Improving Patient-centered Care: How Clinical Staff Overcome Barriers to Patient Engagement at the VHA

"The healthcare system did fail me repeatedly": a qualitative study on experiences of healthcare among Canadian women with Cushing's syndrome

BACKGROUND

As a rare endocrine disorder, Cushing's Syndrome (Cushing's) is characterized by numerous symptoms and a non-specific presentation, leading to a delay to diagnosis for patients with this disease. To date, research examining the lived experiences of patients with Cushing's in healthcare is absent in the literature. This preliminary inquiry into the healthcare experiences of women with Cushing's aimed to examine the utility of this line of inquiry to support the patient centered care of individuals with Cushing's.

METHODS

Seven women from across Canada with endogenous Cushing's participated in the study. Semi-structured interviews were conducted examining participants' healthcare and body-related experiences with Cushing's. Results pertaining to healthcare experiences were analyzed for the current study using reflexive thematic analysis.

RESULTS

Four themes emerged whereby women with Cushing's experienced (1) a lack of patient centered care, characterized by provider miscommunication and medical gaslighting; (2) a misunderstanding of their symptoms as related to weight gain; (3) weight stigma in healthcare encounters; and (4) a shift in their quality of care following diagnosis.

CONCLUSIONS

The results highlight the importance of patient centered care as well as the negative impact of commonly reported barriers to patient centered care. Cushing's specific barriers to patient centered care may include weight stigma as well as the rare incidence of Cushing's. Further research is needed to better understand the healthcare experiences of people with Cushing's in Canada.

Differences by Sexual Orientation in Patient-Centered Care Outcomes for Veterans Utilizing Primary Care Services at the Veterans Health Administration

Purpose: This study examined the differences by sexual orientation in patient-centered care outcomes (including health care experiences and health-related screening) of veterans utilizing Veterans Health Administration (VHA) primary care. Methods: VHA's adapted version of the Consumer Assessment of Healthcare Providers and Systems was used to compare the health care experience of primary care services among sexual minority (SM) and heterosexual veterans. Health care experience measures were dichotomized to "always" versus "less" and stratified by SM status. Health-related screening measures were dichotomous. Survey data were weighted using provided sample weights. Descriptive statistics were performed on sociodemographic characteristics. Logistic regression coefficients were represented as adjusted odds ratios (aORs). A total of 66,348 veterans were included in the analytic sample, of which 2.9% (n = 1,935) identified as SM. Sexual orientation was ascertained by self-report measures by veterans. Results: SM veterans were significantly younger (56.95 years vs. 63.43 years, p < 0.001), were less likely to report that their provider showed respect for what they had to say (aOR: 0.76; 95% confidence interval [CI]: 0.61-0.95), that they were asked about difficulties taking care of their health (aOR: 0.81; 95% CI: 0.67-0.96), and their provider listened carefully to them (aOR: 0.71; 95% CI: 0.57-0.87) compared to heterosexual veterans. Conclusion: Health care experiences differed between SM and heterosexual veterans who sought VHA primary care, suggesting the need to increase provider trainings, which may improve cultural competency and promote a more welcoming and inclusive environment.

Optimizing Patient Engagement in Treatment for Opioid Use Disorder: Primary Care Team Perspectives on Influencing Factors

BACKGROUND

Opioid use disorder (OUD) care engagement rates in primary care (PC) settings are often low. Little is known about PC team experiences when delivering OUD treatment and potential factors that influence their capacity to engage patients in treatment. Exploring PC team experiences may inform needed supports that can optimize OUD care delivery and improve outcomes for patients with OUD.

OBJECTIVE

We explored multidisciplinary PC team perspectives on barriers and facilitators to engaging patients in OUD treatment.

DESIGN

Qualitative study using in-depth interviews.

PARTICIPANTS

Primary care clinical teams.

APPROACH

We conducted semi-structured interviews (n = 35) with PC team members involved in OUD care delivery, recruited using a combination of criterion and maximal variation sampling. Data collection and analysis were informed by existing theoretical literature about patient engagement, specifically that patient engagement is influenced by factors across individual (patient, provider), interpersonal (patient-provider), and health system domains. Interviews were professionally transcribed and doubled-coded using a coding schema based on the interview guide while allowing for emergent codes. Coding was iteratively reviewed using a constant comparison approach to identify themes and verified with participants and the full study team.

KEY RESULTS

Analysis identified five themes that impact PC team ability to engage patients effectively, including limited patient contact (e.g., phone, text) in between visits, varying levels of provider confidence to navigate OUD treatment discussions, structural factors (e.g., schedules, productivity goals) that limited provider time, the role of team-based approaches in lessening discouragement and feelings of burnout, and lack of shared organizational vision for reducing harms from OUD.

CONCLUSIONS

While the capacity of PC teams to engage patients in OUD care is influenced across multiple levels, some of the most promising opportunities may involve addressing system-level factors that limit PC team time and collaboration and promoting organizational alignment on goals for OUD treatment.

