4 th International Conference on OB in Healthcare, University of Calgary, 19-21 April 2004

1. 4th International Conference on OB in Healthcare, University of Calgary, 19-21 April 2004 Contested Restructuration: Theory Elaboration From U.S. Long-Term Care Martin Kitchener* Charlene Harrington *Department of Social and Behavioral Sciences University of California, San Francisco 3333 California Street, Suite 455 San Francisco, CA 94118 Tel: (415) 502 7364 Fax: (415) 476 6552 Email: martink@itsa.ucsf.edu

2. The Restructuration ‘Project’ (1) Advance understandings of healthcare ‘restructuration’– fundamental change in social systems involving alterations among: logics, actors (individual & collective) & resource distributions (Scott et al 2000). (2) Extend institutional (archetype) analysis, drawing on other perspectives (PS, SMT & RDT) to examine: • Political inter-play between agency & structure (logics & resource distributions) • Role of powerful actors in inertia (Gouldner ‘54) & less powerful actors in change (social movements, Maguire et al 2001)

3. The Approach: Theory Elaboration Refining (updating, specifying, contradicting) general theory (models & concepts) of a phenomenon (restructuration) through successive cases conducted at different levels of analysis (Vaughan 1992: 175). Stage 1: Select/devise ‘sensitizing’ models & concepts Stage 2: Select cases (sequentially) as potential examples of phenomenon that vary along dimensions e.g., level, size, complexity, function etc. Stage 3: Conduct cases, inductive & simultaneous ‘testing’ & elaboration of theory & findings

4. Conceptual Framework for Institutional Analysis Institutional Environment Material-Resource Environment Focal Field Logics e.g. professional dominance, federal involvement, market managerialism Supply & Demand Factors e.g. need, finance system, supply of services Regulative e.g. laws, standards Normative Templates of structure & action Governance Systems e.g. licensing, certification Technologies e.g. equipment, IT, facilities Cognitive Socio-cultural frames Actors Individual & collective Industry/Market Structure e.g. competitors & exchange partners Developed from Scott et al (2000)

5. Restructuration of LTC: 3 Studies Study 1: US LTC Sector (Kitchener & Harrington 2004) Study 2: Nursing Home (NH) Field, Chaining (Kitchener & Solano) Study 3: Home & Community-Based Service (HCBS) Field, Disabled (Kitchener & Harrington)

6. The US LTC Sector: A Dialectic Analysis of Institutional Dynamics (Paper distributed) Aims 1. To provide an account of institutional dynamics (inertia & change) in a sector that: (a) has received less attention than others (hospitals, physician groups), & (b) is increasingly significant e.g., demographics, Govt. pays 57% of $123 bn expenditures, quality & cost concerns etc. 2. Extend institutional (archetype) analysis to context of conflicting logics, actors, & resource demands.

7. Research Design & Conceptual Framework Given the early stage of institutional analysis in the area, historical analysis of 2 secondary data sources: 1. Systematic on-line literature review: (a) collections (e.g., ABI inform, PubMed), (b) terms (e.g., long-term care, institutional theory), & (c) authors (e.g., Vladeck, Scott). 2. Authors’ research library e.g., unpublished reports, working papers, press cutting etc Two boundary limits established: (1) concentrate on LTC for elderly & disabled (c.f. mental health), & (2) national patters (c.f. inter-state variation). Areas for elaboration.

8. Analytical Approach All information initially sorted by Scott et al.’s (2000) 3 institutional eras: (1) Professional dominance, pre-1965; (2) Federal involvement, 1966-1982; & (3) Market-managerialism, post-1982. Following established qualitative coding & analytical procedures (e.g., Brock), identification of national LTC archetypes (Greenwood & Hinings 1988..): distinctive configurations of interpretive schemes, systems & structures. Analysis of ‘tracks of change’ esp. inertia and transformation. Dialectic analysis of opposing social forces (Benson 1977)

9. LTC Fields

10. Dynamics of Inertia & Change • Big Story: Contested emergence of insurgent HCBS field to sit alongside (not replace) traditional NH field. Conflicting logics, actors, resource demands. • Powerful actors (NH industry) peddle hard for inertia. Use political influence to: co-opt of Great Society programs, maintain weak regulation, starve competing HCBS of resources (70 % Medicaid LTC spending). • Less powerful actors (HCBS providers, consumers) pushed hard for change over 100 years. Re-theorization (from quality, social justice) to themes of market-managerialism: cost and consumerism (irony?)

11. Elaborating the Dynamics of Inertia & Change Study 2: Nursing Home Field, Chaining Key change in NH field emergence of large chains (multi-facility) corporations through 5,000 mergers & acquisitions (not new builds) during 1990s. Compared with hospital systems we know little about process or implications. Longitudinal case studies of 2 large chains. Boom-Bust, Casino Capitalism. Funding! Study 2: HCBS Field, Disability Longitudinal analysis of: logics (e.g., independent living, consumer directed care), actors e.g. (ADAPT), ADA, Olmstead, inter-state variation. NIDDR-5 year center grant, PAS.