Patients' Perspectives on Plans Generated During Primary Care Visits and Self-Reported Adherence at 3 Months: Data From a Randomized Trial

BACKGROUND

Effective primary care necessitates follow-up actions by the patient beyond the visit. Prior research suggests room for improvement in patient adherence.

OBJECTIVE

This study sought to understand patients' views on their primary care visits, the plans generated therein, and their self-reported adherence after 3 months.

METHODS

As part of a large multisite cluster randomized pragmatic trial in 3 health care organizations, patients completed 2 surveys-the first within 7 days after the index primary care visit and another 3 months later. For this analysis of secondary outcomes, we combined the results across all study participants to understand patient adherence to care plans. We recorded patient characteristics and survey responses. Cross-tabulation and chi-square statistics were used to examine bivariate associations, adjusting for multiple comparisons when appropriate. We used multivariable logistic regression to assess how patients' intention to follow, agreement, and understanding of their plans impacted their plan adherence, allowing for differences in individual characteristics. Qualitative content analysis was conducted to characterize the patient's self-reported plans and reasons for adhering (or not) to the plan 3 months later.

RESULTS

Of 2555 patients, most selected the top box option (9=definitely agree) that they felt they had a clear plan (n=2011, 78%), agreed with the plan (n=2049, 80%), and intended to follow the plan (n=2108, 83%) discussed with their provider at the primary care visit. The most common elements of the plans reported included reference to exercise (n=359, 14.1%), testing (laboratory, imaging, etc; n=328, 12.8%), diet (n=296, 11.6%), and initiation or adjustment of medications; (n=284, 11.1%). Patients who strongly agreed that they had a clear plan, agreed with the plan, and intended to follow the plan were all more likely to report plan completion 3 months later (P<.001) than those providing less positive ratings. Patients who reported plans related to following up with the primary care provider (P=.008) to initiate or adjust medications (P≤.001) and to have a specialist visit were more likely to report that they had completely followed the plan (P=.003). Adjusting for demographic variables, patients who indicated intent to follow their plan were more likely to follow-through 3 months later (P<.001). Patients' reasons for completely following the plan were mainly that the plan was clear (n=1114, 69.5%), consistent with what mattered (n=1060, 66.1%), and they were determined to carry through with the plan (n=887, 53.3%). The most common reasons for not following the plan were lack of time (n=217, 22.8%), having decided to try a different approach (n=105, 11%), and the COVID-19 pandemic impacted the plan (n=105, 11%).

CONCLUSIONS

Patients' initial assessment of their plan as clear, their agreement with the plan, and their initial willingness to follow the plan were all strongly related to their self-reported completion of the plan 3 months later. Patients whose plans involved lifestyle changes were less likely to report that they had "completely" followed their plan.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03385512; https://clinicaltrials.gov/study/NCT03385512.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/30431.

Chaplain reported plans for end-of-life care conversations: Role clarity for the spiritual care specialists

The present study examined chaplain reported plans for patient conversations regarding end-of-life (EOL) care through the lens of multiple goals. Chaplains (n = 69) were asked to curate a plan for engaging with a patient about EOL treatment options, including how they would engage in the conversation and what they would plan to discuss. Findings indicated that plans primarily consisted of relational and identity goals, with a majority navigating multiple goal orientations. Content overwhelmingly involved developing rapport with patients, eliciting patient preferences for care, and serving as a patient liaison. The current study addresses the paucity of research around the role a chaplain plays on the interdisciplinary team and their respective approach to EOL conversations. Examination of curated plans affords insight to what content is prioritized and which conversational goals are present. Integration of multiple goals offers preliminary evidence for conversational quality. Awareness of goal approach and content prioritized affords clarity on how chaplains can be called upon to support members of the interdisciplinary care team.

A Multiple Goals Approach to Exploring Social Worker Conversational Plans for Advance Care Treatment with Terminally Ill Patients

Social workers play an integral role in end-of-life planning and patient outcomes, and yet how social workers approach such conversations with patients is not well understood. The current study employed a cross-sectional design to examine social worker planned communication about end-of-life care using a multiple goals framework. Recruited from online listservs, a content analysis was conducted with social worker curated plans (n = 20) for end-of-life conversations. Plans were coded for topics and content alignment with instrumental, identity, and relational goal types. Topics found were related to eliciting patient goals and the utilization of written resources. A substantial percentage of social workers also noted the inclusion of other parties in the conversation. Findings suggested that content was predominately instrumental (i.e. task-oriented) with an overwhelming majority adhering to multiple conversational goals. Plan content affords insight to occupational orientation and prioritization during conversations with patients. Further, identifying how the majority of planned responses integrate multiple goals simultaneously gives credence to existing research regarding enhanced conversational effectiveness when social workers are present on the palliative care team.

