Identifying the patient perspective of the quality of mental healthcare for common chronic problems: a qualitative study

Person-centered care for common mental disorders in Ontario's primary care patient-centered medical homes: a qualitative study of provider perspectives

BACKGROUND

For more than a decade, the Patient-Centered Medical Home model has been a guiding vision for the modernization of primary care systems. In Canada, Ontario's Family Health Teams (FHTs) were designed in the mid-2000s with the medical home model in mind. These primary care clinics aim to provide accessible, comprehensive, and person-centered primary care services to communities across Ontario. Their services typically include mental health care for people experiencing common mental disorders, such as depression and anxiety disorders. It remains unclear, however, whether the mental health care delivered within FHTs is consistent with person-centered care approaches. In the current study, we aimed to explore the perspectives of FHT providers on the care delivered to people with common mental disorders to determine whether, and to what extent, they believed this care was person-centered.

METHODS

We conducted a qualitative grounded theory study involving interviews with 65 health professionals and administrators from 18 FHTs across Ontario. Transcripts were coded using a three-step process of initial, focused, and axial coding that mixed inductive and deductive approaches informed by sensitizing concepts on person-centeredness.

RESULTS

Practices and challenges associated with the delivery of mental health care in a person-centered way were captured by several themes regrouped into five domains: (1) patient as unique person, (2) patient-provider relationship, (3) sharing power and responsibility, (4) connecting to family and community, and (5) creating person-centered care environments. FHT providers perceived that they delivered person-centered care by delivering mental health care that was responsive, flexible, and consistent with biopsychosocial approaches. They emphasized the importance of creating long-lasting relationships with patients grounded in empathy and trust. Their challenges included being able to ensure continuity of care, adequately prioritizing patients' mental health issues, and meaningfully engaging patients and families as partners in care.

CONCLUSIONS

Our findings suggest that FHT providers have adopted a range of person-centered practices for people with common mental disorders. However, greater attention to practices such as shared decision making, supporting self-management, and involving families in care would strengthen person-centeredness and bring teams closer to the Patient-Centered Medical Home vision.

Why Mental Illness Diagnoses Are Wrong: A Pilot Study on the Perspectives of the Public

BACKGROUND

Mental illness diagnostic criteria are made based on assumptions. This pilot study aims to assess the public's perspectives on mental illness diagnoses and these assumptions.

METHODS

An anonymous survey with 30 questions was made available online in 2021. Participants were recruited via social media, and no personal information was collected. Ten questions focused on participants' perceptions regarding mental illness diagnoses, and 20 questions related to the assumptions of mental illness diagnoses. The participants' perspectives on these assumptions held by professionals were assessed.

RESULTS

Among 14 survey participants, 4 correctly answered the relationships of 6 symptom pairs (28.57%). Two participants could not correctly conduct the calculations involved in mood disorder diagnoses (14.29%). Eleven (78.57%) correctly indicated that 2 or more sets of criteria were available for single diagnoses of mental illnesses. Only 1 (7.14%) correctly answered that the associations between symptoms and diagnoses were supported by including symptoms in the diagnostic criteria of the diagnoses. Nine (64.29%) correctly answered that the diagnosis variances were not fully explained by their symptoms. The confidence of participants in the major depressive disorder diagnosis and the willingness to take medications for this diagnosis were the same (mean = 5.50, standard deviation [SD] = 2.31). However, the confidence of participants in the symptom-based diagnosis of non-solid brain tumor was significantly lower (mean = 1.62, SD = 2.33, p < 0.001).

CONCLUSION

Our study found that mental illness diagnoses are wrong from the perspectives of the public because our participants did not agree with all the assumptions professionals make about mental illness diagnoses. Only a minority of our participants obtained correct answers to the calculations involved in mental illness diagnoses. In the literature, neither patients nor the public have been engaged in formulating the diagnostic criteria of mental illnesses.

Satisfaction with Primary Care Providers and Health Care Services Among Patients with Chronic Pain: a Mixed-Methods Study

BACKGROUND

Chronic pain is a prevalent health concern in the United States (US) and a frequent reason for patients to seek primary care. The challenges associated with developing effective pain management strategies can be perceived as a burden on the patient-provider relationship.

OBJECTIVE

This study explored the relationship between patients' overall satisfaction with their primary care providers (PCPs) and their satisfaction with their chronic pain treatment, as well as the provider behaviors that contributed to chronic pain patients' satisfaction with their PCPs.