Patients and Healthcare Providers' Perspectives on Patient Experience Factors and a Model of Patient-Centered Care Communication: A Systematic Review

Effective communication between patients and healthcare providers is essential for a positive patient experience (PE), and improving patient-centered care (PCC) involves many factors. This study aimed to (1) identify the factors that affect PE improvement, (2) reflect patients and healthcare providers' perspectives on the factors' importance, and (3) present a structural model for improving PCC. A systematic review of empirical studies that specified PE factors was conducted. Studies that did not reflect users' perspectives and non-empirical studies were excluded. The literature was searched using Google Scholar, PubMed, Web of Science, and the Taylor and Francis online journal. The MMAT 2018 checklist was used to assess bias in the included studies, and frequency, content, and thematic analyses were employed to synthesize the results, yielding 25 articles. The 80 PE factors identified from the analyses were categorized into six categories: Practice, Physical Needs, Psychological Needs, Social Needs, Practical Needs, and Information Needs. From a user perspective, patients emphasized professional, continuous, and comprehensive service delivery, whereas healthcare providers stressed efficient system improvements and positive provider-patient relationships. We propose a structured model for PCC improvement using a service blueprint and system map. The PCC model provides an overview of the interactions and the roles of all stakeholders regarding quality of care to improve healthcare.

Patient engagement in CPD in radiation oncology and radiation therapy across Canada: A national survey

BACKGROUND

The aim of this study was to investigate patient engagement (PE) in the development and delivery of Continuing Professional Development (CPD) programs for health care providers within radiation oncology, radiation therapy and medical physics across Canada. This study looked at the current state of PE in CPD programs across Canada and how to address the benefits and barriers to PE to advance these programs.

METHODS

A quantitative, exploratory survey was conducted among radiation oncologists, radiation therapists and medical physicists across Canada. The questionnaire was developed by a multi-disciplinary team and piloted among interprofessional (IP) faculty with a special interest in patient education. The survey was web-based and disseminated through the Canadian Association of Medical Radiation Technologists (CAMRT) and Canadian Radiation Oncologists (CARO) professional associations.

RESULTS

A total of 97 responses were obtained, 43.3% (n = 41) were radiation oncologists 64% (n = 54) were radiation therapists and 2(2%) were medical physicists. There was representation from all provinces, except Newfoundland, with the majority 36% (n = 35) from Ontario. 57% (n = 46) of participants agreed that patients should be involved in CPD, and 11% (n = 9) disagreed. The most agreed-upon barriers are financial costs for patients and clinician bias when selecting patients. The most agreed-upon solutions were improving patient resources and creating training programs for patients. Radiation therapists agreed significantly more (p<0.05) with the potential benefits of PE in CPD, compared to radiation oncologists.

DISCUSSION

PE in CPD programs is a novel and controversial topic but is still highly rated and important. We intend to advocate for patients to take an active role in our CPD programs. Further research is warranted.

People-centred primary health care: a scoping review

BACKGROUND

Integrated people-centred health services (IPCHS) are vital for ensuring comprehensive care towards achieving universal health coverage (UHC). The World Health Organisation (WHO) envisions IPCHS in delivery and access to health services. This scoping review aimed to synthesize available evidence on people-centred primary health care (PHC) and primary care.

METHODS

We conducted a scoping review of published literature on people-centred PHC. We searched eight databases (PubMed, Scopus, Embase, CINAHL, Cochrane, PsycINFO, Web of Science, and Google Scholar) using search terms related to people-centred and integrated PHC/primary care services. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist to select studies. We analyzed data and generated themes using Gale's framework thematic analysis method. Themes were explained under five components of the WHO IPCHS framework.

RESULTS

A total of fifty-two studies were included in the review; most were from high-income countries (HICs), primarily focusing on patient-centred primary care. Themes under each component of the framework included: engaging and empowering people and communities (engagement of community, empowerment and empathy); strengthening governance and accountability (organizational leadership, and mutual accountability); reorienting the model of care (residential care, care for multimorbidity, participatory care); coordinating services within and across sectors (partnership with stakeholders and sectors, and coordination of care); creating an enabling environment and funding support (flexible management for change; and enabling environment).

CONCLUSIONS

Several people-centred PHC and primary care approaches are implemented in HICs but have little priority in low-income countries. Potential strategies for people-centred PHC could be engaging end users in delivering integrated care, ensuring accountability, and implementing a residential model of care in coordination with communities. Flexible management options could create an enabling environment for strengthening health systems to deliver people-centred PHC services.

Types of Engagement Strategies to Engage High-Risk Patients in VA

BACKGROUND

Many healthcare systems seek to improve care for complex high-risk patients, but engaging such patients to actively participate in their healthcare can be challenging.

