Uitwerking van alle colleges en werkgroepen van het vak Patient Centered Care Delivery (GW4002MV).
Door enkel het leren van deze aantekeningen het vak met een mooi cijfer kunnen afronden (7.5)
Notes of all the lectures and working groups of the course Patient Centered Care Delivery (GW4002MV).
Prof.dr. anna petra nieboer nieboer, prof.dr. martin buijsen, drs. sanne kuipers, dr. renee scheeper
All classes
Subjects
pccd
evidence based medicine
ebpcc
shared decision making
sdm
chronic care
acute care
spf theory
social produ
patient centered care delivery
relational coordination theory
high performance work system
Written for
Erasmus Universiteit Rotterdam (EUR)
Master Healthcare Management
Patient Centered Care Delivery (GW4002MV)
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Lecture 1: PCCD
Introduction on PCCD
One of the six quality domains in health care -> there is a lot of research.
Is patient centred care easy to deliver? This is not easy to answer.
If you’re googling nursing homes than you will learn that the centres are focussing on patient centred
care. They always say that it is their top priority. It is also important on an organisational level.
Patients participating in management teams and in decision making. Sometimes patients
participating in solicitation processes.
Research has shown that most patients do not feel that their participation is sufficient and they often
feel that they are not taking serious by healthcare professionals.
The Netherlands are in the top three of best performing countries of a child’s health being. However,
if you look at the level of patient centered care this is more difficult. Patients are expected to play an
important role in the healthcare decisions. Almost all patients (94%) want to participate in their own
care but 47% find it hard to participate. They feel barriers. Professionals do not always tell al their
treatment options. Patients feel that their involvement is not really wanted. On a individually level,
there is still place for improvement.
How is it possible that almost everyone says that they want to give patient centered care delivery
and it doesn’t work out? M. Berghout shows that healthcare professionals struggle with
communication, it isn’t effective and there is a lot of miscommunication. This is probably the most
significant reason why errors happen. Very often patients are not supported to set their own goals; it
is the doctor telling them. And when patients tell their story to different people, different
information comes out.
Health care professionals experienced barrier to the delivery of patient centered care delivery. This
study is just one example. Many other studies agree.
In Europe almost half of the population has trouble understanding healthcare information. This is for
example the communication about health care between the professional and the patient. But it also
refers to information on prescriptions of medication. In the Netherlands we are performing a little bit
better but 1/3 is not able to use the information as it was intendent.
The professionals are not always aware that patients don’t understand them. They just go home and
professionals think that they did. Which patients do not understand the health care information?
People with pore health status, a high use of health care service, low economic status, low education
and older age. There are differences between countries.
There is not one type of care which is the best for all patients. We need different types of care for
different groups of our society. The main message is that PCC is hard; we know it works but are
clueless to what it looks like.
Organisations with well PCC also report better on patient outcomes. If you take a closer look at this
systematic review (you have to read this) you will notice that the interventions are quite diverse.
Some interventions are focussing on quality improvement while other focus on communication.
How can we compare all these different interventions? What makes care PC or not?
Being respectful and shared decision
Good atmosphere and they know you as a person.
Coördination of care
Involvement of family and friends
, Not only focussing on physical health but also on mental health and social needs of
patients.
If we do want to improve PCC, which interventions can we use? Which should we invest money in?
Only 11% of interventions is proven to be effective. 24% is probably effective. And 7% has both
positive and negative effects. 8% is likely not effective and 50% is unknown. This was in a hospital
(researched in RTCs), in primary healthcare settings it is not even possible to do such RTC's so we
have no clue what the effect of interventions are there. Also multi-morbidity patients are excluded so
we have lack evidence for these interventions.
When someone is low educated it is harder to help someone from a heart attack (because they
explain their symptoms different). They are hard to diagnose so it takes 48h longer. This is one of
the reasons why lower educated people live 7 years shorter than higher educated people. Also do
low educated people spend 18 months in bad health more than high educated people.
There is a movement from authority based care to evidence based medicine now leading to
context based medicine = unravels what care should entail for different patient populations.
Patient centred care video 1
PCC is a trend and professionals try to do this. But why? This is the SPF theory:
Health care aims the over well being of patients. This consist of two equal parts: physical and social.
