Goal-oriented care for patients with chronic conditions or multimorbidity in primary care: A scoping review and concept analysis

Development and validation of a patient-centered communication scale for nurses

BACKGROUND

Patient-centered care aims to prevent disease and promote well-being by actively involving patients in treatment and decision-making that is based on respecting the patients and their families. However, no scales have been developed to assess patient-centered care from the nurse's perspective. This study aimed to develop a scale to measure nurses' level of patient-centered communication and confirm its validity and reliability.

METHODS

A methodological cross-sectional study was adopted to develop and validate the Patient-Centered Communication Scale (PCCS). The items were developed through a literature review and online interviews with nurses. Content validity was assessed by experts and the content validity index was calculated. A pretest of the questionnaire was conducted with 10 clinical nurses. To evaluate the factor structure and internal consistency reliability, the PCCS was administered online to 325 nurses in South Korea. Data were analyzed using descriptive statistics, explanatory factor analysis (EFA), and confirmatory factor analysis (CFA).

RESULTS

The final instrument consisted of 12 items and three factors: (1) information sharing, (2) patient-as-person, and (3) therapeutic alliance. EFA revealed a distinct three-factor structure, explaining 59.0% of the total variance. CFA confirmed the adequacy of the model fit and validated the inclusion of the final items. The Cronbach's alpha values ranged from 0.60 to 0.77, indicating acceptable internal consistency. Convergent validity was evidenced by the correlation between the PCCS and a measure of interpersonal communication competence.

CONCLUSIONS

The 12-item PCCS showed good reliability, construct validity, and convergent validity. The scale has utility for measuring the level of patient-centered communication skills in nurses.

International cross-cultural development and field testing of the primary care practice questionnaire for the PaRIS survey (PaRIS-PCPQ)

BACKGROUND

The PaRIS survey, an initiative of the Organisation for Economic Co-operation and Development (OECD), aims to assess health systems performance in delivering primary care by measuring the care experiences and outcomes of people over 45 who used primary care services in the past six months. In addition, linked data from primary care practices are collected to analyse how the organisation of primary care practices and their care processes impact care experiences and outcomes. This article describes the development and validation of the primary care practice questionnaire for the PaRIS survey, the PaRIS-PCPQ.

METHOD

The PaRIS-PCPQ was developed based on domains of primary care practice and professional characteristics included in the PaRIS conceptual framework. Questionnaire development was conducted in four phases: (1) a multi-step consensus-based development of the source questionnaire, (2) translation of the English source questionnaire into 17 languages, (3) cross-national cognitive testing with primary care professionals in participating countries, and (4) cross-national field-testing.

RESULTS

70 items were selected from 7 existing questionnaires on primary care characteristics, of which 49 were included in a first draft. Feedback from stakeholders resulted in a modified 34-item version (practice profile, care coordination, chronic care management, patient follow-up, and respondent characteristics) designed to be completed online by medical or non-medical staff working in a primary care practice. Cognitive testing led to changes in the source questionnaire as well as to country specific localisations. The resulting 32-item questionnaire was piloted in an online survey and field test. Data from 540 primary care practices from 17 countries were collected and analysed. Final revision resulted in a 34-item questionnaire.

CONCLUSIONS

The cross-national development of a primary care practice questionnaire is challenging due to the differences in care delivery systems. Rigorous translation and cognitive testing as well as stakeholder engagement helped to overcome most challenges. The PaRIS-PCPQ will be used to assess how key characteristics of primary care practices relate to the care experiences and outcomes of people living with chronic conditions. As such, policymakers and care providers will be informed about the performance of primary care from the patient's perspective.

The capability approach in rehabilitation: developing capability care

PURPOSE

To develop a multidisciplinary outpatient rehabilitation intervention for people with neuromuscular diseases (NMD) based on the capability approach: capability care for persons with NMD.

MATERIALS AND METHODS

The development process is described using a framework of actions for intervention development. It has been an iterative process consisting of a design phase based on theoretical insights and project group discussions, and a refine phase involving input from relevant stakeholders.

RESULTS

Multidisciplinary efforts have resulted in the development of capability care for rehabilitation of persons with NMD. It can focus both on facilitating and achieving functionings (beings and doings), as well as looking for alternative functionings that fulfil the same underlying value, thereby contributing to the persons' well-being. To facilitate a conversation on broader aspects that impact on well-being, persons with NMD receive a preparation letter and healthcare professionals are provided with guiding questions and practical tools to use.

