Health care professionals' experiences and enactment of person-centered care at a multidisciplinary outpatient specialty clinic

Inter-relationships between cardiovascular, renal and metabolic diseases: Underlying evidence and implications for integrated interdisciplinary care and management

Cardiovascular, renal and metabolic (CaReMe) diseases are individually among the leading global causes of death, and each is associated with substantial morbidity and mortality. However, as these conditions commonly coexist in the same patient, the individual risk of mortality and morbidity is further compounded, leading to a considerable healthcare burden. A number of pathophysiological pathways are common to diseases of the CaReMe spectrum, including neurohormonal dysfunction, visceral adiposity and insulin resistance, oxidative stress and systemic inflammation. Because of the shared pathology and common co-occurrence of the CaReMe diseases, the value of managing these conditions holistically is increasingly being realized. A number of pharmacological and non-pharmacological approaches have been shown to offer simultaneous metabolic, cardioprotective and renoprotective benefits, leading to improved patient outcomes across the CaReMe spectrum. In addition, increasing value is being placed on interdisciplinary team-based and coordinated care models built on greater integration between specialties to increase the rate of early diagnosis and adherence to practice guidelines, and improve clinical outcomes. This interdisciplinary approach also facilitates integration between primary and specialty care, improving the patient experience, optimizing resources, and leading to efficiencies and cost savings. As the burden of CaReMe diseases continues to increase, implementation of innovative and integrated care delivery models will be essential to achieve effective and efficient chronic disease management and to ensure that patients benefit from the best care available across all three disciplines.

Evaluating person-centered care in neurological outpatient care: a mixed-methods content validity study

BACKGROUND

Person-centered care (PCC) is gaining increased attention. PCC concerns the whole person behind the disease and can improve care for people with long-term conditions such as multiple sclerosis (MS) and Parkinson's disease (PD). However, there is a lack of tools to assess PCC from the patients' perspective, particularly in outpatient care. The Person-Centered Care instrument for outpatient care (PCCoc) is an instrument under development with the intention to fill this gap. The aim of this study was to test the user-friendliness and content validity of the PCCoc as experienced by persons with MS and PD in neurological outpatient care.

METHODS

Twenty persons with MS or PD completed the 35-item PCCoc followed by an interview regarding the instrument's intelligibility and ease of use to assess its user-friendliness. Participants then rated the relevance of each item. These ratings were used to calculate the content validity index (CVI) for individual items (I-CVI) and for the overall scale (S-CVI).

RESULTS

It took a median of 5 min for participants to complete the PCCoc. Instrument instructions were found clear, items easy to understand, and response categories distinct. No important missing areas were reported. I-CVI values ranged between 0.75 and 1, and S-CVI was 0.96.

CONCLUSIONS

We found support for the user-friendliness and content validity of the PCCoc among persons with MS and PD, suggesting that the PCCoc can be useful for evaluating and developing PCC in neurological outpatient care. Further testing in broader contexts, including psychometric testing, is warranted to establish its usefulness.

Translating theory into clinical practice: a qualitative study of clinician perspectives implementing whole person care

Whole Person Care (WPC) is an emerging framework that emphasises the clinician's role in empowering patient healing. However, reliably translating a framework's theory into practice is a recognised challenge for clinicians. Observational studies have revealed discrepancies between a clinician's stated values in theory and how these may be implemented in practice. The aim of this qualitative study is to bridge the gap between the theory of WPC and its practical implementation by clinicians. We interviewed a diverse group of 34 clinicians attending the 2017 International Whole Person Care Congress to explore (1) their conceptions of WPC in theory as well as (2) how they monitor their practice in real time. Data were analysed using Grounded Theory Methodology. Preliminary results were presented in the form of a workshop at the 2019 International Whole Person Care Congress to validate our findings with relevant stakeholders. The results revealed a vision of WPC that highlighted themes of the clinician's way of being, seeing the person beyond the disease, and the clinician-patient relationship. Our results demonstrate that clinicians use a range of strategies to monitor their practice in real time. Mindfulness and self-awareness were frequently cited as being crucial to this ability of self-regulating their practice. This study helps establish a unifying framework of WPC based on a diverse range of clinician-reported experiences. More importantly, it sheds light on the range of strategies employed by clinicians who monitor their practice in real time. These collected insights will be of interest to any clinician interested in translating their stated values into their clinical practice more reliably.

