBHHAs. The sample of VNAs and HBHHAs was representative of the population of VNAs and HBHHAs. Discrepancies between the population distributions and sample distributions, in terms of percent of agencies per region by type of agency, ranged from 0% to 7%, with a mean discrepancy between sample and population of 2.3%. The VNAs were larger than the HBHHAs with higher revenues, more full-time equivalent employees ( R E s ) , and greater numbers of home visits per year (see Table I). In addition, the VNAs were older. The vast majority of the agencies were nonprofit. Only 3% of the agencies (n = 7) were for-profit and these were HBHHAs. The typical respondent was a white female between 41 and 50 years of age with a master’s degree and between 1 1 and 20 years experience in home health care. The VNA respondents had
287
been in home care longer, employed by the agency longer, and in their present director’s position longer than the HBHHA respondents. Finally, more VNA respondents (61%) than HBHHA respondents (33%) had graduate degrees.
Measures A self-administered questionnaire was developed for this study by the investigator. Self-administered questionnaires were deemed an appropriate method of data collection for several reasons. First, the population of home health care agencies is fairly large and geographically diverse. Second, the information sought is considered sensitive in the competitive home health care industry and mailed, self-administered questionnaires can be used successfully to collect anonymous data (Dillman, 1978). Several approaches were taken during instrument development to facilitate reliability and validity. First, prior to development, input was obtained from seven individuals with experience in home health care administration in VNAs and HBHHAs using a focus group format. These discussions provided insight into current issues in service patterns and key environmental factors in home health care. Second, following development of the questionnaire, additional evaluation of the items was done by five individuals with theoretical and methodological expertise; one individual had an extensive background in organizational theory including institutional theory, three individuals were experienced community health nurses, and all had experience with survey methodology. This was followed by a pretest of the questionnaire with individuals experienced in home health care administration in both VNAs and HBHHAs. These individuals had been involved in administration, education and/or consultation in home health care at least 5 years. The pretest allowed an evaluation of the availability of the information sought, length of time for completion, and readability of the instructions and questions. The questionnaireaddressed the following areas. Environment: The organizational environment is composed of factors that contribute to or regulate the services of the home health care agencies. The specific environmental factors and their measurement are described in Table 2. Services: The type of services provided as well as the method of service provision were examined. Description of the service measures also are included in Table 2.
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Table 1. Agency Characterlatlco VNA
HBHHA
No.
Characteristic
(%)
No.
Chi-square ~~
Revenue Less than $500,000 $500.000 to 999,999 $1,000,000 to 4,999,999 $5,000,000 to 9,999,999 $10,000,000 to 20,000,000 Greater than $20,000,000 Home visits for last year Less than 10,000 10,000 to 49,999 50,000 to 99,999 100,000 to 150,000 Greater than 150,000 Number of FTEs Less than 5 5 to 14 15 to 30 31 to50 51 to 100 101 to 500 SO0 Years of operation Less than 2 2 to 5 6 10 10 11 to20 21 to40 >40
31 28 64 18 8 1
(20.7) (18.7) (42.7) (12.0) (5.3) (0.7)
62 27 15 3 0 0
(57.9) (25.2) (14.0) (2.8) (0.0)
30 81 21 10 6
(20.3) (54.7) (14.2) (6.8) (4.1
72 38 2 1 0
(63.7) (33.6) (14 (0.9)
6 26 35 22 30 32 3
(3.9) (16.9) (22.7) (14.3) (19.5) (20.8) (1.9)
26 47 30 9 6 2 0
(21.7) (39.2) (25.0) (7.5) (5.0) (1.7)
1 6 8 15 25 101
(0.6) (3.8) (5.1 (9.6) (16.0) (64.7)
3 56 28 22 10 1
(2.5) (46.7) (23.3) (18.3) (8.3) (0.8)
(0.0)
(0.0)
(0.0)
54.8'**'
58.7b"'
66.1'"'
155.8d"'
'df= 4.n = 257. bdf = 3 , n = 261. cdf = 5 , n = 274. ddf = 4 , n *** p < ,001
= 276.
