The care delivery experience of hospitalized patients with complex chronic disease

Perspectives of older adults with chronic illness on person-centered practice at an inpatient hospital department: a descriptive study

BACKGROUND

The growing aging trend associated with a higher prevalence of chronic illnesses is increasing the demand for the development of person-centered practice in specific care settings. Knowing the person's perception of the care and the care experience is essential to improving inpatient care toward person-centeredness. This study aims to characterize the perceptions of person-centered practice of hospitalized older adults with chronic illness at a Portuguese inpatient hospital department.

METHODS

A quantitative, descriptive, cross-sectional approach was followed. Data were collected using a sociodemographic and health history questionnaire and the Person-Centered Practice Inventory - Care (PCPI-C). The effect of the different variables on each PCPI-C construct was determined using analysis of variance (ANOVA).

RESULTS

The results show that person-centered practice was positively perceived in the five constructs of the person-centered processes domain (M = 3.92; SD = 0.47). The highest-scored construct was working with the person's beliefs and values (M = 4.12; SD = 0.51), and the lowest was working holistically (M = 3.68; SD = 0.70). No significant effect of the independent variables was found to influence the perceptions of any of the constructs in the person-centered processes domain.

CONCLUSIONS

These results might indicate that person-centered processes are perceived uniquely by each person through individualized therapeutic relationships rather than a pattern of care shared by hospitalized older adults.

Experiences of hospital care for people with multiple long-term conditions: a scoping review of qualitative research

BACKGROUND

Multiple long-term conditions-the co-existence of two or more chronic health conditions in an individual-present an increasing challenge to populations and healthcare systems worldwide. This challenge is keenly felt in hospital settings where care is oriented around specialist provision for single conditions. The aim of this scoping review was to identify and summarise published qualitative research on the experiences of hospital care for people living with multiple long-term conditions, their informal caregivers and healthcare professionals.

METHODS

We undertook a scoping review, following established guidelines, of primary qualitative research on experiences of hospital care for people living with multiple long-term conditions published in peer-reviewed journals between Jan 2010 and June 2022. We conducted systematic electronic searches of MEDLINE, CINAHL, PsycInfo, Proquest Social Science Premium, Web of Science, Scopus and Embase, supplemented by citation tracking. Studies were selected for inclusion by two reviewers using an independent screening process. Data extraction included study populations, study design, findings and author conclusions. We took a narrative approach to reporting the findings.

RESULTS

Of 8002 titles and abstracts screened, 54 papers reporting findings from 41 studies conducted in 14 countries were identified as eligible for inclusion. The perspectives of people living with multiple long-term conditions (21 studies), informal caregivers (n = 13) and healthcare professionals (n = 27) were represented, with 15 studies reporting experiences of more than one group. Findings included poor service integration and lack of person-centred care, limited confidence of healthcare professionals to treat conditions outside of their specialty, and time pressures leading to hurried care transitions. Few studies explored inequities in experiences of hospital care.

CONCLUSIONS

Qualitative research evidence on the experiences of hospital care for multiple long-term conditions illuminates a tension between the desire to provide and receive person-centred care and time pressures inherent within a target-driven system focussed on increasing specialisation, reduced inpatient provision and accelerated journeys through the care system. A move towards more integrated models of care may enable the needs of people living with multiple long-term conditions to be better met. Future research should address how social circumstances shape experiences of care.

How do nurses support chronically ill clients' participation and self-management in primary care? A cross-country qualitative study

BACKGROUND

In the context of the advancement of person-centered care models, the promotion of the participation of patients with chronic illness and complex care needs in the management of their care (self-management) is increasingly seen as a responsibility of primary care nurses. It is emphasized that nurses should consider the psychosocial dimensions of chronic illness and the client's lifeworld. Little is known about how nurses shape this task in practice.

METHODS

The aim of this analysis is to examine how primary care nurses understand and shape the participation of patients with chronic illness and complex care needs regarding the promotion of self-management. Guided interviews were conducted with nurses practicing in primary care and key informants in Germany, Spain, and Brazil with a subsequent cross-case evaluation. Interpretive and practice patterns were identified based on Grounded Theory.

RESULTS

Two interpretive and practice patterns were identified: (1) Giving clients orientation in dealing with chronic diseases and (2) supporting the integration of illness in clients' everyday lives. Nurses in the first pattern consider it their most important task to provide guidance toward health-promoting behavior and disease-related decision-making by giving patients comprehensive information. Interview partners emphasize client autonomy, but rarely consider the limitations chronic disease imposes on patients' everyday lives. Alternatively, nurses in the second pattern regard clients as cooperation partners. They seek to familiarize themselves with their clients' social environments and habits to give recommendations for dealing with the disease that are as close to the client's lifeworld as possible. Nurses' recommendations seek to enable patients and their families to lead a largely 'normal life' despite chronic illness. While interview partners in Brazil or Spain point predominantly to clients' socio-economic disadvantages as a challenge to promoting client participation in primary health care, interview partners in Germany maintain that clients' high disease burden represents the chief barrier to self-management.