Health Care Professionals' Experiences of Facilitating Patient Activation and Empowerment in Chronic Illness using a Person-Centered and Strengths-Based Self-Management Program

OBJECTIVE

Patients with chronic illness who are empowered and activated are more likely to engage in self-management in order to stabilise their condition and enhance their quality of life. This study aimed to explore Health Care Professional's (HCP) assessment of a person-centered intervention called 'The Bodyknowledging Program' (BKP) for the facilitation of empowerment and patient activation in the context of chronic illness.

METHODS

This study employed a qualitative process evaluation after programme completion. Data was collected through focus-groups and individual interviews with HCPs and content analysis was used in the analysis.

RESULTS

Four themes were identified: 1) Shifts towards the patient-perspective, 2) The value of a patient-centered conceptual framework, 3) Patient activation through dialogue based support and 4) Challenging competencies. Discussion: This study introduces 'The Bodyknowledging Program' as a useful tool to uncover patients' needs and to activate and empower them to take more responsibility for their health through self-care management. The usability of the new intervention depends on HCP's ability to develop their counselling skills and changing their approach towards utilising patients' individual resources in the promotion of their health.

Electronic patient-reported outcomes (e-PROMs) in palliative cancer care: a scoping review

Background

In palliative oncology settings, electronic patient-reported outcome (PRO) assessment can play an important role in supporting clinical activities for clinicians and patients. This scoping review aims to map the technological innovation of electronic patient-reported outcome measures (e-PROMs) in cancer palliative care and how PRO data collected through e-PROMs can influence the monitoring and management of symptoms and enable better communication between health professionals and patients.

Methods

A scoping review study was designed according to the Arksey and O'Malley framework. Medline, Embase, Web of Science, SCOPUS, PsycINFO and CINAHL and gray literature sources were consulted. The inclusion criteria were people over 18 years old receiving palliative and/or end-of-life care using e-PROMs.

Results

Thirteen primary studies were included: nine quantitative studies, two qualitative studies, and two mixed-method studies. The recently developed software that supports e-PROMs allows patients to receive feedback on their symptoms, helps clinicians prioritize care needs and monitors patients’ conditions as their symptoms change. Electronic PRO data prompt difficult, end-of-life communication between clinicians and patients to better organize care in the last phase of life.

Conclusion

This work shows that electronic PRO data assessment provides valuable tools for patients’ well-being and the management of symptoms; only one study reported conflicting results. However, with studies lacking on how clinicians can use these tools to improve communication with patients, more research is needed.

Operationalisation of person-centred care in a real-world setting: a case study with six embedded units

Background

Although person-centred care (PCC) is growing globally in popularity it is often vague and lacks conceptual clarity and definition. The ambiguity stretches from PCC’s underlying philosophical principles and definitions of the concept to how it is operationalised and practised on the ground by health care professionals. We explore how the PCC model by the Gothenburg University Centre for Person-centred Care (GPCC) was operationalised in a real-world setting by using a set of recommendations by Fixsen and others that define and structure the core components of innovations in four distinct but interrelated components: philosophical principles and values, contextual factors, structural elements and core practices. Thus, this study aimed to increase knowledge about core practices in PCC in six health care units in real-world circumstances.

Methods

A case study with six embedded health care units was conducted from 2016 to 2019. We collected data from three sources: interviews (n = 12) with change agents, activity logs and written documents. Data were triangulated, and core practices were identified and deductively coded to the PCC model’s structural elements: initiating, working and safeguarding the partnership with patients.

Results

We identified operationalisations of PCC in line with the three structural elements in the GPCC model at all included health care units. A range of both similarities and dissimilarities between units were identified, including the level of detail in describing PCC practices, when these practices were conducted and by whom at the workplace. The recommendations for describing the core components of PCC also helped us identify how some operationalisations of PCC seemed more driven by contextual factors, including a new regulation for planning and documenting care across health care specialities.

Conclusions

Our findings show how PCC is operationalised in different health care units in a real-world setting based on change agents’ understanding of the concept and their unique context. Increased knowledge of PCC and its philosophical principles and values, contextual factors, structural elements and core practices, is necessary to build a common understanding of the PCC-concept. Such knowledge is essential when PCC is operationalised as part of implementation efforts in health care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08516-y.

