Background
Person-centered and integrated care
The PC-IC cyclical process
Knowledge gaps and aim for the study
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What can we learn about the patient-experienced quality of care by the application of a PC-IC ideal to 19 iPP experiences of persons with multimorbidity?
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Which lessons from the empirical analysis can contribute to the refinement and operationalization of the PC-IC ideal into an evaluation framework?
Methods
Material
Setting, informants, and recruitment
Informant background | N | N | N |
Gender | 8 males | 11 female | |
Employment status | 7 employed | 7 unemployed | 1 child/4 pensioners |
Living arrangements | 3 alone | 16 with spouse/children | |
Home municipality | 14 rural | 5 urban | |
Care complexity | Mean | Median | Range |
# of diagnoses treated per year | 5 | 4 | (2–10) |
# different health services per year | 6 | 5 | (2–12) |
# of general practice visits per year | 10 | 7 | (1–36) |
# of health service visits per year | 28 | 21 | (5–132) |
# of inpatient days per year | 16 | 4 | (0–130) |
Data collection
Analyses
Evaluative assessment of the iPPs
Refinement and operationalization of the PC-IC framework
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PC-IC Ideal Descriptions: A short qualitative text of each of the four stages, which describes the desired “ideal” iPP attributes, aligned with literature underpinning each stage.
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PC-IC Key Questions: Formulation of open and closed questions designed to assist evaluation of the presence/ absence of desired attributes for each stage. We first formulated questions per case and successively rephrased to a more general form. E.g. Case: “The waiting-time guarantee of max eight weeks has expired, and my symptoms are worse. Why is my case still not prioritized?” = > General: “Did patients have to intervene to avoid or correct mistakes because planned/ expected care was not provided?”
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PC-IC Theoretical underpinning: A heuristic list of salient and relevant literature references linked to the ideals of each PC-IC stage.
Results
Goals
“What matters to you?”
“(P) Person: I had to choose. Either I choose the booze or I choose my son. (…), it was really a simple choice. But of course, it was also a new experience when I met a person [care worker] who confronted me with this choice (…). It was at this point that I really woke up and saw the severity of my situation. That was when I started changing.” (…).(I)Interviewer: How did you react to this [the restrictions?] (…)P: “At first I was truly upset. But when a few more months had passed, I became really grateful. Because, if she had not made these demands, then I would not have made [the necessary] changes.” Male, mental health and substance abuse issues.
“A restlessness, agitation. If I were to make a mind map, I would need 5-6 secretaries nonstop. So, sleeping quality is not good. It becomes exhausting in the end. In addition, you never feel quite awake. I passed 3 months or so without [the medication]. And then I went to see her and I told her that it was… I told her that I want the medication back. “Naahh” she said, we had to weigh effects against risks. Then I said: I do not care about risks. I will take that responsibility myself. It is my life. So, she said that if I assumed responsibility myself, it was ok…” Woman, two mental health diagnoses.
“…That is why I now have asked for rehabilitation, but I didn’t get any. But, if I had gotten well enough to get my driving license back, I could have gotten quite a different “circulation” to my life.”I: Where would you go if you got your license back?P: “Well, I know this lady. [From earlier, he describes her as someone who cares for him]. She lives in the mountains. I could visit her there.” Male, five long-term diagnoses.
Biomedical goals
“If you don’t shout and scream then nothing will happen. (…) I have been incredibly lucky. All I can say is if I hadn’t been admitted to the “X-clinic” if I had gotten a stroke or a heart attack, I would have been dead now. I pestered them and elbowed myself into the hospital. I nagged and pleaded to be admitted. And the general practitioner, he admitted afterward that he didn’t think it [my condition] was as serious as it actually was.” Male, coronary vascular disease.
Goals for self-management
Plans
The care plan
“A great doctor admits me, (…). He says that there are so many issues to deal with here. We will look at your blood pressure first, then the “fibrillation.” Yeah – then we will look at your stomach, and then let all the rest wait until afterward. (…) Nahhh [they] didn’t look at my stomach. I thought it was a great plan he made. Dealt with one issue at a time, [but] then I was given some tablets, then I got better. (…) I was not done with all that either [exercises], because I could have improved even more. That is when they sent me home.” Male, five long-term diagnoses.
“I: Do you experience that there is coordination support for you?”“P: I do not feel there is. I feel it is quite random. When the meeting arrives: Oh, now we are like “formal”, and now we are supposed to make “The Plan”. I get the notes from the meeting where it says what we are all going to do. However, what’s done is not always the same as what the note says. There is not really anyone who keeps tabs on anything. (…) If I don’t make it start, then things tend just to die out. And it is exhausting. I am actually the coordinator in all this. (…) That’s the point isn’t it, with seven persons in a team? It’s that they should give you feedback, and that they should be there in their domains and have completed this and that until the next time.” Male, mental health and substance abuse issues.
Shared decision making
Interdisciplinary review
“There are care planning meetings every six months. At these meetings, the participants typically “look at the floor” when tasks are distributed. The coordinator is very good, but it is clear that there are limitations to what she can do. At these meetings, we try to find out what should be done, who does what, and when, right? (…) But, it’s almost as if the participants want to crawl underneath the table, and not look at me. It is as P [partner] says, a parody. You’re so mad when you leave those meetings because there is no energy, no support. Quite to the contrary.” Parents of a child with multiple disabilities.
