Rural health services' relationships with patients: An enabler and a barrier to advance care planning

Service Provider Perspectives on Advance Care Planning Use in Rural Dementia Patients and Caregivers: A Qualitative Study

Advanced care planning (ACP) utilization remains very limited in rural communities compared to urban areas. ACP earlier in the disease trajectory is particularly important for people with dementia (PWD) due to its progressive nature affecting their decision-making ability. Considering the well-documented benefits of ACP in improving the quality of end-of-life (EOL) care, the rural vs. urban disparity may indicate poorer EOL quality for rural PWD. This study aimed to explore barriers and current resources for ACP of PWD from the perspectives of health or social service providers serving rural communities. Using a qualitative approach, semi-structured face-to-face interviews were conducted with 11 health or social service professionals serving older adults and their caregivers in rural Alabama. Thematic analysis revealed three major barriers: (1) lack of knowledge, (2) psychosocial barriers, and (3) limited access to healthcare. Participants also showed misconception that a lawyer or a notary is required for ACP. Two themes arose in the participants' recommendations to address the barriers: (1) providing ACP-relevant information and (2) addressing psychosocial stressors about ACP. This study highlighted an urgent need for social policy in ACP education for caregivers and service providers in rural settings.

Disparities in Advance Directive Documentation for Rural-Dwelling Persons With Lung Cancer

Purpose: Advance directives (AD) are recommended for persons with lung cancer, yet few studies have investigated AD and healthcare power of attorney (HCPOA) documentation for this population in rural regions of the United States. The purpose of this study was to examine demographic and clinical factors associated with AD and HCPOA documentation for persons with lung cancer in rural eastern North Carolina (ENC). Methods: A cross-sectional retrospective chart review was conducted to collect demographic and clinical data from electronic health records from 2017 to 2021 at a tertiary cancer center and regional satellite sites in ENC. Descriptive statistics and Chi-Square Tests of Independence were used for data analysis. Findings: The sample's mean age was 69.5 years (n = 402, SD = 10.5, range = 28 - 92). Most participants were male (58%) and had a smoking history (93%). Consistent with regional population statistics, 32% of persons were black, and 52% lived in rural counties. Just 18.5% of the sample had a documented AD and 26% had a healthcare power of attorney. Black persons had significantly lower AD and HCPOA (P < .001) documentation than white persons. Rural-dwellers had significantly lower HCPOA documentation than urban-dwellers (P = .03). For all other variables, no significant differences were found. Conclusions: These findings suggest that AD and HCPOA documentation are low for persons with lung cancer in ENC, particularly for black persons and rural-dwellers. This disparity highlights the need for enhanced advance care planning (ACP) access to and outreach in the region.

Barriers and enablers to structured care delivery in Australian rural primary care

OBJECTIVE

The primary aim of this study was to explore the barriers and enablers to structured care delivery in rural primary care, reflecting on Australian research findings.

DESIGN

CINAHL and Scopus databases were searched in August 2021. Inclusion criteria included English language, full-text studies, published since 2011, reporting on the barriers and enablers to the delivery of structured care within rural and remote primary care. Structured care was conceptualised as care that was organised, integrative and planned.

FINDINGS

A total of 435 studies were screened. Thirty-four met the inclusion criteria. Barriers to the provision of structured care related to workforce shortages, limited health care services and health care professional capacity, cultural safety and competency, limited resourcing, insufficient knowledge and education, geographical isolation, inadequate care coordination, unclear roles and responsibilities and poor health professional-patient relationships.

DISCUSSION

Health care system and geographical barriers and enablers encountered in rural areas are complex and multidimensional. Identification of the specific challenges to structured care delivery highlights the need for a focussed review of workforce supply and distribution challenges as well as the investigation of system integration, leadership, governance and funding reform that would be required to support rural primary care.

Palliative Care Within the Primary Health Care Setting in Australia: A Scoping Review

Objectives: This scoping review identifies and details the scope of practice of health professionals who provide palliative care within the primary health setting in Australia.

Methods: A scoping review approach was conducted on the Cinahl (Ebsco), Scopus, Medline (Ovid) and PubMed databases to extract articles from 1 December 2015 to 1 December 2020. Broad text words and MeSH headings were used with relevance to palliative care, general practice, primary health, and community setting. Extracted journal articles were limited to those based on the Australian population or Australian health system.

Results: Eighty-four papers met the inclusion criteria and were included in the review. The review identified the following health professional roles within the Primary Health Care setting undertaking palliative care: General Practitioner, Nurse, Pharmacist, Paramedics, Carers, and Allied Health professionals.