Patients’ and Nurses’ Perceptions of Diabetes Self-Management in Oman: A Qualitative Study

Patient-centered care enhances diabetes self-management; however, the primary care nurse’s role in promoting diabetes self-management within a patient-centered care model is unexplored. This study investigated the perceptions of Omani patients with type-2 diabetes and their clinic nurses on the nurses’ role in promoting diabetes self-management within a patient-centered care approach. The thematic analysis of the data from individual interviews with patients (n = 24) revealed two themes: patients experienced “missteps on an unclear path” and “nurses doing their best.” Patients struggled to identify treatment goals and faltered in their attempts to adopt diabetes self-management behaviors. The nurses’ role was perceived as task-oriented. Nurse narratives (n = 21) revealed that very few nurses were aware of the patient-centered care philosophy. A theme emerged of nurses “needing a new perspective” to transition their care delivery to align with the patient-centered care model. Nurses expected patients to comply with their instructions and missed opportunities for assessment, engagement, and collaborative problem-solving during patient encounters. The shift from a physician-based medical model to a patient-centered primary care delivery system may necessitate that nurses engage more effectively with patients, collaborate on an individual treatment plan, and motivate them to adopt self-management behaviors.

Physician-led in-hospital multidisciplinary team conferences with multiple medical specialities present - A scoping review

INTRODUCTION

Multidisciplinary Team Conferences (MDTs) are complex interventions in the modern healthcare system and they promote a model of coordinated patient care and management. However, MDTs within chronic diseases are poorly defined. Therefore, the aim of this scoping review was to summarise the current literature on physician-led in-hospital MDTs in chronic non-malignant diseases.

METHOD

Following the PRISMA-ScR guideline for scoping reviews, a search on MDT interventions in adult patients, with three or more medical specialties represented, was performed.

RESULTS

We identified 2790 studies, from which 8 studies were included. The majority of studies were non-randomised and focused on a single disease entity such as infective endocarditis, atrial fibrillation, IgG4-related disease, or arterial and venous thrombosis. The main reason for referral was confirmation or establishment of a diagnosis, and the MDT members were primarily from medical specialties gathered especially for the MDT. Outcomes of the included studies were grouped into process indicators and outcome indicators. Process indicators included changes in diagnostic confirmation as well as therapeutic strategy and management. All studies reporting process indicators demonstrated significant changes before and after the MDT.

CONCLUSION

MDTs within chronic diseases appeared highly heterogeneous with respect to structure, reasons for referral, and choice of outcomes. While process indicators, such as change in diagnosis, and treatment management/plan seem improved, such have not been demonstrated through outcome indicators.

Nursing Professional Pride Scale: Turkish adaptation and psychometric properties

PURPOSE

This study established the Turkish validity and reliability of the Nursing Professional Pride Scale (NPPS).

DESIGN AND METHODS

The study was a descriptive and cross-sectional conducted in Turkey. The sample consisted of 301 nurses with at least one year of work experience. Data were collected online between August and September 2020 and analyzed using the SPSS 25.0 and LISREL 8.80. Confirmatory factor analysis, linguistic and content validity, and reliability analyses were performed.

FINDINGS

The Turkish version of the Nursing Professional Pride Scale (NPPS-TR) had a content validity index of 0.95 and Cronbach's alpha of 0.89 and a five-factor structure with acceptable psychometric properties (χ ² /df = 2.85, RMSEA = 0.079, CFI = 0.92, SRMR = 0.08).

PRACTICE IMPLICATIONS

The NPPS-TR is a valid and reliable measure of professional pride in Turkish nurses.

Commentary: how person-centred is pharmaceutical care?

Health systems in many countries are currently undergoing an evolution towards more person-centred care. However, an overview of the literature shows that there is little or no guidance available on how to apply person-centred care to pharmaceutical care and clinical pharmacy practices. In this paper we apply a model for person-centred care created by a national multidisciplinary research centre in Gothenburg, Sweden, to the clinical work tasks of outpatient and inpatient pharmacists and describe how pharmaceutical care can become more person-centred.

[The innovation characteristics of person-centred care as perceived by healthcare professionals: an interview study employing a deductive-inductive content analysis guided by the consolidated framework for implementation research

BACKGROUND

Person-centred care (PCC) is promoted as an innovation that will improve patients' rights and increase their participation in healthcare. Experience shows that the implementation of PCC is challenging and often results in varying levels of adoption. How health care professionals (HCPs) perceive an innovation such as PCC is an important factor to consider in implementation. Yet, such studies are scarce. Thus, in a sample of healthcare units in a region in Sweden, involved in a transition to PCC, we aimed to investigate HCPs' perceptions of PCC.

