Summary Patient Centered Care Delivery lectures, working groups and a few articles
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Course
Patient Centered Care Delivery
Institution
Erasmus Universiteit Rotterdam (EUR)
Summary of patient centered care delivery with all the lectures, working groups and a few articles:
- Patient-centered care and outcomes (Rathert et al)
- Revisiting relational coordination (Bolton, Rendelle, Logan, Caroline, Gittell & Hoffer)
- New directions for relational coordination theory ...
Lecture 1 Patient-centered care
Introduction of the course
Themes of the course
During the course, insight into the concept of PCCD will be provided, including different models,
theories and definitions. Different innovative approaches to PCCD will be introduced as well as their
impact on (patient) outcomes (Theme 1). Attention will be given to various forms of interactions
between professionals and patients. We will focus on legal aspects of informed consent and shared
decision-making (Theme 2). Behind every professional there is a team that influences the quality of
care delivery to patients. Nowadays, with an astonishing rise of chronically ill patients and patients
with multimorbidity, professionals are dealing with patients with complex and multiple needs. These
changing needs from acute to chronically ill patients ask for a different approach in care provision.
Interprofessional collaboration is needed to support the needs of these patients, which requires
communication and coordination between professionals from various occupational backgrounds and a
supportive team climate (Theme 3). In turn, effectiveness of these teams is influenced by the culture,
structure and availability of resources within the larger organisation. Also, leadership affects
interprofessional collaboration between professionals and in turn quality of care delivery to patients
(Theme 4).
In order to create co-care delivery between professionals and patients, diversity in care delivery is
needed. Just as professionals operate within a team and organizational context, patients are influenced
by their individual/personal environment as well. For example, patients differ in their educational
level, their ability to self-manage their well-being, and their way of coping with diseases or illnesses.
Special attention will be given to the continuing rise of socioeconomic health inequalities and how
culture influences effectiveness of care
delivery (Theme 5). Patients are not only
influenced by their individual/personal
environment, but by the neighborhood
context as well. The neighborhood context
plays an important role in (improving)
healthy lifestyles or fostering active and
healthy ageing in the community. We will
discuss the role of neighborhoods and
innovative solutions in the community (e.g.,
community health nurses, collaboration
between health, social care and informal
networks) on PCCD and patient outcomes
(Theme 6).
What is Patient-Centered Care?
In the first theme of the course we will focus on definitions, conceptual models and dimensions of
PCC as well as it’s organization in practice.
PCC has been on the healthcare agenda for several decades. This movement is opposed to the
previously more medically oriented and more paternalistic view of care delivery. The adoption of PCC
is supported by most health care organizations and health care professionals. Many patient centered
care interventions or attributes have been incorporated in health care practices today.
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, Patient Centered Care Delivery
The Institute of Medicine identified PCC in 2001 as one of the six important quality domains in health
care. PCC has received new prominence in health care. The Institute of Medicine recommended
strategies and policies at multiple levels in order to advance patients, of course in collaboration with
health care professionals as leaders and drivers of their own care delivery. This can be done by
informed and shared decision making. According to the Institute of Medicine, is PCC respectful and
responsive to the preferences, needs and values of the patient. This approach adopts patient
perspectives, patient values to guide medical decisions. There is a lot of interest in PCC. The literature
supporting PCC is widespread. All the literature agrees on the importance of PCC (the significance on
PCC health care).
Is patient-centered care easy to deliver?
This is a more complicated questions. A lot of health care organizations argue that they focus on PCC:
Patients are always at the center of our care delivery;
Patient-centered care is our top priority;
Every decision is made with the involvement of patients.
This latter statement reflects also the involvement of patients in the organization of the health care
organizations (at higher organizational levels). A nice example of this type of involvement is from
health care organization Amerpoort. This is an organization for people with intellectual disabilities in
which clients participate at a higher organizational level. These clients are involved in decisions about
hiring new health care professionals. They can share their preferences about the new employees. This
is a good example of patient involvement and shared decision making on the broader organizational
level. This is logical, because these people live at the care facility. The truth is that these examples are
quite rare. Research shows that patients think that their involvement in their care is insufficient. They
often feel that they are not involved in the decision making.
Barriers in active patient participation
Patients are expected to take an active role in their care delivery. But while 94% wants to participate,
48% of Dutch patients find it hard to take an active role in their care. 20% find it extremely hard to
participate. The patients experience barriers to participate. For example, professionals do not always
attempt to involve patients or they do not always present treatment options or present them neutrally.
PCC is that it involves actions in collaboration with patients and not on their behalf.
So how come that everybody claims to be patient centered and wants to be patient centered, but the
reality shows a different picture?
Healthcare professionals’ views on PCCD
Berghout, van Exel, Leensvaart, & Cramm
The study showed that although health care professionals attached great importance to patient
preferences and information and education, they experienced difficulties in the delivery of PCC. For
example, they experienced obstacles in the decision making process.
Very often patients are not supported to set their own goals; it is the doctor telling them.
When patients tell their story to different people, different information comes out.