Procedure
zational variables to be controlled. These covariates were included for theoretical reasons, such as including size (revenue or ~ E s ) because , in organizational research they have been found to be related to organizational structure. In addition, covariates were included for empirical reasons because they were identified in preliminary correlational analyses to be related to the dependent variables. Moreover, the VNAs and HBHHAs differed significantly on a number of these organizational variables. The control variables are defined in Table 2. Adjusted means, controlling for the effects of the covariates on the dependent variable, are provided with the ANCOVA findings.
Human subjects approval was obtained prior to initiation of the study. Following agency selection, the questionnaires were mailed to the directors or department heads with instructions on completion and return of the questionnaires. Two follow-up reminders were sent. The first, mailed 2 weeks after the initial mailing, was a postcard. The second reminder was mailed 4 weeks after the initial mailing and included a letter as well as another copy of the questionnaire. Completion and return of the anonymous questionnaireswere considered consent.
RESULTS Differencesbetween the W A S and HBHHAs were examined using t tests and chi-squares plus analysis of covariance techniques to allow other organi-
Organizational Environments The environmental factors are discussed separately in the following section. In terms of funding sources, both types of agencies received the largest
ORGANIZATIONAL ENVIRONMENTS I BURMAN
percent of funding from Medicare (M = 56.8%; = 26.4) followed by other governmental sources (M = 18.7%; SD = 18.4), private sources (M = 9.9%; SD = 8.4), and clients themselves (M = 5.2%; SD = 9.6). The smallest amount of funding came from “other” sources (M = 0.3%; SD = 0.9). HBHHAs (adj. M = 63.8) had a significantly higher percent of funding from Medicare than VNAs (adj. M = 52.1) (see Table 3). Alternatively, VNAs (adj. M = 22.0) had a significantly higher percent of funding from other governmental sources than hospital-based agencies (adj. M = 13.7). There were no significant differences in the amount of funding for VNAs and HBHHAs from private sources, clients, and “other” sources. Home health care agencies can be accredited by a variety of organizations. HBHHAs (71%) were significantly more likely than VNAs (24%)
SD
289
x2
(1 ,n = 275) = 18.18, p < .001. Specifically, HBHHAs were more likely to be accredited by the Joint Commission on Ac-
to be accredited,
creditation of Healthcare Organizations under the Home Care Program while W A S were more likely to be accredited by the National League for Nursing and/or the National Homecaring Council. VNAs (97%) were significantly more likely to be members of a professional organization than the HBHHAs (82%), xz (1,n = 265) = 55.72, p < .001. Specifically, VNAs were more likely to be members of the National Association for Home Care, the National Homecaring Council, VNA of America, and/or the National League for Nursing while HBHHAs were more likely to be involved with the American Hospital Association. In terms of referral sources, for both types of agencies, the largest percent of referrals was received from hospitals and physicians (M = 81.2;
Table 2. Major Study Constructs and Organlzatlonal Control Varlables Construct
Organizational environment 1) Funding sources
2) Accrediting bodies
3) Professional organizations 4) Referral sources
5) Competing agencies
6) Clients
§awices 1) Type of service
2) Method of service provision
Organlzatlonal control variables 1) Revenue 2) Number of FTEs
3) Agencyage 4) Director’s degree 5) Extent of service area 6) Parent organization
Measurement Percent of funding from typical payment sources including Medicare, other government sources, private sources, clients, and others Whether agency accredited (yes or no) and by whom Whether agency involved with professional organizations (yes or no) and which ones Percent of referrals from typical sources including hospitals and physicians, nursing homes, community agencies, and families, and clients. Extent of competition with different types of home health care agencies using 5-point scales. Total competition was calculated by summing the individual scores for the five types of agencies. Ranking of frequency of clients by primary medical diagnosis, racial background, and age. Number of high-tech services (pharmacy, radiology, IV services, parenteraVenteral therapy, laboratory, and respiratory services). Number of long-term services (homemaker/housekeeping, home delivered meals, personal contact services, transportation, and respite care). Percent of services provided through parent organization, formal contract with another organization, informal arrangement, and other arrangement. Total revenue for agency for last year Total number of full time equivalent employees in direct service and support services currently employed Years of operation for agency Highest degree: 1) BSN, AD or diploma 2) MS or PhD Extent of rural, urban, and suburban service area based on 5-point scales Whether the agency has a parent organization (yes or no)
