Wake up, wake up! It's me! It's my life! patient narratives on person-centeredness in the integrated care context: a qualitative study

Patients' experiences of patient-centred care in hospital setting: A systematic review of qualitative studies

BACKGROUND

Patient-centred care (PCC) has been proposed as an appropriate approach for addressing current shifts in healthcare needs. Although the importance of PCC is generally recognised, PCC is poorly understood by patients in the hospital settings.

OBJECTIVES

To identify patients' experiences of PCC in hospital settings.

METHODOLOGICAL DESIGN

This systematic review followed the Joanna Briggs Institute's (JBI) guidance for systematic reviews of qualitative evidence and the PRISMA checklist for reporting systematic reviews. The search strategy included peer-reviewed qualitative studies published after 2010 in English or Finnish. The databases searched were SCOPUS, MEDLINE, CINAHL and Medic. Unpublished studies and grey literature were searched in MedNar. Ten qualitative studies were included, and their quality was assessed by two independent reviewers using JBI quality assessment criteria. The data were analysed using thematic analysis.

SETTING AND PARTICIPANTS

Studies were included if they had explored adult patient experiences of PCC in hospital settings.

RESULTS

A thematic analysis produced 14 subthemes which were grouped into five analytical themes: the presence of the professional, patient involvement in care, receiving information, the patient-professional relationship and being seen as a person.

CONCLUSIONS AND IMPLICATIONS

This review suggests that the implementation and provision of PCC in hospitals is incomplete and patients' involvement in their own care should be in the focus of PCC. The majority of patients experienced receiving PCC, but others did not. The need for improvement of patient involvement was strongly emphasised. Patients highlighted the importance of professionals being present and spending time with patients. Patients felt well-informed about their care but expressed the need for better communication. Meaningful patient-professional relationships were brokered by professionals demonstrating genuine care and respecting the patient as an individual. To improve the implementation of PCC, patient experiences should be considered in the development of relevant hospital care strategies. In addition, more training in PCC and patient-professional communication should be provided to health care professionals.

Mapping Choice of Healthcare Institutes for Cancer Care: A Study in Northeast India

OBJECTIVE

To map and identify the sequence of visitation to institutes by patients with common cancers.

METHODS

This paper used a mixed method to follow a descriptive multiple-embedded case study. Participants selected in phase one were 388 by stratified random sampling, and in phase two, by purposive sampling, a semi-structured interview was conducted for 21 participants (15 participants and six key informants-oncologists: radiation - 2, medical - 2, surgical - 1 and gynaecology - 1). Ethical clearances were received from the study institutes. Informed consent was obtained from the participants.

RESULTS

Sparse research exists on mapping and choices of healthcare settings by cancer patients from northeast India. The main finding comprises a vivid overview of the decisions taken by cancer patients to get their necessary treatment based on all factors mitigating and inhibiting. Up to five hospitals for cancer treatment across the country. Private hospitals were preferred on the first visit by 74 percent (287), followed by the government by 26 percent (101); this, however, changes in subsequent hospital choices, with the latter preferred over the other, which could be due to the long duration of cancer treatment that is directly influenced by the paying capacity of the individual. Visitation was not limited to famous cancer hospitals, but few participants reported accessing herbal medicines, Ayurveda and Homoeopathy.

CONCLUSION

Mapping patient choices of cancer institutes by patients from northeast India is essential as the challenges faced are unique to the region. By mapping patient choices of cancer institutes, insights into the preferred healthcare facilities can influence policies to improve the accessibility of cancer facilities. Findings from this study can support improving access to quality healthcare services, promoting cultural sensitivity, enhancing the quality of care, and informing policy planning and resource allocation.

A Heideggerian analysis of good care in an acute hospital setting: Insights from healthcare workers, patients and families

This study articulates the relational constituents of good care beyond techno-rational competence. Neoliberal healthcare means that notions of care are readily commodified and reduced to quantifiable assessments and checklists. This novel research investigated accounts of good care provided by nursing, medical, allied and auxiliary staff. The Heideggerian phenomenological study was undertaken in acute medical-surgical wards, investigating the contextual, communicative nature of care. The study involved interviews with 17 participants: 3 previous patients, 3 family members and 11 staff. Data were analysed iteratively, dwelling with stories and writing and rewriting to surface the phenomenality of good care. The data set highlighted the following essential constituents: authentic care: caring encompassing solicitude (fürsorge); impromptu care: caring beyond role category; sustained care: caring beyond specialist parameters; attuned care: caring encompassing family and culture; and insightful care: caring beyond assessment and diagnosis. The findings are clinically significant because they indicate the importance of nurse leaders and educators harnessing the potential capacity of all healthcare workers to participate in good care. Healthcare workers reported that participating in or witnessing good care was uplifting and added meaning to their work, contributing to a sense of shared humanity.

Experiences of a Novel Integrated Service for Older Adults at Risk of Frailty: A Qualitative Study

The UK has a significant and growing population of older adults with frailty and complex healthcare needs, necessitating innovative care solutions. This study aimed to explore patients' and carers' experiences of a novel integrated service that was set up to address the increasing healthcare needs of older people living with frailty. A qualitative study that combined free-text survey questions with in-depth interviews. This study is part of a larger non-randomized trial of the service, with evaluation of wellbeing and quality of life at baseline, 2 to 4 weeks, and 10 to 14 weeks. Patients (aged 65 and above) with an electronic Frailty Index in the severe range and their informal family carers participated in this study. Data were collected between April 2019 and March 2020. Free text survey responses and interview data were subjected to reflexive thematic analyses. Four themes were generated: the overall experience of the service; interactions within the service; treatment and interventions; and outcomes due to the service. Most participants wanted further follow-up and more extensive integration with other services. Most participants described their overall experience positively, especially the available time to address their full range of concerns, but opportunities to integrate the service more fully and to extend follow-up remain.

Exploration of understanding of integrated care from a public health perspective: A scoping review

Background

Many health care systems attempt to develop an integrated care approach that is a whole population health-oriented system. However, knowledge of strategies to support this effort are scarce and fragmented. The aim of the current paper is to investigate existing concepts of integrated care and their elements from a public health perspective and to propose an elaborated approach that could be applied to explore the public health orientation of integrated care.

Design and methods

We applied a scoping review approach. A literature search was conducted in Embase, Medline, CINAHL, Scopus and Web of Science for the period 2000-2020 yielding 16 studies for inclusion.

Results

Across the papers, 14 frameworks were identified. Nine of these referred to the Chronic Care Model (CCM). Service delivery, person-centeredness, IT systems design and utilization and decision support were identified as the core elements of most of the included frameworks. The descriptions of these elements were mainly clinical-oriented focusing particularly on clinical care processes and treatment of diseases instead of wider determinants of population health.

Conclusions

A synthesized model is proposed that emphasizes the importance of mapping the unique needs and characteristics of the population it aims to serve, leans on the social determinants approach with a commitment to individual and community empowerment, health literacy and suggests reorienting services to meet the expressed needs of the population.

A non-randomised controlled study to assess the effectiveness of a new proactive multidisciplinary care intervention for older people living with frailty

Background

Integrated care may improve outcomes for older people living with frailty. We aimed to assess the effectiveness of a new, anticipatory, multidisciplinary care service in improving the wellbeing and quality of life (QoL) of older people living with severe frailty.