CONCLUSIONS

We have shown that it is possible to develop a healthcare intervention based on the capability approach. We hope that rehabilitation professionals will be encouraged to use capability care and that other medical professionals will be inspired to develop capability care in their respective fields.

REGISTRATION

Registered at trialregister.nl NL8946.

How does the external context affect an implementation processes? A qualitative study investigating the impact of macro-level variables on the implementation of goal-oriented primary care

BACKGROUND

Although the importance of context in implementation science is not disputed, knowledge about the actual impact of external context variables on implementation processes remains rather fragmented. Current frameworks, models, and studies merely describe macro-level barriers and facilitators, without acknowledging their dynamic character and how they impact and steer implementation. Including organizational theories in implementation frameworks could be a way of tackling this problem. In this study, we therefore investigate how organizational theories can contribute to our understanding of the ways in which external context variables shape implementation processes. We use the implementation process of goal-oriented primary care in Belgium as a case.

METHODS

A qualitative study using in-depth semi-structured interviews was conducted with actors from a variety of primary care organizations. Data was collected and analyzed with an iterative approach. We assessed the potential of four organizational theories to enrich our understanding of the impact of external context variables on implementation processes. The organizational theories assessed are as follows: institutional theory, resource dependency theory, network theory, and contingency theory. Data analysis was based on a combination of inductive and deductive thematic analysis techniques using NVivo 12.

RESULTS

Institutional theory helps to understand mechanisms that steer and facilitate the implementation of goal-oriented care through regulatory and policy measures. For example, the Flemish government issued policy for facilitating more integrated, person-centered care by means of newly created institutions, incentives, expectations, and other regulatory factors. The three other organizational theories describe both counteracting or reinforcing mechanisms. The financial system hampers interprofessional collaboration, which is key for GOC. Networks between primary care providers and health and/or social care organizations on the one hand facilitate GOC, while on the other hand, technology to support interprofessional collaboration is lacking. Contingent variables such as the aging population and increasing workload and complexity within primary care create circumstances in which GOC is presented as a possible answer.

CONCLUSIONS

Insights and propositions that derive from organizational theories can be utilized to expand our knowledge on how external context variables affect implementation processes. These insights can be combined with or integrated into existing implementation frameworks and models to increase their explanatory power.

Professionals' treatment goals for long-term benzodiazepine and Z-drugs management: a qualitative study

BACKGROUND

Benzodiazepines and Z-drugs (BZD/Z) are frequently prescribed for longer than recommended. Through their interactions with patients taking BZD/Z, primary care and mental health professionals play a key role in the management of this medication.

AIM

To explore how primary care and mental health care professionals set treatment goals with users of long-term BZD/Z.

DESIGN & SETTING

A qualitative study using semi-structured interviews with professionals from mental health, addiction care, and primary care practices in Belgium.

METHOD

Semi-structured interviews were conducted, online and in person, with 24 professionals working in mental health and primary care. Inductive thematic content analysis was performed.

RESULTS

Seven themes were identified from the analysis. Professionals tended not to use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) standard to diagnose a BZD/Z substance use disorder. They described criteria based on their experience. They identified diverse types of patients that influence their choice of treatment goals. Professionals appeared to position themselves according to their own treatment goals for their patients, either by promoting the goal of abstinence or harm reduction. Some of them reported feeling trapped into continuing to prescribe and considered BZD/Z withdrawal to be difficult. Some were afraid to engage in a conversation that might break the bond of trust with the patient. Few professionals mentioned patient participation in the treatment goal setting. They asked for targeted withdrawal recommendations, perceiving the current recommendations to be too broad.

CONCLUSION

Whether primary care or mental health care professionals are more in favour of a total abstinence or a harm reduction approach to BZD/Z, professionals should be guided towards greater patient participation in setting and evaluating goals with patients taking BZD/Z.

Journey Through Healthcare of People With Complications of Type 2 Diabetes: A Qualitative Study of Lived Experiences

Background

Despite its overall good performance, the Belgium healthcare system scores less well in providing equal access to healthcare compared to other European countries. This increases the risk of people worse off to receive late diagnosis and to get complications of chronic diseases.