DESIGN

Concurrent nested mixed-methods design PARTICIPANTS: 97 patients with chronic pain who were assigned to the usual care arm of the Pain Program for Active Coping and Training (PPACT) study.

APPROACH

We analyzed phone interview and survey data (n = 97). Interviews assessed provider behaviors that led to patient satisfaction. Interview transcripts were analyzed based on a content analysis approach. Survey responses assessed patient satisfaction with primary care and pain services. We calculated a Pearson's correlation coefficient using five response categories.

KEY RESULTS

Interviews revealed that high satisfaction with primary care was driven by five concrete PCP behaviors: (1) listening, (2) maintaining communication with patients, (3) acting as an access point to comprehensive pain care, (4) providing an honest assessment of the possibilities of pain care, and (5) taking time during consultations with patients. In surveys, participants reported higher satisfaction with their primary care services than with the pain services they received; these variables were only moderately correlated (r = 0.586).

CONCLUSIONS

Results suggest that patients with chronic pain can view the relationship with their PCPs as positive, even in the face of low satisfaction with their pain treatment. The expectations that these patients held of PCPs could be met regardless of providers' ability to successfully relieve chronic pain.

A person-centered integrated care quality framework, based on a qualitative study of patients' evaluation of care in light of chronic care ideals

BACKGROUND

Person-Centered Integrated Care (PC-IC) is believed to improve outcomes and experience for persons with multiple long-term and complex conditions. No broad consensus exists regarding how to capture the patient-experienced quality of PC-IC. Most PC-IC evaluation tools focus on care events or care in general. Building on others' and our previous work, we outlined a 4-stage goal-oriented PC-IC process ideal: 1) Personalized goal setting 2) Care planning aligned with goals 3) Care delivery according to plan, and 4) Evaluation of goal attainment. We aimed to explore, apply, refine and operationalize this quality of care framework.

METHODS

This paper is a qualitative evaluative review of the individual Patient Pathways (iPP) experiences of 19 strategically chosen persons with multimorbidity in light of ideals for chronic care. The iPP includes all care events, addressing the persons collected health issues, organized by time. We constructed iPPs based on the electronic health record (from general practice, nursing services, and hospital) with patient follow-up interviews. The application of the framework and its refinement were parallel processes. Both were based on analysis of salient themes in the empirical material in light of the PC-IC process ideal and progressively more informed applications of themes and questions.

RESULTS

The informants consistently reviewed care quality by how care supported/ threatened their long-term goals. Personal goals were either implicit or identified by "What matters to you?" Informants expected care to address their long-term goals and placed responsibility for care quality and delivery at the system level. The PC-IC process framework exposed system failure in identifying long-term goals, provision of shared long-term multimorbidity care plans, monitoring of care delivery and goal evaluation. The PC-IC framework includes descriptions of ideal care, key questions and literature references for each stage of the PC-IC process. This first version of a PC-IC process framework needs further validation in other settings.

CONCLUSION

Gaps in care that are invisible with event-based quality of care frameworks become apparent when evaluated by a long-term goal-driven PC-IC process framework. The framework appears meaningful to persons with multimorbidity.

Continuity of care as experienced by mental health service users - a qualitative study

Background

People who struggle with mental health problems can provide valuable insight into understanding and improving the coordination of mental health and welfare services. The aims of the study were to explore service users’ experiences and perceptions of continuity of care within and across services relevant to personal recovery, to elicit which dimensions of continuity of care are most essential to service users, and to generate ideas for improving service users’ experiences of continuity of care.

Methods

In the context of a hermeneutic-phenomenological approach, ten service users at a community mental health centre were interviewed about their experiences of continuity of care in and across services. Eight of these were re-interviewed two years later. A collaborative research approach was adopted. Data were analysed by means of a data-driven stepwise approach in line with thematic analysis.

Results

Following the analysis five themes representing experiences of continuity of care were developed. Each theme ranged from poor to good experiences of continuity of care: Relationship – from experiencing frequent setbacks and anxiety due to breaks in relationships, to feeling safe in an ongoing personal relationship; Timeliness – from experiencing frustrating waiting times with worsening of problems, to getting help when needed; Mutuality – from having a one-sided struggle, to a situation in which both professionals and service users take initiatives; Choice – from not having the opportunity to make practical arrangements within the context of one’s everyday life, to having an array of support options to choose from; Knowledge – from feeling confused and insecure because one does not know what is happening, to feeling safe because one is informed about what is going to happen. Participants provided a range of suggestions for improving experiences of continuity of care.