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Table 3. Differences In Funding Sources between VNAs and HBHHAs Controlling for OrganlzatlonalVariables Source Medicare Covariates Director's degree Agency age Type of agency Residual Total Other governmental sources Covariates Suburban Agency revenue Agency age Type of agency Residual Total
ss
df
MS
F
7712.13 12223.94 4058.05 150164.17 183621.42
1 1 1 258 261
7712.13 12223.94 4058.05 582.03 703.53
13.25"' 21 .OO"' 6.97"
4937.31 1081.21 8077.86 1510.18 601 12.68 77130.48
1 1 1 1 21 7 221
4937.31 1081.21 8077.86 1510.18 277.02 349.02
17.82"* 3.90' 29.16"' 5.45'
SD = 14.4). The percent of referrals from nursing homes (M= 4.2; SD = 4.9), community agencies (M = 4.4; SD = 7.0), and families and clients (M = 10.3; SD = 11.1) was quite low for both types of agencies. HBHHAs (adj. M = 87.0) had a higher percent of referrals from acute medical care sources (MDs and hospitals) than VNAs (adj. M = 76.5) (see Table 4). VNAs (adj. M = 5.4) had a higher percent of referrals from community sources, such as community centers, than HBHHAs (adj. M = 3.1). Moreover, VNAs (adj. M = 13.4) had a higher percent of referrals from families and clients than HBHHAs (adj. M = 6.5). Although the difference was small, HBHHAs (adj. M = 4.8) had a higher percent from nursing homes than VNAs (adj. M = 3.5). For both types of agencies, the extent of competition was greatest with for-profit agencies (M = 3.3, SD = 1.3 for the VNAs and M = 2.4, SD = 1.3 for the HBHHAs, using a 5-point scale). Official agencies were not perceived to be a major source of competition for either type of agency (M = 1.7, SD = 0.9 andM = 1.7, SD = 1.0 for VNAs and HBHHAs, respectively). VNAs perceived higher Competitionfrom other hospitalbased agencies (M = 3.0, SD = 1.5)than HBHHAs (M = 2.0, SD = 1.2). This was also the case for private, nonprofit agencies (M = 2.4, SD = 1.3 for VNAs; M = 2.0, SD = 1.1 for HBHHAs) and other Visiting Nurse Associations (M = 2.1, SD = 1.2 for VNAs; M = 1.8, SD = 1.0 for HBHHAs). Consistently, VNA respondents reported more competition from each of the competing agencies than HBHHA respondents. This was true for total competition. VNAs (M = 12.3,
SD
= 4.4) had higher total competition scores than HBHHAs (M = 9.8; SD = 3.7), t(258) = 4.78, p < .001. The last aspect of the organizational environment examined in this study was the clients or consumers of the agency's services. The typical client for both the HBHHAs and the VNAs was a white person between the ages of 75 and 84 with a diagnosis of either circulatory disease or cancer. There were no significant differences between the two types of agencies in the clients served.
Services Two aspects of services were examined: the number of services provided by type and the methods of service provision. Three-quarters of the agencies provided the following services: homemaker, laboratory, IV therapy, parenteraventera1 therapy, and pediatric care. Less than 25% of the sample provided mental health services, radiology, and transportation. HBHHAs (adj. M = 3.9) were more likely to provide a higher number of high-tech services than VNAs (adj. M = 3.2) (see Table 5). In addition, agencies that had higher revenues and were part of a larger organization (i.e.. had a parent organization) provided more high-tech services. On the other hand, there were no significant differences between VNAs and HBHHAs on the number of long-term services (M = 2.6; SD = 1.5). In general, HBHHAs (adj. M = 51.0%) had a significantly higher percent of their services provided through an outside arrangement than VNAs
291
ORGANIZATIONAL ENVIRONMENTS I BURMAN
Table 4. Dlfferences In Referral Sources between VNAs and HBHHAs Controlling for Organizational Variables Source Physicians and hospitals Covariates Age of agency Number of FTEs Type of agency Residual Total Community Covariate Director's degree Type of agency Residual Total Family and self Covariate Director's degree Type of agency Residual Total Nursing homes Covariate Number of FTEs Type of agency Residual Total
ss
df
MS
F
798.1 1 733.44 3037.31 45801.50 51826.82
1 1 1 247 250
798.1 1 733.44 3037.31 185.44 207.31
4.30' 3.96' 16.38"'
1003.04 289.70 10792.71 12085.46
1 1 243 245
1003.04 289.70 44.41 49.33
22.58"' 6.52"
308.26 2373.25 27565.04 30546.54
1 1 245 247
308.26 2673.25 112.51 123.67
2.74 23.76"'
113.64 89.52 5474.92 5678.08
1 1 246 248
113.64 89.52 22.26 22.90
5.11' 4.02'
(adj. M = 41.9%) (see Table 6). However, there were no differences between the two types of agencies for any of the specific methods of external service provision: provided by parent organization, through an external contract, using informal arrangements, or "other" arrangements.
