Patient Centered Care Delivery
Lecture 1 – Patient centered care delivery
There is consensus on the importance of patient patient centered? Being respectful, taking
centered care in research and healthcare decisions together (shared decisions), but it is
organizations, it is defined as one of the six more than that (comfortable seats, friendly staff,
quality domains by the institute of medicine. etc.). What interventions should be prioritized to
However, patient centered care is not easy. There improve patient centered care? Difficult decision
are examples in which patients are actually put because much of the medical decisions are based
into the center when organizational decisions are on uncertainty. In research it is shown that out of
made. In some healthcare organizations patients 3000 medical treatments in the hospital setting,
are part of the selection procedure for new 11% was proven to be effective, 24% was
healthcare professionals. However, these probably effective, 7% had both positive and
examples are rare (not involved in for example negative effects, 8% is likely not effective and
decisions concerning wages of physicians). Most 50% is unknown. For primary care setting this
patients do not feel that the level of participation may even be lower. Multi-morbidity patients are
is sufficient in decisions concerning their own always excluded from such studies as they
care. In the Netherlands 94% of patients wants to contaminate the research findings. Concluding,
participate, 48% of them find it hard to take an there is a lack of evidence for many interventions.
active role in their care and 22% find it extremely Besides, evidence is not the same for all patient
hard > they want to participate, but there are groups. It takes longer to diagnose patients with a
barriers to be involved. Physicians not always lower educational level as they have more
present different treatment options, leading to difficulties in explaining their problems. In the
patients not being aware of those different Netherlands life expectancy is 7 years lower for
options. When physicians do present different lower educated compared to higher educated
options, they tend to steer to what they think is individuals and they live longer in a poorer health
the best option (involvement is not wanted from status.
the physician). All organizations claim to be and
want to be patient centered, but reality shows a There is a movement going on from authority
different picture as it is hard to provide patient based care in which the professional took all the
centered care to all patients. In country level and decisions themselves based on their authority to
individual level there is a lot of variety in terms of evidence based medicine in which the same
patient centeredness. care is given to all patient populations based on
In Europe, 47% of the population has trouble the evidence now leading to context based
understanding healthcare information medicine in which care should differ for different
(communication between professional and populations. It is very important to take all needs
patients, leaflets, medication/treatment
prescriptions). In the Netherlands 30% is unable
to use the information that was handed to them.
Healthcare professionals are not aware of the fact
patients not understanding their information. Men,
lower educated patients and lower income level
patients have more trouble understanding the
information. Diversity in care delivery is needed;
there is not 1 type of care that fits all patient
groups in society.
Patient centered care is hard, we know it works
but are clueless to what it looks like. Studies show
positive relationships between patient centered
care and more positive outcomes. Organizations
doing well in terms of patient centered care report
better organization and patient outcomes.
However, the interventions are very diverse
(multiple complex interventions, simple
communication intervention). What makes care
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,and wants of patients into account and make dignity and respect. Professionals should ask
decisions together > context matters. about needs, wants and preferences of
patients as healthcare is more effective when
adjusted to those preferences. Patients set
Patient centered care is a growing movement in their own treatment goals; not only about the
healthcare organizations to improve healthcare. physical aspect but also quality of life.
Overall wellbeing exists out of physical well-being Example: do no resuscitate token; you need
and social well-being, which exist of instrumental to respect that.
goals. Before patient centered care they mostly - Information and education – patients need
focused on the physical part (comfort; the to be in charge of their own care and
presence of a safe, pleasant environment and the therefore need to be informed and
absence of physiological needs (pain, hunger, understand it. Everyone needs to understand
thirst), stimulation; to have a physical or mental the given information, and therefore it needs
activity to prevent boredom). However, the social to be provided in different ways depending on
well-being (affection; friendship, intimacy and the patient. Communication skills are very
emotional support from relatives, behavioral important. For example the use of decision
confirmation; living according to relevant others’ aids to see what treatment options exist and
or own norms, status; social ranking based on read about it and what suits them best. Those
occupation, lifestyle) is a large part as well > aids are rarely used as patients don’t always
patient centered care aims to enhance both understand it as medical jargon is used often.