Methods

A community-based non-randomised controlled study. Participants (≥65 years, electronic Frailty Index ≥0.36) received either the new integrated care service plus usual care, or usual care alone. Data collection was at three time points: baseline, 2-4 weeks, and 10-14 weeks. The primary outcome was patient wellbeing (symptoms and other concerns) at 2-4 weeks, measured using the Integrated Palliative care Outcome Scale (IPOS); the secondary outcome was QoL, measured using EQ-5D-5L. To test duration of effect and safety, wellbeing and QoL were also measured at 10-14 weeks. Descriptive statistics were used to characterise and compare intervention and control groups (eligible but had not accessed the new service), with t-test, Chi-Square, or Mann-Whitney U tests (as appropriate) to test differences at each time point. Generalised linear modelling, with propensity score matching, was used for further group comparisons. Data were analysed using STATA v17.

Results

199 intervention and 54 control participants were recruited. At baseline, intervention and control groups were similar in age, gender, ethnicity, living status, and body mass index, but not functional status or area deprivation score. At 2-4 weeks, wellbeing had improved in the intervention group but worsened in the control (median IPOS -5 versus 2, p<0.001). QoL improved in the intervention group but was unchanged in the control (median EQ-5D-5L 0.12, versus 0.00, p<0.001). After adjusting for age, gender, and living status, the intervention group had an average total IPOS score reduction at 2-4 weeks of 6.34 (95% CI: -9.01: -4.26, p<0.05); this improvement was sustained, with an average total IPOS score reduction at 10-14 weeks of 6.36 (95% CI: -8.91:-3.80, p<0.05). After propensity score matching based on functional status/area deprivation, modelling showed similar results, with a reduction in IPOS score at 2-4 weeks in the intervention group of 7.88 (95% CI: -12.80: -2.96, p<0.001).

Conclusions

Our findings suggest that the new, anticipatory, multidisciplinary care service may have improved the overall wellbeing and quality of life of older people living with frailty at 2-4 weeks and the improvement in wellbeing was sustained at three months.

Ethics approval

NHS Research Ethics Committee 18/YH/0470 and IRAS-250981.

Trial registration

The trial was retrospectively registered at the International Standard Randomised Controlled Trial Number (ISRCTN) registry (registration date: 01/08/2022, registration number: ISRCTN10613839).

Barriers and facilitators for coherent rehabilitation among people with inflammatory arthritis – a qualitative interview study

Background

People with chronic diseases have contact with several different professionals across hospital wards, municipality services and general practice and often experience lack of coherence. The purpose was to explore perceived barriers and facilitators to coherent rehabilitation pathways for health care users with inflammatory arthritis and how coherence can be improved.

Methods

Semi-structured individual interviews were conducted before a planned inpatient rehabilitation stay, 2-3 weeks and 4-6 months after discharge. Thematic reflexive analysis guided the analysis of data. Concepts of person-centred care, complex adaptive systems and integrated care were applied in the interpretations.

Results

In all, 11 participants with IA were included. There was one overarching theme, The importance of a person-centred approach, illuminating the significance of professionals who respect healthcare user’ preferences. To use a person-centred approach, demands professionals who are interested in exploring the persons own values, preferences and experiences and incorporate these when planning care and rehabilitation.Connected to the overarching theme, three sub-themes were derived; 1) Experiences of empowerment and dis-empowerment, covering that most want to be in control and act themselves, but felt overwhelmed and lost energy and they tended to give up; 2) Experiences of communication and coordination, encompass how people feel forced to take on coordination and communication tasks themselves although they do not always feel qualified for this. Some asked for a coordination person and 3) Facing everyday life after discharge, covering how initiatives taken by professionals were not always experienced as helpful after discharge. Some gave up and some tried to find alternative paths themselves.

Conclusion

Professionals taking a person-centred approach facilitated coherent rehabilitation pathways. This encompassed care with respect for individual needs and professionals who empowered patients to self-management. Furthermore, to be aware that interprofessional communication and coordination need to take place both between professional within the same department, between departments and between professionals in different sectors.

After discharge, some patients were challenged in their everyday life when trying to follow the advice from the professionals. Professionals, who do not use a person-centred approach, hinder coherence. Patients thus feel compelled to take on communication and coordination tasks.

Dimensional Analysis of Shared Decision Making in Contraceptive Counseling

OBJECTIVE

To conduct a dimensional analysis to identify conceptual gaps around shared decision making (SDM) in reproductive health care and to refine the conceptual definition of SDM as related to contraceptive counseling.

DATA SOURCES

We identified source data through systematic searches of the CINAHL and PubMed databases.

STUDY SELECTION

We included peer-reviewed research and nonresearch articles that addressed contraceptive counseling for pregnancy prevention in the United States. We did not consider date of publication as an inclusion criterion. We included 35 articles in the final review.

DATA EXTRACTION

Using dimensional analysis, we extracted data to clarify the definition of SDM as a socially constructed concept that varies by perspective and context.

DATA SYNTHESIS

Data synthesis enabled us to compare SDM from patient and provider perspectives and to identify four primary dimensions of SDM that varied by context: Patient Preferences, Relationship, Provider Bias, and Clinical Suitability.

CONCLUSION

The four dimensions we identified illustrate the complexity and depth of SDM in contraceptive counseling encounters and broaden the definition of SDM to more than an encounter in which decision making incorporates clinician expertise and patient participation. We identified several assumptions that indicate the need for improved understanding that SDM is not a universal concept across perspectives and contexts. Most researchers in the included articles addressed the Patient Preferences dimension. Fewer considered the patient-provider relationship, the effect of provider bias, and the effect of specific clinical circumstances on SDM. We propose a conceptual map and model that can be used to refine the concepts that inform SDM and guide providers and researchers. Future research is needed to address the remaining gaps.

A Patient-Centred Medical Home Care Model for Community-Dwelling Older Adults in Singapore: A Mixed-Method Study on Patient's Care Experience

Patient-Centred Medical Home (PCMH) is a strategy to enhance patient-centredness to improve care experience. We aimed to understand patient experience of an integrated PCMH model for complex community-dwelling older adults in Singapore. We used a mixed-method design with a prospective single-group pre-post quantitative component and a concurrent qualitative component. Participants were administered the validated Consumer Assessment of Health Providers and Systems Clinician & Group Survey (CG-CAHPS) at baseline (N = 184) and 6-month (N = 166) post-enrolment. We conducted focus group discussions (FGDs) on a purposive sample of 24 participants. Both methods suggest better care experience in PCMH relative to usual care. There were improvements in the CG-CAHPS measures on patient–provider communication, care coordination, office staff interactions, support for patients in caring for their own health, and provider rating in PCMH relative to usual care. In the FGDs, participants reported benefits of consolidated appointments and positive experience in sustained patient–provider relationship, shared-decision making, and family/caregiver engagement in PCMH. Participants may not fully comprehend the concept of integrated care, hindering both the effective communication of the intended care model and perceived benefits such as the provision of multidisciplinary team-based care.

Understanding the Experience of Service Users in an Integrated Care Programme for Obesity and Mental Health: A Qualitative Investigation of Total Wellbeing Luton

Obesity is a complex public health issue with multiple contributing factors. The emphasis on joined care has led to the development and implementation of a number of integrated care interventions targeting obesity and mental health. The purpose of this study was to examine user experience in an integrated care programme for obesity and mental health in Luton, UK. Semi-structured interviews were conducted with a purposeful sample of service users (N = 14). Interview transcripts were analysed using thematic analysis. Analysis of the interviews identified six main themes for understanding service users' experiences of integrated care: (1) 'A user-centered system', (2) 'Supports behaviour change', (3) 'Valued social support', (4) 'Communication is key', (5) 'Flexible referral process', and (6) 'Positive impact on life'. These themes describe how the service is operated, evidence perceived value service users place on social support in behavior change intervention, and address which service areas work well and which require improvement. The findings of these interviews have offered a significant contribution to understanding what service users value the most in an integrated healthcare setting. Service users value ongoing support and being listened to by healthcare professionals, as well as the camaraderie and knowledge acquisition to support their own behaviour change and promote self-regulation following their participation in the programme.