Conclusions

A discrepancy between aspects of continuity that are essential for service users and their experiences of actual practice was revealed. The valid evidence generated in the present collaborative study therefore offers knowledge to policy makers, professionals and service users that may be of help in their future efforts in orienting primary care, mental health, addiction and welfare services towards recovery.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2719-9) contains supplementary material, which is available to authorized users.

Service user involvement in mental health care: an evolutionary concept analysis

BACKGROUND

The concept of service user involvement is an evolving concept in the mental health-care literature.

OBJECTIVE

This study sought to explore and analyse the concept of service user involvement as used in within the field of mental health care.

METHODOLOGICAL APPROACH

An evolutionary concept analysis was conducted using a literature-based sample extracted from an electronic database search. One hundred and thirty-four papers met the inclusion criteria and were analysed to discover key attributes, antecedents and consequences of service user involvement and to produce a definition of the concept.

FINDINGS

Five key attributes of service user involvement within the context of mental health care were identified: a person-centred approach, informed decision making, advocacy, obtaining service user views and feedback and working in partnership.

DISCUSSION AND CONCLUSIONS

Clarity of the attributes and definition of the concept of service user involvement aims to promote understanding of the concept among key stakeholders including mental health professionals, service users and community and voluntary organizations. The findings of the research have utility in the areas of theory and policy development, research on service user involvement in mental health care and service user involvement in mental health practice. Directions for further research regarding the concept are identified.

Responsiveness of primary care services: development of a patient-report measure – qualitative study and initial quantitative pilot testing

Background

Primary care service providers do not always respond to the needs of diverse groups of patients, and so certain patients groups are disadvantaged. General practitioner (GP) practices are increasingly encouraged to be more responsive to patients’ needs in order to address inequalities.

Objectives

(1) Explore the meaning of responsiveness in primary care. (2) Develop a patient-report questionnaire for use as a measure of patient experience of responsiveness by a range of primary care organisations (PCOs). (3) Investigate methods of population mapping available to GP practices.

Design setting

PCOs, including GP practices, walk-in centres and community pharmacies.

Participants

Patients and staff from 12 PCOs in the East Midlands in the development stage, and 15 PCOs across three different regions of England in stage 3.

Interventions

To investigate what responsiveness means, we conducted a literature review and interviews with patients and staff in 12 PCOs. We developed, tested and piloted the use of a questionnaire. We explored approaches for GP practices to understand the diversity of their populations.

Main outcome measures

(1) Definition of primary care responsiveness. (2) Three patient-report questionnaires to provide an assessment of patient experience of GP, pharmacy and walk-in centre responsiveness. (3) Insight into challenges in collecting diversity data in primary care.

Results

The literature covers three overlapping themes of service quality, inequalities and patient involvement. We suggest that responsiveness is achieved through alignment between service delivery and patient needs, involving strategies to improve responsive service delivery, and efforts to manage patient expectations. We identified three components of responsive service delivery: proactive population orientation, reactive population orientation and individual patient orientation. PCOs tend to utilise reactive strategies rather than proactive approaches. Questionnaire development involved efforts to include patients who are ‘seldom heard’. The questionnaire was checked for validity and consistency and is available in three versions (GP, pharmacy, and walk-in centre), and in Easy Read format. We found the questionnaires to be acceptable to patients, and to have content validity. We produced some preliminary evidence of reliability and construct validity. Measuring and improving responsiveness requires PCOs to understand the characteristics of their patient population, but we identified significant barriers and challenges to this.

Conclusions

Responsiveness is a complex concept. It involves alignment between service delivery and the needs of diverse patient groups. Reactive and proactive strategies at individual and population level are required, but PCOs mainly rely on reactive approaches. Being responsive means giving good care equally to all, and some groups may require extra support. What this extra support is will differ in different patient populations, and so knowledge of the practice population is essential. Practices need to be motivated to collect and use diversity data. Future work needed includes further evaluation of the patient-report questionnaires, including Easy Read versions, to provide further evidence of their quality and acceptability; research into how to facilitative the use of patient experience data in primary care; and implementation of strategies to improve responsiveness, and evaluation of effectiveness.