Methods

This study aims to achieve a deeper understanding of how people with complications of a chronic disease - diabetes type 2 - experience care in the Belgium health system through semi-structured interviews with extreme case study sampling of people with advanced diabetes, and inductive analysis.

Results

The results show that most respondents were diagnosed late in the course of their disease. There are variations in treatment and type of provider. People appreciate the personal and long-lasting contact with a medical doctor, while the contact with and role of paramedical providers was less recognized. Disease management has a significant impact on their financial budget and some respondents experienced barriers to obtain additional financial support.

Discussion

Non-medical costs are not reimbursed, presenting a high burden to people. Self-management is tedious and hampered by other worries that people may have, such as financial constraints and coping with important life events. To conclude this study highlighted the need to improve diabetes screening. We suggest to enhance the role of paramedical professionals, integrate a social care worker, reduce financial constraints, and increase health literacy through more patient-centered, goal-oriented care.

Exploring Goal-Setting and Achievement Within Reablement: A Comparative Case Study of Three Countries

Purpose

Over the last two decades, reablement programs have been studied and implemented internationally. Goal-setting and multidisciplinary collaboration are central elements of reablement. Unfortunately, limited intervention descriptions leave questions on how they are applied in practice and how goals set by the user are achieved. As a consequence, healthcare providers and organizations often lack knowledge to implement and align reablement to their national and local context. This study aimed to collect data on goal-setting and achievement, and multidisciplinary collaboration within reablement services to provide insight into how these processes inform reablement practice as well as to explore the experiences of healthcare professionals in Norway, New Zealand, and the Netherlands.

Material and Methods

A qualitative exploratory design was used comprising three focus group interviews with 20 healthcare professionals (nursing and allied health) involved in reablement programs from the three countries. Purposive sampling was employed considering a mix of gender, age and educational level.

Results

Findings reflected healthcare professionals' experiences and reablement processes in three main themes: (1) Goal-setting processes; clearly demonstrating goal-setting as an essential part of reablement and contributing to better understanding of users' motives; (2) Impact of goal-setting on multidisciplinary collaboration; promoting a sense of community, learning climate, job satisfaction and task-shifting; and (3) Behavior change techniques used to reach users' goals, promoting self-reflection and changing users' perspectives.

Conclusion

This study offers valuable insights from three countries. Goal-setting serves a crucial role enabling effective reablement implementation across diverse contexts. More specifically, to facilitate tailoring of reablement programs to the user's needs as well as establish more effective multidisciplinary collaboration by promoting trust, shared vision, and utilizing each other's expertise. However, despite the acknowledgement of the significance of reablement, it was reported by all that a cultural shift is necessary for users, informal caregivers as well as healthcare professionals.

Developing a Novel Web-Based Self-Management Support Intervention for Polycystic Ovary Syndrome: Mixed Methods Study With Patients and Health Care Professionals

BACKGROUND

Polycystic ovary syndrome (PCOS) represents a significant global health burden requiring urgent attention. This common chronic endocrine and cardiometabolic condition affects around 1 in 10 women and individuals assigned female at birth, with significant adverse effects on well-being, quality of life, and mental health, as well as serious and complex long-term health consequences. International guidelines for best health care practice recommend the provision of comprehensive cognitive behavioral interventions to support self-management and improve health outcomes for those living with PCOS. Web-based health interventions have the potential to meet this need in an accessible and scalable way.

OBJECTIVE

We aim to identify barriers to self-management and psychological well-being in women with PCOS and adapt a web-based self-management program to provide a prototype digital support intervention for them.

METHODS

We adapted an existing support program (HOPE) for PCOS using the antecedent target measure approach. We conducted qualitative interviews with 13 adult women living with PCOS, 3 trustees of a patients with PCOS advocacy charity, and 4 endocrinologists to identify "antecedents" (barriers) to self-management and psychological well-being. Framework analysis was used to identify potentially modifiable antecedents to be targeted by the novel intervention. At a national conference, 58 key stakeholders (patients and health professionals) voted for the antecedents they felt were most important to address. We used research evidence and relevant theory to design a prototype for the PCOS intervention.

