PCCD: Introduction
The context plays an important role in PCCD. Different settings and contexts should be considered for
PCCD to be beneficial for patients.
- Community context, organizational context etc.
The core of PCCD is the interactions between patients and healthcare professionals.
Team context:
- A healthcare professional is also influenced by the team in which they works.
- Improved patient outcomes can be achieved when teams communicate and collaborate
effectively.
o Lack of communication among team members can even lead to closing of hospitals.
Organizational context:
- The professional is also dependent on the healthcare organization where they work.
- Some procedures differ between hospitals. Hospitals thus differ in the what they think is the
best type of care for their patients.
Patient’s context:
- The patient’s context is important. There are differences in care delivery and patient
outcomes based on the educational levels of patient. People also differ in resources,
cognitive abilities and culture.
Community context:
- Here we explore the role of the community in striving for healthy
populations.
Part A: What is patient-centered care?
Patient-centered care delivery is opposed to the previous, more medically oriented, more
paternalistic view of care delivery. PCCD is supported by healthcare organizations, and healthcare
professionals who invest in working patient centered. PCC-interventions or attributes have been
incorporated in health care practices already.
By including PCCD as an important indicator of quality, PCC has received new prominence in
healthcare (e.g. much more research & changed policies) to advance patients, in collaboration with
health care professionals, as leaders and drivers of their own care delivery.
- PCCD is respectful and responsive of patients’ preferences, their needs and their values. So it
adopts the patients perspective and ensures that patient values guide all clinical decisions in
the care process.
,Literature supporting PCCD is also widespread. We all agree that patient-centered care delivery is
important, but it isn’t easy to deliver.
Most healthcare organizations argue that they are focussed on patient centered care.
- The last quote reflects involvement of patients in their care
delivery, but also in organizational decisions. For example by
patients participating in the management teams, or patients that
participate in the decision making at higher organizational levels
(e.g. clients are involved in the decision of hiring new employees.
this is an example of patient involvement and shared decision
making on the broader organizational level).
- Most research however shows that most patients feel the level of participation in their own
care is insufficient. They feel like they are not taken seriously or are insufficiently involved.
The Netherlands performs well in rankings if we look at healthcare in Europe. However, if you look at
the level of patient centred care in the Netherlands (on an individual level), it’s a bit more difficult.
- Almost all people (94%) want to participate in their care delivery, but 48% of Dutch patients
find it hard to take an active role in their care process. 22% finds it even extremely hard to
participate. - So, people want to participate, but experience barriers for their engagement.
o For example because: professionals do not always attempt to involve patients (e.g.
by not presenting all treatment options to their patients. This makes patients
unaware that there is something to choose).
o Or for example: the professionals do not present the options neutrally or equally,
this might cause the patient to feel that their involvement is not really wanted or
needed.
Patient centred care involves actions undertaken in collaboration with patients and not just on their
behalf. It requires professionals to share power, even when that sharing feels uncomfortable to
them.
How come everyone strives for patient centred care delivery, but the reality shows a different
picture?:
- A study (Berghout et al) shows that although healthcare professionals attach great
importance to patients preferences, effective coordination and good information and
education, they also experience difficulties in the delivery of patient centered care. E.g.
obstacles in decision making processes (patients do not always receive the support they need
to set their own goals, the doctor often tells them). And open communication is perceived as
very important but many professionals struggle with effective communication and education.
In Europe almost half of the population (47%) has trouble understanding healthcare information.
, - Limited health literacy: inadequately understanding healthcare information or unable to use
the information in the way it was intended.
o Refers to health communication and communication between professional and
patients. But also it refers to information brochures and medication prescriptions for
example.
o One third of the Dutch population has limited health literacy (inadequately
understand health information or is unable to use the information in the way it was
intended).
o Healthcare professionals are not fully aware that patients do not understand
them/the information correctly. Most patients do not mention that they don’t
understand the professional, they go home and try to figure it out themselves.
o Subgroups who have relatively large proportion with limited health literacy:
People with poor health status, people with high health services usage,
people with lower SES.
o In some countries health literacy is lower among people compared to other
countries.
In the Netherlands this proportion is below 50%.
We are increasingly aware of the importance of diversity in healthcare => there is not ‘one type of
care’ that works best for all patient populations. We need different types of patient centred care for
different groups in our society!
Patient centred care is hard: we know it works but are clueless what it looks like.
- Many studies do show relations between patient centred care and improved outcomes for
patients, which is why we all agree patient centredness is important.
Literature:
- An example of a systematic review shows how organizations implement patient centred care.
- Organizations that do well on patient centredness also report better organizational and
patient outcomes.
o The interventions of each included study however are pretty diverse. So, some focus
on communication, some on improving access to care, some interventions are very
complex, while others focus on only one aspect of care). - The question remains ‘how
can we compare all these different interventions that aim to be patient centred?’ (so
what makes care patient centred?)
1. Shared decision making: Being respectful in taking decisions together.
2. Coordination of care
3. Involvement of family and friends
4. Etc. (see part B for the 8 dimensions of PCCD)
, Which interventions should we choose. Which interventions are most effective when considering the
limited budget and manpower?
- This question is quite difficult, as they are based on a lot of uncertainty.
- Mostly used interventions in hospitals (a study):
o Only 11% of treatments is proven to be effective
o 24% is probably effective
o 7% has both positive and negative effects
o 8% is likely not effective
o 50% is unknown
In the primary care setting or community care setting, we are even less
knowledgeable of the effects of interventions.
In the hospital settings, most interventions are conducted in RCT’s. This is hardly
possible for interventions in the primary care setting.
We lack evidence of what patient centred care should look like for patients with
complex problems (e.g. multimorbidity). In many studies, patients with
multimorbidity are excluded as they might contaminate the research findings.
The effectiveness of interventions is not the same for all groups of patients. For
example: it may take 48 hours to diagnose a heart attack among a lower educated
patient compared to a highly educated patient. So, although we are aware of
differences between subgroups of patients, we still no not tailor our care effectively
to this.
o We for example lack specific protocols that incorporate differences in the
expression of complaints among different types of patients (e.g. based on
their educational level).
Care delivery is thus complex, and we more and more realize that the context matters.
- In response to this: a movement from authority based care (professionals central in decision
making, based on their authority) to evidence based medicine (care is provided to all patient
populations based on the best available evidence) leading to context based medicine (to
unravel what care should entail for different patient populations, professional should focus
on the context of the patients.)
Patient centred care requires various sources of knowledge: local knowledge, knowledge from the
patients themselves, knowledge about the context (living conditions, inclusion of patient
preferences). The professionals must adjust their practice of shared decision making to fit the
context of the patient.
Part B: Eight dimensions of PCC