METHODS

An interview study was conducted in 2018 during the implementation of PCC with HCPs (n = 97) representing diverse vocational roles in six healthcare contexts. Data were collected via focus groups (n = 15), dyadic interviews (n = 5), and individual interviews (n = 22) and analysed using a deductive-inductive content analysis. The deductive approach was guided by the Consolidated Framework for Implementation Research (CFIR), followed by an inductive analysis to describe HCPs' in-depth perceptions of PCC in relation to each of the CFIR constructs.

RESULTS

Eight constructs from two of the CFIR domains, Intervention characteristics and Inner setting, were used to code HCPs' perceptions of PCC. One construct, Observability, was added to the coding sheet to fully describe all the data. The constructs Relative advantage, Complexity, Compatibility, Observability, and Available resources were discussed in depth by HCPs and resulted in rich and detailed data in the inductive data analysis. This analysis showed large variations in perceptions of PCC among HCPs, based on factors such as the PCCs ethical underpinnings, its operationalisation into concrete working routines, and each HCPs' unique recognition of PCC and the value they placed on it.

CONCLUSIONS

We identified nine CFIR constructs that seem pertinent to HCPs' perceptions of PCC. HCPs report an array of mixed perceptions of PCC, underlining its complex nature. The perceptions are shaped by a range of factors, such as their individual understandings of the concept and the operationalisation of PCC in their local context. Stakeholders in charge of implementing PCC might use the results as a guide, delineating factors that may be important to consider in a wide range of healthcare contexts.

Digital tools as promoters for person-centered care practices in chronic care? Healthcare professionals' experiences from rheumatology care

Background

Person-centered care (PCC) emphasize the importance of supporting individuals’ involvement in care provided and self-care. PCC has become more important in chronic care as the number of people living with chronic conditions is increasing due to the demographic changes. Digital tools have potential to support interaction between patients and healthcare providers, but empirical examples of how to achieve PCC in chronic care and the role of digital tools in this process is limited. The aim of this study was to investigate strategies to achieve PCC used by the healthcare professionals at an outpatient Rheumatology clinic (RC), the strategies’ relation to digital tools, and the perceived impact of the strategies on healthcare professionals and patients.

Methods

A single case study design was used. The qualitative data consisted of 14 semi-structured interviews and staff meeting minutes, covering the time period 2017–2019. The data were analyzed using conventional content analysis, complemented with document analyses.

Results

Ten strategies on two levels to operationalize PCC, and three categories of perceived impact were identified. On the individual patient level strategies involved several digital tools focusing on flexible access to care, mutual information sharing and the distribution of initiatives, tasks, and responsibilities from provider to patients. On the unit level, strategies concerned involving patient representatives and individual patients in development of digital services and work practices. The roles of both professionals and patients were affected and the importance of behavioral and cultural change became clear.

Conclusions

By providing an empirical example from chronic care the study contributes to the knowledge on strategies for achieving PCC, how digital tools and work practices interact, and how they can affect healthcare staff, patients and the unit. A conclusion is that the use of the digital tools, spanning over different dimensions of engagement, facilitated the healthcare professionals’ interaction with patients and the patients’ involvement in their own care. Digital tools complemented, rather than replaced, care practices.

Time-driven activity-based costing for patients with multiple chronic conditions: a mixed-method study to cost care in a multidisciplinary and integrated care delivery centre at a university-affiliated tertiary teaching hospital in Stockholm, Sweden

OBJECTIVE

This study can be applied to cost the complex non-standardised processes used to treat patients with multiple chronic conditions.

DESIGN

A mixed-method approach to cost analysis, following a modified healthcare-specific version of the seven-step Time-Driven Activity-Based Costing (TDABC) approach.

SETTING

A multidisciplinary integrated and person-centred care delivery centre at a university-affiliated tertiary teaching hospital in Stockholm, Sweden, designed to improve care coordination for patients with multiple chronic conditions, specifically diabetes, cardiovascular disease and kidney disease.

PARTICIPANTS

314 patients (248 men and 66 women) fit inclusion criteria. Average age was 80 years.

RESULTS

This modified TDABC analysis costed outpatient care for patients with multiple chronic conditions. The approach accounted for the difficulty of conceptualising care cycles. The estimated total cost, stratified by resources, can be reviewed together with existing managerial accounting statements to inform management decisions regarding the multidisciplinary centre.

CONCLUSIONS

This article demonstrates that the healthcare-specific seven-step approach to TDABC can be applied to cost care for patients with multiple chronic conditions, where pathways are not yet discernable. It became clear that there was a need for slight methodological adaptations for this particular patient group to make it possible to cost these pathways, stratified by activity and resource. The value of this approach can be discerned from the way management incorporated the results of this analysis into the development of their hospital strategy. In the absence of integrated data infrastructures that can link patients and resources across financial, clinical and process data sets, the scalability of this method will be difficult.