CONCLUSIONS

Nurses in practice should be sensitive to client's lifeworlds, as well as to challenges that arise as they attempt to strengthen clients' participation in care and self-management. Regular communication between clients, nurses, and further professionals should constitute a fundamental feature of person-centered primary care models.

Definition of patient complexity in adults: A narrative review

Background

Better identification of complex patients could help to improve their care. However, the definition of patient complexity itself is far from obvious. We conducted a narrative review to identify, describe, and synthesize the definitions of patient complexity used in the last 25 years.

Methods

We searched PubMed for articles published in English between January 1995 and September 2020, defining patient complexity. We extended the search to the references of the included articles. We assessed the domains presented in the definitions, and classified the definitions as based on (1) medical aspects (e.g., number of conditions) or (2) medical and/or non-medical aspects (e.g., socio-economic status). We assessed whether the definition was based on a tool (e.g., index) or conceptual model.

Results

Among 83 articles, there was marked heterogeneity in the patient complexity definitions. Domains contributing to complexity included health, demographics, behavior, socio-economic factors, healthcare system, medical decision-making, and environment. Patient complexity was defined according to medical aspects in 30 (36.1%) articles, and to medical and/or non-medical aspects in 53 (63.9%) articles. A tool was used in 36 (43.4%) articles, and a conceptual model in seven (8.4%) articles.

Conclusion

A consensus concerning the definition of patient complexity was lacking. Most definitions incorporated non-medical factors in the definition, underlining the importance of accounting not only for medical but also for non-medical aspects, as well as for their interrelationship.

The beginnings of health system transformation: How Ontario Health Teams are implementing change in the context of uncertainty

PURPOSE/ SETTING

The launch of Ontario Health Teams (OHTs) by the Canadian province of Ontario in 2019 represented a milestone in the journey towards integrated care and population health management. However, early model development was riddled with uncertainty. We explore what makes transformation possible even in the context of uncertainty.

METHODS

We conducted 125 interviews with administrators, clinicians, and patient and family advisors across 12 OHTs, representatively selected across geography and leadership sector, between January to September 2020. Interviews were transcribed and thematically coded, and a Foucauldian approach informed analysis.

FINDINGS

A sense of uncertainty was identified at three levels: (a) at a cross-organizational level, policymakers were perceived as providing inadequate direction; (b) at a sectoral level, certain sectors were uncertain about participating due to historic vulnerabilities; and (c) at a professional level, physicians were uncertain about the value of the new model and their place within it. These concerns were countered by a recognition of the need for change, inclusive decision-making, and developing empathy and awareness of each other's needs. This helped unsettle traditional hierarchies and facilitate new forms of certainty.

CONCLUSION

Understanding the possibilities and challenges of this endeavour will be helpful to program implementers negotiating uncertain environments as well as to policymakers seeking to provide guidance without stymieing local innovation.

The Cost Consequences of the Gold Coast Integrated Care Programme

Introduction

The Australian Gold Coast Integrated Care programme trialled a model of care targeting those with chronic and complex conditions at highest risk of hospitalisation with the goal of producing the best patient outcomes at no additional cost to the healthcare system. This paper reports the economic findings of the trial.

Methods

A pragmatic non-randomised controlled study assessed differences between patients enrolled in the programme (intervention group) and patients who received usual care (control group), in health service utilisation, including Medicare Benefits Schedule and Pharmaceutical Benefits Scheme claims, patient-reported outcome measures, including health-related quality of life, mortality risk, and cost.

Results

A total of 1,549 intervention participants were enrolled and matched on the basis of patient level data to 3,042 controls. We found no difference in quality of life between groups, but a greater decrease in capability, social support and satisfaction with care scores and higher hospital service use for the intervention group, leading to a greater cost to the healthcare system of AUD$6,400 per person per year. In addition, the per person per year cost of being in the GCIC programme was AUD$8,700 equating to total healthcare expenditures of AUD$15,100 more for the intervention group than the control group.

Conclusion

The GCIC programme did not show value for money, incurring additional costs to the health system and demonstrating no significant improvements in health-related quality of life. Because patient recruitment was gradual throughout the trial, we had only one year of complete data for analysis which may be too short a period to determine the true cost-consequences of the program.

Putting the Patient First: A Scoping Review of Patient Desires in Canada

Patient-centred care is a key priority for governments, providers and stakeholders, yet little is known about the care preferences of patient groups. We completed a scoping review that yielded 193 articles for analysis. Five health states were used to account for the diversity of possible preferences based on health needs. Five broad themes were identified and expressed differently across the health states, including personalized care, navigation, choice, holistic care and care continuity. Patients' perspectives must be considered to meet the diverse needs of targeted patient groups, which can inform health system planning, quality improvement initiatives and targeting of investments.