RESULTS

Voting identified 32 potentially modifiable antecedents, relating to knowledge, understanding, emotions, motivation, and behaviors, as priorities to be targeted in the new intervention. A modular, web-based prototype HOPE PCOS intervention was developed to address these, covering six broad topic areas (instilling HOPE for PCOS; managing the stress of PCOS; feeding your mind and body well; body image, intimacy, and close relationships; staying healthy with PCOS; and keeping PCOS in its place).

CONCLUSIONS

We identified barriers to self-management and psychological well-being in women with PCOS and used these to adapt a web-based self-management program, tailoring it for PCOS, which is a comprehensive group intervention combining education, empowerment, lifestyle management, peer support with cognitive behavioral tools, and goal-setting (to be delivered by peers or codelivered with health care professionals). The modular structure offers flexibility to adapt the program further as new clinical recommendations emerge. The intervention has the potential to be delivered, evaluated for feasibility, and, if effective, integrated into health care services. Self-management interventions are not designed to replace clinical care; rather, they serve as an additional source of support. The HOPE PCOS program conveys this message in its content and activities. Future research should evaluate the prototype intervention using primary outcomes such as measures of psychological well-being, self-management self-efficacy, depression, anxiety, and PCOS-related quality of life. They should also assess the intervention's acceptability, scalability, and cost-effectiveness.

My Wellbeing Journal: Development of a communication and goal-setting tool to improve care for older adults with chronic conditions and multimorbidity

BACKGROUND

Chronic conditions and multimorbidity, the presence of two or more chronic conditions, are increasingly common in older adults. Effective management of chronic conditions and multimorbidity in older adults requires a collaborative and person-centred approach that considers the individual's goals, preferences and priorities. However, ensuring high-quality personalised care for older adults with multimorbidity can be challenging due to the complexity of their care needs, limited time and a lack of patient preparation to discuss their personal goals and preferences with their healthcare team.

OBJECTIVE

To codesign a communication and goal-setting tool, My Wellbeing Journal, to support personalised care planning for older adults with chronic conditions and multimorbidity.

DESIGN

We drew on an experience-based codesign approach to develop My Wellbeing Journal. This article reports on the final end-user feedback, which was collected via an online survey with older adults and their carers.

SETTING AND PARTICIPANTS

Older adults with chronic conditions, multimorbidity and informal carers living in Australia. Personalised care planning was considered in the context of primary care.

RESULTS

A total of 88 participants completed the online survey. The survey focused on participants' feedback on the tool in terms of effectiveness, efficiency, satisfaction and errors encountered. This feedback resulted in modifications to My Wellbeing Journal, which can be used during clinical encounters to facilitate communication, goal setting and progress tracking.

DISCUSSION AND CONCLUSIONS

Clinicians and carers can use the tool to guide discussions with older adults about their care planning and help them set realistic goals that are meaningful to them. The findings of this study could be used to inform the development of recommendations for healthcare providers to implement person-centred, goal-oriented care for older adults with chronic conditions and multimorbidity.

PATIENT OR PUBLIC CONTRIBUTION

Older adults living with chronic conditions and multimorbidity and their carers have contributed to the development of a tool that has the potential to significantly enhance the experience of personalised care planning. Their direct involvement as collaborators has ensured that the tool is optimised to meet the standards of effectiveness and usability.

Connection and recovery in the COVID-19 age: An analysis of changes in goal-setting throughout the pandemic by consumers living with enduring mental illness

Goal-setting is a tool that empowers consumer recovery. Though the pandemic has affected consumer goal-setting, the nature and extent of this impact have not been examined in a recovery setting. The aim of this study is to assess whether the recovery goals of individuals with serious mental illness changed in association with the COVID-19 pandemic. In this mixed-methods design, data were collected from a purposeful sample of consumers (nTOTAL  = 355) aged 19-67 years (MAGE  = 44.56, SD = 13.05) attending Recovery Camp, a 5-day therapeutic-recreation programme for individuals living with severe mental illness (e.g., PTSD, schizophrenia). Consumer-set goals were examined across 5 programmes prior to March 2020 (nPRE  = 126) and 11 following (nPOST  = 229). Goals were set on day one, with attainment self-scored on day five. Chi-squared goodness-of-fit tests compared goal proportions per domain; tests of independence assessed changes in goals pre- and post-pandemic. Six goal domains were identified: Approach-Based Recovery, Avoidance-based Recovery, Novel Physical Activities, Relationships, Health, and Recreation/Relaxation. Irrespective of the pandemic, goal attainment was consistently high across all programmes (86.56%). Approach-based Recovery goals were predominant pre-pandemic, but were significantly reduced post-pandemic (p = 0.040). Goals related to Relationships and Novel Physical Activities took precedence throughout the pandemic. Post-COVID-19, consumer recovery goals reveal increased desire for connection, novelty-seeking, and positive behavioural change.