OBJECTIVE

To identify and describe types of patient engagement strategies reported as successfully deployed by providers/teams and experienced by patients in a Veterans Health Administration (VA) intensive primary care (IPC) pilot program.

METHODS

We conducted semi-structured qualitative telephone interviews with 29 VA IPC staff (e.g., physicians, nurses, psychologists) and 51 patients who had at least four IPC team encounters. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach.

RESULTS

The engagement strategies successfully deployed by the IPC providers/teams could be considered either more "facilitative," i.e., facilitated by and dependent on staff actions, or more "self-sustaining," i.e., taught to patients, thus cultivating their ongoing patient self-care. Facilitative strategies revolved around enhancing patient access and coordination of care, trust-building, and addressing social determinants of health. Self-sustaining strategies were oriented around patient empowerment and education, caregiver and/or community support, and boundaries and responsibilities. When patients described their experiences with the "facilitative" strategies, many discussed positive proximal outcomes (e.g., increased access to healthcare providers). Self-sustaining strategies led to positive (self-reported) longer-term clinical outcomes, such as behavior change.

CONCLUSION

We identified two categories of strategies for successfully engaging complex, high-risk patients: facilitative and self-sustaining. Intensive primary care program leaders may consider thoughtfully building "self-sustaining" engagement strategies into program development. Future research can confirm their effectiveness in improving health outcomes.

Developing an in-depth understanding of patient and caregiver engagement across care transitions from hospital: protocol for a qualitative study exploring experiences in Canada

INTRODUCTION

Patient and caregiver engagement is critical, and often compromised, at points of transition between care settings, which are more common, and more challenging, for patients with complex medical problems. The consequences of poor care transitions are well-documented, both for patients and caregivers, and for the healthcare system. With an ageing population, there is greater need to focus on care transition experiences of older adults, who are often more medically complex, and more likely to require care from multiple providers across settings. The overall goal of this study is to understand what factors facilitate or hinder patient and caregiver engagement through transitions in care, and how these current engagement practices align with a previously developed engagement framework (CHOICE Framework). This study also aims to co-develop resources needed to support engagement and identify how these resources and materials should be implemented in practice.

METHODS AND ANALYSIS

This study uses ethnographic approaches to explore the dynamics of patient and caregiver engagement, or lack thereof, during care transitions across three regions within Ontario. With the help of a front-line champion, patients (n=18-24), caregivers (n=18-24) and healthcare providers (n=36-54) are recruited from an acute care hospital unit (or similar) and followed through their care journey. Data are collected using in-depth semi-structured interviews. Workshops will be held to co-develop strategies and a plan for future implementation of resources and materials. Analysis of the data will use inductive and deductive coding techniques.

ETHICS AND DISSEMINATION

Ethics clearance was obtained through the Western University Research Ethics Board, University of Windsor Research Ethics Board and the University of Waterloo Office of Research Ethics. The findings from this study are intended to contribute valuable evidence to further bridge the knowledge to practice gap in patient and caregiver engagement through care transitions. Findings will be disseminated through publications, conference presentations and reports.

US practice adoption of patient-engagement strategies and spending for adults with diabetes and cardiovascular disease

Patient-engagement strategies are being encouraged by payers and governments, but with limited evidence about whether practice adoption of these strategies impacts utilization and spending. We examine the association of physician practice adoption of patient-engagement strategies (low vs moderate vs high) with potentially preventable utilization and total spending for patients with type 2 diabetes and/or cardiovascular disease using US physician practice survey (n = 2086) and Medicare fee-for-service (n = 736 269) data. In adjusted analyses, there were no differences in potentially preventable utilization associated with practice adoption of patient-engagement strategies. Compared with patients attributed to practices with moderate adoption, patients attributed to practices with high adoption had higher total spending ($26 364 vs $25 991; P < .05) driven by spending for long-term services and supports, including home health agency, long-term care, skilled nursing facilities, and hospice payments. In contrast, patients attributed to practices with low adoption had higher total spending ($26 481 vs $25 991; P < .01) driven by spending for tests and acute care and clinical access spending. The results highlight that stakeholders that encourage the use of patient-engagement strategies should not necessarily expect reduced spending.

Using a person-centered approach in clinical care for patients with complex chronic conditions: Perspectives from healthcare professionals caring for Veterans with COPD in the U.S. Veterans Health Administration's Whole Health System of Care

BACKGROUND

The largest nationally integrated health system in the United States, the Veterans Health Administration (VHA), has been undergoing a transformation toward a Whole Health (WH) System of Care. WH Clinical Care, a component of this system, includes holistically assessing the Veteran's life context, identifying what really matters to the Veteran, collaboratively setting and monitoring personal health and well-being goals, and equipping the Veteran with access to conventional and complementary and integrative health resources. Implementation of WH Clinical Care has been challenging. Understanding healthcare professionals' perspectives on the value of and barriers and facilitators to practicing WH Clinical Care holds relevance for not only VHA's efforts but also other health systems, in the U.S. and internationally, that are engaged in person-centered care implementation.

