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Biography [eng]

Ulrika Winblad, Ph.D., is an associate professor, senior lecturer, and director of postgraduate studies in the Department of Public Health and Caring Sciences at Uppsala University. Winblad’s research interests include the marketization of health care, quality and performance in health and elder care organizations; and the implementation of health policy.  Winblad received her Ph.D. in health services research from Uppsala University. 

Publications (10 of 120) Show all publications
Shield, R., Winblad, U., McHugh, J., Gadbois, E. & Tyler, D. (2019). Choosing the Best and Scrambling for the Rest: Hospital–Nursing Home Relationships and Admissions to Post-Acute Care. Journal of Applied Gerontology, 38(4), 479-498
Open this publication in new window or tab >>Choosing the Best and Scrambling for the Rest: Hospital–Nursing Home Relationships and Admissions to Post-Acute Care
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2019 (English)In: Journal of Applied Gerontology, ISSN 0733-4648, E-ISSN 1552-4523, Vol. 38, no 4, p. 479-498Article in journal (Refereed) Published
Abstract [en]

Objective: We explored post-Affordable Care Act hospital and skilled nursing facility (SNF) perspectives in discharge and admission practices. Method: Interviews were conducted with 138 administrative personnel in 16 hospitals and 25 SNFs in eight U.S. markets and qualitatively analyzed. Results: Hospitals may use prior referral rates and patients' geographic proximity to SNFs to guide discharges. SNFs with higher hospital referral rates often use licensed nurses to screen patients to admit more preferred patients. While SNFs with lower hospital referral rates use marketing strategies to increase admissions, these patients are often less preferred due to lower reimbursement or complex care needs. Conclusion: An unintended consequence of increased hospital-SNF integration may be greater disparity. SNFs with high hospital referral rates may admit well-reimbursed or less medically complex patients than SNFs with lower referral rates. Without policy remediation, SNFs with lower referral rates may thus care for more medically complex long-term care patients.

Keywords
post-acute care, qualitative and mixed methods, impact of health care policy
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-343260 (URN)10.1177/0733464817752084 (DOI)000461200900005 ()29307258 (PubMedID)
Available from: 2018-02-26 Created: 2018-02-26 Last updated: 2019-05-06Bibliographically approved
Wisell, K., Winblad, U. & Kälvemark Sporrong, S. (2019). Diversity as salvation?: A comparison of the diversity rationale in the Swedish pharmacy ownership liberalization reform and the primary care choice reform. Health Policy, 123(5), 457-461
Open this publication in new window or tab >>Diversity as salvation?: A comparison of the diversity rationale in the Swedish pharmacy ownership liberalization reform and the primary care choice reform
2019 (English)In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 123, no 5, p. 457-461Article in journal (Refereed) Published
Abstract [en]

Widespread liberalizing reform of the Swedish community pharmacy and primary care sectors took place in 2009–2010, including opening the market to private providers. One important rationale for the reforms was to increase diversity in the health-care system by providing more choices for individuals. The aim of this study was to increase the understanding how policy makers understood and defined diversity as a concept, and as a rationale for the reforms. The method used was document analysis of preparatory work and plenary parliament debate protocols. The results show that policy makers held vague and unclear definitions of diversity, which complicated its implementation. Diversity was sometimes seen as an effect of competition–a goal–while in other cases it was seen as a condition to be met in order to achieve competition–a means. Thus, policy makers viewed diversity both as a goal and as a means, making the underlying mechanisms unclear. The findings also revealed that policy makers failed to consistently demonstrate how the introduction of competition would lead to diversity.