What matters to you? A mixed-method evaluation of goal setting and attainment within reablement from a client perspective

BACKGROUND

Goal setting is an essential component of reablement programmes. At the same time it is also an important aspect in the evaluation of reablement from the perspective of clients.

OBJECTIVES

As part of the TRANS-SENIOR project, this research aims to get an in-depth insight of goal setting and goal attainment within reablement services from the perspective of the older person.

MATERIAL AND METHODS

A convergent mixed methods design was used, combining data from electronic care files, and completed Canadian Occupational Performance Measure (COPM) forms with individual interviews.

RESULTS

In total, 17 clients participated. Participants' meaningful goals mainly focused on self-care, rather than leisure or productivity. This mattered most to them, since being independent in performing self-care tasks increased clients' confidence and perseverance. Regarding goal attainment, a statistically significant and clinically relevant increase in self-perceived performance and satisfaction scores were observed.

CONCLUSION

Although most goals focused on self-care, it became apparent that these tasks matter to participants, especially because these often precede fundamental life goals.

SIGNIFICANCE

Reablement can positively contribute to goal setting and attainment of clients and may contribute to increased independence. However, effectiveness, and subsequently long-term effects, are not yet accomplished and should be evaluated in future research.

Patient perspectives of diabetes care in primary care networks in Singapore: a mixed-methods study

BACKGROUND

Type 2 diabetes (T2D) remains an important chronic condition worldwide requiring integrated patient-centred care as advocated by the Chronic Care Model (CCM). The Primary Care Networks (PCNs) in Singapore organise general practitioners (GPs) with nurses and care coordinators to deliver team-based care for patients with chronic conditions. This study examined the quality of care in the PCNs as defined by the CCM from the patients' perspective.

METHODS

This study followed a cross-sectional convergent mixed-method design with T2D patients across three PCN types (GP-led, Group, and Cluster). The Patient Assessment of Chronic Illness Care (PACIC, range 1-5) was completed by a convenience sample of 343 patients. Multivariate linear regression was performed to estimate the associations between patient and service characteristics and PACIC summary score. Twenty-four participants were purposively recruited for interviews on the experienced care until thematic saturation was reached. Quantitative and qualitative data were collected concurrently and independently. Integration occurred during study design and data analysis using the CCM as guidance. Quantitative and qualitative results were compared side-by-side in a joint comparison table to develop key concepts supported by themes, subthemes, and patients' quotes.

RESULTS

The PACIC mean summary score of 3.21 for 343 patients evidenced that some have received CCM consistent care in the PCNs. Being younger and spending more time with the GP were associated with higher PACIC summary scores. PACIC summary scores did not differ across PCN types. The 24 patients interviewed in the qualitative study reported receiving team-based care, nurse services, good continuity of care, as well as patient-centred care, convenient access, and affordable care. Key concepts showed that integrated care consistent with the CCM was sometimes received by patients in the PCNs. Patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling were sometimes received by patients, while follow-up/coordination was generally not received.

CONCLUSIONS

Patients with T2D from the Singapore Primary Care Networks received integrated care consistent with the Chronic Care Model, particularly in patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling. Follow-up/coordination needed improvement to ensure higher quality of diabetes care.

Advance care planning among older adults in Belgium with Turkish backgrounds and palliative care needs: A qualitative interview study

BACKGROUND

Data on advance care planning (ACP) among migrants in Europe is lacking. Research has shown that few older migrants in the United States perform ACP due to healthcare system distrust, collectivistic values and spirituality/religion.

OBJECTIVES

To explore the ACP knowledge and perspectives of older Turkish-origin adults in Belgium requiring palliative care.

METHOD

General practitioners (GPs) in Brussels and Antwerp recruited Turkish-origin participants aged ≥ 65 years with palliative care eligibility for this qualitative study. A GP conducted semi-structured interviews in Turkish in respondents' homes between May 2019 and February 2022 using a topic guide. Two researchers performed combined inductive/deductive thematic data analysis.

