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Tietbohl CK, Dafoe A, Jordan SR, Huebschmann AG, Lum HD, Bowles KH, Jones CD. Palliative Care across Settings: Perspectives from Inpatient, Primary Care, and Home Health Care Providers and Staff. Am J Hosp Palliat Care 2023; 40:1371-1378. [PMID: 36908002 PMCID: PMC10495535 DOI: 10.1177/10499091231163156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Early introduction of palliative care can improve patient-centered outcomes for older adults with complex medical conditions. However, identifying the need for and introducing palliative care with patients and caregivers is often difficult. We aim to identify how and why a multi-setting approach to palliative care discussions may improve the identification of palliative care needs and how to facilitate these conversations. METHODS Descriptive qualitative study to inform the development and future pilot testing of a model to improve recognition of, and support for, unmet palliative care needs in home health care (HHC). Thematic analysis of semi-structured interviews with providers across inpatient (n = 11), primary care (n = 17), and HHC settings (n = 10). RESULTS Four key themes emerged: 1) providers across settings can identify palliative care needs using their unique perspectives of the patient's care, 2) identifying palliative care needs is challenging due to infrequent communication and lack of shared information between providers, 3) importance of identifying a clinical lead of patient care who will direct palliative care discussions (primary care provider), and 4) importance of identifying a care coordination lead (HHC) to bridge communication among multi-setting providers. These themes highlight a multi-setting approach that would improve the frequency and quality of palliative care discussions. CONCLUSIONS A lack of structured communication across settings is a major barrier to introducing and providing palliative care. A novel model that improves communication and coordination of palliative care across HHC, inpatient and primary care providers may facilitate identifying and addressing palliative care needs in medically complex older adults.
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Affiliation(s)
- Caroline K. Tietbohl
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO, USA
| | - Ashley Dafoe
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO, USA
| | - Sarah R. Jordan
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Amy G. Huebschmann
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Ludeman Family Center for Women’s Health Research, University of Colorado School of Medicine, Department of Medicine, Aurora, CO, USA
| | - Hillary D. Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kathryn H. Bowles
- New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, NY, USA
| | - Christine D. Jones
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO, USA
- Veterans Health Administration, Eastern Colorado Health Care System, Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Aurora, CO, USA
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Cole CS, Dafoe A, Tietbohl CK, Jordan SR, Huebschmann AG, Lum HD, Jones CD. Care challenges of home health patients living with dementia: a pathway forward with palliative care. BMC Palliat Care 2023; 22:122. [PMID: 37641096 PMCID: PMC10464392 DOI: 10.1186/s12904-023-01247-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Home health care (HHC) is a leading source of care support for older adults with serious illness, particularly patients living with dementia (PLWD). Demand for HHC is expected to continue to grow, driven by an aging population and preference for non-institutional care. HHC agencies are frequently under pressure to find effective approaches for improving care delivery and quality. One strategy that has the potential to improve the quality of life and patient satisfaction in HHC for PLWD is the integration of palliative care. Therefore, we sought to understand the experiences and needs of PLWD and their family caregivers specifically focusing on ways that HHC and palliative care may be integrated as part of the care transition from hospital to home, to better support PLWD and their families. METHODS We conducted a descriptive qualitative study focusing on the perspectives of patients, caregivers, and healthcare team members about palliative care delivery for patients receiving HHC. Interviews were audio-recorded and professionally transcribed. In this analysis, we specifically report on dementia-related content using an iterative, team-based thematic analysis approach. RESULTS We identified three themes: 1) 'Living in the Whirlwind' which describes the many competing demands on caregivers time and the associated feeling of loss of control, 2) 'Thinking Ahead' which describes the importance of thinking beyond the day-to-day tasks to begin planning for the future, and 3) 'Pathways Forward' which describes the integration of palliative care into HHC to provide enhanced support for PLWD and their caregivers. CONCLUSION In this qualitative study, our formative work identified the importance of providing anticipatory guidance (e.g., safety, advance care planning) coupled with emotional and pragmatic care supports (e.g., finding resources, navigating insurance) to sustain caregivers who are struggling with the whirlwind.