Supporting students undertaking the Specialist Practitioner Qualification in District Nursing

The ever-evolving role of the Specialist Practitioner Qualified District Nurse (SPQDN) presents an increasing number of challenges for Practice Teachers and mentors in preparing SPQDN students for the elevated level clinical and transformational leadership necessary to ensure high-quality patient care. The daily challenges of clinical practice within the community nursing setting in addition to undertaking educational interventions in the clinical arena demand that a structured approach to supervision and mentorship is crucial. Employing learning plans to assess individual students learning needs, prepare plans for educational developments and interventions and evaluate a student's progress can be a helpful tool in aiding the learning journey for both the SPQDN student and Practice Teacher or mentor. This article examines how and why a structured learning plan may be used in supporting learning and competency in achieving the necessary level of practice to meet the requirements of the SPQDN.

Suicidal Plans and Attempts Among Adolescents in Mongolia

BACKGROUND

Although 75% of suicides occur in low- and middle-income countries, few studies have examined suicidal behaviors among young people in these countries.

AIMS

This study aimed to examine what individual characteristics were associated with suicidal plans and attempts among Mongolian youth and whether suicidal risks and behaviors varied by urban and rural locations.

METHOD

Logistic regression analyses were utilized to investigate suicidal plans and attempts among 5,393 adolescents using the Global Student Health Survey - 2013.

RESULTS

Adolescents who lived in urban areas were at higher risk for suicidal plans and behaviors than those who lived in rural areas; however, the patterns of suicidal risks were similar. Specifically, individual characteristics, such as being female, feeling lonely and worried, smoking cigarettes, drinking alcohol, and having fights at school, were associated with suicidal plans and behaviors regardless of the residential places.

LIMITATIONS

A number of important variables have not been included in the questionnaire such as depression, family and parental support, household income, family constructs etc.

CONCLUSION

Given the comparable patterns of risk between urban and rural adolescents and the relatively high rates of suicidal plans and attempts, similar mental health services and interventions are necessitated for both urban and rural areas.

Goals and Plans of Incarcerated Men Postrelease

Prior research has not examined the self-identified goals and plans of incarcerated people as they approach release from prison. This study analyzed the goals and plans generated during a motivational interviewing counseling session of incarcerated men who participated in a randomized controlled trial of a smoking abstinence intervention in a tobacco-free prison in the northeastern United States. Using thematic analysis, 53 written goals and plans were independently coded by trained research assistants to identify major themes that included (1) staying smoke-free or reducing the number of cigarettes smoked postrelease, (2) engaging in physical activities to improve health and wellness, and (3) spending time with family and/or friends. Implications for working with inmates to identify their plans and goals to remain smoke-free after incarceration are discussed.

The lebanese society of cardiology: plans and perspectives, navigating against contrary winds and progressing against all odds

Scientific societies in medicine theoretically aim to improve a medical field as a science; however, this role is expanding nowadays to seeking also the improved practice of a certain medical field. In this regard, the current Lebanese Society of Cardiology (2013-2015) has laid many plans and considered many perspectives. These concern mainly, but not exclusively, the increase of public awareness regarding prevention, investment in research, implementation of guidelines, support of continuous medical education, organization of cardiology symposia and congresses, and achievement of national registries regarding main cardiac conditions, as well as the society's main objective of decreasing the burden of cardiovascular diseases in Lebanon. Nonetheless, the implementation of such plans and perspectives is facing contrary winds related to a multifaceted phenomenon: the dominance of private medicine with a subsequent lack of teamwork, the dominance of private media, the social and political unrest in Lebanon, significant discrepancies in the scientific background of cardiologists, and the absence of a standardized national cardiology licensing exam. Importantly, the implementation of such plans and perspectives requires individual commitment, along with the cooperation of the Order of Physicians, the Syndicate of Hospitals in Lebanon (representing private hospitals) and the Ministry of Health. Moreover, industry must be more committed to medical scientific societies; the support of cardiology events organized without the auspices of the Lebanese Society of Cardiology is not encouraged because of the presence of significant conflict of interest.

11. Strategic planning

There are several types of planning processes and plans, including strategic, operational, tactical, and contingency. For this document, operational planning includes tactical planning. This chapter examines the strategic planning process and includes an introduction into disaster response plans. "A strategic plan is an outline of steps designed with the goals of the entire organisation as a whole in mind, rather than with the goals of specific divisions or departments". Strategic planning includes all measures taken to provide a broad picture of what must be achieved and in which order, including how to organise a system capable of achieving the overall goals. Strategic planning often is done pre-event, based on previous experience and expertise. The strategic planning for disasters converts needs into a strategic plan of action. Strategic plans detail the goals that must be achieved. The process of converting needs into plans has been deconstructed into its components and includes consideration of: (1) disaster response plans; (2) interventions underway or planned; (3) available resources; (4) current status vs. pre-event status; (5) history and experience of the planners; and (6) access to the affected population. These factors are tempered by the local: (a) geography; (b) climate; (c) culture; (d) safety; and (e) practicality. The planning process consumes resources (costs). All plans must be adapted to the actual conditions--things never happen exactly as planned.

