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The political economy of a public health case management program's transition into medical homes


  • Wells, Rebecca
  • Cilenti, Dorothy
  • Issel, L. Michele


Throughout the United States, public health leaders are experimenting with how best to integrate services for individuals with complex needs. To that end, North Carolina implemented a policy incorporating both local public health departments and other providers into medical homes for low income pregnant women and young children at risk of developmental delays. To understand how this transition occurred within local communities, a pre-post comparative case study was conducted. A total of 42 people in four local health departments across the state were interviewed immediately before the 2011 policy change and six months later: 32 professionals (24 twice) and 10 pregnant women receiving case management at the time of the policy implementation. We used constant comparative analysis of interview and supplemental data to identify three key consequences of the policy implementation. One, having medical homes increased the centrality of other providers relative to local health departments. Two, a shift from focusing on personal relationships toward medical efficiency diverged in some respects from both case managers' and mothers' goals. Three, health department staff re-interpreted state policies to fit their public health values. Using a political economy perspective, these changes are interpreted as reflecting shifts in public health's broader ideological environment. To a large extent, the state successfully induced more connection between health department-based case managers and external providers. However, limited provider engagement may constrain the implementation of the envisioned medical homes. The increased focus on medical risk may also undermine health departments' role in supporting health over time by attenuating staff relationships with mothers. This study helps clarify how state public health policy innovations unfold at local levels, and why front line practice may in some respects diverge from policy intent.

Suggested Citation

  • Wells, Rebecca & Cilenti, Dorothy & Issel, L. Michele, 2015. "The political economy of a public health case management program's transition into medical homes," Social Science & Medicine, Elsevier, vol. 145(C), pages 98-106.
  • Handle: RePEc:eee:socmed:v:145:y:2015:i:c:p:98-106
    DOI: 10.1016/j.socscimed.2015.10.003

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    References listed on IDEAS

    1. repec:mpr:mprres:6908 is not listed on IDEAS
    2. Matt E. Ryan, 2014. "Allocating Infection: The Political Economy Of The Swine Flu (H1n1) Vaccine," Economic Inquiry, Western Economic Association International, vol. 52(1), pages 138-154, January.
    3. Ahmed Mushfiq Mobarak & Andrew Sunil Rajkumar & Maureen Cropper, 2011. "The Political Economy of Health Services Provision in Brazil," Economic Development and Cultural Change, University of Chicago Press, vol. 59(4), pages 723-751.
    4. Buescher, P.A. & Roth, M.S. & Williams, D. & Goforth, C.M., 1991. "An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina," American Journal of Public Health, American Public Health Association, vol. 81(12), pages 1625-1629.
    5. Moehling, Carolyn M. & Thomasson, Melissa A., 2012. "The Political Economy of Saving Mothers and Babies: The Politics of State Participation in the Sheppard-Towner Program," The Journal of Economic History, Cambridge University Press, vol. 72(1), pages 75-103, March.
    6. Schenck, A.P. & Meyer, A.M. & Kuo, T.-M. & Cilenti, D., 2015. "Building the evidence for decision-making: The relationship between local public health capacity and community mortality," American Journal of Public Health, American Public Health Association, vol. 105, pages 211-216.
    7. L. Michele Issel & Sarah G. Forrestal & Jaime Slaughter & Anna Wiencrot & Arden Handler, "undated". "A Review of Prenatal Home-Visiting Effectiveness for Improving Birth Outcomes," Mathematica Policy Research Reports dadf48a4556844ec95c362b14, Mathematica Policy Research.
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