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Affiliation(s)
- Connie S Cole
- Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Ashley Dafoe
- Adult and Child Center for Outcomes Research and Delivery Science, School of Medicine, University of Colorado, Children's Hospital Colorado, Aurora, CO, USA
| | - Caroline K Tietbohl
- Adult and Child Center for Outcomes Research and Delivery Science, School of Medicine, University of Colorado, Children's Hospital Colorado, Aurora, CO, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sarah R Jordan
- Division of Healthcare Services, Molina Healthcare of Illinois, Oak Brook, IL, USA
| | - Amy G Huebschmann
- Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Adult and Child Center for Outcomes Research and Delivery Science, School of Medicine, University of Colorado, Children's Hospital Colorado, Aurora, CO, USA
- Ludeman Family Center for Women's Health Research, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Christine D Jones
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Veterans Health Administration, Eastern Colorado Health Care system, Aurora, CO, USA
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO, USA
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Tietbohl CK, Bergen C. "I was gonna ask you": How patients use agency framing to display engagement in primary care. Soc Sci Med 2022; 314:115496. [PMID: 36343460 DOI: 10.1016/j.socscimed.2022.115496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/22/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
The message that patients should be responsible for their health is pervasive. Health promotion campaigns encourage patients to "ask your doctor" about potential illnesses and treatments, preventive medicine guidelines call for patients to self-monitor to avoid future health problems, and models like shared decision-making advocate for greater patient involvement in medical decisions. Research shows that patients can participate in medical dialogue by asking questions, but that doing so is difficult due to the structure and social norms of medical visits. In this article, we ask: how can patients participate more actively in medical care? Drawing on video recordings of older patients (aged 65 and older) and primary care physicians, we use conversation analysis to describe one practice that patients use to demonstrate personal responsibility for their health; agency framing. This involves prefacing questions to the doctor with phrases that project a prior intended action, such as "I was gonna ask you", "I was gonna tell you" or "I wanted to ask you". Patients use agency framing to cast their questions as 1) independently motivated, 2) well-informed, and 3) personally responsible. Consequently, patients exert agency within the confines of the medical visit structure to resist the potential interpretation that their question was responsive to the doctor or to the local interactional context. Rather, agency framing allows patients to show that their question was considered independently. Questions designed with agency framing work to portray the speaker as a responsible patient who is not only meeting the bare minimum of expected health maintenance, but is staying ahead of medical problems. This article discusses the particular importance of this practice among older patients, for whom demonstrating a willingness and ability to cope with medical problems may be significant for maintaining independence.
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Affiliation(s)
- Caroline K Tietbohl
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA; Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.
| | - Clara Bergen
- Health & Innovations Division, Didi Hirsch Mental Health Services, Los Angeles, CA, USA; Division of Health Services Research and Management, City University of London School of Health Sciences, London, United Kingdom
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Abstract
The quality of healthcare communication can impact both experiences and outcomes. We highlight aspects of communication that can be systematically examined using Conversation Analysis (CA) and provide guidance about how researchers can incorporate CA into healthcare studies. CA is a qualitative method for studying naturally occurring communication by analyzing recurrent, systematic practices of verbal and nonverbal behavior. CA involves examining audio- or video-recorded conversations and their transcriptions to identify practices speakers use to communicate and interpret behavior. We explain what distinguishes CA from other methods that study communication and highlight three accessible CA approaches that researchers can use in their research design, analysis, or implementation of communication interventions. Specifically, these approaches focus on how talk is produced (specific words, framing, and syntax), by whom, and when it occurs in the conversation. These approaches can be leveraged to generate hypotheses and to identify patterns of behavior that inform empirically driven communication interventions.
