Table 4.

Mixed-method results of “concurrent QUAL + quant” analysis of reform impact on safety-net institution personnel

Approach	Mixed-method results
	Qualitative	Quantitative	Convergence
Question	How has implementation of the reform impacted SNI workplaces and personnel?
Answer	Key changes included new IT systems and administrative procedures, the elimination of case management and simultaneous introduction of CCSS, and the transition from the 1/12th draw-down to fee-for-service reimbursement. In terms of reactions, SNI personnel complained of heightened stress levels and generally engaged in greater administrative work related to these changes, sometimes at the expense of time spent with patients. On the organizational level, some SNIs provided uncompensated care and/or reduced salaries, staffing, and services. Consequences of change articulated by SNI personnel included greater work burden, lower morale, fear about job security, and financial stress for SNIs	Consequences of change: For the system as a whole (includes all personnel who persisted, entered, or left throughout the study period), the results were mixed. Job satisfaction diminished somewhat between T1 and T3. Organizational commitment appeared to decrease at T2 relative to T1, but no difference from T1 was evident by T3. No changes over time were evident for TI	Qualitative results underscore that SNIs and personnel struggled to adapt to changing organizational conditions under the reform, and may partly explain decreases in job satisfaction captured quantitatively
Question	Have rural SNI personnel experienced the reform differently from urban SNI personnel?
Answer	There was minimal variation in the type of key changes identified by rural and urban SNI personnel. Reactions tended toward greater negativity among rural personnel, who were less familiar with managed care, struggled with the loss of case management as a revenue source and CCSS, and whose SNIs traditionally depended on the 1/12th draw-down. The consequences of greater work burden, lower morale, job security fear, and financial stress for SNIs seemed to disproportionately affect rural personnel. These consequences were possibly intensified by the limited workforce capacity and infrastructure of rural SNIs	Consequences of change: For the system as a whole (includes all personnel who persisted, entered, or left throughout the study period), rural personnel typically indicated lower job satisfaction, lower organizational commitment, and higher turnover intentions overall. The differences were particularly evident at T2. Among rural personnel, all three measures indicated a decrease at T2 relative to T1. However, no such decrease from T1 was identified among urban personnel. For rural personnel, job satisfaction at T3 remained lower than at T1	Qualitative and quantitative findings suggest that rural personnel experienced more negative reactions to changes under the reform