Association Between Multimorbid Disease Patterns and Pain Outcomes Among a Complex Chronic Care Population in Canada

PURPOSE

Disease multimorbidity and pain is a complex, yet common, problem for the aging population, and a significant burden on the health-care systems around the world. Despite this, disease comorbidity and the association with pain in a complex chronic care population is not well understood. This study examined the most prevalent disease combinations and their association with pain.

PATIENTS AND METHODS

The study initially included 139,920 residents, aged 18-101 years, admitted to publicly funded hospital facilities for complex chronic care in Canada between the years 2006 and 2016. Data were acquired through the Canadian Institute for Health Information (CIHI) Facility-Based Continuing Care Reporting System (CCRS). Descriptive and chi-square statistics were used to summarize and compare the sample characteristics. Binary logistic regression analyses were used to examine the association between multimorbid disease categories and pain outcomes.

RESULTS

The sample consisted of 139,573 residents (57% female), mostly older (mean age = 77.32 years), married (40%), or widowed (36%). Residents took an average of 11.9 medications and 77% were using analgesic medications. On average, residents had diagnoses from 3.06 disease categories (SD = 1.43). Heart/circulation diseases were the most prevalent among the sample (73%), with neurological second (46%) and musculoskeletal third (44%). Overall, 73% of residents reported pain, with 43% reporting moderate pain severity. Residents with multiple disease categories were more likely to report the presence of pain (OR = 1.08, 95% CI: 1.07-1.08, p < 0.001), with each additional disease category associated with an 8% increase in the odds of reporting pain.

CONCLUSION

The findings from this study help identify common comorbid disease patterns related to pain in an institutionalized, complex chronic care population. This information contributes to both the pain and multimorbidity literature, and is invaluable for creating care plans to meet the demands of a challenging population.

Speaking Up for Fundamental Care: the ILC Aalborg Statement

OBJECTIVE

The International Learning Collaborative (ILC) is an organisation dedicated to understanding why fundamental care, the care required by all patients regardless of clinical condition, fails to be provided in healthcare systems globally. At its 11th annual meeting in 2019, nursing leaders from 11 countries, together with patient representatives, confirmed that patients' fundamental care needs are still being ignored and nurses are still afraid to 'speak up' when these care failures occur. While the ILC's efforts over the past decade have led to increased recognition of the importance of fundamental care, it is not enough. To generate practical, sustainable solutions, we need to substantially rethink fundamental care and its contribution to patient outcomes and experiences, staff well-being, safety and quality, and the economic viability of healthcare systems.

KEY ARGUMENTS

We present five propositions for radically transforming fundamental care delivery:Value: fundamental care must be foundational to all caring activities, systems and institutionsTalk: fundamental care must be explicitly articulated in all caring activities, systems and institutions.Do: fundamental care must be explicitly actioned and evaluated in all caring activities, systems and institutions.Own: fundamental care must be owned by each individual who delivers care, works in a system that is responsible for care or works in an institution whose mission is to deliver care.

RESEARCH

fundamental care must undergo systematic and high-quality investigations to generate the evidence needed to inform care practices and shape health systems and education curricula.

CONCLUSION

For radical transformation within health systems globally, we must move beyond nursing and ensure all members of the healthcare team-educators, students, consumers, clinicians, leaders, researchers, policy-makers and politicians-value, talk, do, own and research fundamental care. It is only through coordinated, collaborative effort that we will, and must, achieve real change.

Reciprocal Dynamics of Dignity in End-of-Life Care: A Multiperspective Systematic Review of Qualitative and Mixed Methods Research

Background:

Preserving terminally ill patients’ dignity and well-being through dignified and holistic care has become the overarching goal in palliative care services. However, dignity is a multifaceted concept with a wide range of interpretations under different cultural contexts.

Aim:

The aim of this review is to understand the variations in subjective interpretations and constitutions of dignity in palliative or end-of-life care via an integrative worldview.

Design:

This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline and used SPIDER tool to screen for appropriate and relevant articles for analysis.

Data Sources:

Four major databases were searched including CINAHL, ERIC, Medline, and PsycARTICLES between 2009 and 2018. Forty-eight qualitative studies that examined dignity from the perspectives of patients, family caregivers, and health-care professionals were selected for full text data analysis using thematic synthesis.

Results:

Analysis of the various concepts of dignity revealed 18 themes that were further categorized into 7 conceptual categories: (1) self-determination, (2) existential liberty, (3) relational connectedness, (4) caregiving revitalization, (5) mindful humanity, (6) patient–family care, and (7) sustainable culture. These 7 categories span across individual, familial, and institutional dimensions, forming a new Dynamic Reciprocity of Dignity model.