Keywords
Community pharmacy, Community health care, Regulations, Liberalization, Sweden, Diversity
National Category
Pharmaceutical Sciences
Research subject
Social Pharmacy
Identifiers
urn:nbn:se:uu:diva-380072 (URN)10.1016/j.healthpol.2019.03.005 (DOI)000468719700003 ()30890380 (PubMedID)
Available from: 2019-03-23 Created: 2019-03-23 Last updated: 2019-06-24Bibliographically approved
Egholm, C. L., Helmark, C., Christensen, J., Eldh, A. C., Winblad, U., Bunkenborg, G., . . . Nilsen, P. (2019). Facilitators for using data from a quality registry in local quality improvement work: a cross-sectional survey of the Danish Cardiac Rehabilitation Database. BMJ Open, 9(6), Article ID e028291.
Open this publication in new window or tab >>Facilitators for using data from a quality registry in local quality improvement work: a cross-sectional survey of the Danish Cardiac Rehabilitation Database
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2019 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, no 6, article id e028291Article in journal (Refereed) Published
Abstract [en]

Objectives To investigate use of data from a clinical quality registry for cardiac rehabilitation in Denmark, considering the extent to which data are used for local quality improvement and what facilitates the use of these data, with a particular focus on whether there are differences between frontline staff and managers. Design Cross-sectional nationwide survey study. Setting, methods and participants A previously validated, Swedish questionnaire regarding use of data from clinical quality registries was translated and emailed to frontline staff, mid-level managers and heads of departments (n=175) in all 30 hospital departments participating in the Danish Cardiac Rehabilitation Database. Data were analysed descriptively and through multiple linear regression. Results Survey response rate was 58% (101/175). Reports of registry use at department level (measured through an index comprising seven items; score min 0, max 7, where a low score indicates less use of data) varied significantly between groups of respondents: frontline staff mean score 1.3 (SD=2.0), mid-level management mean 2.4 (SD=2.3) and heads of departments mean 3.0 (SD=2.5), p=0.006. Overall, department level use of data was positively associated with higher perceived data quality and usefulness (regression coefficient=0.22, p=0.019), management request for data (regression coefficient=0.40, p=0.008) and personal motivation of the respondent (regression coefficient=1.63, p<0.001). Among managers, use of registry data was associated with data quality and usefulness (regression coefficient=0.43, p=0.027), and among frontline staff, reported data use was associated with management involvement in quality improvement work (regression coefficient=0.90, p=0.017) and personal motivation (regression coefficient=1.66, p<0.001). Conclusions The findings suggest relatively sparse use of data in local quality improvement work. A complex interplay of factors seem to be associated with data use with varying aspects being of importance for frontline staff and managers.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2019
National Category
Occupational Health and Environmental Health Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-389818 (URN)10.1136/bmjopen-2018-028291 (DOI)000471197000083 ()31196902 (PubMedID)
Available from: 2019-07-30 Created: 2019-07-30 Last updated: 2019-07-30Bibliographically approved
Gadbois, E. A., Tyler, D. A., Shield, R., McHugh, J., Winblad, U., Teno, J. M. & Mor, V. (2019). Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility. Journal of general internal medicine, 34(1), 102-109
Open this publication in new window or tab >>Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility
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2019 (English)In: Journal of general internal medicine, ISSN 0884-8734, E-ISSN 1525-1497, Vol. 34, no 1, p. 102-109Article in journal (Refereed) Published
Abstract [en]

Objective

This research aimed to understand the experiences of patients transitioning from hospitals to skilled nursing facilities (SNFs) by eliciting views from patients and hospital and skilled nursing facility staff.

Design

We conducted semi-structured interviews with hospital and skilled nursing facility staff and skilled nursing facility patients and their family members in an attempt to understand transitions between hospital and SNF. These interviews focused on all aspects of the discharge planning and nursing facility placement processes including who is involved, how decisions are made, patients' experiences, hospital-SNF communication, and the presence of programs to improve the transition process.

Participants

Participants were 138 staff in 16 hospitals and 25 SNFs in 8 markets across the country, and 98 newly admitted, previously community-dwelling SNF patients and/or their family members in five of those markets.

Approach

Interviews were qualitatively analyzed to identify overarching themes.

Key Results

Patients reported they felt rushed in making their SNF decisions, did not feel they were appropriately prepared for the hospital-SNF transition or educated about their post-acute needs, and experienced transitions that felt chaotic, with complications they associated with timing and medications. Hospital and SNF staff expressed similar opinions, stating that transitions were rushed, there were problems with the timing of the discharge, with information transfer and medication reconciliation, and that patients were not appropriately prepared for the transition. Staff at some facilities reported programs designed to address these problems, but the efficacy of these programs is unknown.