Why doesn't integrated care work? Using Strong Structuration Theory to explain the limitations of an English case

Integrated care is an aim and a method for organising health and care services, particularly for older people and those with chronic conditions. Policy expects that integrated care programmes will provide person-centred coordinated care which will improve patient or client experience, enable population health, prevent hospital admissions and thereby reduce costs. However, empirical evaluations of integrated care interventions have shown disappointing results. We analysed an in-depth case study using Strong Structuration Theory to ask: how and why have efforts to integrate health and social care failed to produce desired outcomes? In our case, integrated case management and the creation of cost-saving plans were dominant practices. People working in health and social care recursively produced a structure of integrated care: a recognised set of resources created by collective activities. Integrated care, intended to help patients manage their long-term conditions and avoid hospital admission, was only a small part of the complex network that sustained patients at home. The structures of integrated care were unable to compensate for changes in patients' health. The result was that patients' experiences remained largely unaffected and hospital admissions were not easily avoided.

In Limbo: Seven Families' Experiences of Encounter with Cancer Care in Norway

INTRODUCTION

Like many other countries, Norway has seen a shift from inpatient to outpatient cancer care, with pathways aimed at improving the integration and coordination of health services. This study explores the perspectives of seven patients and their family members in light of this change. We focus on one particular phase of the pathway: the first encounter. Our interviews were set in the period from referral until the start of treatment.

METHODS

Nineteen individual in-depth interviews were conducted in seven families. Seven patients with cancer and 12 family members were interviewed.

RESULTS

Three categories of experiences stood out in the empirical material: 'Being in between different health professionals', 'Overwhelmed by written and oral information' and 'Lack of involvement'.

CONCLUSION

This study provides insight into families' experiences with cancer care from referral until the start of treatment. Our findings indicate that families often experience cancer care as fragmented and confusing. Although evaluations have shown that the introduction of cancer pathways seems to have a positive effect on waiting times and standardization of examinations across hospitals and regions, there is still potential for improvement in coordination between services, family involvement, and emotional and practical support. We argue that our findings highlight the tension between two ideals of professional care: standardization and patient-centredness. The study illustrates shortcomings in translating the ideal of patient-centredness into professional practice.

Implementing a person centred collaborative health care model - A qualitative study on patient experiences

BACKGROUND

Collaborative Health Care (CHC) is a unique model in which ambulance services, home health care, hospital care and the national telephone helpline for healthcare in Sweden - Swedish health care direct (SHD1177) collaborate to provide the fastest possible health care for inhabitants living in eleven municipalities in western region of Sweden.

AIM

To explore how patients experience and perceive health care received in the CHC.

METHOD

Qualitative descriptive study using open-ended individual telephone interviews with fifteen community dwelling persons with experiences of care throughthe model CHC were conducted.

RESULTS

Two main categories and six subcategories were identified. The category "Thoughts of time in regard to acute health care" include "CHC leads to shorter waiting time for health care", "Knowledge about the staff working hours" and "To alert or not alert". The category "Thoughts on unplanned health care from CHC" involved "Receiving health care in my home", "Coordination from SHD1177 surprises" and "Accessibility of health care values higher than continuity".

CONCLUSION

Integrated health care models such as CHC are time saving and highly appreciated by community dwelling persons. The benefits of provision of coherent health care like in CHC, addresses the need to implement innovative integrated healthcare models in today's health care.

Patient experiences of integrated care within the United Kingdom: A systematic review

Introduction

Integrated care and patient experience are central to the coordination and delivery of high quality health and social care in the UK, but their joint application is poorly understood. This systematic review aimed to gain an understanding of patient experience within current integrated care services in the UK, and specifically, whether they reflect person-centred coordinated care (PCCC).

Methods

Following PRISMA, electronic databases (ProQuest, EBSCO and Cochrane Library) were searched from 2012 to 2019 for primary, peer-reviewed literature. Papers were included where patients’ or carers’ experiences of integrated care were reported. Papers were excluded where they focused on acute integrated care interventions, measured experience via satisfaction scores only, or findings lacked sufficient depth to answer the research question. Quality was assessed using Mixed Methods Appraisal Tool, and findings synthesised using a framework approach, incorporating the Rainbow Model of Integrated Care and Measuring Integrated Care Patient Framework.

Results

Sixteen studies were included. Person-centred and shared responsibility experiences were most often discussed. Experiences were not always described as positive and some patients experienced a lack of PCCC. Clinical, professional/organisational and functional integration processes were associated with experiencing domains of PCCC.

Discussion

People with complex needs experience a lack of coordination across teams and wider community resources, and limited associations were made between integration processes and patient experience. Further research which gives context to individual experience, provides greater detail of integration processes and utilises validated patient experience measures of PCCC is required to understand the association between integration processes and domains of PCCC.

Experiences with and attitudes towards geriatric screening among older emergency department patients: a qualitative study

BACKGROUND

The patient perspective on the use of screening for high risks of adverse health outcomes in Emergency Department (ED) care is underexposed, although it is an important perspective influencing implementation in routine care. This study explores the experiences with, and attitudes towards geriatric screening in routine ED care among older people who visited the ED.

METHODS

This was a qualitative study using individual face-to-face semi-structured interviews. Interviews were conducted in older patients (≥70 years) who completed the 'Acutely Presenting Older Patient' screener while visiting the ED of a Dutch academic hospital. Purposive convenience sampling was used to select a heterogeneous sample of participants regarding age, disease severity and the result from screening. Transcripts were analyzed inductively using thematic analysis.

RESULTS

After 13 interviews (7 women, median age 82 years), data saturation was reached. The participants had noticed little of the screening administration during triage and screening was considered as a normal part of ED care. Most participants believed that geriatric screening contributes to assessing older patients holistically, recognizing geriatric problems early and comforting patients with communication and attention. None of the participants had a negative attitude towards screening or thought that screening is discrimination on age. Care providers should communicate respectfully with frail older patients and involve them in decision-making.

CONCLUSIONS

Older patients experienced geriatric screening as a normal part of ED care and had predominantly positive attitudes towards its use in the ED. This qualitative study advocates for continuing the implementation of geriatric screening in routine ED practice.

The practice environment's influence on patient participation in intermediate healthcare services - the perspectives of patients, relatives and healthcare professionals

BACKGROUND

Intermediate care (IC) bridges the clinical pathway of older patients transitioning from the hospital to home. Currently, there is a strong consensus that the practice environment is an important factor in helping older people overcome their limitations and regain function after illness or injury. Regardless of the arising attention related to person-centred care, the practice environment is yet to be recognised as a vital part of care, and a small extent of focus has been given the environmental dimensions of IC services. Thus, more research is required regarding the complex relationships between older people and the practice environment. This study explores the perspectives of older patients, their relatives and healthcare professionals related to the practice environment's influence on patient participation among older people in the context of intermediate healthcare services.

METHODS

Using purposive sampling and theoretical approaches, including frameworks of patient participation, the practices environment and person-centred care, semi-structured interviews were conducted with 15 older patients, 12 relatives and 18 healthcare professionals from three different IC institutions in Norway to discuss their experiences and preferences regarding patient participation. A thematic analysis was used to explore patterns across the interviews.

RESULTS

Three main themes were identified: 'location and access to physical facilities', 'symbolic expression of patients' and professionals' possibilities' and 'participating in meaningful activities'. The findings show that both the physical and the psychosocial environments influenced older patients' various types of participation in IC services.

CONCLUSIONS

To optimise rehabilitation care for older people, the ward configuration should focus on supportive environments that facilitate patient participation and provide options for the patients and relatives to independently access the facilities, balancing the personal capabilities with the environmental demands. To foster patient participation, the practice environment should thus align with the model of person-centred rehabilitation.