Conclusions:

The Dynamic Reciprocity of Dignity model highlights the importance of adopting a systemic lens to address dignity-related needs and concerns at the end of life, while providing insights on how compassionate care and self-compassion can serve as the foundation of dignified care, which in turn serve as a buffer against patients’ existential suffering as well as caregivers’ burnout and fatigue. Recommendations for clinical practice and future research directions are discussed.

Using Ockham's razor to redefine "nursing science"

Confusion remains about the concept "nursing science." Definitions vary, depending on country, context and setting. Even among nurse scholars and scientists there is disagreement about the content and boundaries of nursing science. There is an urgent need for an acceptable definition that can guide nursing knowledge development, education, and practice. In this article, we highlight the problems for the profession of this sort of conceptual ambiguity, arguing that it is an ethical responsibility for the profession to gain clarity about the meaning and apt focus of our knowledge development initiatives. We parse out nursing and science as separate concepts and synthesize from this analysis a simple yet comprehensive definition of nursing science. We propose that this definition is capable of unifying ongoing nursing endeavors and should serve as the basis for evaluating nursing's knowledge development and educational initiatives.

"It's a fight to get anything you need" - Accessing care in the community from the perspectives of people with multimorbidity

BACKGROUND

There is a growing interest in redesigning health-care systems to better manage the increasing numbers of people with multimorbidity. Knowing how patients experience health-care delivery and what they need from the health-care system are critical pieces of evidence that can be used to guide health system reforms.

OBJECTIVE

The purpose of this study was to understand the challenges patients with multimorbidity face in accessing care in the community, and the implications for patients and their families.

METHODS

A secondary analysis of qualitative data was conducted on semi-structured interviews with 116 patients who were receiving care in an urban rehabilitation facility in 2011. Exploratory interpretive analysis was used to identify themes about access to care.

RESULTS

Challenges occurred at two levels: at the health system level and at the individual (patient) level. Issues at the health system level fell into two broad categories: availability of services (failing to qualify, coping with wait times, struggling with scarcity and negotiating the location of care) and service delivery (unreliable care, unmet needs, incongruent care and inflexible care). Challenges at the patient level fell into the themes of logistics of accessing care and financial strain. Patients interacted and responded to these challenges by: managing the system, making personal sacrifices, substituting with informal care, and resigning to system constraints.

CONCLUSION

Identifying the barriers patients encounter and the lengths they go to in order to access care highlights areas where policy initiatives can focus to develop appropriate and supportive services that are more person and family-centred.

A Policy Guide on Integrated Care (PGIC): Lessons Learned from EU Project INTEGRATE and Beyond

Efforts are underway in many European countries to channel efforts into creating improved integrated health and social care services. But most countries lack a strategic plan that is sustainable over time, and that reflects a comprehensive systems perspective. The Policy Guide on Integrated Care (PGIC) as presented in this paper resulted from experiences with the EU Project INTEGRATE and our own work with healthcare reform for patients with chronic conditions at the national and international level. This project is one of the largest EU funded projects on Integrated Care, conducted over a four-year period (2012–2016) and included partners from nine European countries. Project Integrate aimed to gain insights into the leadership, management and delivery of integrated care to support European care systems to respond to the challenges of ageing populations and the rise of people living with long-term conditions. The objective of this paper is to describe the PGIC as both a tool and a reasoning flow that aims at supporting policy makers at the national and international level with the development and implementation of integrated care. Any Policy Guide on Integrated should build upon three building blocks, being a mission, vision and a strategy that aim at capturing the large amount of factors that directly or indirectly influence the successful development of integrated care.

Community Care for People with Complex Care Needs: Bridging the Gap between Health and Social Care

INTRODUCTION

A growing number of people are living with complex care needs characterized by multimorbidity, mental health challenges and social deprivation. Required is the integration of health and social care, beyond traditional health care services to address social determinants. This study investigates key care components to support complex patients and their families in the community.

METHODS

Expert panel focus groups with 24 care providers, working in health and social care sectors across Toronto, Ontario, Canada were conducted. Patient vignettes illustrating significant health and social care needs were presented to participants. The vignettes prompted discussions on i) how best to meet complex care needs in the community and ii) the barriers to delivering care to this population.

RESULTS

Categories to support care needs of complex patients and their families included i) relationships as the foundation for care, ii) desired processes and structures of care, and iii) barriers and workarounds for desired care.

DISCUSSION AND CONCLUSIONS

Meeting the needs of the population who require health and social care requires time to develop authentic relationships, broadening the membership of the care team, communicating across sectors, co-locating health and social care, and addressing the barriers that prevent providers from engaging in these required practices.