OBJECTIVES

We sought to understand perspectives of healthcare professionals at VHA on providing WH Clinical Care to Veterans with COPD, as a lens to understand the broader issue of WH Clinical Care for Veterans living with complex chronic conditions.

DESIGN

We interviewed 25 healthcare professionals across disciplines and services at a VA Medical Center in 2020-2021, including primary care providers, pulmonologists, palliative care providers, and chaplains. Interview transcripts were analyzed using qualitative content analysis.

KEY RESULTS

Each element of WH Clinical Care raised complex questions and/or concerns, including: (1) the appropriate depth/breadth of inquiry in person-centered assessment; (2) the rationale for elicitation of what really matters; (3) the feasibility and appropriate division of labor in personal health goal setting and planning; and (4) challenges related to referring Veterans to a broad spectrum of supportive services.

CONCLUSIONS

Efforts to promote person-centered care must account for healthcare professionals' existing comfort with its elements, advocate for a team-based approach, and continue to grapple with the conflicting structural conditions and organizational imperatives.

The role of health care organizations in patient engagement: Mechanisms to support a strong relationship between patients and clinicians

BACKGROUND

Patient engagement (PE) is critical to improving patient experience and outcomes, as well as clinician work life and lowering health care costs, yet health care organizations (HCOs) have limited guidance about how to support PE. The engagement capacity framework considers the context of engagement and examines precursors to engagement, including patients' self-efficacy, resources, willingness, and capabilities.

PURPOSE

The aim of this study was to explore clinician and patient perspectives related to mechanisms through with the HCOs can facilitate PE through the lens of the engagement capacity framework.

METHODOLOGY/APPROACH

We administered an online open-ended survey to clinicians and patient advisors across the United States, including questions focused on the influences of, barriers to, and skills and tools required for PE. A common theme emerged focusing on the role of HCOs in facilitating engagement. Our analysis examined all responses tagged with the "health care system" code.

RESULTS

Over 750 clinicians and patient advisors responded to our survey. Respondents identified offering advice and support for patients to manage their care (self-efficacy), providing tools to facilitate communication (resources), working to encourage connection with patients (willingness), and training for HCO employees in cultural competency and communication skills (capabilities) as important functions of HCOs related to engagement.

CONCLUSION

HCOs play an important role in supporting a strong partnership between the patient and clinicians. Our study identifies important mechanisms through which HCOs can fulfill this role.

PRACTICE IMPLICATIONS

HCO leadership and administration can help establish the culture of care provided. Policies and initiatives that provide appropriate communication tools and promote culturally competent care can increase engagement.

Addressing Equity and Social Needs: The New Frontier of Patient Engagement Research

Patient engagement has been a focus of patient-centered care in recent years, encouraging health care organizations to increase efforts to facilitate a patient's ability to participate in health care. At the same time, a growing body of research has examined the impact that social determinants of health (SDOH) have on patient health outcomes. Additionally, health care equity is increasingly becoming a focus of many organizations as they work to ensure that all patients receive equitable care. These three domains - patient engagement, SDOH, and health care equity - can intersect in the implementation of social needs screenings among health care organizations. We present a case study on a two-phase social needs screening implementation project and describe how this process focuses on equity. As health care organizations seek to increase patient engagement, address SDOH, and improve health equity, we highlight the need to move away from a siloed approach and view these efforts as interrelated. By approaching efforts to address these challenges and barriers as the duty of all those involved in the patient care process, there may be larger strides made toward equitable health care.

Adoption of Patient Engagement Strategies by Physician Practices in the United States

BACKGROUND

Patient engagement strategies can equip patients with tools to navigate treatment decisions and improve patient-centered outcomes. Despite increased recognition about the importance of patient engagement, little is known about the extent of physician practice adoption of patient engagement strategies nationally.

METHODS

We analyzed data collected from the National Survey of Healthcare Organizations and Systems (NSHOS) on physician practice adoption of patient engagement strategies. Stratified-cluster sampling was used to select physician practices operating under different organizational structures. Multivariable linear regression models estimated the association of practice ownership, health information technology functionality, use of screening activities, patient responsiveness, chronic care management processes, and the adoption of patient engagement strategies, including shared decision-making, motivational interviewing, and shared medical appointments. All regression models controlled for participation in payment reforms, practice size, Medicaid revenue percentage, and geographic region.

RESULTS

We found modest and varied adoption of patient engagement strategies by practices of different ownership types, with health system-owned practices having the lowest adoption of ownership types. Practice capabilities, including chronic care management processes, routine screening of medical and social risks, and patient care dissemination strategies were associated with greater practice-level adoption of patient engagement strategies.