Funding

The National Institute for Health Research Service Delivery and Organisation programme.

Creating a Patient-Centered Health Care Delivery System: A Systematic Review of Health Care Quality From the Patient Perspective

Patient experience is one of key domains of value-based purchasing that can serve as a measure of quality and be used to improve the delivery of health services. The aims of this study are to explore patient perceptions of quality of health care and to understand how perceptions may differ by settings and condition. A systematic review of multiple databases was conducted for studies targeting patient perceptions of quality of care. Two reviewers screened and extracted data independently. Data synthesis was performed following a meta-narrative approach. A total of 36 studies were included that identified 10 quality dimensions perceived by patients: communication, access, shared decision making, provider knowledge and skills, physical environment, patient education, electronic medical record, pain control, discharge process, and preventive services. These dimensions can be used in planning and evaluating health care delivery. Future research should evaluate the effect of interventions targeting patient experience on patient outcomes.

Blessed alienation: the Christian monastery as a caring and restorative environment

Being mentally ill is often associated with experiencing alienation from society because sensations are not easily shared with others. Modern health care leads us to pose many questions. Some sufferers search and find their way to monasteries as they did centuries ago. We interviewed six persons staying in a monastery to understand the meaning of health and care in a monastic environment in contemporary Sweden. We analyzed the transcripts by means of a hermeneutic approach and discovered that the helping effect of the monastery was based on its contradictory/paradoxical structure that corresponded to the lifeworld of a person suffering from mental illness. The monastery was a place where one could be different but equal, and simultaneously provided freedom within boundaries, calmness and intensity, privacy and relations, demands and confirmation. This facilitated experiences of health and wholeness, necessary to manage the challenges of recovery.

Intellectual disability and mental health problems: a qualitative study of general practitioners' views

OBJECTIVES

To investigate general practitioners' (GPs) experiences in managing patients with intellectual disabilities (ID) and mental and behavioural problems (MBP).

DESIGN

Qualitative study using in-depth interviews.

SETTING

General practice in Hedmark county, Norway.

PARTICIPANTS

10 GPs were qualitatively interviewed about their professional experience regarding patients with ID and MBP. Data were analysed by all authors using systematic text condensation.

RESULTS

The participants' knowledge was primarily experience-based and collaboration with specialists seemed to be individual rather than systemic. The GPs provided divergent attitudes to referral, treatment, collaboration, regular health checks and home visits.

CONCLUSIONS

GPs are in a position to provide evidence-based and individual treatment for both psychological and somatic problems among patients with ID. However, they do not appear to be making use of evidence-based treatment decisions. The GPs feel that they are left alone in decision-making, and find it difficult to find trustworthy collaborative partners. The findings in this study provide useful information for further research in the field.

The INFORM project: a service user-led research endeavor

Effective engagement with people who experience mental health care services, as research participants and as research leads, is presented. A group of volunteer mental health survivors, called INFORM, worked for 6 years to develop and complete a research project, exploring service user experience of a home treatment and crisis resolution service. Within the article, discussion is given to the significance of service continuity, alongside personal accounts of the impact and consequences of health care staff's interpersonal interactions. Two contrasting messages arise from this study: first, the articulation of what services users want from services, and how that relates to what they actually receive, continues to be a necessary debate and issue for consideration at a time of considerable health care reform. The second message is that such articulation, although necessary, is not sufficient in itself to ensure that services are responsive to service user needs and preferences. Findings from the evaluation are consistent with other service user-led research. However, what is also evident is that more work is required in enabling health care consumers to provide feedback that can then be used to inform practice and service delivery improvement.

Evaluation of innovative strategies in the organization of Primary Health Care

OBJECTIVE

To compare the performance of Primary Care Units according to the implementation of new arrangements and strategies in primary care and mental health.

METHODOLOGICAL PROCEDURES

Evaluative research with triangulation of methods and theoretical framework of critical hermeneutics, carried out at six Primary Care Units of the two most populous health districts of the city of Campinas (Southeastern Brazil) in 2007. The Primary Care Units were analyzed according to clinical resolution, articulation between the primary care and mental health networks and implementation of health promotion strategies. Two groups were defined by cluster analysis: one with higher and another one with lower degree of implementation of the actions. The groups were compared based on the improvement in clinical follow-up, given by the occurrence of cerebral vascular accident; evaluation of dispensation of psychiatric medicines; focal groups with workers, users and community health agents; and interviews with users and relatives. Inclusive and participatory research strategies were employed.