Impact of Organizational Environment on Services The number of each type of service, high-tech or long-term, was regressed on environmental factors
and control variables in a series of hierarchical multiple regressions with control variables entered first followed by environmental factors. The most explanatory model for the number of high-tech services is shown in Table 7. The number of hightech services was positively associated with the percent of referrals from nursing homes and the amount of services provided by outside arrangements. These environmental factors explained a significant amount of variance in the number of high-tech services even after controlling for type of agency and agency revenue. The number of
Table 5. Differences In Number of High-Tech Services Between VNAs and HBHHAs Controlling for Organizational Variables
Covariates Agency revenue Presence of parent organizationa Type of agency Residual Total .dummy coded: No = 0; Yes = 1. ' p < .05. " p < .01. " ' p < ,001.
ss
df
MS
F
7.26 45.87 15.02 466.02 531.36
1 1 1 250 253
7.25 45.87 15.02 1.86 2.10
3.89' 24.61 *** 8.06"
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RESEARCH IN NURSING 8 HEALTH
Table 6. D W VNAa and HBHHAs
In Percent of Total Servlces Provlded by Outslde Arrangements Between
Covariate Extent of rural service area Type of agency Residual Total
ss
df
MS
F
0.33 0.53 20.58 21.44
1 1 262 264
0.33 0.53
4.25' 6.70"
.08
.08
' p < .05. * * p < .01.
long-term services was positively associated with the percent of funding from "other" sources and the percent of referrals from family and self and community sources (see Table 7). In the case of long-term services, agency revenue or size explained 11% of the variance and the environmental factors accounted for an additional 4% of the variance.
DISCUSSION One of the major aims of this study was to examine the organizational environments and services of home health care agencies. Although only VNAs and HBHHAs were examined, the intent of this study was to gain insight into the broader field of home health care. The study documented differences between VNAs and HBHHAs in their en-
Table 7. E
vironments and services. VNAs and HBHHAs differed in the key environmental factors. Specifically, differences were found between the HBHHAs and VNAs on funding sources, competing agencies, referral sources, involvement in professional organizations, and accrediting bodies. HBHHAs had a higher percent of funding from Medicare, were more likely to be accredited, and had a higher percent of referrals from physicians and hospitals than VNAs. VNAs had a greater number of funding sources, a higher percent of funding from other governmental sources such as Medicaid, were more likely to be involved in professional organizations, and received a higher percent of referrals from families and clients than HBHHAs. These findings are consistent with other recent studies (Balinsky & Rehman, 1984; Pettigrew et al., 1988) and the differing origins of the two types of agencies. VNAs developed in the public health tradition as independent agencies
M of EnvlronmentalFactors on Hlgh-Tech and LongTerm Services
Service High-tech Control variables Type of agency' Agency revenue Environmental factors Percent referrals from nursing homes Percent services provided by outside sources Long-term Control variables Agency revenue Environmental factors Percent referrals from family and self Percent referrals from community sources Percent funding from "other" sources 'dummy coded: HBHHAs = 0; VNAs ' p < .05. " p < .01. " ' p < .001.
beta
t
-.78 .23
-..27
.19
-4.01 *** 2.78"
.06
.20
3.29"'
1.29
.25
4.23*"
.1 8b'
.42
.32
5.23"'
.11***
.02
.13
2.20'
.03
.14
2.30'
.16
.11
1.75
b
=
1. ' F = 13.40(4,227). ' F
=
11.11(4,229).
R2
R2 Change
.08"
15c***
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serving community needs. On the other hand, HBHHAs originated within the medical care system connected with hospitals as a means to facilitate continuity of care. The differences between the two types of agencies in services were relatively minor. VNAs provided more long-term care services than HBHHAs, but this finding was related to the larger revenue of the VNAs. HBHHAs provided significantly more high-tech services than VNAs when revenue was controlled for in the analyses. Therefore, agency services were not greatly different once size (or revenue) was taken into account. HBHHAs in general had more services provided by some external mechanism; however, there were no differences between the two types of agencies in the specific methods of service provision. Although there were some differences, the similarities between the two types of agencies also must be emphasized. In regard to the organizational environment, there were no differences between the VNAs and the HBHHAs in the types of clients being served. Both received the largest percent of their funding from Medicare and referrals from hospitals and physicians. The changes in home health care, such as joint ventures, have led to a blurring of the distinctions between types of agencies. New classifications may be necessary for the type of agencies delivering home health care based on factors such as size, age, or corporate structure. Another purpose of this study was to examine the impact of the organizational environment on agency services. The organizational environment was found to have an impact upon agency services. Funding and referral sources were related to the number of high-tech and long-term services. Overall, these findings are plausible. Funding sources have become increasingly involved with the delivery of health care, defining what services will be reimbursed and what staff can provide c e h n services. In the acute care setting, hospitals have been found to alter their services in response to fiscal changes (Gay et al., 1989). Therefore, it is not surprising that agency services are influenced by funding sources. On the other hand, referral sources make it possible for agencies to provide services by making available necessary resources, for example, clients. It also is illuminating to examine the environmental factors that did not influence agency services. The client characteristics of those served did not have an impact. This may be due in part to the relatively unrefined nature of the measure. Examining the technological needs of clients might lead to different results. However, clients, re-
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gardless of need, are generally viewed as having less power in the health care field (Hasenfeld, 1983). Neither accrediting bodies nor professional organizations had any influence in agency services. Perhaps these organizations are taken for granted in home health care because their influence is ongoing and less apt to change dramatically as in the case of funding sources. Finally, the amount of competition from other agencies was not related to agency services. This may be because some of the current high demand services, such as hightech services, were provided by a majority of the agencies in the study. However, further investigation and refinement of the measurement of competition is needed. Although this was not a specific aim of this study, examination of the organizational factors that were related to both the organizational environment and agency services is interesting. Size (as measured by revenue or FTEs)was a significant covariate in many of the analyses and this is consistent with other organizational research (Sutton & D’Aunno, 1989). Agency age was also a significant covariate. According to institutional theory, organizational structure is “imprinted at the time of founding and certain organizational characteristics remain throughout the life of the organization (Scott, 1987). Director’s degree was found to be correlated with environmental factors and services. The educational preparation of the director could influence herhis preference for funding and referral sources. However, these findings are confounded because of the differences between VNAs and HBHHAs in directors’ degrees and further study is warranted. There are several implications of this study for future research. First, differences were found in organizational environments of VNAs and HBHHAs. Therefore, it would be useful to include other types of home health care agencies, such as freestanding private agencies, in further research to examine differences in environments. Second, additional research is needed examining the impact of organizational and environmental factors on agency services. There were only minor differences between VNAs and HBHHAs in agency services; however, size of agency, as measured by revenue, did have an impact. Moreover, funding and r e f e d sources influenced services, while client characteristics, accrediting bodies, and competition did not. Incorporating all types of home health care agencies and refining measures of environmental factors such as competition, would be beneficial in more clearly identifying the influence of organizational and environmental factors. Finally, it would be useful to extend this research. Do
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RESEARCH IN NURSING 8 HEALTH
agencies with different service patterns have different client outcomes? Do agencies in different environmentshave different outcomes? How does the environment influence agency services in terms of patient outcomes? What effect do agencies have on the environment? How can agencies influence the environment to bring about more positive outcomes for their clients? There are several implications of this study for nursing practice. The impact of the organizational environment, which is the context of nursing practice, must be considered. Nursing personnel need to identify environmental factors, such as the mix of funding and referral sources, that influence the provision of services in their agencies. Key environmental factors may have positive and negative and intended and unintended effects upon the practice of nursing and their influenceon agency structure must be recognized. Consequently, evaluation of the agency should include identification of environmental factors that influence care. Focusing on just the home health care agency, in terms of services and staffing, ignores key aspects of the organizational environment that can have an impact on services.