Understanding Young People and Their Care Providers' Perceptions and Experiences of Integrated Care Within a Tertiary Paediatric Hospital Setting, Using Interpretive Phenomenological Analysis

Introduction:

Benefits of integrated care include improved health outcomes and more satisfaction with experiences of care for consumers. For children and young people with chronic and complex health conditions, their care may be fragmented due to the multitude of healthcare providers involved. This paper describes the experiences of integrated care in a paediatric tertiary hospital.

Theory and methods:

Using an Interpretive Phenomenological Analysis approach, semi-structured interviews were conducted with children and young people, their parents and healthcare providers to explore stakeholders’ integrated care experiences.

Results:

Nineteen interviews were completed (6 children and young people, 7 parents and 6 healthcare providers) and transcribed verbatim. Two recurrent themes were applicable across the three cohorts: ‘agency and empowerment’ and ‘impact of organisational systems, supports and structures’.

Discussion and conclusion:

Stakeholders’ experiences of integrated care highlighted the need to examine the discrepancies between healthcare strategies, policies and service delivery within a complex, and often inflexible organisational structure. Power imbalance and family agency (including directly with children and young people) needs to be addressed to support the implementation of integrated care.

Health and social care professionals' experiences of collaborative planning-Applying the person-centred practice framework

Aim

To explore how person‐centred practice framework can be applied to professionals participating in collaborative planning.

Design

An explorative, deductive approach.

Method

Eleven professionals from health care and social care participated in the study. A deductive content analysis was performed using a framework for person‐centred practice for the analysis.

Results

Practicing person‐centred care and collaborative planning is a complex process that needs to take into account system factors on both the macro‐ and the microlevel. Everyone working within the system needs to apply the same approach. Using a framework analysis offered new insights into how person‐centred care is expressed in practice during collaborative planning between the patient, and healthcare and social care professionals.

The Patient and Family Narratives seminars at the University of Saskatchewan connect health professions students with patient experiences

The Patient and Family Narratives (PFN) seminars make patient perspectives part of the education of students from healthcare professions. These sessions consist of a story shared by a patient, interdisciplinary small group discussions, and a question and answer period. Based on the findings of our evaluation, we will modify the orientation exercise and small group sessions. The simple design of these seminars makes their implementation suitable for other institutions as a way of sharing patient stories in an interprofessional setting. However, the success of a PFN program may depend on a lack of authentic patient contact in the pre-existing curriculum.

Case study method to design and evaluate person-centred integrated palliative and end-of-life care

Purpose

This case study aims to understand the experience of care from a patient/carer perspective and to describe how the method can be replicated to address gaps in evidence relating to integrated person-centred care.

Design/methodology/approach

The case study was constructed using data extracted from personal diaries and medical records kept by a person with a complex condition, correspondence with family from the last 18 months of life and interviews with the carer and long-term conditions coordinator. The number of professionals or teams involved in providing care from statutory services, the third sector, and private providers were counted to understand the ecosystem of care. The number of contacts was plotted by provider and purpose of care. The type of care and hours of respite were estimated. A protocol was developed to assess the feasibility of replicating the data and analyses used.

Findings

There were 35 care providers from the public, private and the third sector, demonstrating that only the patient or carer can identify the ecosystem of care. The majority of care was for respite and on average, the carer provided four hours of care per every respite care hour. The method was replicated successfully.

Research limitations/implications

The case study formed the basis of a workshop that brought together health care professionals from the public services and the third sector. The discussion led to the identification of gaps and areas where greater coordination between providers would benefit patients.

Originality/value

The case study method combines contemporaneous patient and carer sources of data and health service activity to create a detailed account of care at the end of life. The approach addresses gaps in person-centred evidence for the development and evaluation of integrated palliative and end-of-life care.

Improving Person-Centredness in Integrated Care for Older People: Experiences from Thirteen Integrated Care Sites in Europe

Introduction

Although person-centredness is a key principle of integrated care, successfully embedding and improving person-centred care for older people remains a challenge. In the context of a cross-European project on integrated care for older people living at home, the objective of this paper is to provide insight at an overarching level, into activities aimed at improving person-centredness within the participating integrated care sites. The paper describes experiences with these activities from the service providers' and service users' perspectives.

Methods

A multiple embedded case study design was conducted that included thirteen integrated care sites for older people living at home.

Results

Service providers were positive about the activities that aimed to promote person-centred care and thought that most activities (e.g. comprehensive needs assessment) positively influenced person-centredness. Experiences of service users were mixed. For some activities (e.g. enablement services), discrepancies were identified between the views of service providers and those of service users.

Discussion and conclusion

Evaluating activities aimed at promoting person-centredness from both the service providers' and service users' perspectives showed that not all efforts were successful or had the intended consequences for older people. Involvement of older people in designing improvement activities could ensure that care and support reflect their needs and preferences, and build positive experiences of care and support.

Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts

Policy Points Integrated care is best understood as an emergent set of practices intrinsically shaped by contextual factors, and not as a single intervention to achieve predetermined outcomes. Policies to integrate care that facilitate person-centered, relationship-based care can potentially contribute to (but not determine) improved patient experiences. There can be an association between improved patient experiences and system benefits, but these outcomes of integrated care are of different orders and do not necessarily align. Policymakers should critically evaluate integrated care programs to identify and manage conflicts and tensions between a program's aims and the context in which it is being introduced.

CONTEXT

Integrated care is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. Despite examples of successful integrated care systems, evidence for consistent and reproducible benefits remains elusive. We sought to inform policy and practice by conducting a systematic hermeneutic review of literature covering integrated care strategies and concepts.

METHODS

We used an emergent search strategy to identify 71 sources that considered what integrated care means and/or tested models of integrated care. Our analysis entailed (1) comparison of strategies and concepts of integrated care, (2) tracing common story lines across multiple sources, (3) developing a taxonomy of literature, and (4) generating a novel interpretation of the heterogeneous strategies and concepts of integrated care.

FINDINGS

We identified four perspectives on integrated care: patients' perspectives, organizational strategies and policies, conceptual models, and theoretical and critical analysis. We subdivided the strategies into four framings of how integrated care manifests and is understood to effect change. Common across empirical and conceptual work was a concern with unity in the face of fragmentation as well as the development and application of similar methods to achieve this unity. However, integrated care programs did not necessarily lead to the changes intended in experiences and outcomes. We attribute this gap between expectations and results, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other.

CONCLUSIONS

Those looking for universal answers to narrow questions about whether integrated care "works" are likely to remain disappointed. Models of integrated care need to be valued for their heuristic rather than predictive powers, and integration understood as emerging from particular as well as common contexts.

Integrating care: the work of diabetes care technicians in an integrated care initiative

Background

As diabetes prevalence rises world-wide, the arrangement of clinics and care packages is increasingly debated by health care professionals (HCPs), health service researchers, patient groups and policy makers. ‘Integrated care’, while representing a range of approaches, has been positioned as a promising solution with potential to benefit patients and health systems. This is particularly the case in rural populations which are often removed from centres of specialist care. The social arrangements within diabetes integrated care initiatives are understudied but are of particular importance to those implementing such initiatives. In this paper we explore the ‘work’ of integration through an analysis of the role played by Health Care Assistants (HCAs) who were specially trained in aspects of diabetes care and given the title ‘Diabetes Care Technician’ (DCT).

Methods

Using thematic analysis of interview (n = 55) and observation data (n = 40), we look at: how the role of DCTs was understood by patients and other HCPs, as well as the DCTs; and explore what DCTs did within the integrated care initiative.