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Affiliation(s)
- Caroline K Tietbohl
- Adult and Child Center for Health Outcomes Research and Delivery Science, Department of Family Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Anne E C White
- Department of Family Medicine, Sanford Institute for Empathy and Compassion, University of California San Diego, La Jolla, CA, USA
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Tietbohl CK. Empathic Validation in Physician-Patient Communication: An Approach to Conveying Empathy for Problems With Uncertain Solutions. Qual Health Res 2022; 32:413-425. [PMID: 34894864 DOI: 10.1177/10497323211056312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Interest in systematic approaches to improving clinical empathy has increased. However, conceptualizations of empathy are inconsistent and difficult to operationalize. Drawing on video recordings of primary care visits with older adults, I describe one particular communication strategy for conveying empathy-empathic validation. Using conversation analysis, I show that the design of empathic validations and the context in which they are delivered are critical to positive patient responses. Effective empathic validations must (a) demonstrate shared understanding and (b) support the patient's position. Physicians provided empathic validation when there was no medical solution to offer and within this context, for three purposes: (1) normalizing changes in health, (2) acknowledging individual difficulty, and (3) recognizing actions or choices. Empathic validation is a useful approach because it does not rely on patients' ability to create an "empathic opportunity" and has particular relevance for older adults.
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Affiliation(s)
- Caroline K Tietbohl
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), Children's Hospital Colorado, 129263University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Tietbohl CK, Rendle KAS, Halley MC, May SG, Lin GA, Frosch DL. Implementation of Patient Decision Support Interventions in Primary Care: The Role of Relational Coordination. Med Decis Making 2015; 35:987-98. [PMID: 26314727 DOI: 10.1177/0272989x15602886] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 07/15/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND The benefits of patient decision support interventions (DESIs) have been well documented. However, DESIs remain difficult to incorporate into clinical practice. Relational coordination (RC) has been shown to improve performance and quality of care in health care settings. This study aims to demonstrate how applying RC theory to DESI implementation could elucidate underlying issues limiting widespread uptake. METHODS Five primary care clinics in Northern California participated in a DESI implementation project. We used a deductive thematic approach guided by behaviors outlined in RC theory to analyze qualitative data collected from ethnographic field notes documenting the implementation process and focus groups with health care professionals. We then systematically compared the qualitative findings with quantitative DESI distribution data. RESULTS Based on DESI distribution rates, clinics were placed into 3 performance categories: high, middle, and low. Qualitative data illustrated how each clinic's performance related to RC behaviors. Consistent with RC theory, the high-performing clinic exhibited frequent, timely, and accurate communication and positive working relationships. The 3 middle-performing clinics exhibited high-quality communication within physician-staff teams but limited communication regarding DESI implementation across the clinic. The lowest-performing clinic was characterized by contentious relationships and inadequate communication. LIMITATIONS Limitations of the study include nonrandom selection of clinics and limited geographic diversity. In addition, ethnographic data collected documented only DESI implementation practices and not larger staff interactions contributing to RC. CONCLUSIONS These findings suggest that a high level of RC within clinical settings may be a key component and facilitator of successful DESI implementation. Future attempts to integrate DESIs into clinical practice should consider incorporating interventions designed to increase positive RC behaviors as a potential means to improve uptake.
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Affiliation(s)
- Caroline K Tietbohl
- University of California, Los Angeles, Los Angeles, CA, USA (CKT, DLF),Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA (CKT, KASR, MCH, SGM, DLF)
| | - Katharine A S Rendle
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA (CKT, KASR, MCH, SGM, DLF),Cancer Prevention Fellowship Program, Division of Cancer Prevention, National Cancer Institute, Bethesda, MD, USA (KASR)
| | - Meghan C Halley
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA (CKT, KASR, MCH, SGM, DLF)
| | - Suepattra G May
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA (CKT, KASR, MCH, SGM, DLF),Precision Health Economics, Los Angeles, CA, USA (SGM)
| | - Grace A Lin
- University of California, San Francisco, CA, USA (GAL)
| | - Dominick L Frosch
- University of California, Los Angeles, Los Angeles, CA, USA (CKT, DLF),Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA (CKT, KASR, MCH, SGM, DLF),Gordon and Betty Moore Foundation, Palo Alto, CA, USA (DLF)
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May SG, Cheng PH, Tietbohl CK, Trujillo L, Reilly K, Frosch DL, Lin GA. Shared medical appointments to screen for geriatric syndromes: preliminary data from a quality improvement initiative. J Am Geriatr Soc 2014; 62:2415-9. [PMID: 25440111 DOI: 10.1111/jgs.13142] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Older adults are at greater risk of developing conditions that affect health outcomes, quality of life, and costs of care. Screening for geriatric conditions such as memory loss, fall risk, and depression may contribute to the prevention of adverse physical and mental comorbidities, unnecessary hospitalizations, and premature nursing home admissions. Because screening is not consistently performed in primary care settings, a shared medical appointment (SMA) program was developed to fill this gap in care. The goals of the program were to improve early identification of at-risk individuals and ensure appropriate follow-up for memory loss, fall risk, and depression; facilitate discussion about prevention, diagnosis, and treatment of these conditions; implement strategies to reduce risks for these conditions; and increase access to screening and expand preventive health services for older adults. Between August 2011 and May 2013, 136 individuals aged 60 and older participated in the program. Three case studies highlighting the psychosocial and physiological findings of participation in the program are presented. Preliminary data suggest that SMAs are an effective model of regularly screening at-risk older adults that augments primary care practice by facilitating early detection and referral for syndromes that may otherwise be missed or delayed.
