VA is undergoing a major transformation to improve how care is delivered. Two aspects of this transformation are an emphasis on patient-centered care, and the use of new models of care that increase access to and choice for care delivery. To facilitate delivery of patient-centered care that may include care delivered through technology, it is important that we understand not only the patient's medical condition but also his or her contextual factors and preferences. Contextual factors are defined as things that occurare expressed outside the patient's skin that can influence their health (e.g., competing responsibilities, cultural beliefs, economic situation). This project involves the development and testing of a patient inventory that can complement existing information (e.g., history and physical) to identify and make available to patients and providers contextual information to support collaborative decision making and optimal patient-centered care delivery.
1. To identify contextual factors (e.g., patient preferences, situational characteristics, resources) that influence the delivery of patient-centered care.
a) Identify contextual factors that affect delivery of patient-centered care from the patient's perspective.
b) Identify patient contextual factors that providers believe are important in delivery of patient-centered care.
2. To examine the role of technology in health care delivery from patient and provider perspectives.
a) To assess patients' experiences, resources, awareness of and willingness, to use technology for care delivery.
b) To assess providers' knowledge of and experiences with care delivered through technology.
3. To develop and test a patient inventory that facilitates collaborative decision-making between patients and providers, and supports the delivery of patient-centered care by making contextual information and preferences available during the patient/provider encounter.
a) To develop a patient inventory tool that can be deployed using an iPad or other device (e.g. kiosk).
b) To conduct a randomized trial of Veterans to assess whether there is greater patient-centered care and collaborative decision making when the patient inventory is used.
We hypothesized that incorporating patient contextual information into the patient/provider encounter results in care that is more patient-centered and decision making that is collaborative.
As an exploratory aim, we examined workload processes and time involved in utilizing the patient inventory to assess potential workflow and cost impacts of this intervention.
Focus groups with patients, interviews with VA providers, and a literature review were conducted. Forty-nine patients participated in eight focus groups (4 VA facilities and 4 CBOCs) and interviews were conducted with 19 providers. A literature search was conducted to generate a repository for possible inventory items.
A Delphi panel of 17 participants (Veterans, researchers, operations partners, physicians and nurses) provided input during 3 email rounds on the items developed during Phase I.
An inventory tool was developed (and deployed using an iPad) that consisted of six questions regarding common situations or red flags which could signal that something in the patient's life circumstances, or context, was impacting their ability to manage their health care. If a red flag was endorsed, the patient was then offered further selections on the inventory that could help identify any specific contextual factors that may have accounted for the red flag.
After the inventory was developed and tested, Veterans with primary care appointments whose providers consented to participate in the study were recruited at two VA facilities. Veterans were randomized to either complete the inventory (the intervention group) or view brief educational videos on eating wisely and being physically active (the control group). Patients carried audio-recorders into their appointments. Following the visit, patients completed questions on measures of patient centered care including the CARE (Consultation and Relational Empathy) measure. Audios were coded for contextualization using the 4C (Content Coding for Contextualizing Care) and Informed Decision Making (IDM).
Aim 1: identifying contextual factors.
Focus groups and interviews were analyzed using constant comparative techniques. Using a published list of ten domains of patient context, coders notated contextual factors that participants discussed. Modified and new domains emerged resulting in a revised list of 12 domains that formed the basis for the inventory.
Aim 2: the role of technology.
Veterans' experiences with technology in health care varied widely so we included an item on patients' preferences for to communicating with their providers.
Aim 3: develop and test a patient inventory.
The initial literature review of patient centered care related measures (PCC) and context yielded >2500 articles; 80 articles were included with 236 items. Inventory items were developed based on the themes that emerged from the qualitative data analysis, as these items were more relevant to patient context than existing items.
The patient inventory consisted of prompts asking about any health-care related issues that could be the result of contextual factors. If the patient identified an issue, s/he was prompted to check any factors that impacted their healthcare. The following issues were agreed upon during the Delphi panel as most likely to be the result of a contextual factor: missed medications, missed appointments, not adhering to plan of care, >1 ER visits in the past six months, declining recommended treatments, tests or procedures, and difficulty with medical equipment.
In the intervention group the patient completed the inventory just prior to his/her appointment. Responses from the inventory were printed out and given to the provider at the beginning of the encounter.
Two hundred seventy two Veterans were randomized to complete the inventory (the intervention) or to view brief educational videos (136 participants each). 52.2% of the intervention group participants checked any red flags on the inventory, the most frequent being flag being multiple visits to the emergency room (47.5%). While the inventory increased the number of red flags identified, it did not affect the likelihood of a provider making a plan of care that incorporated contextual factors (36% per group; p=0.84). Measures of PCC did not differ by group. The most common contextual factors included patient skills, abilities and knowledge; and access to care. While the inventory was successful in identifying red flags and associated contextual factors that patients had (e.g., missed appointments because no day care available for young children), providers did not utilize this information in their care planning (e.g. reschedule appointments when childcare was available). Efforts to increase provider use of this information are needed to improve PCC delivery.
While the inventory increased patients' likelihood of identifying red flags and contextual factors, providers did not incorporate this information into their plans of care. It appears that providers did not review the information provided and that there may be better ways to present this information to providers. Halfway through the project we suspected this was the problem and requested CIRB approval to add a prompt for intervention patients to also verbalize what they had marked on the inventory. No differences were noted in measures before and after the prompt indicating that other strategies are needed to convey information to providers.
- Weaver FM, Binns-Calvey A, Gonzalez B, Kostovich C, LaVela S, Stroupe KT, Kelly B, Ashley N, Miskevics S, Gerber B, Burkhart L, Schwartz A, Weiner SJ. Alerting Doctors About Patient Life Challenges: A Randomized Control Trial of a Previsit Inventory of Contextual Factors. MDM policy & practice. 2019 Jan 1; 4(1):2381468319852334.
- Binns-Calvey AE, Malhiot A, Kostovich CT, LaVela SL, Stroupe K, Gerber BS, Burkhart L, Weiner SJ, Weaver FM. Validating Domains of Patient Contextual Factors Essential to Preventing Contextual Errors: A Qualitative Study Conducted at Chicago Area Veterans Health Administration Sites. Academic Medicine. 2017 Sep 1; 92(9):1287-1293.
- Malhiot A, Binns-Calvey A, Burkhart L, Kostovich C, LaVela SL, Stroupe KT, Gerber BS, Weiner SJ, Weaver FM. Perceptions of Patient-Centered Care in VAMCs and CBOCs. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
- Malhiot A, Kostovich C, Binns-Calvey A, LaVela SL, Stroupe KT, Gerber BS, Weiner SJ, Weaver FM. Patient-Centered Care from the Veterans Perspective. Poster session presented at: Ruth K. Palmer Annual Research Symposium; 2015 Apr 11; Maywood, IL.