Conclusion: This review offers a first understanding of the individual health professional roles and multidisciplinary team approach to actively providing palliative care within the Primary Health Care setting in Australia.

Modelling enablers of efficiency and sustainability of healthcare: a m-TISM approach

Purpose

It would not be an exaggeration to say that healthcare is the most crucial one in today's perspective. The healthcare sector, in general, is engaged in working on various dimensions simultaneously like the safety, care, quality and cost of services, etc. Still, the desired outcomes from this sector are far away, and it becomes pertinent to address all such issues associated with healthcare on a priority basis for sustaining the outcomes in a long-term perspective. The present study aims to explore the healthcare sector and list out the directly associated enablers contributing to increasing the viability of the healthcare sector. Besides, the interrelationship among the enlisted enablers needs to be studied, which further helps in setting-out the priority to deal with individual enablers based on their impedance in the contribution towards viability increment.

Design/methodology/approach

The authors have done an extensive review to list out the enablers of the healthcare sector to perform efficiently and effectively. Further, the attempt has been made on the enablers to rank them by using the modified Total Interpretative Structure Modelling (m-TISM) approach. The validation of the study reveals the importance of enablers based on their position in the hierarchical structure. Further, the MICMAC analysis on the identified enabler is performed to categorize the identified enablers in the different clusters based on their driving power and dependence.

Findings

The research tries to envisage the importance of the healthcare sector and its contribution towards national development. The outcomes of the m-TISM model in the present study reveal the noteworthy contribution of the organizational structure in managing the healthcare facilities and represented it as the perspective of future growth. The well-designed organizational structure in the healthcare industry helps in establishing better employee–employer cooperation, workforce coordination and inter-department cooperation.

Research limitations/implications

Every research work has limitations. Likewise, the present research work also has limitations, i.e. input taken for developing the models are from very few experts that may not reflect the opinion of the whole sector.

Practical implications

The healthcare sector is the growing sector in the present-day scenario, and it is essential to keep the quality of treatment in check along with the quantity. The present study has laid down the practical foundations for improvement in the healthcare sector viability. Besides, the study emphasized on accountability of the healthcare sector officials to go with the enablers having the strong driving power for effective utilization of all the resources. This would further help them in customer (patients) satisfaction.

Originality/value

Despite an increase in demand for good quality healthcare facilities worldwide, the growth of this sector is bounded by the economic, demographic, cultural and environmental concerns, etc. The present study proposed a unique framework that provides a better understanding of the enablers. It would further help in playing a key role in increasing the viability of the healthcare sector. The hierarchy developed with the help of m-TISM and MICMAC analysis will help the viewers to recognize the important enablers based on their contribution to the viability improvement of the healthcare sector.

Communication of advance care planning decisions: a retrospective cohort study of documents in general practice

BACKGROUND

Doctors, particularly general practitioners, play a significant role in assisting patients to create advance care plans. When medically indicated, these documents are important tools to promote congruence between end-of-life care and patient's personal preferences. Despite this, little is known regarding the availability of these documents in hospitals. The aim of this study was to identify the proportion of people who died in hospital without an advance care plan and how many of these had advance care planning (ACP) documents in their general practice records.

METHODS

A retrospective cohort study was conducted of patient hospital records with manual linkage to general practice records. The large regional hospital in Victoria, Australia has a catchment population in excess of 300,000 people. The study sample was patients aged 75 years and over who died in the hospital between 1 January 2016 and 31 December 2017. The hospital records of these patients were examined to identify those which did not have a system alert for ACP documents on the file. Alerted ACP documents were limited to those legislated in the state of Victoria: advance care plan, Enduring Power of Attorney (Medical Treatment) or Enduring Power of Guardianship. Where no ACP document system alert was found in the hospital record, the patient's nominated general practice was consented to participate and the corresponding general practice record was examined. Data were analysed using descriptive statistics.

RESULTS

Of the 406 patients who died in hospital, 76.1% (309) did not have a system alert for any ACP document. Of the 309 hospital records without a system alert, 144 (46.7%) corresponding general practice records were examined. Of these, 14.6% included at least one ACP document, including four advance care plans, that were not available in hospital.

CONCLUSIONS

Unless ACP documents are consistently communicated from general practice, patient's preferences may be unknown during end-of-life care. It is important that both doctors and patients are supported to use connected electronic health records to ensure that documents are readily available to healthcare staff when they are required.