Extreme Consumers of Health Care: Patterns of Care Utilization in Patients with Multiple Chronic Conditions Admitted to a Novel Integrated Clinic

PURPOSE

Patients with multiple chronic conditions (MCC) of diabetes, cardiovascular and kidney diseases; hereafter referred to as HND (heart/cardiac-, nephrology-, diabetes mellitus-) patients, are high utilizers of health care. However, the care received is often insufficiently coordinated between different specialties and health-care providers. This study aims to describe the characteristics of HND patients and to explore the initial effects of a multidisciplinary and person-centered care on total care utilization.

PATIENTS AND METHODS

We conducted a sub-study of HND patients recruited in an ongoing randomized trial CareHND (NCT03362983). Descriptive statistics of patient characteristics, including diagnostic data and Charlson Comorbidity Index scores, informed a comparison of care utilization patterns between HND patient care and traditional care. Diagnostic and care utilization data were collected from a regional database. Wilcoxon signed ranked sum tests were performed to compare care utilization frequencies between the two groups.

RESULTS

Patients included in the study were care-intensive with several diagnoses and experienced a high level of variation in care utilization and diagnoses profiles. HND patients were sicker than their counterparts in the control group. Utilization indicators were similar between the two arms. There was some indication that the HND center is beginning to perform as expected, but no results were statistically significant.

CONCLUSION

This study sits among many studies reporting difficulties obtaining statistically significant findings for MCC patients. However, previous research has shown that the key components of this intervention, such as integrated, multidisciplinary, inter-professional collaboration within patient-centered care have had a positive effect on health-care outcomes. More innovative methods beyond the RCT, such as machine learning should be explored to evaluate the impact of integrated care interventions on care utilization.

Multidisciplinary Chronic Kidney Disease Clinic Practices: A Scoping Review

Background:

Multidisciplinary chronic kidney disease (CKD) clinics improve patient outcomes but their optimal design is unclear.

Objective:

To perform a scoping review to identify and describe current practices (structure, function) associated with multidisciplinary CKD clinics.

Design:

Scoping review.

Setting:

Databases included Medline, EMBASE, Cochrane, and CINAHL.

Patients:

Patients followed in multidisciplinary CKD clinics globally.

Measurements:

Multidisciplinary CKD clinic composition, entry criteria, follow-up, and outcomes.

Methods:

We systematically searched the literature to identify randomized controlled trials, non-randomized interventional studies, or observational studies of multidisciplinary CKD clinics defined by an outpatient setting where two or more allied health members (with or without a nephrologist) provided longitudinal care to 50 or more adult or pediatric patients with CKD. Included studies were from 2002 to present. Searches were completed on August 10, 2018. Title, abstracts, and full texts were screened independently by two reviewers with disagreements resolved by a third. We abstracted data from included studies to summarize multidisciplinary CKD clinic team composition, entry criteria, follow-up, and processes.

Results:

40 studies (8 randomized controlled trials and 32 non-randomized interventional studies or observational studies) involving 23 230 individuals receiving multidisciplinary CKD care in 12 countries were included. Thirty-eight focused on adults (27 with CKD, 10 incident dialysis patients, one conservative therapy) while two studies focused on adolescents or children with CKD. The multidisciplinary team included a mean of 4.6 (SD 1.5) members consisting of a nephrologist, nurse, dietician, social worker, and pharmacist in 97.4%, 86.8%, 84.2%, 57.9%, and 42.1% of studies respectively. Entry criteria to multidisciplinary CKD clinics ranged from glomerular filtration rates of 20 to 70 mL/min/1.73m² or CKD stages 1 to 5 without any proteinuria or risk equation-based criteria. Frequency of follow-up was variable by severity of kidney disease. Team member roles and standardized operating procedures were infrequently reported.

Limitations:

Unstandardized definition of multidisciplinary CKD care, studies limited to CKD defined by glomerular filtration rate, and lack of representation from countries other than Canada, Taiwan, the United States, and the United Kingdom.

Conclusions:

There is heterogeneity in multidisciplinary CKD team composition, entry criteria, follow-up, and processes with inadequate reporting of this complex intervention. Additional research is needed to determine the best model for multidisciplinary CKD clinics.

Trial registration:

Not applicable.