Conclusions

Results indicate problematic transitions stemming from insufficient care coordination and failure to appropriately prepare patients and their family members. Previous research suggests that problematic or hurried transitions from hospital to SNF are associated with medication errors and unnecessary rehospitalizations. Interventions to improve transitions from hospital to SNF that include a focus on patients and families are needed.

National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-368032 (URN)10.1007/s11606-018-4695-0 (DOI)000454888300025 ()30338471 (PubMedID)
Available from: 2018-12-03 Created: 2018-12-03 Last updated: 2019-01-28Bibliographically approved
Gofen, A., Blomqvist, P., Needham, C. E., Warren, K. & Winblad, U. (2019). Negotiated compliance at the street level: Personalizing immunization in England, Israel and Sweden. Public Administration, 97(1), 195-209
Open this publication in new window or tab >>Negotiated compliance at the street level: Personalizing immunization in England, Israel and Sweden
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2019 (English)In: Public Administration, ISSN 0033-3298, E-ISSN 1467-9299, Vol. 97, no 1, p. 195-209Article in journal (Refereed) Published
Abstract [en]

Often portrayed as behaviour that is inconsistent with policy goals, public noncompliance poses a significant challenge for government. To explore what compliance efforts entail on the ground, this study focuses on childhood immunization as a paradigmatic case where a failure to ensure compliance poses a public health risk. The analysis draws on 48 semi‐structured interviews with frontline nurses and regional/national public health officials in England (N = 15), Sweden (N = 17) and Israel (N = 16), all of which have experienced periodic noncompliance spikes, but differ in direct delivery of vaccination provision. Compliance efforts emerged as a joint decision‐making process in which improvisatory practices of personalized appeals are deployed to accommodate parents’ concerns, termed here ‘street‐level negotiation’. Whereas compliance is suggestive of compelling citizens’ adherence to standardized rules, compliance negotiation draws attention to the limited resources street‐level workers have when encountering noncompliance and to policy‐clients’ influence on delivery arrangements when holding discretionary power over whether or not to comply.

Place, publisher, year, edition, pages
WILEY, 2019
National Category
Public Administration Studies
Identifiers
urn:nbn:se:uu:diva-383004 (URN)10.1111/padm.12557 (DOI)000464433000013 ()
Available from: 2019-05-21 Created: 2019-05-21 Last updated: 2019-05-21Bibliographically approved
Vengberg, S., Fredriksson, M. & Winblad, U. (2019). Patient choice and provider competition: Quality enhancing drivers in primary care?. Social Science and Medicine, 226, 217-224
Open this publication in new window or tab >>Patient choice and provider competition: Quality enhancing drivers in primary care?
2019 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 226, p. 217-224Article in journal (Refereed) Published
Abstract [en]

Patient choice of provider and provider competition have been introduced with the claim that they would lead to improved quality. For this to occur, certain conditions must be fulfilled on both the demand and the supply side. However, supply side-mechanisms – with provider behaviour as central – have been largely neglected in the literature, especially in primary care markets. In this article, we focus on provider behaviour and explore if and how choice and competition function as quality enhancing drivers in Swedish primary care. We explore this through semi-structured interviews with 24 managers and physicians at 13 Swedish primary healthcare centres, conducted from May 2016 to February 2017. The analysis draws on assumptions that for enhanced quality, providers must receive information on patients' choices, analyse it and respond accordingly. One conclusion is that Swedish primary care providers lack information on patients' choices and "exits", which makes it difficult for providers to respond to patients' choices. Furthermore, it is questionable whether choice and competition stimulate enhanced clinical quality. At the same time, choice and competition seems to make providers more aware of accessibility concerns and of their reputation, which they may be stimulated to improve. The article contributes evidence on supply side-mechanisms, and encourages clarification of "quality" in this respect, both on the political arena as well as in theoretical models.