CONCLUSIONS

This national study is the first to characterize the adoption of patient engagement strategies by US physician practices. We found modest adoption of shared decision-making and motivational interviewing, and low adoption of shared medical appointments. Risk-based payment reform has the potential to motivate greater practice-level patient engagement, but the extent to which it occurs may depend on internal practice capabilities.

Reframing Patient Experience Approaches and Methods to Achieve Patient-Centeredness in Healthcare: Scoping Review

(1) There has been growing attention among healthcare researchers on new and innovative methodologies for improving patient experience. This study reviewed the approaches and methods used in current patient experience research by applying the perspective of design thinking to discuss practical methodologies for a patient-centered approach and creative problem-solving. (2) A scoping review was performed to identify research trends in healthcare. A four-stage design thinking process ("Discover", "Define", "Develop", and "Deliver") and five themes ("User focus", "Problem-framing", "Visualization", "Experimentation", and "Diversity"), characterizing the concept, were used for the analysis framework. (3) After reviewing 67 studies, the current studies show that the iterative process of divergent and convergent thinking is lacking, which is a core concept of design thinking, and it is necessary to employ an integrative methodology to actively apply collaborative, multidisciplinary, and creative attributes for a specific and tangible solution. (4) For creative problem-solving to improve patient experience, we should explore the possibilities of various solutions by an iterative process of divergent and convergent thinking. A concrete and visualized solution should be sought through active user interactions from various fields. For this, a specific methodology that allows users to collaborate by applying the integrative viewpoint of design thinking should be introduced.

Factors that influence older patients’ participation in clinical communication within developed country hospitals and GP clinics: A systematic review of current literature

Background

Engaging older adults in clinical communication is an essential aspect of high-quality elder care, patient safety and satisfaction in hospitals and GP clinics. However, the factors that influence older adults’ participation during their appointments with health professionals from the older patient’s perspective remain under-investigated.

Objectives

We aimed to fill this knowledge gap by reviewing research articles that have examined older patients’ involvement in clinical communication. In doing so, we hope to assist healthcare professionals and institutions in developing new strategies to improve older patients’ participation and engagement in clinical communication.

Methods

A systematic review of nine databases was conducted for studies reporting identified influences on older patients’ participation in clinical communication published from 2010. These studies were then subjected to thematic analysis for stratification.

Results

Twenty-one articles with a total of 36,797 participants were included and highlighted three major themes that influenced older patients’ participation in the clinical communication. The first theme identified includes accessibility to appointments, support, health information and person-centred care, highlighting that access to appointments, person centred care and health information significantly influences clinical communication participation. Relevant and understandable healthcare information identified that communication factors [i.e. tailored health information, health literacy and patient language barriers, and communication impairments] influences older patients’ participation. Older Patient perceptions of HCP credibility and trustworthiness highlighted how patient’s perceptions of health professionals influence their willingness to participate in clinical communications.

Conclusions and implications

This review demonstrates that there are several factors that contribute to insufficient or no participation of older patients in clinical communication in hospitals and GP clinics. These include accessibility to relevant and understandable health information, and the perceived health professional credibility and trustworthiness. Identifying ways to address these factors may improve patient participation, doctor-patient collaboration and overall health outcomes for older patients.

Bridging the Patient Engagement Gap in Research and Quality Improvement Utilizing the Henry Ford Flexible Engagement Model

PURPOSE

This paper was intended to share a flexible engagement model (FEM) for organizing a structure to obtain patient input regarding health care operations and research, provide greater detail on recruitment, retention, and dissemination strategies, and demonstrate successes and potential applications in other health care settings.

METHODS

Utilizing a pragmatic approach, the Patient-Engaged Research Center (PERC) at Henry Ford Health System developed the FEM, a 7-step process to introduce interested patients/caregivers to the patient advisor program and to follow up with placements. PERC developed a meeting evaluation to measure participant satisfaction. Retention and dissemination methods to keep participants consistently engaged included monthly email blasts, an annual patient advisor retreat, and inviting patient advisors to attend/present at local and national conferences.

RESULTS

As of January 2020, the program had 419 patient advisors. Almost 50% self-reported as Caucasian and 31% as African American; 73% were women, and most were 45-74 years of age. Recruitment methods proved effective, as 85% of advisors were initially engaged through print and digital marketing. Mean advisor orientation workshop evaluation scores regarding content, facilitators, and logistics were high, with all 4.5 or higher on a Likert scale of 1 (strongly negative) to 5 (strongly positive).

CONCLUSIONS

Given the FEM's flexible nature and adaptability, PERC has been successful in effectively leveraging the patient voice and experiences in research and health care delivery. Further research could investigate the model's generalizability, return on investment, and how to formally embed its methodology institutionally.

Comparing Surgeon Approaches to Patient-Centered Cancer Care Using Vignette Methodology

BACKGROUND

We sought to characterize surgeon perceptions of patient attachment-related behaviors relative to patient-centered approaches during treatment decision-making within the clinical encounter.