physical and social well-being. The social Example: in waiting rooms the most
production function is based on the concept that important questions that can be asked to
people make diverse efforts to improve their living physicians.
conditions with the aim of achieving physical and - Access to care – it should be easy to
social well-being; society protects the well-being schedule an appointment in a care
by providing care and support to those who organization. In the Netherlands we have an
depend on it. (chronic) illness impacts the well- easy access healthcare system in which we
being. Functional limitations leading to withdrawal can visit the GP as we have an insurance, but
from important activities impacts well-being; for in other countries it is not that easy. But it is
example it affects the ability to engage in not only about the physical accessibility, but
exercise with others affecting the physical well- also the setting; are there clear directions in
being and social well-being. the hospital (do you know where to go), easy
access for those who are blind, speak foreign
Patient centered care is healthcare that language.
establishes a partnership among practitioners, Example: waiting times, having insurance,
patients, and their families (when appropriate) to
ensure 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.
According to Stewart it is the exploration of both
the disease and the illness experience,
understanding the whole person, finding common
ground, incorporating prevention and health
promotion, enhancing the patient-doctor
relationship, and being realistic. Most definitions
stress patient participation in decision making and
individualization of treatment in accord with
patient preferences and circumstances.
There are eight dimensions of patient centered
- Emotional support – when being
care that can help to organize patient centered
severely/terminally ill, not only the physical
care:
state needs attention but the emotional state
- Respect for patient preferences – the
as well; depressed about what has happened,
interaction between healthcare professionals
anxious about what to come. Mental quality of
and patients. Professionals and patients need
life is important as well. Physicians need to
to treat patients and professionals with
pay attention to the mental state as well; not
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, always their part of the job and not always patients, and increased job satisfaction of
able to but they can refer to professionals professionals. In this model there are
that are able to offer the support needed. moderators (explain conditions under which an
Example: giving mental support independent variable may influence outcomes;
- Family and friends – when having chronic patient type: cancer patients are in greater need
conditions or being a child the illness impacts of emotional support and therefore treatment
patient, but family and friends as well as they planning and communications could be designed
need to adjust their lives to the condition. to target patient emotional needs, in terminal
Professionals need to take into account the patients the process may be so good, but the
needs and questions of relatives as well, how clinical outcomes will not be very good) and
can they support patients best, what to do to mediators (help explain how or why a
help them. relationship exists between an independent
Example: Ronald McDonald house so the variable and outcome; when taking all patient
family can stay nearby the child in hospital. preferences into account in the treatment
- Coordination of care – multiple decision patient adherence will be higher)
professionals of one organization are often influencing the outcome > they may explain
involved (coordination between providers of significant variance in patient outcomes.
one organization). For example in a GP This model may be applied by physicians. When
practice the GP and nurse practitioner. Here it two patients get the same treatment but differ in
is about multi-disciplinary meetings or having outcomes, it may be interesting to look what is
case managers that patients know where to moderated and mediated to look for the reason
go when having questions (first point of why. Interesting for the physician as they may use
contact). Different physicians within the the process for other patients as well to increase
organization. outcomes. More usable on micro level
Example: case managers and multi-
disciplinary meetings. There are different perspectives/models
- Physical comfort – helping people in their integrating evidence-based and patient centered
daily living needs; pain management (patient care Lacy. Evidence based medicine is defined
self in illness), setting of organizations as the conscientious, explicit, and judicious use of
(hygiene, comfort (chair), privacy, chemo current best evidence in making decisions about
garden). the care of patients. There is no model that fits
Example: having nice chairs to wait. best; it is context dependent.
- Continuity and transition – multiple - Either or model – evidence based medicine
professionals are often used in the care and patient centered care are seen as
process (specialist, GP, psychologist). Patient separate entities, mutual exclusive.
information need to be transferred well - Integrated model – the two separate
between all professionals involved to ensure entities can be integrated into evidence
continuity and transition. When patients are based patient centered care. Evidence based
transferred to other professionals they need medicine is not without taking into account
to know why, where they need to go etc. patient preferences > professionals apply
Different physicians of different organizations. concepts from both entities.