Evaluation of a Specialized Yoga Program for Persons Admitted to a Complex Continuing Care Hospital: A Pilot Study

Introduction. The purpose of this study was to evaluate a specialized yoga intervention for inpatients in a rehabilitation and complex continuing care hospital. Design. Single-cohort repeated measures design. Methods. Participants (N = 10) admitted to a rehabilitation and complex continuing care hospital were recruited to participate in a 50–60 min Hatha Yoga class (modified for wheelchair users/seated position) once a week for eight weeks, with assigned homework practice. Questionnaires on pain (pain, pain interference, and pain catastrophizing), psychological variables (depression, anxiety, and experiences with injustice), mindfulness, self-compassion, and spiritual well-being were collected at three intervals: pre-, mid-, and post-intervention. Results. Repeated measures ANOVAs revealed a significant main effect of time indicating improvements over the course of the yoga program on the (1) anxiety subscale of the Hospital Anxiety and Depression Scale, F(2,18) = 4.74, p < .05, and η_p² = .35, (2) Self-Compassion Scale-Short Form, F(2,18) = 3.71, p < .05, and η_p² = .29, and (3) Magnification subscale of the Pain Catastrophizing Scale, F(2,18) = 3. 66, p < .05, and η_p² = .29. Discussion. The results suggest that an 8-week Hatha Yoga program improves pain-related factors and psychological experiences in individuals admitted to a rehabilitation and complex continuing care hospital.

Results from 10 Years of a CBT Pain Self-Management Outpatient Program for Complex Chronic Conditions

Background. Traditional unimodal interventions may be insufficient for treating complex pain, as they do not address cognitive and behavioural contributors to pain. Cognitive Behavioural Therapy (CBT) and physical exercise (PE) are empirically supported treatments that can reduce pain and improve quality of life. Objectives. To examine the outcomes of a pain self-management outpatient program based on CBT and PE at a rehabilitation hospital in Toronto, Ontario. Methods. The pain management group (PMG) consisted of 20 sessions over 10 weeks. The intervention consisted of four components: education, cognitive behavioural skills, exercise, and self-management strategies. Outcome measures included the sensory, affective, and intensity of pain experience, depression, anxiety, pain disability, active and passive coping style, and general health functioning. Results. From 2002 to 2011, 36 PMGs were run. In total, 311 patients entered the program and 214 completed it. Paired t-tests showed significant pre- to posttreatment improvements in all outcomes measured. Patient outcomes did not differ according to the number or type of diagnoses. Both before and after treatment, women reported more active coping than men. Discussion. The PMGs improved pain self-management for patients with complex pain. Future research should use a randomized controlled design to better understand the outcomes of PMGs.

Patterns of community follow-up, subsequent health service use and survival among young and mid-life adults discharged from chronic care hospitals: a retrospective cohort study

BACKGROUND

Despite the demand for rehabilitation and chronic care services across the life course, policy and care strategies tend to focus on older adults and overlook medically complex younger adult populations. This study examined young and mid-life adults discharged from tertiary chronic care hospitals in order to describe their health service use and to examine the association between patterns of timely community follow-up, and subsequent health outcomes.

METHODS

This population-based retrospective cohort study used linked administrative data to identify 1,906 individuals aged 18-64 years and discharged alive from tertiary chronic care hospitals in Ontario, Canada between April 1, 2005 and March 31, 2006. Multivariate Cox proportional hazard models were used to examine the effect of community follow-up within 7 days of discharge (home care and/or a primary care physician visit or neither) on time to first hospitalization and emergency department (ED) visit. Five-year survival was examined using Kaplan-Meier survival curves.

RESULTS

The cohort had a high prevalence of multi-morbidity and use of hospital, emergency services and physician services was high in the year following discharge. Most individuals received follow-up care from a primary care physician and/or home care within 7 days of discharge while 30 % received neither. Within 1 year of discharge, 18 % of individuals died. Among those who survived, time to acute care hospitalization in the year following discharge was significantly longer among those who received both a home care and a physician follow-up visit compared to those who received neither. No significant associations were found between community follow-up and ED visits within 1 year.

CONCLUSIONS

Immediate community follow-up may reduce subsequent use of acute care services. Future research should determine why some individuals, who would likely benefit from services, are not receiving them including barriers to access.

Measuring patient satisfaction in complex continuing care/rehabilitation care

Purpose

To develop a psychometrically validated survey to assess satisfaction in complex continuing care/rehabilitation patients.

Design/methodology/approach

A paper or computer-based survey was administered to 252 complex continuing care/ rehabilitation patients (i.e., post-acute hospital care setting for people who require ongoing care before returning home) across two hospitals in Toronto, Ontario, Canada.

Findings

Using factor analysis, five domains were identified with loadings above 0.4 for all but one item. Behavioral intention and information/communication showed the lowest patient satisfaction, while patient centredness the highest. Each domain correlated positively and significantly predicted overall satisfaction, with quality and safety showing the strongest predictive power and the healing environment the weakest. Gender made a significant contribution to predicting overall satisfaction, but age did not.