METHODS

An online survey including clinical vignettes was sent to board-certified surgeons to assess their approach to patient-centered treatment decision-making. Within these vignettes, patient behaviors associated with attachment styles (secure vs 3 insecure subtypes: avoidant, anxious, and fearful) were fixed and patient factors (age, race, occupation, and gender) were randomized. Analysis included repeated measures mixed-effects linear regression.

RESULTS

Among the 208 respondents, the majority were male (65.4%) and White/Caucasian (84.5%) with an average age of 51.6 years (SD = 9.9). Most surgeons had been in practice for more than 10 years (66.8%) and treated adult patients (77.4%). Surgical specializations included breast (27.2%), HPB (35.0%), and broad-based/general (21.8%). Patient race, age, and gender did not impact surgeons' patient-centered approach to treatment decision-making (all ps > 0.05). However, when the "patient" had a white collar occupation and were securely attached, surgeons reported a greater likeliness to spend equal time presenting all treatment options (p = 0.02 and p < 0.001, respectively) and believe the patient wanted an active role in decision-making (p = 0.01 and p < 0.001, respectively). Surgeons reported being least likely to agree with a patient's treatment decision (p < 0.001) and an increased likelihood of being directive (p = 0.002) when patients exhibited behaviors associated with avoidant attachment.

CONCLUSION

Attachment-related behaviors were associated with differences in surgeon approaches to patient-centered decision-making. Attachment styles may offer a framework for providers to understand patient behaviors and needs, thereby providing insight on how to tailor their approach and provide optimal patient-centered care.

Strategies to improve implementation of medications for opioid use disorder reported by veterans involved in the legal system: A qualitative study

BACKGROUND

Veterans involved in the legal system have a high risk of overdose mortality but limited utilization of medications for opioid use disorder (MOUD). To increase the use of MOUD in Veterans Health Administration (VHA) facilities and reduce overdose mortality, the VHA should incorporate strategies identified by legal-involved veterans to improve quality of care and ensure that their patients' experiences are integrated into care delivery. This study aims to determine strategies to increase use of MOUD from the perspective of legal-involved veterans with a history of opioid use or opioid use disorder (OUD).

METHODS

Between February 2018 and March 2019, we conducted semistructured interviews with 18 veterans with a history of opioid use or OUD and legal involvement (15 men and 3 women; mean age 41, standard deviation 13, range 28-61). Veterans were from 9 geographically dispersed United States VHA facilities. The study analyzed verbatim transcripts using the framework method. The primary focus was themes that represented legal-involved veteran-identified strategies to improve the use of MOUD.

RESULTS

The 18 veterans interviewed had legal involvement directly related to their opioid use and most (n = 15; 83%) had previously used MOUD. Veteran-identified strategies to improve access to and use of MOUD included: (1) VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver compassionate, patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities to veterans.

CONCLUSIONS

Legal-involved veterans provided strategies that can inform and expand MOUD to better meet their needs and the treatment needs of all patients with OUD. The VHA should consider incorporating these strategies into care, and should evaluate their impact on patients' experience, initiation of and retention on medications, and overdose rates.

Competing Demands: Scheduling Challenges in Being Veteran-centric in the Setting of Health System Initiatives to Improve Access

INTRODUCTION

The Veterans Health Administration's (VHA) history of enhancing Veterans' healthcare access continued in 2016 with the launch of ChooseVA (née: MyVA Access). This initiative was designed to transform the VHA and rapidly increase Veteran's access to care across all the VHA facilities. Relevant to this article include mandates to improve patient-centered scheduling. In prioritizing patient-centered scheduling, the VHA and other large healthcare systems have the paradoxical task of providing health care that meets not only the needs of individual patients but also the collective needs of the population served. To our knowledge, meeting these competing needs has not been explored through the perspectives and experiences of providers and staff implementing patient-centered scheduling practices.

MATERIALS AND METHODS

This was a qualitative exploratory study and was sanctioned as quality improvement (and thus exempt from Institutional Review Board review). We conducted visits at 25 VHA facilities. Sites were selected based on rurality, region, and facility access performance ratings. Data collection included semi-structured interviews and focus groups. Key informant participants included local leadership, administrators, providers, and support staff across primary care, specialty care, and mental health service lines. We analyzed transcribed audio recordings using inductive content analysis to identify barriers, facilitators, and contextual factors affecting the implementation of patient-centered scheduling.

RESULTS

We conducted 208 individual interviews and focus groups between July and November 2017. Participants expressed dedication to patient-centered approaches to improve access to care for Veterans, stating efforts and challenges to meeting Veterans' needs and preferences. Being Veteran-centric meant accommodating Veterans, with a tension between meeting the needs of one Veteran versus all Veterans, managing expectations of same-day access, and potential hits to performance metrics. Strategies focused on engaging Veterans through education and establishing new expectations while recognizing the differing needs among subgroups receiving VHA care.