13. Operational planning for a specific intervention

Every intervention must follow an operational plan. Operational plans delineate actions required to meet an objective that is part of the strategic plan (overarching goal). Operational plans dictate the critical pathways for the interventions that will be followed during and following the implementation of the intervention. Operational plans include: (1) an introduction and brief situation report; (2) an overview of the task(s), objectives, and the overarching goal to be addressed; (3) the methods that will be employed; (4) planning factors; (5) the resources that will be required including personnel, equipment, and supplies; (6) timelines, benchmarks, and milestones including their respective indicators, startup time, end point, and estimates of the time required for completion; (7) the administrative structure to be employed; (8) an operating budget; (9) the strategy for acquiring the funding required; (10) roles and responsibilities of the personnel including position descriptions and the competencies required of the personnel (skill sets); (11) mechanisms for monitoring the progress including the indicators that will be employed, (12) safety, including health of the personnel, required immunisations, accommodations, and reporting structure; (13) self-sufficiency; and (14) reporting and accounting. There are many generic items in an operational plan that can be used in successive plans. Without a detailed operational plan, interventions are doomed to probable failure and can profoundly negatively impact other projects operational in the area.

15. Evaluation

Evaluations are an essential part of disaster management and preparedness. Evaluations provide the evidence necessary to build the science. The deconstructed processes from assessments through implementation and conclusion of the interventions have been outlined and can now be evaluated so as to define critical points of success and/or failure within the respective processes. Interventions should be examined for their effectiveness in achieving the objectives for which they were selected and for their contributions to attaining the goal outlined in the strategic plan. Effects of an intervention other than those for which the intervention was selected may have an additive benefit or they may have a negative impact on the affected society. Resource consumption (costs) is an important element of evaluations. Health disaster management evaluations aim at quality improvement for future interventions (preparedness). However, evaluation based on participating and/or concomitant observation also may open for improvement of ongoing interventions.

8. The operational processes

There are two principal directions that disaster studies pursue: (1) interventional; and (2) noninterventional. Interventional studies are used to evaluate specific responses as to their effectiveness in meeting their respective objectives, their contribution to the overarching goal, the efficiency with which they are able to achieve their objectives, other effects created, and their respective costs. On the other hand, noninterventional studies examine the epidemiology of disasters and for the most part are observational. Both interventional and noninterventional studies require data/information obtained from assessments. This section of these Guidelines examines the operational framework used to study interventions/responses and includes the following processes: (1) assessments, (2) identification of needs; (3) strategic planning; (4) selection of intervention(s); (5) operational planning; (6) execution of interventions; and (7) monitoring and evaluation of effects and changes in levels of functions resulting from the intervention(s) being studied.

Plans and detours

At various stages of my career, I made and followed plans for progress and growth. However, owing to several unexpected challenges, I had to make detours into unplanned vistas. When I look around at the careers of my former students and younger colleagues, I see fewer long-term, stable positions and frequent changes both in employers and in functions every ten or twenty years. Our curriculum prepares our students for manufacturing careers in the United States, but the current trend of corporate merger and outsourcing can suddenly turn their work into marketing or finance in the Far East. A fox that knows many tricks may be better suited to changing environments than a hedgehog that knows only one single trick. Perhaps future education should not only teach few subjects in depth for immediate career needs but also teach adaptability to unrelated challenges.

Attribution of foodborne illnesses, hospitalizations, and deaths to food commodities by using outbreak data, United States, 1998-2008

Each year, >9 million foodborne illnesses are estimated to be caused by major pathogens acquired in the United States. Preventing these illnesses is challenging because resources are limited and linking individual illnesses to a particular food is rarely possible except during an outbreak. We developed a method of attributing illnesses to food commodities that uses data from outbreaks associated with both simple and complex foods. Using data from outbreak-associated illnesses for 1998–2008, we estimated annual US foodborne illnesses, hospitalizations, and deaths attributable to each of 17 food commodities. We attributed 46% of illnesses to produce and found that more deaths were attributed to poultry than to any other commodity. To the extent that these estimates reflect the commodities causing all foodborne illness, they indicate that efforts are particularly needed to prevent contamination of produce and poultry. Methods to incorporate data from other sources are needed to improve attribution estimates for some commodities and agents.

Sleep to implement an intention

STUDY OBJECTIVES

Sleep supports the consolidation of new memories. However, this effect has mainly been shown for memories of past events. Here we investigated the role of sleep for the implementation of intentions for the future.

DESIGN

Subjects were instructed on a plan that had to be executed after a delay of 2 days. After plan instruction, subjects were either allowed to sleep or stayed awake for one night (Exp. 1) or had a 3-h sleep period either during the early night (SWS-rich sleep) or late night (REM-rich sleep; Exp. 2). In both experiments, retesting took place 2 days later after one recovery night.

SETTING

Sleep laboratory.

PATIENTS OR PARTICIPANTS

A total of 56 healthy young adults participated in the study.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

All of the subjects who were allowed to sleep after plan instruction executed the intention 2 days later, whereas only 61% of wake subjects did so (P = 0.004; Exp. 1). Also after early SWS-rich sleep all of the subjects remembered to execute the intention, but only 55% did so after late REM-rich sleep (P = 0.015; Exp. 2).

CONCLUSIONS

Sleep, especially SWS, plays an important role for the successful implementation of delayed intentions.