Results

Our findings suggested that the DCTs saw their role as part of a hierarchy, providing links between members of the integrated team, and explaining and validating clinical decisions. Patients characterised DCTs as friends and advisors who provided continuity. Other HCPs perceived the DCTs as supportive, providing long-term monitoring and doing a different job to conventional HCAs. We found that DCTs had to navigate local terrain (social, ethical and physical), engage in significant conversation and negotiate treatment plans created through integrated care. The analysis suggests that relationships between patients and the DCTs were strong, had the quality of friendship and mitigated loneliness.

Conclusions

DCTs played multidimensional roles in the integrated care initiative that required great social and emotional skill. Building friendships with patients was central to their work, which mitigated loneliness and facilitated the care they provided.

From the service user association's perspective

Purpose

The aim of this study was to identify key components of integrated mental health and social care services that contribute to value for service users in Sweden.

Design/methodology/approach

An explorative research study design was used, based on data from four group interviews conducted in June and August 2017 with service user representatives.

Findings

The analysis resulted in eight subcategories reflecting components that were reported to contribute to value for service users. These subcategories were grouped into three main categories: (1) professionals who see and support the whole person, (2) organizational commitment to holistic care and (3) support for equal opportunities and active participation in society.

Research limitations/implications

The findings are primarily transferable to integrated mental health and social care services, as they emphasize key components that contribute to value for service users in these specific settings.

Practical implications

The complexity of integrated mental health and social care services requires coordination across the individual and organizational levels as well as ongoing dialogue and partnerships between service users, service user associations and health and social care organizations. In this integration, it is important that service users and service user associations not only are invited but also keen to participate in the design of care and support efforts.

Originality/value

Service User Associations (SUAs) can act as a bridge between county and municipal services through their participation in the development of local activities; at the regional and national levels, SUAs can help achieve more equitable integrated services. It is important that SUAs are not only invited but encouraged to actively participate in the design of such care and support efforts.

A state-of-the-art review of the experience of care coordination interventions for people living with multimorbidity

AIM

To explore recent research on care coordination interventions for people living with multimorbidity, from the perspective of the person receiving care.

BACKGROUND

Care coordination interventions for people living with multimorbidity show some effectiveness in improving management of their health and reducing potentially preventable hospitalisations. The experience of people enrolled in care coordination interventions requires further exploration.

DESIGN

State-of-the-art review.

METHODS

A review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist where five databases (The Cochrane Library, PsycINFO, Scopus, CINAHL and MEDLINE) were searched for qualitative sources published from January 2008-March 2019. Two additional databases focused on multimorbidity and integrated care were included in the search. Titles, abstracts and full texts were screened using inclusion criteria. Reference lists of the included articles were hand-searched. Summary tables were developed for data extraction, and the data were mapped to the research question.

RESULTS

Eighteen primary research articles were included. Three themes of participant experience were identified: (a) relationships built on trust, (b), a sense of safety and security and (c) feeling cared for and respected.

CONCLUSION

The contribution of qualitative approaches to evaluating the experiences of care for people living with multimorbidity is growing. Participants' describe a focus on relationships formed with healthcare professionals during care coordination. Further research incorporating lived experiences of participants could illuminate these concepts further.

RELEVANCE TO CLINICAL PRACTICE

People living with multimorbidity who require assistance via care coordination value trusting relationships with healthcare professionals, who respect their needs and provide a sense of security. Understanding participant experiences is important to shape care coordination interventions that incorporate person-centred approaches.

Relational continuity of oral health care in Indigenous communities: a qualitative study

Background

The relational continuity of care is an essential function of primary health care. This study reports on the perspectives of Cree communities and their primary health care providers regarding the barriers and enablers of relational continuity of oral health care integrated at a primary health care organization.

Methods

A multiple case study design within a qualitative approach and developmental evaluation methodology were used to conduct this research study in Cree communities of Northern Québec. Maximum variation sampling and snowball techniques were used to recruit the participants. Data collection consisted of individual interviews and focus group discussions. Thematic analysis was conducted which included transcription, debriefing, codification, data display, and interpretation. The consolidated criteria for reporting qualitative studies (COREQ) were used to guide the reporting of study findings.

Results

A total of six focus group discussions and 36 individual interviews were conducted. Five major themes emerged from the thematic analyses for barriers (two) and enablers (three). Themes for barriers included impermanence and lack of effective communication, whereas themes for enablers included culturally competent professionals, working across professional boundaries, and proactive organizational engagement.

Conclusions

Based on these findings, relational continuity can be empowered by effective strategies for overcoming barriers and encouraging enablers, such as recruitment of permanent professionals, organizing cultural competency training, development of a Cree language dental glossary, encouraging inter-professional collaboration, and promoting the organization’s efforts.

Effects Of Increasing The Involvement Of Community-Dwelling Frail Older Adults In A Proactive Assessment Service: A Pragmatic Trial

BACKGROUND

Older adults and care professionals advocate a more integrated and proactive care approach. This can be achieved by proactive outpatient assessment services that offer comprehensive geriatric assessments to better understand the needs of older adults and deliver person-centered and preventive care. However, the effects of these services are inconsistent. Increased involvement of the older adult during the assessment service could increase the effects on older adult's well-being.

METHODS

We studied the effect of an assessment service (Sage-atAge) for community-dwelling frail adults aged ≥65 years. After studying the local experiences, this service was adapted with the aim to increase participant involvement through individual goal setting and using motivational interviewing techniques by health-care professionals (Sage-atAge+). Within Sage-atAge+, when finishing the assessment, a "goal card" was written together with the older adult: a summary of the assessment, including goals and recommendations. We measured well-being with a composite endpoint consisting of health, psychological, quality of life, and social components. With regression analysis, we compared the effects of the Sage-atAge and Sage-atAge+ services on the well-being of participants.

RESULTS

In total, 453 older adults were eligible for analysis with a mean age of 77 (± 7.0) years of whom 62% were women. We found no significant difference in the change in well-being scores between the Sage-atAge+ service and the original Sage-atAge service (B, 0.037; 95% CI, -0.188 to 0.263). Also, no change in well-being scores was found even when selecting only those participants for the Sage-atAge+ group who received a goal card.

CONCLUSION

Efforts to increase the involvement of older adults through motivational interviewing and goal setting showed no additional effect on well-being. Further research is needed to explore the relationship between increased participant involvement and well-being to further develop person-centered care for older adults.

A narrative review on the consultation tools available for pharmacists in the United Kingdom: do they facilitate person-centred care?

OBJECTIVES

To identify consultation tools cited in the published literature and undertake a narrative review which establishes their scope to support the delivery of person-centred medicine-focused consultations between community pharmacists and patients in the United Kingdom (UK).

KEY FINDINGS

Nine consultation tools used in a pharmacy context were identified. Four tools (Calgary-Cambridge guide, MRCF, MUR and NMS advanced services and PaCT) were selected for further appraisal. None of the tools identified provided a suitable format or sufficient guidance to address all components required for the delivery of a person-centred patient consultation in practice.

SUMMARY

Tools available to UK pharmacists are inadequate for fully supporting delivery of a person-centred consultation in practice. Revision of existing tools or creation of more pharmacy-specific tools will support UK pharmacists' delivery of person-centred consultations in practice.

Patients' perspectives on integrated oral healthcare in a northern Quebec Indigenous primary health care organisation: a qualitative study

OBJECTIVE

Patient-centred care is considered to be an important element in the evaluation of integrated healthcare and has been effective in addressing oral health disparities. This study explored the patients' perspectives of patient-centred integrated care in oral health services integrated into a primary healthcare organisation serving a northern Quebec Cree population.

DESIGN

This study used a multiple case study design within a qualitative approach and developmental evaluation methodology. Two theoretical models, Picker's Principles of Patient-Centred Care and Valentijn's Rainbow Model of Integrated Care, guided data collection and data analysis. The thematic analysis included transcription, debriefing, codification, data display and interpretation.