CONCLUSIONS

Veterans Health Administration staff employed a mission-driven, culturally sensitive approach to meeting the diverse scheduling needs of the Veteran population. While potentially unique to the VHA, it may inform patient-centered scheduling practices for other culturally specific populations in other healthcare systems. Continued efforts to put Veterans at the center of VHA healthcare delivery by engaging them in meaningful ways while honoring their distinct needs are essential. Data are forthcoming on Veterans' perspectives of access, which we hope will further contribute to unfolding understandings of access within the VHA.

The Gears of Knowledge Translation: Process Evaluation of the Dissemination and Implementation of a Patient Engagement Toolkit

BACKGROUND

Patient engagement is a key tenet of patient-centered care and is associated with many positive health outcomes. To improve resources for patient engagement, we created a web-based, interactive patient engagement toolkit to improve patient engagement in primary care across the Veterans Health Administration (VHA).

OBJECTIVE

To use the knowledge translation (KT) framework to evaluate the dissemination and implementation of a patient engagement toolkit at facilities across one region in the VHA.

DESIGN

Using a mixed-methods approach, this process evaluation involved phone monitoring via semi-structured interviews and group meetings, during which we explored barriers and facilitators to KT. Outcomes were assessed using a structured rubric and existing patient satisfaction measures.

PARTICIPANTS

We enlisted implementers at 40 VHA facilities primarily serving Pennsylvania, New Jersey, and Delaware to implement patient engagement practices at their sites. Sites were randomly assigned into a high or low coaching group to assess whether external support influenced implementation.

KEY RESULTS

Sites with high rubric scores employed and possessed several elements across the KT trajectory from identification of the problem to sustainment of knowledge use. Key factors for successful implementation and dissemination included implementer engagement, organizational support, and strong collaborators. The most frequently cited barriers included short staffing, time availability, lack of buy-in, and issues with leadership. Successful implementers experienced just as many barriers, but leveraged facilitators to overcome obstacles. While sites that received more coaching did not have different outcomes, they were more likely to revisit the toolkit and indicated that they felt more accountable to local personnel.

CONCLUSIONS

Because leveraging available resources is a key component of successful implementation, future toolkits should highlight the type of facilitators necessary for successful implementation of toolkit content in healthcare settings. The ability to tailor interventions to local context is critical for overcoming barriers faced in most healthcare settings.

Perceived barriers and facilitators to chronic kidney disease care among patients in Singapore: a qualitative study

OBJECTIVE

To outline the facilitators and barriers to patients' self-management of predialysis chronic kidney disease (CKD).

DESIGN

Qualitative.

SETTING

Three polyclinics in a public primary care institution in Singapore.

PARTICIPANTS

20 patients entered and completed the study. Inclusion criteria were: (1) English speaking, (2) aged 40 years and above, (3) identified by clinical coding as 'DM (diabetes mellitus) nephropathy-overt' and 'DM nephropathy-incipient', by their physicians in the polyclinic, with an estimated glomerular filtration rate of less than 60 mL/min/1.73 m² (based on electronic health records) and (4) aware of their CKD illness. Exclusion criteria were: (1) receiving dialysis or had received a kidney transplant, (2) suffered from any visual, auditory or cognitive impairment which could hinder their ability to participate in the study or (3) pregnant.

RESULTS

We found that the major barriers to CKD management were a lack of knowledge and awareness of CKD, a passive attitude toward self-management and insufficient patient-physician communication. Major facilitators included patient trust and satisfaction with the physician and family support. Many patients reported that there was an overload of information and too little guidance on how to manage their condition, especially regarding dietary recommendations.

CONCLUSION

We identified several barriers and facilitators to the management of predialysis CKD among patients. A multi-pronged approach for raising CKD awareness is required: improving patient-physician communication, implementing CKD workshops and home-visits and disseminating accurate online information about CKD. Strategies should also focus on increasing patient engagement and optimising family support by involving family members in patients' care. Furthermore, clear dietary recommendations and patient-specific advice are needed to empower patients to manage their own condition.

Male Nurses' Dealing with Tensions and Conflicts with Patients and Physicians: A Theoretically Framed Analysis

Proposes

Delivery of healthcare involves engagements of patients, nurses and other health professionals. The Social Identity Theory (SIT) can provide a lens to investigate intergroup interactions. This study explores how male nurses deal with intergroup tensions and conflicts with patients and physicians when delivering healthcare.

Methods

A collaborative qualitative research study was conducted by two research teams, with one from Mainland China and the other from Macau. Twenty-four male nurses were recruited, with 12 from each of the two regions. A similar guide was used by the two teams to conduct in-depth interviews with the participants. Thematic analysis was used, and SIT guided the data analysis and interpretation of the results.

