Involving families in clinical decision making, care plans, and educational efforts, commonly referred to as family-centered care, has been shown to improve patient outcomes. While the private sector and the Department of Defense endorse practices that engage family members in patients' care, the VA has historically concentrated its clinical efforts directly on the patient. Following the 2008 implementation of a quality improvement project to improve family-centered care in the four inpatient Polytrauma Rehabilitation Centers (PRCs), the TBI/Polytrauma Family Care Advisory Group, PT/BRI QUERI and the PM&R Program Office recognized the need to expand family-centered practices to outpatient clinical teams. Little was known about the family-centered practices (FCP) currently in use in the TBI/polytrauma outpatient clinics or the structures the clinics have developed to become family-centered.
To identify characteristics of TBI/polytrauma outpatient clinician and programs associated with use of family-centered practices in the outpatient polytrauma clinics. We had three research questions: RQ1) Which clinician characteristics are associated with clinician use of the family-centered practices? RQ2) Which program characteristics are associated with overall program use of each of the family-centered practices? RQ3) Do program characteristics account for differences among clinicians in use of the family-centered practices?
We measured two levels of characteristics to address our research questions using two web-based national surveys of: 1) clinical staff in the Polytrauma Network Sites (PNS) and Polytrauma Support Clinical Teams (PSCT) to describe clinician use of family-centered practices; and 2) program leaders to describe characteristics of the outpatient practice setting that affect overall program use of family-centered practices (FCP). Four domains of patient-family centered care were assessed using the 27-item Measures of Processes of Care (MPOC) to assess providers' perceptions of their delivery of four domains of patient-family centered care. Showing Interpersonal Sensitivity (10 items [SIS]) measures behaviors that support families caring for a family member with a chronic health condition; Treating People Respectfully ( 9 items[TPR]) assesses the extent of clinician use of behaviors that treat patients/families as individuals and equals; Providing General Information (5 items [PGI]) assesses behaviors to provide family members with general information about the patient's condition and services; and Communicating Specific Information (3 items[CSI]) measures behaviors that convey information about the patient's status and treatment. The MPOC uses a 7-point Likert response scale (7 = 'To a Very Great Extent' to 1 = 'Not At All', respectively), and a 'Not applicable' box rated as 0). To understand differences between programs, we aggregated the individual scores to create a program score for each site.
Our explanatory variables were assessed at both the individual clinician and program levels. We identified five clinician and seven program variables we expected to be associated with clinician and program FCP scores. At the provider/ clinician level, our study population was all current clinical staff members of all 22 PNS and 85 PSCT programs. We used email to invite 1067 individuals to complete a web-based survey; 602 unique surveys met inclusion criteria and were deemed complete for analysis (response rate = 56.4%). At the program (PNS/PSCT) level we began with 107 programs and did not include 6 centers for which we did not have verified staffing rosters. Seventy surveys were designated as unique and "complete" for use in analyses about the program characteristics (response rate = 69%).
Univariate analyses were used to identify the clinician-level and PNS or PSCT program-level characteristics associated with our dependent variables. Basic descriptive measures were used as a basis for all subsequent analyses and regression analysis was used to answer all research questions. Clinician level outcome measures were modeled with clinician characteristics to answer RQ1. Aggregated clinician level outcome measures were modeled with program characteristics to answer RQ2. The moderating effects of clinician characteristics on program characteristics were examined for RQ3 to account for differences in the clinician level outcomes. To test for these moderating effects, ANOVA models were used to look at the interaction between the levels of care (PNS vs PSCT) and clinician characteristics for the four measures of family-centered practice. The question of non-responders and their possible biasing effect on the results were studied by investigating the possible lack of balance on the measure covariates.
RQ1) Clinicians in PSCT sites report less contact with family members at patient's clinic visits ( p=0.008). Those who scored higher on Showing Interpersonal Sensitivity (SIS) had more years of experience in TBI/Polytrauma (p = 0.04), reported full-time, rather than part-time, status with the TBI/Polytrauma program (p=0.04); and reported contact with family members at more than 25% of weekly clinic visits (p= 0.001). Higher scores on Treating People Respectfully (TPR) were predicted by full-time status (p=0.03) and clinicians reported contact with family members at more than 25% of weekly clinic visits ( p=0. 02). Those who scored higher on Providing General Information (PGI) reported full-time status with the TBI/Polytrauma program and contact with Veteran family members at more than 25% of weekly clinic ( p=0. 0001). The extent of missing data prevented us from using "busyness" as an explanatory variable.
RQ2) PNS programs scored slightly higher than the PSCTs on Treating People Respectfully (TPR [p =0.048]).
RQ3) We identified a significant interaction between the level of care (PNS or PSCT) and the clinician characteristic in two domains.
1) Showing Interpersonal Sensitivity (SIS) and percent of weekly clinic visits attended by Veterans family members (p = 0.006).For those who responded that their clinic contact with family members was <25% of clinic visits, the SIS scores are greater for PNS facilities than PSCT facilities; SIS scores are greater for PSCT facilities than PNS facilities for those who reported their contact was >25% of weekly clinic visits.
2) Treating People Respectfully (TPR) and percent of weekly clinic visits attend by Veteran's family members (p =0.004). For those who responded that their clinic contact with family members was <25% of weekly clinic visits, the TPR scores are greater for PNS facilities than PSCT facilities; TPR scores are greater for PSCT facilities than PNS facilities for those who reported their contact was >25% of weekly clinic visits.
This study provided a description of current family-centered practices in outpatient TBI/polytrauma programs. Findings are being used to guide selection of practice changes to mitigate barriers to family care and to foster promising practices to engage both patients and their family members in the plan of care and have implications for training and acculturation of interdisciplinary team members.
- Hall CG, Smith JL, Benedict S, Brooks J. Nothing about Them, without Them: Techniques for Including Clinicians in Implementation Research. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD.