Patient centered care is care that is respectful of and responsive to patient preferences, needs, and values, such that patients' individual values guide clinical decisions. Patient centered care is related to better physician-patient relationships and to patient adherence to clinical regiments. Despite the enthusiasm for patient centered care, adoption is slow and understanding of the barriers is limited. Identified barriers include time pressure, clinician exhaustion, and being surrounded by other clinicians who are not delivering patient centered care. Clinicians may also struggle to find information that supports patient centered care in a timely matter. Clinicians spend up to 44% of their EHR time reading or searching electronic notes. To effectively support clinicians in delivering patient centered care we must first characterize where clinicians find information they use to deliver patient centered care and what information clinicians find most valuable. Clinician's attitudes and strategies for patient centered care delivery may be especially important for older patients. Patients of all ages are expected to benefit from patient centered care, but given older patients' particular vulnerabilities and the dearth of work in this area efforts were focused here.
The study aims were as follows:
Specific Aim 1: Describe and characterize primary care clinicians' situation models, strategies, and information needs relevant to delivering patient centered care.
Specific Aim 2: Assess clinicians' delivery of patient centered care, patient perspectives on this execution, and barriers to patient centered care. Including identification of information components and strategies and patient perspectives on clinician strategies. Identify information components and strategies used during patient care delivery and barriers to obtaining information.
Specific Aim 3: Define predictors of patterns of practice regarding patient centered care including using q-sort techniques to identify groups of providers who use similar strategies.
This was a mixed-methods descriptive study. In Aim 1, 10 expert providers (practicing for at least 10 years in VA) working in VA primary care clinics were recruited to participate in a Cognitive Work Analysis. A modified version of Rasmussen's decision ladder was used to guide providers through mapping the work of decision making in providing PCC. This model of eliciting mental models was used because it focuses on information needs in relation to goals. Interviewees were asked to describe what they "typically" do and to describe what they do in a situation with a patient (age 65 and older) who is complex and whom they know well. In Aim 2, 15 primary care and geriatrics clinic providers at two sites (Salt Lake City VA and Bedford VA) were recruited for participation. A set of 32 clinic visits were videotaped and audiotaped. Patients were interviewed about their relationship with their provider following the visit. The principal investigator reviewed tapes to identify patient centered "moments" in which contextual information or patient centered care tasks occurred. The providers were then interviewed and asked to comment on the activities, strategies, and information needs demonstrated in the video tapes. Interviews were audiotaped and transcribed. Preliminary sets of patient centered care strategies, information needs, and values were generated from analysis of the post-clinic interviews. These strategies were then further analyzed by the investigative team and used to construct the q-sort. VA primary care providers then rated strategies used and information needs that characterize their practice in patient centered care.
Expert providers interviewed did not generally differentiate patient centered care from any other patient care. When prompted with questions addressing patient centered care domains (patient as a whole person, partnership, fostering shared decision making), providers indicated that a decision to engage more deeply in patient centered care processes was made when there were indications that a patient: 1) had low health literacy; 2) had poor adherence; 3) had experienced a change in functional status; 4) there were discrepant reports from the patient and other information sources (such as from patient family members); and 5) was not adequately supported by their social network for independent living.
A diverse set of strategies and information needs emerged from the strategy interviews for use during the q-sort. These strategies included: 1) ways to collect and use contextual information; 2) strategies for providing emotional support to patients; and 3) strategies related to motivating patients in multiple ways. Ongoing analysis will establish pilot typologies of providing patient centered care.
This study was designed to reveal the mental models and activities providers engage in when delivering patient centered care. A basic definition of patient centered care is not apparent from expert provider interviews, suggesting that providers may not have a very uniform definition of patient centered care and additional understanding of the concept of patient centered care and how to support it is important to foster patient centered care. Providers need access to information about patient attributes, status changes, and social context to support their practice of patient centered care suggesting implications for information displays that can support patient centered care particularly for geriatric patients.
Results from this pilot proposal lay the foundation for a program of research into patient-centered care that integrates patient centered care strategies and information components using sociotechnical approaches. The VA is uniquely poised to conduct this line of research as it is currently implementing a medical home model across the nation, has extensive experience with the electronic medical record and has made an institutional commitment to patient centered care. This pilot will lead to IIRs that test decision support interventions, educational programs and new metrics for measurement in the domain of patient centered care. An IIR was submitted for consideration during the June 2016 cycle building on the work completed in this proposal.
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