Results

Four themes identified are related to nurse/patient relationships: respecting patients’ decisions, neglecting minor offenses, defending dignity, taking a dominant position; two themes are related to nurse/physician relationships: rationalizing physicians’ superiority over nurses, establishing relationships with physicians by interpersonal interactions.

Conclusion

Male nurses avoid confrontation with patients in case of disagreements but take on gender- and profession-based dominance in dealing with intense conflicts to maintain healthcare order. They do not challenge the status hierarchy between nurses and physicians but manage to maintain harmonious relationships with physicians by engaging in interpersonal activities with physicians in leisure times.

Implication

Male nurses can take the lead to create inclusive groups to engage patients and physicians in delivering healthcare. The masculine traits of male nurses do not subvert the nurse/physician hierarchy stereotype but strengthen it.

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Opportunity or Burden? A Behavioral Framework for Patient Engagement

BACKGROUND

Engaging patients as partners in their care is clinically appealing, yet challenging to implement, and we lack a measurement framework that is applicable to vulnerable populations. To address this gap, we conducted a qualitative study to refine a conceptual framework that reflects an individual's propensity to engage with care.

OBJECTIVES

Our objectives were to refine the framework's domains of engagement behavior; identify key behaviors within each domain that describe engagement with providers, health systems or settings; and illustrate examples for each behavior where higher self-efficacy describes an opportunity to enhance engagement, and lower self-efficacy describes difficulties with engagement that risk burden.

RESEARCH DESIGN AND SAMPLE

We elicited patient perspectives by conducting individual semistructured interviews with veterans receiving care for mental health and/or chronic conditions from the Veterans Health Administration. Data were analyzed using the framework method.

RESULTS

The resulting engagement framework encompassed 4 interrelated domains: Self-Management, Health Information Use, Collaborative Communication, and Healthcare Navigation. The propensity to engage with care was conceptualized as the cumulative self-efficacy to engage in behaviors across these domains. Results emphasize the collaborative nature of engagement behaviors and the impact of veteran cultural influences via perceptions of collective efficacy.

CONCLUSIONS

This framework can be applied to judgments regarding a patient's propensity to engage in care. Because self-efficacy is an individual's context-specific judgment of their capabilities, this framework may inform health care and social service interventions that aim to engage patients. This maybe especially useful for public sector settings and populations with social risks.

Linking Practice Adoption of Patient Engagement Strategies and Relational Coordination to Patient-Reported Outcomes in Accountable Care Organizations

Policy Points Accountable care organizations (ACOs) have incentives to promote the adoption of patient engagement strategies such as shared decision making and self-management support programs to improve patient outcomes and contain health care costs. High adoption of patient engagement strategies among ACO-affiliated practices did not improve patient-reported outcomes (PROs) of physical, emotional, and social function among adult patients with diabetes and/or cardiovascular disease over a one-year time frame, likely because implementing these strategies requires extensive clinician and staff training, workflow redesign, and patient participation over time. A dominant focus on improving clinical measures to meet external requirements may crowd out time needed for care team members to address other outcomes that matter to patients, including PROs. Payers and policy-makers should explicitly incentivize the collection and use of PROs when contracting with ACOs.

CONTEXT

Adult primary care practices of accountable care organizations (ACOs) are adopting a range of patient engagement strategies, but little is known about how these strategies are related to patient-reported outcomes (PROs) and how relational coordination among team members aids implementation.

METHODS

We used a mixed-methods cohort study design integrating administrative and clinical data with two data collection waves (2014-2015 and 2016-2017) of clinician and staff surveys (n = 764), surveys of adult patients with diabetes and/or cardiovascular disease (CVD) (n = 1,276), and key informant interviews of clinicians, staff, and administrators (n = 103). Multivariable linear regression estimated the relationship of practice adoption of patient engagement strategies, relational coordination, and PROs of physical, social, and emotional function. The mediating role of patient activation was examined using cross-lagged panel models. Key informant interviews assessed how relational coordination influences the implementation of patient engagement strategies.

FINDINGS

There were no differential improvements in PROs among patients of practices with high vs. low adoption of patient engagement strategies or among patients of practices with high vs. low relational coordination. The Patient Activation Measure (PAM) is strongly related to better physical, emotional, and social PROs over time. Relational coordination facilitated the implementation of patient engagement strategies, but key informants indicated that resources and systems to systematically track treatment preferences and goals beyond clinical indicators were needed to support effective implementation.

CONCLUSIONS

Adult patients with diabetes and/or CVD of ACO-affiliated practices with high adoption of patient engagement strategies do not have improved PROs of physical, emotional, and social function over a one-year time frame. Implementing patient engagement strategies increases task interdependence among primary care team members, which needs to be carefully managed. ACOs may need to make greater investment in collecting, monitoring, and analyzing PRO data to ensure that practice adoption and implementation of patient engagement strategies leads to improved physical, emotional, and social function among patients.