SETTING

This study was conducted in purposefully selected four Cree communities of Northern Quebec.

PARTICIPANTS

Adult patients in need of oral healthcare and who attended the local dental clinic were identified and recruited by maximum variation sampling and snowball techniques.

OUTCOME MEASURES

Patients' perspectives of patient-centred integrated oral healthcare.

RESULTS

Data analysis generated six major themes: enhanced accessibility, creating supportive environment, building trust through shared decision making, appreciation of public health programmes, raising oral health awareness and growing cultural humility among healthcare providers. Patients identified the integration of dental care into primary healthcare with respect to co-location, provision of free oral healthcare services, care coordination and continuity of care, referral services, developing supportive environment, shared decision making, oral health promotion and culturally competent care.

CONCLUSION

These results confirmed that patient-centred care is an important element of integrated care. Patients valued the use of this concept in all domains and levels of integration. They recommended to further strengthen the clinical integration by involving parents in oral health promotion as well as optimising care coordination and empowering a supportive environment in organisational integration.

Development of a tool to support person-centred medicine-focused consultations with stroke survivors

OBJECTIVE

To develop a tool to support medicine-focused person-centred consultations between community pharmacists and stroke survivors.

METHOD

Semi-structured interviews with 15 stroke survivors and 16 community pharmacists were conducted. Thematic analysis of the data was performed and emerging themes examined to determine their relevance to the principles of delivering person-centred care. Findings were used to generate a framework from which a consultation tool was created. Face validity and the feasibility of using the tool in practice were explored with participating pharmacists.

RESULTS

Three major themes were identified; personal, process and environmental factors. A tool, in two parts, was developed, A 'Getting to know me' form which would help the pharmacist to appreciate the individual needs of the stroke survivor and a consultation guide to facilitate the consultation process. Pharmacists considered that both were useful and would support a person-centred medicine-focussed consultation.

CONCLUSION

A consultation tool, reflecting the needs of stroke survivors, has been developed and is feasible for use within community pharmacy practice.

PRACTICE IMPLICATIONS

Pharmacists must recognise the individual needs of stroke survivors to ensure that they provide consultations which are truly person-centred. The tool developed could support medicine-related consultations with patients with other long term conditions.

Explaining experiences of community-dwelling older adults with a pro-active comprehensive geriatric assessment program - a thorough evaluation by interviews

INTRODUCTION

Pro-active assessment programs are increasingly used to improve care for older adults. These programs include comprehensive geriatric tailored to individual patient preferences. Evidence for the effects of these programs on patient outcomes is nevertheless scarce or ambiguous. Explaining these dissatisfying results is difficult due to the multi-component nature of the programs. The objective of the current study was to explore and explain the experience of older adults participating in a pro-active assessment program, to help to clarify the effects.

METHODS

Semi-structured in-depth interviews were held with 25 participants of a pro-active assessment program for frail community-dwelling adults aged 65+. This study was part of an evaluation study on the effects of the program. Transcripts were analysed with thematic analysis and cross-case analysis.

RESULTS

The participants' mean age was 78.5 (SD 6.9) and 56% was female. The majority of the participants were satisfied with the program but based this on communication aspects, since only a few of them expressed real program benefits. Participant experiences could be clustered in six themes: (1) All participants expressed the need for a holistic view which was covered in the program, (2) the scope of the CGA was broader than expected or unclear, (3) the program delivered unexpected but valued help, (4) participants described a very low sense of ownership, (5) timing of the program implementation or the CGA was difficult and(6), participants and care workers had a different view on what to consider as a problem. These experiences could be explained by three program components: the degree of (the lack of) integration of the program within usual care, the pro-active screening method and the broader than expected, but appreciated multi-domain approach.

CONCLUSION

Older adults' need for a holistic view is covered by this outpatient assessment program. However, their engagement and the correct timing of the program are hampered by the pro-active recruitment and the limited integration of the program within existing care. Furthermore, satisfaction seems an insufficient guiding factor when evaluating CGA programs for older adults because it does not reflect the impact of the program.

Diagnosis and Decision-Making in Telemedicine

This article provides an analysis of the skills that health professionals and patients employ in reaching diagnosis and decision-making in telemedicine consultations. As governmental priorities continue to emphasize patient involvement in the management of their disease, there is an increasing need to accurately capture the provider–patient interactions in clinical encounters. Drawing on conversation analysis of 10 video-mediated consultations in 3 National Health Service settings in England, this study examines the interaction between patients, General Practitioner (GPs), nurses, and consultants during diagnosis and decision-making, with the aim to identify the range of skills that participants use in the process and capture the interprofessional communication and patient involvement in the diagnosis and decision-making phases of telemedicine consultations. The analysis shows that teleconsultations enhance collaborative working among professionals and enable GPs and nurses to develop their skills and actively participate in diagnosis and decision-making by contributing primary care–specific knowledge to the consultation. However, interprofessional interaction may result in limited patient involvement in decision-making. The findings of this study can be used to inform training programs in telemedicine that focus on the development of effective skills for professionals and the provision of information to patients.

Improving care for older people with long-term conditions and social care needs in Salford: the CLASSIC mixed-methods study, including RCT

Background

The Salford Integrated Care Programme (SICP) was a large-scale transformation project to improve care for older people with long-term conditions and social care needs. We report an evaluation of the ability of the SICP to deliver an enhanced experience of care, improved quality of life, reduced costs of care and improved cost-effectiveness.

Objectives

To explore the process of implementation of the SICP and the impact on patient outcomes and costs.

Design

Qualitative methods (interviews and observations) to explore implementation, a cohort multiple randomised controlled trial to assess patient outcomes through quasi-experiments and a formal trial, and an analysis of routine data sets and appropriate comparators using non-randomised methodologies.

Setting

Salford in the north-west of England.

Participants

Older people aged ≥ 65 years, carers, and health and social care professionals.

Interventions

A large-scale integrated care project with three core mechanisms of integration (community assets, multidisciplinary groups and an ‘integrated contact centre’).

Main outcome measures

Patient self-management, care experience and quality of life, and health-care utilisation and costs.

Data sources

Professional and patient interviews, patient self-report measures, and routine quantitative data on service utilisation.

Results

The SICP and subsequent developments have been sustained by strong partnerships between organisations. The SICP achieved ‘functional integration’ through the pooling of health and social care budgets, the development of the Alliance Agreement between four organisations and the development of the shared care record. ‘Service-level’ integration was slow and engagement with general practice was a challenge. We saw only minor changes in patient experience measures over the period of the evaluation (both improvements and reductions), with some increase in the use of community assets and care plans. Compared with other sites, the difference in the rates of admissions showed an increase in emergency admissions. Patient experience of health coaching was largely positive, although the effects of health coaching on activation and depression were not statistically significant. Economic analyses suggested that coaching was likely to be cost-effective, generating improvements in quality of life [mean incremental quality-adjusted life-year gain of 0.019, 95% confidence interval (CI) –0.006 to 0.043] at increased cost (mean incremental total cost increase of £150.58, 95% CI –£470.611 to £711.776).

Limitations

The Comprehensive Longitudinal Assessment of Salford Integrated Care study represents a single site evaluation, with consequent limits on external validity. Patient response rates to the cohort survey were < 40%.

Conclusions

The SICP has been implemented in a way that is consistent with the original vision. However, there has been more rapid success in establishing new integrated structures (such as a formal integrated care organisation), rather than in delivering mechanisms of integration at sufficient scale to have a large impact on patient outcomes.