ANALYSIS OF RESULTS

There were no pure models, but a mosaic of organizational proposals. Positive advances were identified in the group with higher implementation of innovative strategies in relation to better integration of the community agents in the Units' teams; to the workers' and agents' perception of improvement in the assistance; and to the facility for referrals and assistance of mental health cases. The difficulties identified in both groups were: communication among the levels of care and within the teams, in the implementation of matrix support, and incipient health promotion actions.

CONCLUSIONS

The development and implementation of mechanisms to fix professionals in Primary Care in large cities are necessary. The community health agents are fundamental to perform the territorial work proposed by the Family Health Strategy, using mechanisms to integrate the community health agents into the healthcare teams in order to counterbalance the tendency to isolation. The researched arrangements proved to be potent to produce this integration.

What do we know about patients' perceptions of continuity of care? A meta-synthesis of qualitative studies

OBJECTIVE

The increasing complexity in healthcare delivery might impede the achievement of continuity of care, being defined as 'one patient experiencing care over time as coherent and linked'. This article aims to improve the knowledge on patients' perceptions of relational (RC), informational (IC) and management continuity (MC) across care levels.

DESIGN

A descriptive, qualitative meta-synthesis was conducted based on a literature search in various electronic databases using the subject heading 'continuity of care' and linked key terms. We scanned retrieved articles for adherence to inclusion criteria: (i) relevance to research topic, (ii) original study adopting a qualitative design and (iii) investigating the patient's perspective. Content analysis was conducted by identification of themes and aggregation of findings.

RESULTS

The selected 25 studies most frequently investigated RC. Being attended to regularly and over time by one physician (RC) was valued by chronic ill patients, but balanced with convenient access by young patients (MC). Communication and information transfer across care settings as well as the gathering of holistic information about the patient were perceived to foster IC. Critical features for achieving MC were accessibility between care levels, individualized care and a smooth discharge process including the receipt of support. Patients further considered that their personal involvement was one facilitating element of continuity of care.

CONCLUSIONS

Patients identified elements that enhance or distract from continuity of care across boundaries. Variations in perceived importance seem to depend on both individual and contextual factors which should be taken into account during healthcare provision.

Involvement in mental health and substance abuse work: conceptions of service users

Service user involvement (SUI) is a principal and a guideline in social and health care and also in mental health and substance abuse work. In practice, however, there are indicators of SUI remaining rhetoric rather than reality. The purpose of this study was to analyse and describe service users' conceptions of SUI in mental health and substance abuse work. The following study question was addressed: what are service users' conceptions of service user involvement in mental health and substance abuse work? In total, 27 users of services participated in the study, and the data was gathered by means of interviews. A phenomenographic approach was applied in order to explore the qualitative variations in participants' conceptions of SUI. As a result of the data analysis, four main categories of description representing service users' conceptions of service user involvement were formed: service users have the best expertise, opinions are not heard, systems make the rules, and courage and readiness to participate. In mental health and substance abuse work, SUI is still insufficiently achieved and there are obstacles to be taken into consideration. Nurses are in a key position to promote and encourage service user involvement.

A tale of two systems: perceptions of primary care for depression in London and Melbourne

BACKGROUND

Depression represents a major and growing disease burden. About 90% of depressed patients are treated solely in primary care, yet there are system-related barriers to primary care for people with depression in the UK and Australia, countries which have different health care arrangements.

OBJECTIVES

The aim was to explore the views of GPs and patients in London and Melbourne about primary care system features which support or hinder best care for mild-to-moderate depression. The study differentiated between policy and reality 'on the ground'.

METHODS

Two round Delphi technique methodology with four panels: GPs and patients in London and GPs and patients in Melbourne, to elicit views on the extent to which system features were reflected in policy, reflected in reality and were of value for best care.

RESULTS

Four themes were generated: system and financing, responsibility and continuity, consultations and primary care team. Patient-centred care, having sufficient time during a consultation, and the GP-patient relationship extending over time were rated highly by all panels. Panellists differentiated between policy and reality on a number of features.

CONCLUSIONS

The Australian system does not guarantee continuity of care with practitioner or practice but patients took steps to see the same doctor for depression. There was a difference in the way London and Melbourne panels responded to finance-related statements. There was a tendency for panellists to value aspects of their own system and to fail to see possibilities of other systems.