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Affiliation(s)
- Suepattra G May
- Research Institute, Palo Alto Medical Foundation, Palo Alto, California
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Abstract
Purpose The purpose of this study was to explore the everyday barriers to and practices of low-income patients managing their diabetes. Methods The study team conducted semistructured qualitative interviews with 20 patients with type 2 diabetes who were receiving care at safety-net clinics in Southern California. Transcripts were analyzed using grounded theory to identify emergent themes across participants. Results Participants described managing diabetes with limited financial resources as often a game of balance and negotiation, whereby purchasing healthy foods is abandoned because of a more pressing concern in their life. Although participants described strategic attempts at incorporating healthy dietary practices for diabetes management into their daily decisions, these efforts were significantly impeded by the existence of persistent and seemingly insurmountable barriers. Conclusions Although the challenges that low-income patients face in managing their diabetes may seem insurmountable at times, there are several ways that health care providers can help reduce the burden of these challenges, including tailoring their recommendations to incorporate the everyday socioeconomic environment of patients and engaging in clear, open communication with patients.
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Affiliation(s)
- Katharine A. S. Rendle
- University of Michigan, Ann Arbor, Michigan (Ms Rendle)
- Palo Alto Medical Foundation Research Institute, Palo Alto, California (Ms Rendle, Dr May, Ms Tietbohl, Dr Frosch)
- University of California, Los Angeles, California (Mr Uy, Dr Mangione, Dr Frosch)
| | - Suepattra G. May
- University of Michigan, Ann Arbor, Michigan (Ms Rendle)
- Palo Alto Medical Foundation Research Institute, Palo Alto, California (Ms Rendle, Dr May, Ms Tietbohl, Dr Frosch)
- University of California, Los Angeles, California (Mr Uy, Dr Mangione, Dr Frosch)
| | - Visith Uy
- University of Michigan, Ann Arbor, Michigan (Ms Rendle)
- Palo Alto Medical Foundation Research Institute, Palo Alto, California (Ms Rendle, Dr May, Ms Tietbohl, Dr Frosch)
- University of California, Los Angeles, California (Mr Uy, Dr Mangione, Dr Frosch)
| | - Caroline K. Tietbohl
- University of Michigan, Ann Arbor, Michigan (Ms Rendle)
- Palo Alto Medical Foundation Research Institute, Palo Alto, California (Ms Rendle, Dr May, Ms Tietbohl, Dr Frosch)
- University of California, Los Angeles, California (Mr Uy, Dr Mangione, Dr Frosch)
| | - Carol M. Mangione
- University of Michigan, Ann Arbor, Michigan (Ms Rendle)
- Palo Alto Medical Foundation Research Institute, Palo Alto, California (Ms Rendle, Dr May, Ms Tietbohl, Dr Frosch)
- University of California, Los Angeles, California (Mr Uy, Dr Mangione, Dr Frosch)
| | - Dominick L. Frosch
- University of Michigan, Ann Arbor, Michigan (Ms Rendle)
- Palo Alto Medical Foundation Research Institute, Palo Alto, California (Ms Rendle, Dr May, Ms Tietbohl, Dr Frosch)
- University of California, Los Angeles, California (Mr Uy, Dr Mangione, Dr Frosch)
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