RESULTS

All 15 interviewees (average age, 79 years) lacked ACP awareness and information. Some had discussed specific end-of-life preferences (e.g. care location, burial place) with family. Still, many did not feel the need to discuss future healthcare preferences, due mainly to trust in God and family for caretaking and decision-making. Some respondents viewed ACP discussions as applicable, relieving the burden on family and enabling proactive addressing of 'what if' questions. Self-identified ACP barriers were fear of making wrong decisions, 'living in the moment' and difficulty discussing death. Facilitators were obtaining sufficient ACP information and recent family illness or death.

CONCLUSION

Our sample of Turkish-origin older adults in Belgium requiring palliative care lacked ACP knowledge. Our findings suggest that their lack of engagement in discussing end-of-life medical care planning was linked to their family dynamics and religion. The findings have implications for healthcare providers to ethnic-minority groups.

Operationalizing the Chronic Care Model with Goal-Oriented Care

The Chronic Care Model has guided quality improvement in health care for almost 20 years, using a patient-centered, disease management approach to systems and care teams. To further advance efforts in person-centered care, we propose strengthening the Chronic Care Model with the goal-oriented care approach. Goal-oriented care is person-centered in that it places the focus on what matters most to each person over the course of their life. The person's goals inform care decisions, which are arrived at collaboratively between clinicians and the person. In this paper, we build on each of the elements of the Chronic Care Model with person-centered, goal-oriented care and provide clinical examples on how to operationalize this approach. We discuss how this adapted approach can support our health care systems, in particular in the context of growing multi-morbidity.

Feasibility of Goal Attainment Scaling as a patient-reported outcome measure for older patients in primary care

BACKGROUND

Goal Attainment Scaling (GAS) is an outcome measure that reflects the perspectives and experiences of patients, consistent with patient-centred care approaches and with the aims of patient-reported outcome measures (PROMs). GAS has been used in a variety of clinical settings, including in geriatric care, but research on its feasibility in primary care practice has been limited. The time required to complete GAS is a barrier to its use by busy primary care clinicians. In this study, we explored the feasibility of lay interviewers completing GAS with older primary care patients.

METHODS

Older adults were recruited from participants of a larger study in five primary care clinics in Alberta and Ontario, Canada. GAS guides were developed based on semi-structured telephone interviews completed by a non-clinician lay interviewer; goals were reviewed in a follow-up interview after six months.

RESULTS

Goal-setting interviews were conducted with 41 participants. GAS follow-up guides could be developed for 40 patients (mean of two goals/patient); follow-up interviews were completed with 29 patients. Mobility-focused goals were the most common goal areas identified.

CONCLUSIONS

Study results suggest that it is feasible for lay interviewers to conduct GAS over the telephone with older primary care patients. This study yielded an inventory of patient goal areas that could be used as a starting point for future goal-setting interviews in primary care. Recommendations are made for use of GAS and for future research in the primary care context.

Will the implementation process for goal-oriented primary care succeed? A qualitative study investigating five perceived attributes of goal-oriented care

Throughout the western world, goal oriented care (GOC) is increasingly promoted as a strategy towards more person-centered, integrated care. The implementation of goal-oriented care not only takes place at the micro-level with individual primary care providers (PCPs) changing their approach, but also requires meso- and macro-level investment. In this study, we zoom in on experiences and actions of various meso- and macro-level actors that are actively engaged with implementing GOC, both within their organization or at the policy level. In-depth interviews were conducted with n = 23 actors from a variety of different organizations (governmental institutions, provider organizations, patient organizations, health/social care organizations, primary care zones/care councils, etc.), using a semi- interview guide inspired by realist interviewing. Three main drivers for implementation were identified: recognition, commitment and coordination. On top of that, results were interpreted through Rogers' Diffusion of Innovations (Dol) theory in which five attributes are discussed that contribute to or hinder implementation success. Our findings can help define actions to support and facilitate the implementation process of an innovation such as GOC.