Care delivery
The system is responsible
“But for the most part, I have met, yes, persons you could call angels. (…) They [the oncology nurses] were so humane and warm and good. It was a good experience to come to them and feel their concern for you.” Woman, breast cancer.
“The worst about our care system, in which I include all psychiatric and substance abuse services and the whole package, it is when you are unable to voice your problems. When you are so far down there that you cannot make them listen, you are not seen, not heard. And I feel that it is in such a contradiction to what healthcare is really there to do. You feel inferior, you feel invisible, and you feel so lost. It is as if you’re not worth anything.” Male, mental health and substance abuse issues.
Delivered according to plan
“I used nine days to get the prescriptions I should have been given so that I could start treatment [anti hormonal adjunct treatment for breast cancer] in January. And it was a little bit… In the end I had to say: “Who is responsible here?” At that point I had gone to the mammography center, the oncology department, and the oncology outpatient clinic… And in the end, I said to them – I am NOT leaving. Now you MUST find me a doctor who can listen to my challenge which is to get the right prescriptions for the medications that I should have begun taking yesterday.” Woman, breast cancer.
Informational continuity
“There are as many opinions as there are doctors. The doctors are of course wonderful, but it was truly interesting to come straight from the doctor’s consultation to the oncology nurses who said: Don’t listen to the doctors. We are the ones who know!” Woman, breast cancer.
Evaluation
From ideal to framework – What does our study add?
Description of ideal care | Key questions | Supporting literature |
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1. Goals | ||
The unit of observation is the long-term iPP. The ideal iPP should meet the overarching personalized goals, which reflect “What matters to the person.” The overarching goal defines the scope of the care plan. It includes; • an empathic and sensitive effort to understand what the person’s needs, values and preferences are • Negotiating and documenting goals of care that are relevant, realistic and observable. • eliciting and recording the person’s resources as a partner in decision making regarding health and wellbeing Overarching personal goals can be broken down into supporting sub-goals in a goal hierarchy. In case of conflict between professional recommendations and personal goals, the person’s goals should prevail, unless they compromise legal or ethical principles. In case of legal or ethical barriers, a documentation of how the conflict was explored with the person and what conclusions were reached is desirable. | How do persons express “What matters to them?” What are the patients’ perceptions of healthcare’s reaction to his/her articulation of “What matters to them?” Did the informants express unmet needs, values or preferences? If there were unmet needs, conflicting view of goals, were these described or explained in the EHR? What needs for self-management support do informants voice, and were these needs met? | • The informed, active patient [84] • Patient-centered care [33] • Person-Centered care [85] • People centered care [86] • Self-management support, patient involvement, and engagement [87] • Self-determination theory [88] • The ethics of authenticity [89] |
2. The care plan | ||
The care plan is based on a multidisciplinary review of the goals from step 1. The first step is to identify skills and competencies needed to achieve these goals. There are no organizational limits regarding whom to include in the iPP plan. The decision process should involve all relevant providers and the patient/caregivers as far as possible to promote engagement, realism, and ownership of the plan. Plans take into account and document the patient’s resources as a partner in the collaborative work for health and wellbeing The care plan should ideally: • Be committed to and aligned with personal goals • Be evidence-based • Include a multidisciplinary review in cases of multimorbidity • Ignore organizational boundaries • Describe self-management and its support • Describe monitoring for exacerbations • Include a crisis management plan • Include a time and method for goal evaluation. • Include community resources that can be leveraged to help meet goals | Was a written or verbal care plan described in the EHR, or by the patient? What are the patient’s descriptions of involvement and engagement in care planning and shared decision-making (SDM)? What are the EHR descriptions of SDM? Do care plans include the following components: • Reference to personalized goals? • Self-management support? • Multidisciplinary review whenever relevant? • Monitoring for exacerbations? • Emergency or crisis management? • Checkpoints for evaluation of goal attainment, or goal revision? | • Prepared proactive healthcare team [84] • Decision support [84] • Evidence-based medicine [91] • Self-management support, patient involvement, and engagement [87] |
3. Care delivery | ||
Care delivery builds on the care plan from step 2. The delivery of care is a system property, not a feature of individual professionals. The care system should identify the resources necessary to reach overarching goals irrespective of organizational boundaries and responsibilities. A marker of high quality care delivery is that the person feels that he/she is seen, heard and recognized as a person. Seamless care delivery depends on the recruitment of the resources that will implement the care plan with attention to Continuity of Care, and it’s organizational, informational and relational dimensions as described by Haggerty [93]. Haggerty’s “relational continuity,” serves primarily to elicit and communicate “what matters” to the system. Thus, we argue that “relational continuity” is a kind of informational continuity. | • Was the care plan operationalized to show where, when and who would provide their care? • If so: What was the perceived usefulness of such operationalized plans? • Did patients experience unexpected care events? • Did patients have to intervene to correct mistakes because expected care delivery was not provided? • Were patients directed to community resources outside of the healthcare system such as peer support organizations or social services? • What were patient’s statements regarding the organizational, informational and relational continuity of care across their iPP? | • Delivery system design [84] • Community resources [84] • Care pathways [94] • Continuity of care [93] |
4. Goal attainment | ||
The iPP success is measured by the degree of goal attainment of goals set in step 1. Goal evaluation enables learning and adjustment of the iPP for the next turn of the care cycle. | • Did they plan and assess goal attainment? • If so: Did they adjust the future care plan according to lessons learned? | • Health and Functional outcomes [84] |