Keywords
Sweden, Patient choice, Competition, Quasi-market, Primary care
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-379412 (URN)10.1016/j.socscimed.2019.01.042 (DOI)000466251700025 ()30878640 (PubMedID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2014-4763
Available from: 2019-03-15 Created: 2019-03-15 Last updated: 2019-06-20Bibliographically approved
Winblad, U. & Olsson, F. (2019). Uppföljning och tillsyn av privata aktörer. In: Anders Hanberger; Lena Lindgren (Ed.), Perspektiv på granskning inom offentlig sektor:: med äldreomsorgen som exempel. Stockholm: Gleerups Utbildning AB
Open this publication in new window or tab >>Uppföljning och tillsyn av privata aktörer
2019 (Swedish)In: Perspektiv på granskning inom offentlig sektor:: med äldreomsorgen som exempel / [ed] Anders Hanberger; Lena Lindgren, Stockholm: Gleerups Utbildning AB, 2019Chapter in book (Other academic)
Place, publisher, year, edition, pages
Stockholm: Gleerups Utbildning AB, 2019
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-369723 (URN)9789151100654 (ISBN)
Available from: 2018-12-17 Created: 2018-12-17 Last updated: 2019-04-10Bibliographically approved
Blomqvist, P. & Winblad, U. (2019). Why No Nonprofits?: State, Market, and the Strive for Universalism in Swedish Elder Care. Nonprofit and Voluntary Sector Quarterly, 48(3), 513-531
Open this publication in new window or tab >>Why No Nonprofits?: State, Market, and the Strive for Universalism in Swedish Elder Care
2019 (English)In: Nonprofit and Voluntary Sector Quarterly, ISSN 0899-7640, E-ISSN 1552-7395, Vol. 48, no 3, p. 513-531Article in journal (Refereed) Published
Abstract [en]

Elder care is one of the sectors where nonprofit organizations are most active. One exception is the Scandinavian countries, where the nonprofit sector plays a marginal role in this area. In the article, we ask why this is the case. The findings show that in Sweden, nonprofit organizations have found it hard to compete with for-profits and that this inability to compete, in turn, reflects their relative organizational weakness. A main argument in the article is that this weakness must be understood in the context of the historical development of the modern elder care system in Sweden, where social democratic reformers in the 1940s chose to create a universal public system for providing services to the elderly, thereby making the nonprofit sector redundant. Universalism in this interpretation was seen as incompatible with service delivery by private organizations, a view that has come to change in recent years.

Place, publisher, year, edition, pages
SAGE PUBLICATIONS INC, 2019
Keywords
Sweden, privatization, nonprofit, elder care, welfare state
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-385965 (URN)10.1177/0899764018819870 (DOI)000468339900003 ()
Funder
Riksbankens Jubileumsfond
Available from: 2019-06-19 Created: 2019-06-19 Last updated: 2019-06-19Bibliographically approved
Tyler, D. A., McHugh, J. P., Shield, R. R., Winblad, U., Gadbois, E. A. & Mor, V. (2018). Challenges and Consequences of Reduced Skilled Nursing Facility Lengths of Stay. Health Services Research, 53(6), 4848-4862
Open this publication in new window or tab >>Challenges and Consequences of Reduced Skilled Nursing Facility Lengths of Stay
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2018 (English)In: Health Services Research, ISSN 0017-9124, E-ISSN 1475-6773, Vol. 53, no 6, p. 4848-4862Article in journal (Refereed) Published
Abstract [en]

Length of stay (LOS) among postacute care patients in skilled nursing facilities (SNFs) has been steadily decreasing for the past several years. Empirical studies on overall SNF LOS are scant because most studies focus on LOS for certain conditions or procedures (e.g., Haghverdian, Wright, and Schwarzkopf 2017). However, analysis of LOS data available at Brown University's LTCFocus website (www.ltcfocus.org) illustrates that SNF LOS has been dropping in recent years. These reductions have been due, in part, to Medicare policy changes and market based pressures, including the emergence of accountable care organizations (ACOs) and bundled payment and shared savings programs, as well as the growth of Medicare Advantage. However, little is known about how shorter LOS is affecting SNFs or their postacute care patients.