Research limitations/implications

Results provide evidence of the survey’s psychometric properties. Owing to a small sample, supplemental testing with a larger patient-group is required to confirm the five-factor structure and to assess test-retest reliability.

Originality/value

Improving the health system requires integrating patient perspectives. The patient experience, however, will vary depending on the population being served. This is the first psychometrically validated survey specific to a smaller speciality patient group receiving care at a complex continuing care/rehabilitation facility in Canada.

What makes stroke rehabilitation patients complex? Clinician perspectives and the role of discharge pressure

BACKGROUND

Approximately 80% of people who survive a stroke have on average five other conditions and a wide range of psychosocial issues. Attention to biopsychosocial issues has led to the identification of 'complex patients'. No single definition of 'patient complexity' exists; therefore, applied health researchers seek to understand 'patient complexity' as it relates to a specific clinical context.

OBJECTIVE

To understand how 'patient complexity' is conceptualized by clinicians, and to position the findings within the existing literature on patient complexity.

METHODS

A qualitative descriptive approach was utilized. Twenty-three stroke rehabilitation clinicians participated in four focus groups.

RESULTS

Five elements of patient complexity were identified: medical/functional issues, social determinant factors, social/family support, personal characteristics, and health system factors. Using biopsychosocial factors to identify complexity results in all patients being complex; operationalization of the definition led to the identification of systemic elements. A disconnect between acute, inpatient rehabilitation and community services was identified as a trigger for increased complexity.

CONCLUSIONS

Patient complexity is not a dichotomous state. If applying existing complexity definitions, all patients are complex. This study extends the understanding by suggesting a structural element of complexity from manageable to less manageable complexity based on ability to discharge.

Evaluating Intention and Effect

Objective:

This post occupancy evaluation (POE) assessed the impact of architectural design on psychosocial well-being among patients and staff in the context of a new complex continuing care and rehabilitation facility.

Background:

Departing from typical POEs, the hospital design intentions formed the theoretical basis to assess outcomes. Intentions included creating an environment of wellness; enhancing connection to the community, the city, and nature; enhancing opportunities for social interaction; and inspiring activity.

Methods:

A pretest–posttest quasi experiment, including quantitative surveys, assessed the impact of the building design on well-being outcomes across three facilities—the new hospital, the former hospital, and a comparison facility with a similar population.

Results:

With the exception of connection to neighborhood (for patients) and opportunities to visit with others (for staff) and wayfinding (for patients and staff), impressions of the new hospital mirrored the design intentions relative to the former hospital and the comparison facility among patients and staff. Perceptions of improvement in mental health, self-efficacy in mobility, satisfaction, and interprofessional interactions were enhanced at the new hospital relative to the former hospital, whereas optimism, depressive symptoms, general well-being, burnout, and intention to quit did not vary. Interestingly, patients and staff with favorable impressions of the building design fared better on most well-being-related outcomes relative to those with less favorable impressions.

Conclusions:

Beyond the value of assessing the impact of the design intentions on outcomes, the approach used in this study would benefit evaluation strategies across a diversity of health and other public and large-scale buildings.

Perceived value of support for older adults coping with multi-morbidity: patient, informal care-giver and family physician perspectives

This study investigated the perceived value of informal and formal supports for older adults with multi-morbidity from the perspectives of patients, care-givers and family physicians. Semi-structured interviews were conducted with 27 patients, their informal care-givers and their family physicians in an urban academic family health team in Ontario. Analysis was conducted using a General Inductive Approach to facilitate identification of main themes and build a framework of perceived value of supports. Participant views converged on supports that facilitate patient independence and ease care-giver burden. However, important differences in participant perceptions arose regarding these priorities. Physicians and care-givers valued supports that facilitate health and safety while patients prioritised supports that enable self-efficacy and independence. While formal supports which eased care-giver burden were viewed positively by all members of the triad, many patients also rejected formal supports, citing that informal support from their care-giver was available. Such conflicts between patient, care-giver and physician-perceived value of supports may have important implications for consumer and care-giver willingness to accept formal supports when supports are available. These findings contribute to the broader literature on community-based care by incorporating the perspectives of patients, informal care-givers and family physicians to understand better the barriers and facilitators of uptake of supportive services that contribute to successful ageing at home.

Perceived risk factors of health decline: a qualitative study of hospitalized patients with multimorbidity

Background

Effectively preventing and managing chronic illness are key goals for health systems worldwide. A growing number of people are living longer with multiple chronic illnesses, accompanied by a high degree of treatment burden and heavy use of health care resources. People with multimorbidity typically have to manage their care needs for a number of years, and from this experience may offer valuable perspectives on factors that influenced their health outcome.