Balinsky, W. (1985). A comparative analysis of agencies providing home health services. Home Health Care Services Quarterly, 6 , 45-64. Balinsky, W., & Rehman, S. (1984). Home health care: A comparative analysis of hospital-based and community-based agency patients. Home Health Care Services Quarterly, 5 , 45-60. Dillman, D. (1978). Mail and telephone surveys: The total design method. New York: Wiley. Dobbin, F.R., Edelman, L., Meyer, J. W., Scott, W.R., & Swindler, A. (1988). The expansion of due process in organization. In L.G. Zucker (Ed.), institutional patterns and organizations, culture and environment (pp. 71-98). Cambridge, MA: Ballinger Publishing Co. Gay, E . G . , Kronenfeld, J.J., Baker, S . L . , & Amidon, R.L. (1989). An appraisal of organizational response to fiscally constraining regulation: The case of hospitals and DRGs. Health and Social Behavior, 30, 56-76. Harrington, C. (1988). Quality, access and costs: Public policy and home health care. Nursing
Outlook, 3 6 , 164-166. Hasenfeld, Y. (1983). Human service organizations. Englewood Cliffs, NJ: Prentice-Hall, Inc. Home care in U.S.Hospitals (1989). Hospitals, 63, 46-54.
Lerman, D. (1987). Room to expand home care business in 1987. Hospitals, 6 1 , 51-52. Meyer, J.W., & Rowan, B. (1983). Institutionalized organizations: Formal structure as myth and ceremony. In J.W. Meyer & W.R. Scott (Eds.), Organizational environments: Ritual and rationality (pp. 21 -44). Beverly Hills: Sage. Meyer, J., Scott, W.R., & Strang, D. (1987). Centralization, fragmentation, and school district complexity. Administrative Science Quarterly, 32, 186- 201.
Pesznecker, B., Horn, B., Werner, J . , & Kenyon, V. (1987). Home health services in a climate of cost containment. Home Health Care Services Quarterly, 8 , 5-21. Pettigrew, M.L., Kramer, A.M., & Shaughnessy, P. W. (1988). Hospital-based and freestanding home health care case mix: Implications for Medicare reimbursement policy. Home Health Care Services Quarterly, 8 , 75-88. Pfeffer, J., & Salancik, G.R. (1978). The external control of organizations. A resource dependence perspective. New York: Harper & Row. Powell, W.W. (1988). Institutional effects on organizational structure and performance. In L.G. Zucker (Ed.), institutional patterns and organizations, culture and environment (pp. 115136). Cambridge, MA: Ballinger Publishing Co. Scott, W.R. (1983). The organization of environments: Network, culture, and historical elements. In J.W. Meyer & W.R. Scott (Eds.), Organizational environments: Ritual and rationality (pp. 155-175). Beverly Hills: Sage. Scott, W.R. (1987). The adolescence of institutional theory. Administrative Science Quarterly, 32, 493-5 1 1.
Sheets, R.G., & Ting, Y.(1988). Determinants of employee-termination benefits in organizations. Administrative Science Quarterly, 33, 607-624. Spiegel, A.D. (1987). Home health care (2nd ed.). Owings Mills, MD: National Health Publishing. Spohn, P.H., Bergthold, L . , & Estes, C.L. ( 1 988). From cottages to condos: The expansion of the home health care industry under Medicare. Home Health Care Services Quarterly, 8 , 25-55. Sutton, R.I., & D’Aunno, T. (1989). Decreasing organizational size: Untangling the effects of money and people. Academy of Management Review, 14, 194-212.