Nowadays, physical wellbeing being is the biggest part (patients are not in pain etc). But health care
doesn’t focus on the other part. However, research shows that investing in both leads to better
outcomes. There is a challenge to invest in social well-being as well.
Around the world, PCC is hot topic. It became popular in 2001. The institute of medicine introduced
it. One of their objectives for improving healthcare in the 21 century was working to more PCC.
PCC: Healthcare that establishes a partnership among practitioners, patients, and their families
(when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that
patients have the education and support they need to make decisions and participate in their own
care.
,How can we organize PCC? In order to avoid the interpretation of PCC we need structure. There are 8
dimensions of PCC what shows us how to organize it in an organisation.
Investing in these dimensions will result in better outcomes for organisations and patients:
Patient preferences: the interaction between the professional and patients. The professional
needs to treat patients with dignity and respect. They should not only focus on treatment but
also on improving the quality of life. Patients should be supportive to set and achieve their
own treatment goals. For example, we work with personal treatments plans. They are
tailored to the patient’s individually needs. Patients can set their own goals and choose their
focus -> often broader than health outcomes only.
Access to care: health care should be accessible to all people. Financially, making quick
appointments, acceptable wait times, e-consults or telephone consults. But also the building
should be accessible for those with wheelchairs, who speak a foreign language, those who
are blind. This might seem normal but it isn’t.
1. Emotional support: also the emotional aspect of a disease is important. When you have a
disease there will be a lot of emotion, for example fear or anxiety for the treatment. It is
important for the professional to take that serious and addres this during a consult. You can
promote a social worker, psychologist or peer group support.
2. Physical comfort: this is two sided! The pain management, supporting patients with they
daily needs (patients need to sleep well, they need walkers etc). But physical comfort in an
organisation is also important, enough privacy and comfortable chairs. Tergooi has a chemo
garden, patients get chemo outside and the treatment works better because their veins are
more acceptable to the chemo.
3. Family and friends: children their parents will always accompany them to consultations so
they play an important part in the care of the children so they should be involved in the care
as well. Professionals should pay attention to questions and needs of the relatives or what
kind of rolls they have. But also accommodation for the relatives, for example the Ronald
McDonald house.
4. Information and education: PCC is all about putting patients in charge of their own care. But
to be in charge, you need to be informed about all aspects of your care otherwise it’s really
hard to be in charge. Information should be provided and adjusted to the level of the patient
(education level, background, language). This should be supported by the professional by
, getting the information but also in for example having excess to your own care records.
Sometimes communication skill training are offered to health care professionals. Use of
decision aids can help patients to make decisions to be in charge of their own care.
5. Transition and continuity: this is all about all health care disciplines that can be involved in
care of one patient. This can be the specialist in hospital, physiotherapist, the GP,
psychologist etc. The relevant patient information needs to be transferred. Transition care
from child to adult is known to be problematic. Now there are programs to smooth in this
transition.
6. Coordination of care: this is all about the team within one discipline that is involved for the
patient. In the GP practice: the triage assistant, the nurse practitioner and the GP are all
involved. It is important that all professionals are well informed and patients should tell their
story only once. Professionals should work as a team and a patient should know who’s
coordinate their care and is there first point of contact.
If you want to work patient centred, you need to improve on all dimensions in order to become more
patient centred . But it is not as easy as it seems, as we can see in this example. We take a look at a
study with patients with multiple chronical conditions in a primary care setting:
Study of 216 patients at GP in Noord-Brabant with multi-morbidity and they had to score PCC with
the 8 dimensions model. The overall score was good (3.84 on 1-5 scale). PCC is significantly
associated with greater social and physical well-being, and satisfaction with care.
When you look at the 8 dimensions score, some dimensions score really high (patient preferences
and accessibility). But also some dimensions score really low (emotional support and family and
friends)
Barriers of PCC are: time, money and patient characteristics:
You only have 10 minutes and you can’t discuss everything, sometimes there isn’t time for emotional
aspects. Time is money so money is a problem as well. Often you need a lot of money for
communication training and new information systems etc.
Patients characteristics are barriers as well. Patients are heterogenous. Not every patient wants to
discuss their emotional problems, they don’t have the same education level, not every patient can
express what he needs so this is a huge barrier.
Patient centred care video 2
According to the systematic review of S. Ratelt organizing care according to the 8 dimensions of PCC
will result in better organisation outcomes and better patient outcomes.
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