"At the time I only wanted to relieve stress": Exploring motivation for behaviour change in long-term hypnotic users

Background

Motivating patients to discontinue long-term benzodiazepine receptor agonist (BZRA) use for insomnia remains an important challenge in primary care because of the medication's unfavourable risk-benefit profile. Previous studies have shown that understanding the complexity of patients' motivation is crucial to the primary care physician for providing effective interventions efficiently. Theoretical frameworks about behaviour change show that motivation is a multi-layered concept that interacts with other concepts, which aligns with a holistic perspective or implementation of the biopsychosocial model.

Aim

Exploring primary care patients' views and ideas on what factors helped or hindered them in discontinuing long-term BZRA use, in relation to motivation as conceptualised in the Behaviour Change Wheel, and associated domains of the Theoretical Domains Framework.

Design and setting

A qualitative study with semi-structured interviews in primary care in Belgium between September 2020 and March 2021.

Method

Eighteen interviews with long-term hypnotic users were audio recorded, transcribed and thematically analyzed, using the Framework Method.

Results

The success of discontinuation interventions does not solely rely on patients' spontaneous sense of striving for improvement. Reinforcement and identity were found to be important domains for motivation. Beliefs about personal capabilities, and about consequences of both BZRA intake and discontinuation, differed between previous and current users.

Conclusion

Motivation is a multi-layered concept which is not fixed in time. Patient empowerment and goal setting could help long-term BZRA users to lower their intake. As well as public health interventions that might change social attitudes towards the use of hypnotic medication.

Building an understanding of goal-oriented care through the experiences of people living with chronic conditions

OBJECTIVE

To understand the concept of goal-oriented care (GOC) through the experiences of people with chronic conditions.

METHOD

Interviews with people living with chronic conditions (n = 50) were analyzed in two ways. A deductive approach based on GOC attributes generated in a concept analysis on GOC: goal-elicitation, goal-setting, goal-evaluation, patients' context, and patients' needs and preferences. An inductive approach based on a thematic analysis using descriptive phenomenology.

RESULTS

The phase of goal-elicitation was recognized by the participants, whereas goal-setting and goal-evaluation were experienced to a lesser extent. Regarding the underpinning attributes, mixed feelings were reported concerning the integration of the patient's context and the presence of their needs and preferences throughout the care process. The inductive analysis revealed specific attention to informing patients about their condition and treatment options and discussing goals in interprofessional collaboration.

CONCLUSION

Goal-elicitation was already present and seems to be a good foundation for GOC. More attention should be given to goal-setting and goal-evaluation.

PRACTICE IMPLICATIONS

Developing guidance by means of a workflow, tools, or questions might support people with chronic conditions and providers to underpin the entire care process with patients' personal goals.

Protocols and Features of Goal-Setting-Based Intervention for Frail Older Adults in Community Exercise Facilities

Appropriate goal setting for frail older adults is important because it drives effective rehabilitation. However, more insights into the types and degrees of frailty and goal-setting trends should be obtained. We conducted a multicenter prospective study to qualitatively examine the relation between each frailty domain (physical, social, and cognitive) and the goals of 201 subjects (median age: 79, 43.8% male) who began rehabilitation at a long-term care prevention facility. Goal setting was determined by the specific, measurable, achievable, relevant, and time to goal (SMART) framework up to three months, categorized according to the International Classification of Functioning, Disability, and Health. The results showed that approximately 90% of the subjects had frailty in at least one domain, and about half had frailties in two or more domains. In total, 176 (87.6%) subjects had goals corresponding to activities and participation. The tendency to set goals to improve mobility was confirmed when the number of overlapping frailties was high, especially those in the physical and social domains. Those with milder frailties were more likely to establish goals targeting improvements in community, social, and civic life. These findings will lead to the development of practical goal-setting guidelines for frail older adults.

The future of personalized care for vascular patients: an industry perspective

Healthcare has entered a brave new world in the early part of the 21st century: the landscape has changed and continues to change rapidly, evolving at a rate as never seen before. Fuelled by technological advancement, big data analytics, and the explosion of apps and sensors, as well as by telemedicine and remote monitoring needs driven by the COVID-19 pandemic, the healthcare ecosystem is metamorphosing literally before our eyes. So, what is the role for the Medtech industry as healthcare systems reshape themselves to address emerging patients’ needs and desires, and how can the use of data and novel technologies be leveraged to bring about the kind of change needed to deliver truly holistic patient care?