Future work

Further research could focus on each of the mechanisms of integration. The multidisciplinary groups may require improved targeting of patients or disease subgroups to demonstrate effectiveness. Development of a proven model of health coaching that can be implemented at scale is required, especially one that would provide cost savings for commissioners or providers. Similarly, further exploration is required to assess the longer-term benefits of community assets and whether or not health impacts translate to reductions in care use.

Trial registration

Current Controlled Trials ISRCTN12286422.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 31. See the NIHR Journals Library website for further project information.

Enacting person-centredness in integrated care: A qualitative study of practice and perspectives within multidisciplinary groups in the care of older people

Background

Person‐centredness is important in delivering care for long‐term conditions. New models of care aim to co‐ordinate care through integration of health and social care which require new ways of working, often remotely from the patient.

Objective

To describe how person‐centred care is enacted within multidisciplinary groups (MDGs) created as part of a new service, integrating health and social care for older people.

Methods

We followed the implementation of eight neighbourhood MDGs, observing and interviewing staff from three MDGs at different phases of programme implementation using semi‐structured topic guides.

Results

Thirty‐four MDG meetings were observed and 32 staff interviewed. Three core themes were identified which impacted on enactment of person‐centred care: the structural context of MDGs enabling person‐centred care; interaction of staff and knowledge sharing during the MDG meetings; and direct staff involvement of the person outside the MDG discussion.

Conclusions

This study provides new insights into attempts to enact person‐centred care within a new model of service delivery. Teams did what they could to enact person‐centred care in the absence of the “real” patient within MDG meetings. They were successful in delivering and co‐ordinating some aspects of care (eg prompting medication reviews, referring to social worker, health improvement and arranging further multidisciplinary team meetings for complex cases). This “absence of patients” and time pressures within the MDGs led to reliance on the “virtual” record, enhanced by additional “soft” knowledge provided by staff, rather than ensuring the patient's voice was included.

Be good, communicate, and collaborate: a qualitative analysis of stakeholder perspectives on adding a chiropractor to the multidisciplinary rehabilitation team

Background

While chiropractors are integrating into multidisciplinary settings with increasing frequency, the perceptions of medical providers and patients toward adding chiropractors to existing healthcare teams is not well-understood. This study explored the qualities preferred in a chiropractor by key stakeholders in a neurorehabilitation setting.

Methods

This qualitative analysis was part of a multi-phase, organizational case study designed to evaluate the planned integration of a chiropractor into a multidisciplinary rehabilitation team. The setting was a 62-bed rehabilitation specialty hospital located in the northeastern United States. Participants included patients, families, community members, and professional staff of the administrative, medical, nursing, and therapy departments. Data collection consisted of audiotaped, individual interviews and profession-specific focus groups guided by a semi-structured interview schedule. Transcripts were imported into a qualitative data analysis program for data analysis. An iterative coding process using thematic content analysis categorized key themes and domains.

Results

Sixty participants were interviewed in June 2015, including 48 staff members, 6 patients, 4 family members, and 2 community members. Our analysis generated a conceptual model of The Preferred Chiropractor for Multidisciplinary Rehabilitation Settings composed of 5 domains and 13 themes. The central domain, Patient-Centeredness, or the provision of healthcare that is respectful, responsive, and inclusive of the patient’s values, preferences, and needs, was mentioned in all interviews and linked to all other themes. The Professional Qualities domain highlighted clinical acumen, efficacious treatment, and being a safe practitioner. Interpersonal Qualities encouraged chiropractors to offer patients their comforting patience, familiar connections, and emotional intelligence. Interprofessional Qualities emphasized teamwork, resourcefulness, and openness to feedback as characteristics to enhance the chiropractor’s ability to work within an interdisciplinary setting. Organizational Qualities, including personality fit, institutional compliance, and mission alignment were important attributes for working in a specific healthcare organization.

Conclusions

Our findings provide an expanded view of the qualities that chiropractors might bring to multidisciplinary healthcare settings. Rather than labeling stakeholder perceptions as good, bad or indifferent as in previous studies, these results highlight specific attributes chiropractors might cultivate to enhance the patient outcomes and the experience of healthcare, influence clinical decision-making and interprofessional teamwork, and impact healthcare organizations.

Electronic supplementary material

The online version of this article (10.1186/s12998-018-0200-4) contains supplementary material, which is available to authorized users.

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.

Paradoxes of Practice Guidelines, Professional Expertise, and Patient Centeredness: The Medical Care Triangle

The coexistence of institutionalized evidence-based practice guidelines, professional expertise of medical practitioners, and the patient centeredness approach form a triangle. Each component of this Medical Care Triangle has characteristics that create paradoxes for health care professionals and their patients. The value of a paradox lies in uncovering and utilizing the contradiction to better understand the underlying organizational phenomenon. Method: Following Poole and van de Ven’s (1989) suggested approaches to resolving paradoxes, each paradox of the Medical Care Triangle is defined and analyzed. Results: A total of 10 paradoxes related to practice guidelines, professional expertise, and patient centeredness are revealed. The resolution of each paradox yields insights specific to structuring health care organizations in ways that support the delivery of medical care. Implications: The results renew an emphasis on the centrality of practitioners’ work processes to health care organizations; this has potential benefits for organizations, clinicians/employees, and patients.

Health and Health Care From the Perspective of Intimate Partner Violence Adult Female Victims in Shelters: Impact of IPV, Unmet Needs, Barriers, Experiences, and Preferences

Intimate partner violence (IPV) predicts poor health for victims and their children, but little is known about the perspective of victims. This study reports the perspectives of adult female IPV victims about the impact of IPV on their health and barriers of health care access for themselves and their children. The majority rated their health as good to excellent (69%). However, 83.5% indicated that IPV negatively affected their health; 53.5% had unmet health care needs. Mental health care was the most common unmet need for women; children's unmet needs were immunizations and preventive care. Transportation difficulties posed the biggest barrier to health care access.

Choosing Doctors Wisely: Can Assisted Choice Enhance Patients’ Selection of Clinicians?

We conducted a simulated clinician-choice experiment, comparing choices and decision-making processes of participants ( N = 688) randomized among four experimental arms: a conventional website reporting only quantitative performance information, a website reporting both qualitative (patient comments) and quantitative information, the second website augmented by a decision aid (labeling of patient comments), and the decision-aided website further augmented by the presence of a trained navigator. Introducing patient comments enhanced engagement with the quality information but led to a decline in decision quality, particularly the consistency of choices with consumers’ stated preferences. Labeling comments helped erase the decline in decision quality, although the highest percentage of preference-congruent choices was seen in the navigator arm. Engagement with the quality information and satisfaction with choices available were likewise highest in the navigator arm. Findings held for high- and low-skilled decision makers. Thus, navigator assistance may be a promising strategy for equitably promoting higher quality choices in information-rich contexts.

Effects of lifestyle intervention using patient-centered cognitive behavioral therapy among patients with cardio-metabolic syndrome: a randomized, controlled trial

BACKGROUND

Cardio-metabolic syndrome (CMS) is a highly prevalent condition. There is an urgent need to identify effective and integrated multi-disciplinary approaches that can reduce risk factors for CMS.

METHODS

Sixty-two patients with a history of CMS were randomized 1:1 into two groups: a standard information -only group (control), or a self-regulated lifestyle waist circumference (patient-centered cognitive behavioral therapy) intervention group. A pretest and posttest, controlled, experimental design was used. Outcomes were measured at the baseline (week 0) and at the end of intervention (week 12). Comparisons were drawn between groups and over time.