Bad communication, not ineffective and miscommunication is probably the most significant
reason why errors happen.
Although open communication between professionals and patients is perceived as very important,
many professionals struggle with effective communication and education.
While PCC is highly valued, viewpoints appear to differ between health care professionals and they
experience barriers in practice.
Health literacy
Health literacy is the ability of people to make sound decisions about health in daily live.
A study on health literacy showed that in Europe almost half of the population (47%) has trouble
understanding healthcare information.
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, Patient Centered Care Delivery
This refers to health communication between the professional and the patients, but also health
brochures and subscriptions. Health care professionals where not aware that the patients did not
understand them. In this study researchers focused on specific groups of patients who where more
likely to experience health literacy (people with poor health status or with a lower SE status). Some
countries have more proportion of people with health literacy.
Diversity of care
Through this study, but also through other research, we are increasingly aware of the diversity of
health care. Not one type of care is the best for all types of populations. We need different PCC for
different populations in our society.
Patient centered care is hard; we know it works, but are clueless to what it looks like.
There is an article in theme 1 about the implementation of PCC. Organizations who do well in terms
of patient centeredness, also report better organizational and patient outcomes. If you look at the
underlying studies of this systematic review, the interventions are diverse. Some report quality
improvement initiatives with some PCC, other interventions focus on communication or access to
care. In some studies the interventions are very complex and other focus just on one aspect. We need
to compare all these interventions that aim to be patient centered. But what makes care patient
centered? It is important to be respectful and taking decisions together (shared decision making).
Patient centered care is more than this (atmosphere, friendly staff, professionals who know the
patient). Certain aspects are more important when it comes to patient centeredness, for example
coordination of care and the importance of family and friends and not just considering fysical health,
but also the mental health of patients.
If we want to improve different aspects of PPC, which interventions should we use? Which
interventions are the most effective when considering the limited health care budget and limited
manpower?
This is difficult and based on a lot of uncertainty.
Only 11% of treatments is proven to be effective.
24% is probably effective.
7% has both positive and negative effects.
8% is likely not effective.
50% is unknown.
We lack evidence how PCC should look like with patients with complex problems and problems with
multimorbidity. Patients with multimorbidity are excluded of the trial because they might contaminate
the research findings (is the idea). We know that the effectiveness of interventions is not the same with
all patients (lower education/higher education). We still do not tailer our care to these differences. So
care delivery is complex and the context matters.
Movement from authority based care to evidence based medicine leading to context based
medicine
Authority based: professionals are central in decision making, based on their authority.
Evidence based medicine: care is provided to all patient populations, based on the best
available evidence.
Context based medicine: this is to unravel what care should entail for different patient
populations, professionals put focus on the context of their patients. In addition to the external
knowledge that they have, PCC requires various sources of knowledge (this includes local
knowledge, knowledge about the context, knowledge from the patient themselves about their
living conditions and their preferences). Health care professionals must adjust the practice of
shared decision making to fit the context of the patients.
Social Production Function theory
Overall well-being
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, Patient Centered Care Delivery
This model represents the Social Production Function theory (SPF). Health care aims to ensure the
overall wellbeing of patients. This consists of physical well-being and social well-being. Nowadays
healthcare is focused mostly on physical wellbeing (making sure that the comfort is sufficient or
stimulate physical activities). Health care is insufficiently focused on social well-being. While
research shows that the focus on physical and social well-being results in more effective care and
better patient outcomes.
Patient-centered care
“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”.
A patient-centered vision on care delivery can be summarized as:
“Providing care that the patients needs, in the manner the
patient desires it and at the time the patients needs it”.
Increasingly patient wish access to important information. This
is necessary to be an active partner in the care process and be
part of the decisions making process.
How to organize PCC?
The eight dimensions patient-centered care
Patient preferences;
Access to care;
Information and education;
Emotional support;
Family and friends;
Coordination of care;
Physical comfort;
Continuity and transition (between health care settings).
These where applied to hospital settings, but can also be applied to other health care settings.
Eight dimensions PCC
1. Patient preferences
This is about the interaction between the health care professional and the patient. Professionals need to
understand the patient and understand them as persons and get to know their preferences. They should
treat each other with respect. Patients should set their own treatment and life goals. These can change
overtime.
Personal care plans (patients can set their own goals and focus of care. These are broader than
health, also life goals).
2. Access to care
Health care should be affordable and accessible (waiting times to schedule an appointment, the
waiting time during a visit, multiple options for consultations). Second, it is also about accessible
buildings (wheelchairs). Third, access to medication (easily get a prescription).
3. Information and education
The provision of essential information to patients about all aspects of their care delivery. Patients
should have access to their medical records and be in charge of their care process. To foster this: clear
and easy to understand information about the condition and the treatment. This information is
necessary. Open communication between patients and health care professionals is key (this asks high
communication skills from health care professionals).
Decision aids: helping patients to make informed choices that take the preferences and values
of patients into account. This makes discussing treatment options between the professional
and the patient easier. It also improves the communication between the professional and the
patient.
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