Example: chain care; systems that make it - Continuum model – balance ranging from
possible that physicians from different purely evidence based (paternalistic) to
organizations have the needed information. purely patient centered (consumeristic). Best
Investment and improvement on all the different practice is where there is a balance between
dimensions is needed in order to become more
patient centered taking a lot of effort and it is not
as easy as it seems.
Conceptual model Rathert the processes (eight
dimensions of patient centered care) have a
positive influence on the outcomes (from
Donabedian model: good structure increases the
likelihood of good process, and good process
increases the likelihood of good outcome); it leads
to higher patient satisfaction, an increased quality
and safety of care, improved well-being of
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, the two and both are incorporated. There is patient wants. There are some barriers to ask
no perfect balance that fits all situations, it is about patient preferences; for example when
patient dependent. there are language difficulties between
- Cyclical model – more a dynamic model; it professionals and patients.
goes from evidence based to patient centered - Emotional support – 3.45; due to time
and back to evidence based. It is a dynamic pressure and other things professionals may
movement between the two modes of lose the good questions. A lot of GPs don’t
operating. think always about emotional support as they
Barriers to evidence based patient centered care thought it was not always necessary to ask.
are time restraints (costs more time to do the When having an older patient they may be
two), relational challenges (mostly with new very active or vulnerable and this is not
patients as they want someone who knows them) always known; it is difficult to determine the
and finding common ground (when patients wants cut-off point whether someone needs extra
is very different from evidence). Evidence based support.
patient centered care is perceived as a journey; it - Access to care – 3.99; giving patients the
is a pathway to improve outcomes for the patients option to use technology more often (internet
using the best available resources. Two markers appointment making, e-consults) making it
were developing a strong and trustful relationship easier to contact the health organization. But
with patients and open and honest means of a lot of patients don’t know how to use those
communication. Professionals say it is important technologies and there are still waiting times.
to start with the patient and relationship and then Some people hate it to wait long as they have
add evidence to the existing context > make a other appointments that day, while other
connection between the two. Longitudinal patients sometimes need more time of the
relationships with a focus on continuity of care are professional as well, when others need that as
encouraged. Communication includes consulting well they are fine with that as they need it
with patient, listening to patient, negotiate themselves.
treatment options. Differences in the population - Family and friends – 3.57; GPs did not always
exist and therefore there is need to weigh the ask family and friends they were aware that
potential harm and benefit for each individual. when patients became more vulnerable and
Patient education was another strategy to more dependent on care of relatives they
overcome the barriers through availability and need to be alert. Cut-off point when someone
accessibility of information (handout, websites is dependent on caregivers or when they
etc.). cannot understand information provided on
There is room for an integrated model of evidence their own is difficult to determine. When
based patient centered care that is acceptable to having children it is more common to bring a
practitioners of both evidence based medicine parent. Patients said that they brought
and patient centered care. There is diversity in relatives as two hear more than one, but
the definitions of evidence based medicine and others don’t have relatives or said it was
patient centered care leading to important more private related and they don’t want to
questions about the practice of any particular scare children making it hard to improve on
model. patient centered care.
In practice, all organizations claim to be very There are different barriers to delivering patient
patient centered, but there are still barriers and centered care
things go wrong. In a cross sectional study of - Time – consultation hour is only 10 minutes,
patient centered care for patients (n=216 aged making it difficult to ask about other things
between 47-94) with multi-morbidity in the (emotional, anxiety etc.) than their problem
primary care setting the overall patient centered for which they are visiting the professional.
care score was 3.84 (scale 1-5) > high score but Professionals cannot ask about all domains in
improvement can be made. It was found that this consultation hour.
when investing in patient centered care it is - Money – investments have to be made in
significantly associated with greater social and order to deliver good patient centered care;
physical well-being and satisfaction with care. good communication trainings for
- Patient preferences – 3.96; before working professionals, good information system
patient centered GPs worried about between healthcare providers to increase
administrative tasks and worked with continuity.
protocols. Now they focus more on what the
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