RESULTS

The mean (standard deviation) age of the subjects was 48.6 (5.8) years ranging from 32 to 63, and 56.9% of the participants were female. Both groups showed no significant differences in Demographic variables and the metabolic syndrome indicators at baseline. While the control group only showed modest improvement after 12 weeks, compared to baseline, the intervention group demonstrated significant improvement from baseline. This study controlled for patients' demographics and baseline characteristics when assessing the effects of intervention. After adjusting for age, education and baseline level, the experimental group and the control group were statistically significant different in the following post-treatment outcomes: WC (F = 35.96, P < 0.001), TG (F = 18.93, P < 0.001), RSBP (F = 33.89, P < 0.001) and SF-36(F = 157.93, P < 0.001). The results showed patients' age and education were not strong predictors of patients' outcome (including WC, TG, RSBP and SF-36).

CONCLUSIONS

Lifestyle intervention on patient-centered cognitive behavioral therapy can improve the physical and mental health conditions among individuals reporting a history of cardio-metabolic syndrome, and possibly provided preliminary benefits for the treatment of CMS.

TRIAL REGISTRATION

Chinese Clinical Trial Register #, ChiCTR15006148 .

Achieving Coordinated Care for Patients With Complex Cases of Cancer: A Multiteam System Approach

Patients with cancer with multiple chronic conditions pose a unique challenge to how primary care and specialty care teams provide well-coordinated, patient-centered care. Effectiveness of these care teams in providing optimal health care depends on the extent to which they coordinate their goals and knowledge as components of a multiteam system (MTS). This article outlines challenges of care coordination in the context of an MTS, illustrated through the care experience of "Mr Fuentes," a patient in the Dallas County integrated safety-net system, Parkland. As a continuing patient with chronic illnesses, the patient being discussed is managed through one of the Parkland community-oriented primary care clinics. However, a cancer diagnosis triggered an additional need for augmented coordination between his different provider teams. Further research and practice should investigate the relationships of MTS coordination for shared care management, transfer to and from specialty care, treatment compliance, barriers to care, and health outcomes of chronic comorbid conditions, as well as cancer control and surveillance.

Developing a framework for gathering and using service user experiences to improve integrated health and social care: the SUFFICE framework

BACKGROUND

More people than ever receive care and support from health and social care services. Initiatives to integrate the work of health and social care staff have increased rapidly across the UK but relatively little has been done to chart and improve their impact on service users. Our aim was to develop a framework for gathering and using service user feedback to improve integrated health and social care in one locality in the North of England.

METHODS

We used published literature and interviews with health and social care managers to determine the expected service user experiences of local community-based integrated teams and the ways in which team members were expected to work together. We used the results to devise qualitative data collection and analysis tools for gathering and analyzing service user feedback. We used developmental evaluation and service improvement methodologies to devise a procedure for developing service improvement plans.

FINDINGS

We identified six expected service user experiences of integrated care and 15 activities that health and social care teams were expected to undertake. We used these to develop logic models and tools for collecting and analysing service user experiences. These include a narrative interview schedule, a plan for analyzing data, and a method for synthesizing the results into a composite 'story'. We devised a structured service improvement procedure which involves teams of health and social care staff listening to a composite service user story, identifying how their actions as a team may have contributed to the story and developing a service improvement plan.

CONCLUSIONS

This framework aims to put service user experiences at the heart of efforts to improve integration. It has been developed in collaboration with National Health Service (NHS) and Social Care managers. We expect it to be useful for evaluating and improving integrated care initiatives elsewhere.

Physicians' professionalism at primary care facilities from patients' perspective: The importance of doctors' communication skills

BACKGROUND

Professionalism is the core duty of a doctor to be responsible to the society. Doctors' professionalism depicts an internalization of values and mastery of professionals' standards as an important part in shaping the trust between doctors and patients. Professionalism consists of various attributes in which current literature focused more on the perspective of the health professionals. Doctors' professionalism may influence patients' satisfaction, and therefore, it is important to know from the patients' perspectives what was expected of medical doctors' professionalism.

OBJECTIVE

This study was conducted to determine the attributes of physician professionalism from the patient's perspective.

MATERIALS AND METHODS

This was a qualitative research using a phenomenology study design. In-depth interviews were conducted with 18 patients with hypertension and diabetes who had been treated for at least 1 year in primary care facilities in the city of Yogyakarta, Indonesia. The results of the interview were transcribed, encoded, and then classified into categories.

RESULTS

Communication skills were considered as the top priority of medical doctors' attributes of professionalism in the perspectives of the patients.

CONCLUSION

This study revealed that communication skill is the most important aspects of professionalism which greatly affected in the process of health care provided by the primary care doctors. Doctor-patient communication skills should be intensively trained during both basic and postgraduate medical education.

That's not how the learning works - the paradox of Reverse Innovation: a qualitative study

Background

There are significant differences in the meaning and use of the term ‘Reverse Innovation’ between industry circles, where the term originated, and health policy circles where the term has gained traction. It is often conflated with other popularized terms such as Frugal Innovation, Co-development and Trickle-up Innovation. Compared to its use in the industrial sector, this conceptualization of Reverse Innovation describes a more complex, fragmented process, and one with no particular institution in charge. It follows that the way in which the term ‘Reverse Innovation’, specifically, is understood and used in the healthcare space is worthy of examination.

Methods

Between September and December 2014, we conducted eleven in-depth face-to-face or telephone interviews with key informants from innovation, health and social policy circles, experts in international comparative policy research and leaders in the Reverse Innovation space in the United States. Interviews were open-ended with guiding probes into the barriers and enablers to Reverse Innovation in the US context, specifically also informants' experience and understanding of the term Reverse Innovation. Interviews were recorded, transcribed and analyzed thematically using the process of constant comparison.

Results

We describe three main themes derived from the interviews. First, ‘Reverse Innovation,’ the term, has marketing currency to convince policy-makers that may be wary of learning from or adopting innovations from unexpected sources, in this case Low-Income Countries. Second, the term can have the opposite effect - by connoting frugality, or innovation arising from necessity as opposed to good leadership, the proposed innovation may be associated with poor quality, undermining potential translation into other contexts. Finally, the term ‘Reverse Innovation’ is a paradox – it breaks down preconceptions of the directionality of knowledge and learning, whilst simultaneously reinforcing it.

Conclusions

We conclude that this term means different things to different people and should be used strategically, and with some caution, depending on the audience.

Electronic supplementary material

The online version of this article (doi:10.1186/s12992-016-0175-7) contains supplementary material, which is available to authorized users.

Experiences of Community-Living Older Adults Receiving Integrated Care Based on the Chronic Care Model: A Qualitative Study

Background

Integrated care models aim to solve the problem of fragmented and poorly coordinated care in current healthcare systems. These models aim to be patient-centered by providing continuous and coordinated care and by considering the needs and preferences of patients. The objective of this study was to evaluate the opinions and experiences of community-living older adults with regard to integrated care and support, along with the extent to which it meets their health and social needs.

Methods

Semi-structured interviews were conducted with 23 older adults receiving integrated care and support through “Embrace,” an integrated care model for community-living older adults that is based on the Chronic Care Model and a population health management model. Embrace is currently fully operational in the northern region of the Netherlands. Data analysis was based on the grounded theory approach.

Results

Responses of participants concerned two focus areas: 1) Experiences with aging, with the themes “Struggling with health,” “Increasing dependency,” “Decreasing social interaction,” “Loss of control,” and “Fears;” and 2) Experiences with Embrace, with the themes “Relationship with the case manager,” “Interactions,” and “Feeling in control, safe, and secure”. The prospect of becoming dependent and losing control was a key concept in the lives of the older adults interviewed. Embrace reinforced the participants’ ability to stay in control, even if they were dependent on others. Furthermore, participants felt safe and secure, in contrast to the fears of increasing dependency within the standard care system.

Conclusion

The results indicate that integrated care and support provided through Embrace met the health and social needs of older adults, who were coping with the consequences of aging.