Purpose

The purpose of this study was to explore factors that may serve as tipping points into poor health from the perspective of hospitalized patients with multimorbidity.

Participants and methods

Patient interview data were analyzed from 43 hospitalized patients with multimorbidities who indicated that something could have been done to either avoid or slow down their health decline. The study used qualitative description as the analytic method to generate themes from a specific question collected through one-on-one interviews. Two reviewers independently analyzed and thematically coded the data and reached consensus on the final themes after a series of meetings.

Results

According to patient accounts, factors at the personal level (eg, personal behaviors), provider level (eg, late diagnoses), and health care system level (eg, poor care transitions) contributed to their health decline.

Conclusion

This paper focuses on prevention in the context of multimorbidity. While some respondents indicated personal behaviors that impacted health, many pointed to factors outside themselves (providers and the broader health system). The orientation of health care systems, historically designed to support acute and episodic care and not multimorbidity, places patients, at least in some cases, at additional risk of decline. The patient accounts suggest that the notion of prevention should evolve throughout the course of illness. A successful health system would embrace this notion and see the goal as forestalling not only mortality (as achieved for the most part in high socioeconomic nations) but morbidity as well. High rates of multimorbidity and health system challenges suggest that we have not yet achieved this latter aim.

Complex health conditions and mental health training: How prepared is the frontline service provider?

How prepared are frontline service providers for dealing with mental illness in patients with multiple, complex health conditions? The aims of this study were two-fold, to gain insight into the kinds of training and education desired by frontline service providers in a healthcare setting and to compile a list of key questions for health service managers and education leaders to address based on our findings. Over 100 care providers responded to a survey. Over half of the respondents indicated no mental health training, and the majority desired increased training and support. Suggested approaches ranged from regular workshops (eg, case presentations) to systems-level strategies (eg, partnering with mental health organizations). This study provides a critical first look into what frontline service providers identify as being essential to their skill set in working with a complex population and raises important questions for healthcare managers and educators to consider in addressing this gap.

Tying eHealth Tools to Patient Needs: Exploring the Use of eHealth for Community-Dwelling Patients With Complex Chronic Disease and Disability

BACKGROUND

Health policy makers have recently shifted attention towards examining high users of health care, in particular patients with complex chronic disease and disability (CCDD) characterized as having multimorbidities and care needs that require ongoing use of services. The adoption of eHealth technologies may be a key strategy in supporting and providing care for these patients; however, these technologies need to address the specific needs of patients with CCDD. This paper describes the first phase of a multiphased patient-centered research project aimed at developing eHealth technology for patients with CCDD.

OBJECTIVE

As part of the development of new eHealth technologies to support patients with CCDD in primary care settings, we sought to determine the perceived needs of these patients with respect to (1) the kinds of health and health service issues that are important to them, (2) the information that should be collected and how it could be collected in order to help meet their needs, and (3) their views on the challenges/barriers to using eHealth mobile apps to collect the information.

METHODS

Focus groups were conducted with community-dwelling patients with CCDD and caregivers. An interpretive description research design was used to identify the perceived needs of participants and the information sharing and eHealth technologies that could support those needs. Analysis was conducted concurrently with data collection. Coding of transcripts from four focus groups was conducted by 3 authors. QSR NVivo 10 software was used to manage coding.

RESULTS

There were 14 total participants in the focus groups. The average age of participants was 64.4 years; 9 participants were female, and 11 were born in Canada. Participants identified a need for open two-way communication and dialogue between themselves and their providers, and better information sharing between providers in order to support continuity and coordination of care. Access issues were mainly around wait times for appointments, challenges with transportation, and costs. A visual depiction of these perceived needs and their relation to each other is included as part of the discussion, which will be used to guide development of our eHealth technologies. Participants recognized the potential for eHealth technologies to support and improve their care but also expressed common concerns regarding their adoption. Specifically, they mentioned privacy and data security, accessibility, the loss of necessary visits, increased social isolation, provider burden, downloading responsibility onto patients for care management, entry errors, training requirements, and potentially confusing interfaces.

CONCLUSIONS

From the perspective of our participants, there is a significant potential for eHealth tools to support patients with CCDD in community and primary care settings, but we need to be wary of the potential downfalls of adopting eHealth technologies and pay special attention to patient-identified needs and concerns. eHealth tools that support ongoing patient-provider interaction, patient self-management (such as telemonitoring), and provider-provider interactions (through electronic health record integration) could be of most benefit to patients similar to those in our study.

Relationship between symptom burden, distress, and sense of dignity in terminally ill cancer patients

CONTEXT

Maintaining a sense of dignity in terminally ill patients and enabling a dignified dying are important aims of palliative care.

OBJECTIVES

To evaluate the impact of symptom burden, distress, overall condition, and individual patient characteristics on self-perceived dignity in terminally ill cancer patients.

