Browsing by Subject "South Carolina"

High and variable rates of patients leaving hospice before death have increasingly caught the attention of health services researchers. Found to be associated with poorer patient outcomes and higher medical expenditures, these so-called live discharges may reflect poor quality care or that the Medicare hospice benefit is not being used as intended. This dissertation uses quantitative and qualitative methods to investigate factors relating to live discharges from three novel perspectives. There is substantial state variation in live discharge rates, yet despite the influence of local factors on health care utilization, research has not explored variation in live discharge rates at the county level. My first study assesses the relationship between county-level characteristics and live discharge rates in North and South Carolina’s 146 counties using fractional logistic regression analysis. I find that greater hospice market competition and the presence of a hospital in the county with inpatient palliative care were associated with a lower live discharge rate. I also find that an increase in the proportion of the county population living in poverty was associated with a higher rate of live discharge. Lastly, counties in South Carolina (which lacks hospice certificate of need (CON) legislation) had a significantly higher rate of live discharge than counties in North Carolina (which has hospice CON legislation). My second study examined the relationship between characteristics of 168 hospice providers and live discharge rates in North and South Carolina. Using fractional logistic regression analysis, I found that being located in counties with lower hospice market competition was associated with a lower live discharge rate. Having a greater proportion of patients who had state buy-in, who had a primary hospice diagnosis of cancer, who were white, and who were older was associated with lower live discharge rate. Additionally, I found that having a higher proportion of patients in assisted living facilities was associated with a higher rate of live discharge. Being a for-profit hospice provider was also associated with a higher live discharge rate. Finally, I found that providing general inpatient level of hospice care was associated with a lower rate of live discharge. The hospice admission is typically a patient’s introduction to hospice. Often conducted during a period of heightened emotions and stress, this interaction offers an opportunity for hospice staff to assess patient and caregiver readiness for and understanding of hospice services, ensure support throughout the patient’s disease course, and prepare patients and caregivers for the reality of managing a terminal illness most often in the home setting. Through 35 semi-structured interviews, this third study explored hospice admission staff and bereaved caregiver perspectives of the hospice admission process. Our findings indicate three overarching areas where the transition to hospice might be improved: referring provider issues, hospital discharge process, and the first touch of hospice. Staff interviews also provided insight into how the Covid-19 pandemic had altered the conducting of hospice admissions. Optimizing the hospice admission process may be one avenue for reducing future live discharges. These studies contribute to our understanding of variation in live discharge rates across geographic regions and between hospice providers. Additionally, our interviews with hospice staff and caregivers offer important perspectives on the hospice admission process and areas for improving the transition to hospice. Findings from these three papers may inform policy and practice changes to improve end-of-life care outcomes and potentially reduce unnecessary disenrollment from hospice.

This dissertation examines the changing concepts and experiences of slavery and freedom in South Carolina from its founding in 1670 through 1747, a period during which the legal status of "slave" became solidified in law. During the course of South Carolina's first eight decades of settlement, the legal statuses of "slave" and "free" evolved as the colony's slaveholders responded to both local and imperial contexts. Slaves and slaveholders engaged in a slow process of defining and refining the contours of both slavery and freedom in law. The dissertation explores how this evolution occurred by focusing on three topics: constant conflict that afflicted the colony, free white colonists' reliance on the loyalty of slaves, and South Carolina's law and legal system.

Through its use of social and legal history, as well as close reading, the dissertation shows that South Carolina's legal and military contexts gave unplanned meaning to slaves' activities, and that this had the effect of permitting slaves to shape slavery and freedom's development in practice and in law. In various ways, the actions of slaves forced slaveholders to delineate what they considered appropriate life and work conditions, as well as forms of justice, for both slaves and free people. As such, slavery as an institution helped give form to freedom. Drawing on legal records, newspapers, pamphlets, and records of the colonial elite, the dissertation argues that slaves' actions--nonviolent as well as violent-- served as a driving force behind the legal trajectory of slavery and freedom in South Carolina. These processes and contexts change our understanding of colonial America. They reveal that slaves influenced the legal regulation of slavery and that slavery and the enslaved population played a critical role in defining freedom, a central tenet of American democracy. Contrary to modern assumptions about freedom and even the ideals expressed in the Declaration of Independence, this dissertation shows how slavery actually constrained freedom.

In 1760, when British victory was all but assured and hostilities in the northeastern colonies of North America came to an end, the future of the southeastern colonies was not nearly so clear. British authorities in the South still faced the possibility of a local French and Indian alliance and clashed with angry Cherokees who had complaints of their own. These tensions and events usually take a back seat to the climactic proceedings further north. I argue that in South Carolina, by destabilizing relations with African and Native Americans, the Cherokee Indians raised the social and political anxieties of coastal elites to a fever pitch during the Anglo-Cherokee War. Threatened by Indians from without and by slaves from within, and failing to find unbridled support in British policy, the planter-merchant class eventually sought to take matters into its own hands. Scholars have long understood the way the economic fallout of the French and Indian War caused Britain to press new financial levies on American colonists. But they have not understood the deeper consequences of the war on the local stage. Using extensive political and military correspondence, ethnography, and eighteenth-century newspapers, I offer a narrative-driven approach that adds geographic and ethnographic breadth and context to previous scholarship on mid-eighteenth century in North America. I expand understandings of Cherokee culture, British and colonial Indian policy, race slavery, and the southeastern frontier. At the same time, I also explain the origins of the American Revolution in the South.

This dissertation examines federal farm policy between 1933 and 1965 and its implementation in North and South Carolina. It argues that restricted economic democracy in the Farm State - the full array of agriculture regulations, programs, and agencies associated with the federal government - enabled policy makers to adhere strictly to the principles of progressive farming and parity in the development and implementation of farm policies. These ideals emphasized industrialized, commercial farming by ever-larger farms and excluded many smaller farms from receiving the full benefit of federal farm aid. The resulting programs, by design, contributed significantly to the contraction of the farm population and the concentration of farm assets in the Carolinas. They also steered rural economic development into the channels of agribusiness as a strategy to manage the consequences of those policies. The processes and programs that drove the smallest farms out of business in the early post-war era were beginning to threaten even larger, commercial farming enterprises by the 1960s. In this context, the economic and political interests of farmers became separate from and oppositional to those of industry or consumers and removed incentives to seek common ground. The unwavering pursuit of commercial farming and agribusiness prevented diversified rural development in the Carolinas and contributed to uneven distributions of prosperity in the region.

Using the methodologies of policy, business, and social history, this work draws upon evidence from a wide variety of sources including the papers of government farm agencies, correspondence of farmers, political office holders, and personnel of the USDA. It also consults the farm press and local press, the writings of farm policy leaders, and Congressional hearings and reports. These documents provide a multifaceted perspective on the development and implementation of farm programs in the Carolinas and offers a new look at the contested process through which farm policy was made and implemented in the post war period.