Personalized vascular healthcare: insights from a large international survey

Fragmentation of healthcare systems through limited cross-speciality communication and intermittent, intervention-based care, without insight into follow-up and compliance, results in poor patient experiences and potentially contributes to suboptimal outcomes. Data-driven tools and novel technologies have the capability to address these shortcomings, but insights from all stakeholders in the care continuum remain lacking. A structured online questionnaire was given to respondents (n = 1432) in nine global geographies to investigate attitudes to the use of data and novel technologies in the management of vascular disease. Patients with coronary or peripheral artery disease (n = 961), physicians responsible for their care (n = 345), and administrators/healthcare leaders with responsibility for commissioning/procuring cardiovascular services (n = 126) were included. Narrative themes arising from the survey included patients' desire for more personalized healthcare, shared decision-making, and improved communication. Patients, administrators, and physicians perceived and experienced deficiencies in continuity of care, and all acknowledged the potential for data-driven techniques and novel technologies to address some of these shortcomings. Further, physicians and administrators saw the 'upstream' segment of the care journey-before diagnosis, at point of diagnosis, and when determining treatment-as key to enabling tangible improvements in patient experience and outcomes. Finally, despite acceptance that data sharing is critical to the success of such interventions, there remains persistent issues related to trust and transparency. The current fragmented care continuum could be improved and streamlined through the adoption of advanced data analytics and novel technologies, including diagnostic and monitoring techniques. Such an approach could enable the refocusing of healthcare from intermittent contacts and intervention-only focus to a more holistic patient view.

Continuity of care for older adults in a Canadian long-term care setting: a qualitative study

Background

Continuity of care has been shown to improve health outcomes and increase patient satisfaction. Goal-oriented care, a person-centered approach to care, has the potential to positively impact continuity of care. This study sought to examine how a goal-oriented approach impacts continuity of care in a long-term care setting.

Methods

Using a case study approach, we examined what aspects of goal-oriented care facilitate or inhibit continuity of care from the perspectives of administrators, care providers, and residents in a long-term care centre in Ontario, Canada. Data was collected through documentary evidence and semi-structured interviews.

Results

We analyzed six internal documents (e.g., strategic plan, client information package, staff presentations, evaluation framework, program logic model), and conducted 13 interviews. The findings indicated that the care provided through the goal-oriented approach program had elements that both facilitated and inhibited continuity of care. These factors are outlined according to the three types of continuity, including aspects of the program that influence informational, relational, and management continuity.

Conclusions

Aspects of the goal-oriented care approach that facilitate continuity can be targeted when designing person-centered care approaches. More research is needed on goal-oriented care approaches that have been implemented in other long-term care settings to determine if the factors identified here as influencing continuity are confirmed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08583-1.

Home-dwelling older adults' experiences of living with both frailty and multimorbidity: A meta-ethnography

OBJECTIVES

To systematically review qualitative studies about home-dwelling older adults' experiences of living with both frailty and multimorbidity.

METHODS

This study adopted a meta-ethnography; the databases included PubMed, Embase, CINAHL, Web of Science, PsycINFO, SCOPUS, and Google Scholar. Qualitative peer-reviewed articles in English were searched up to December 31, 2021. Themes and concepts were extracted through constant comparison across the included studies by three reviewers.

RESULTS

Of the 147 articles screened, nine qualitative articles, encompassing a total sample of 173 participants, were included. The four final synthesised themes were 'Being isolated in a closed life,' 'Being dependent on help from others,' 'Rebuilding to maximise quality of life,' and 'Struggling to live a meaningful life.'

CONCLUSION

Home-dwelling older adults with both frailty and multimorbidity are more likely to be socially isolated due to their physical limitations and lack of integration between hospital-based care and community healthcare services.

Belgium's Healthcare System: The Way Forward to Address the Challenges of the 21st Century Comment on "Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study"

In this paper we have tried, starting from the results of an analysis of the functioning of integrated care in the Belgian Health System by Martens et al, to design a strategy that could contribute to better addressing the challenges of the 21st century in Belgium. We proposed health system changes at the macro-, meso- and micro-level. We focused on health policy development and organization of care, emphasizing the importance of a shift from a hospital-centric towards a primary care based approach. Special attention was paid to the need for institutional reforms, in order to facilitate the further development of interprofessional integrated care, that focuses on the achievement of the life-goals of a person.