Implementation of the Affordable Care Act (ACA) included several programs to improve care quality, increase efficiency, and reduce costs through value‐based payment models. In these programs, participating providers, including doctors, hospitals, and other health care organizations, join together voluntarily to provide coordinated care to their Medicare patients. These groups are reimbursed for episodes of care, payments are capitated and risk‐adjusted, and participating organizations share savings they achieve from their Medicare population (Centers for Medicare and Medicaid Services 2017). Because over 20% of Medicare patients who are hospitalized each year are discharged to postacute care (PAC; Tian 2016), many of the patients covered by these programs are cared for in SNFs. However, research has shown that a minority of ACOs, for example, actually include SNFs as full participants (Colla et al. 2016). This means that ACOs are relying on SNFs to provide better care at lower costs without including those SNFs in the shared savings or through contractual or other formal relationships.

In the last several years, there has also been extraordinary growth in the Medicare Advantage program, which now covers one‐third of all Medicare beneficiaries (Jacobson et al. 2017). Medicare Advantage is the managed care version of Medicare where private insurers are paid by Medicare on a per beneficiary per month basis for the care of all their enrolled beneficiaries. Unlike traditional Medicare where patients have choice among all available providers, Medicare Advantage managed care organizations (MCOs) are free to form networks of preferred providers. This affords MCOs some control over the care delivered by providers in their networks, including increased control over LOS.

Decreases in LOS due to these market and policy pressures are likely having an effect on SNFs. Therefore, the purpose of this research was to identify the key challenges that reductions in LOS pose for SNFs, the unintended consequences of reduced LOS for SNFs and SNF patients, SNF responses to these, and suggestions for modifications to current policy.

National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-360832 (URN)10.1111/1475-6773.12987 (DOI)000450017700046 ()29873063 (PubMedID)
Available from: 2018-09-18 Created: 2018-09-18 Last updated: 2019-01-22Bibliographically approved
Kullberg, L., Blomqvist, P. & Winblad, U. (2018). Market-orienting reforms in rural health care in Sweden: how can equity in access be preserved?. International Journal for Equity in Health, 17, Article ID 123.
Open this publication in new window or tab >>Market-orienting reforms in rural health care in Sweden: how can equity in access be preserved?
2018 (English)In: International Journal for Equity in Health, ISSN 1475-9276, E-ISSN 1475-9276, Vol. 17, article id 123Article in journal (Refereed) Published
Abstract [en]

Background: Health care provision in rural and urban areas faces different challenges. In Sweden, health care provision has been predominantly public and equitable access to care has been pursued mainly through public planning and coordination. This is to ensure that health needs are met in the same manner in all parts of the country, including rural or less affluent areas. However, a marketization of the health care system has taken place during recent decades and the publicly planned system has been partially replaced by a new market logic, where private providers guided by financial concerns can decide independently where to establish their practices. In this paper, we explore the effects of marketization policies on rural health care provision by asking how policy makers in rural counties have managed to combine two seemingly contradictory health policy goals: to create conditions for market competition among health care providers and to ensure equal access to health care for all patients, including those living in rural and remote areas. Methods: A qualitative case study within three counties in the northern part of Sweden, characterized by vast rural areas, was carried out. Legal documents, the "accreditation documents" regulating the health care quasi-markets in the three counties were analyzed. In addition, interviews with policy makers in the three county councils, representing the political majority, the opposition, and the political administration were conducted in April and May 2013. Results: The findings demonstrate the difficulties involved in introducing market dynamics in health care provision in rural areas, as these reforms not only undermined existing resource allocation systems based on health needs but also undercut attempts by local policy makers to arrange for care provision in remote locations through planning and coordination. Conclusion: Provision of health care in rural areas is not well suited for market reforms introducing competition, as this may undermine the goal of equity in access to health care, even in a publicly financed health care system.

Keywords
Rural health care, Marketization, Patient choice, Health care planning, Health governance, Sweden
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-362645 (URN)10.1186/s12939-018-0819-8 (DOI)000441946700002 ()30119665 (PubMedID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, Dnr 2011-01137
Available from: 2018-10-09 Created: 2018-10-09 Last updated: 2018-10-09Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-3921-5522

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