METHODS

In this cross-sectional study, 61 patients were recruited through a palliative care inpatient ward within 48 hours after admission. Patients completed the Patient Dignity Inventory, a modified version of the Memorial Symptom Assessment Scale, the National Comprehensive Cancer Network Distress Thermometer, and a single-item scale rating subjective of overall condition. Sociodemographic parameters and performance status were taken from the patients' records.

RESULTS

Dignity total score correlated highest with lack of energy (P<0.001), anxiety (P<0.001), sadness (P=0.002), pain (P=0.009), shortness of breath (P=0.019), irritability (P=0.023), thirst (P=0.029), and tiredness (P=0.041). Psychological symptoms showed more consistent associations with the different dignity dimensions than physical symptoms except for the dependency dimension. Psychological distress correlated with all dignity dimensions: symptom distress (P<0.001), existential distress (P<0.001), dependency (P=0.020), peace of mind (P<0.001), and social support (P=0.024). Overall condition was significantly associated with existential distress (P=0.013), but not with symptom distress, dependency, peace of mind, or social support. Performance status showed significant association with dependency (P=0.001).

CONCLUSION

Self-perceived dignity in terminally ill cancer patients is significantly associated with physical as well as psychological symptoms, distress, overall condition, performance status, and comorbidities. Knowledge of these specific interactions is essential for adequate, comprehensive palliative care.

Communication challenges in complex medical environments

The provision of health care is becoming increasingly complex and can involve multiple providers and care setting transitions, particularly as the population is living longer, and often with chronic disease. The Electronic Health Record (EHR) was intended to provide a comprehensive documentation of a patient's health-related information; however, health care systems often function in isolation with EHRs that are unique only to that system. The EHR may also limit face-to-face communication between treating physicians within the same system. It is only with diligent effort that changes in medical management plans are conveyed among providers. When multiple providers are involved in a patient's care, physician-to-patient communication may also suffer, which can impact patient satisfaction and outcome. This article describes a scenario in which several lapses in communication occurred, and it outlines other common pitfalls while providing possible solutions for improving communication across the health care spectrum.

"Where do we go from here?" Health system frustrations expressed by patients with multimorbidity, their caregivers and family physicians

OBJECTIVES

This study explored the care challenges experienced by older patients with multimorbidity, their informal caregivers and family physicians.

APPROACH

Semi-structured interviews were conducted with 27 patients, their informal caregivers and family physicians. Qualitative description was used to identify key themes in the interview transcripts.

RESULTS

Participants experienced many common challenges when managing multimorbidity, including a lack of decision-making support, poor communication and uncoordinated health services. Within these themes, unique perspectives specific to the role of being a patient, caregiver or family physician emerged.

CONCLUSION

The study adds to a limited evidence base on the experience of patients with multimorbidity. By including the perspectives of their family caregivers and physicians, we provide important insight into the management of multimorbidity and recommend the uptake of specific strategies to address them.

A qualitative descriptive study on the alignment of care goals between older persons with multi-morbidities, their family physicians and informal caregivers

Background

Goal setting is a recommended approach in clinical care that can help individuals with multi-morbidities and their caregivers manage chronic conditions. In this paper, the types of goals that were important for older persons with multi-morbidities were explored from the perspectives of patients, their caregivers and physicians. Comparisons of goals were made across each patient, caregiver and physician triad to determine alignment.

Methods

The study was a qualitative descriptive study facilitated through semi-structured one-on-one interviews. The study took place between May and October 2012 at a Family Health Team located in Ontario, Canada. The sample included 28 family medicine patients, their informal caregivers and family physicians. Socio-demographic data were analyzed via descriptive statistics in SPSS Version 17. Open ended questions pertaining to patient goals of care were analyzed thematically using NVivo9. Themes were derived on patient care goals for each of the participant groups (patients, caregivers and family physicians). Following this, alignment of goals across each of the triads was examined. Goal alignment was defined as concurrence on at least one goal by all three parties in a particular triad (i.e., patient, caregiver and family physician).

Results

Just over half of the patients were male (56%); they had an average age of 82.3 years and 4.61 health conditions. Most of the caregivers were female (82%); and 61% were a spouse of the care recipient. At the aggregate level, common goals expressed among patients, caregivers and family physicians were the maintenance of functional independence of patients and the management of their symptoms or functional challenges. Despite these common goals at the aggregate level, little alignment of goals was found when looking across patient-caregiver and physician triads. Lack of alignment tended to occur when patients had unstable or declining functional or cognitive health; when safety threats were noted; and when enhanced care services were required.

Conclusions

The data suggest that goal divergence tends to occur when patients are less medically stable. While goal divergence may be expected due to the different roles and responsibilities of each of the players involved, these perspectives should be illuminated when building care plans. Further research is required to observe the extent to which goal setting occurs in family practice as well as how it can be embedded as a standard of practice.