Background
Study objectives
Methods
Setting
Patient preferences | Healthcare professionals treat patients with dignity and respect and involve them in decisions regarding their care. They support patients in setting and achieving treatment goals, e.g., via individualized care plans based on patients’ needs, wishes, and preferences |
Information and education | To empower them to be in charge of their care, patients are informed about all aspects of their care and have access to their medical records. The information provided is suitable for all education levels, migration backgrounds, languages, and ages, among others. The need for informative and open communication between patients and healthcare professionals is recognized |
Access to care | Healthcare is affordable, and medical buildings are easily accessible for all patients (including, e.g., those who are blind and those who use wheelchairs or walkers). Appointment scheduling is easy and wait times are short |
Physical comfort | Healthcare professionals pay attention to patients’ physical comfort by, e.g., providing pain management and addressing sleep problems and shortness of breath. Physical comfort is optimized at the organizational level via the provision of comfortable, clean (waiting) rooms and sufficient privacy |
Coordination of care | The organization’s team of healthcare professionals is well informed about the care delivered to their patients, and care delivery is well coordinated, e.g., via frequent team meetings. Patients know who is coordinating their care and whom they can contact when they have questions about their care |
Continuity and transition | When multiple healthcare professionals are involved in care provision to a patient, they all transfer information regularly and adequately, and ensure that their care delivery and advice are well coordinated. When patients are referred to healthcare professionals in other disciplines, they know where to go and why |
Emotional support | Healthcare professionals offer emotional support to patients when needed, by paying attention to patients’ possible fear, depression, and anxiety, and the impacts of chronic conditions on patients’ private lives. Patients are made aware of their ability to obtain emotional support, e.g., from social workers or peer groups |
Family and friends | As many conditions impact not only patients, but also their family members and friends, healthcare professionals involve these individuals in the care process (with patients’ consent). They provide support and address any questions and needs regarding patients’ care |
Study design and data collection
Data analysis
Results
Study participants
Intervention components of the PCC improvement program
Consultation videotaping | A workshop aiming to improve the coaching role of healthcare professionals during consultations by discussing video recordings of consultations with patients |
Evaluation of PCC on the job | A workshop aiming to help all healthcare professionals employed at an organization to improve their patient-centeredness. All daily care activities, from appointment making via internet/telephone to front desk work, provision of advice, and consultation structure, are evaluated |
Listening | A workshop aiming to help healthcare professionals understand patients’ questions and needs at the start of consultation by listening to patients first, instead of immediately asking questions |
Motivational interviewing | A training session in a directive, patient-centered approach to counseling that prepares patients for behavior changes. With motivational interviewing, attention is payed to building a strong patient–provider relationship and working toward patient autonomy and responsibility during the care process |
NIVEA | A workshop aiming to help healthcare professionals avoid judgement or interpretation of patients’ feelings without asking for clarification or further information |
Shared decision making | A workshop aiming to train healthcare professionals to use shared decision making during consultations to 1) prepare patients for the decision-making process (e.g., by informing them of consultation goals), 2) determine goals (e.g., jointly explore patients’ situations, share relevant medical information, and formulate goals), 3) agree on action points (e.g., by discussing all options), and 4) act and evaluate (e.g., by acting on agreements and reflecting on progression) |
Teach-back method | A workshop in which healthcare professionals learn to always check whether patients fully understand the information provided by asking patients to explain/repeat what they have just been told. This approach provides healthcare professionals with better insight on whether their information provision is adjusted adequately to patients’ skills, and whether patients remember the right elements |
Three good questions | An intervention based on a Dutch national campaign that aims to reassure patients that their wishes, anxieties, and needs matter during healthcare consultations. The ‘three good questions’ that patients can ask their healthcare professionals are 1) What are my options? 2) What are the pros and cons of those options? and 3) What does that mean in my situation? |
Topic list | An intervention exploring areas in which patients need support. The topic list is sent to patients before consultations; it contains depictions of pain and topics such as stress and lack of sleep. The list makes patients aware of the range of topics that they can discuss with their healthcare professionals |
Training in illiteracy recognition | A training session focusing on healthcare professionals’ recognition of illiterate patients and adjustment of their communication accordingly during consultations. The training also addresses such recognition by triage assistants and front desk staff when answering the telephone |
Experiences of healthcare professionals with PCC improvement
Patient preferences
“In the past, we used to let people come and draw blood for all kinds of tests, and thus, we thought, provided good care for that patient. And now we look more and more at what suits the patient; what does the patient need? Some measure several values themselves, such as blood pressure or sugar levels, and someone who is well regulated may not need to come as often as someone else. So it is more patient centered, meaning that the patients decide for themselves what their goals are and how often they need support, instead of us telling them ‘you have to come so often and this is what we are going to do.’ We have more of a coaching role now.” (GP7)
“Suppose I sit here on the edge of my chair and do not let the patient finish, but immediately start asking counter-questions. The result is that he or she does not feel heard, because in the end I have not asked what he or she wants to know from me. Instead, I come up with solutions, without knowing what the real question is. The calmer you are, the more serenity you radiate, the more open you stay, the more information you get, and the faster it goes. That is the trick.” (GP1)
“I use this list especially with cardiovascular risk management and with diabetic patients. I usually tell them: ‘The list contains all kinds of aspects that can affect your health. Your illness, but also how you feel and how healthy you feel. Is there anything on this list that makes you think that is just something I would like to talk about, because I have a problem with that or I have a question about it?’" (NP2)
“With diabetes, we have check-ups four times a year, but a number of patients tell me: 'I have had diabetes for twenty years now. Everything has already been said, it is all going very well. I feel good, the check-ups are good, why do I have to come four times a year?" It used to be protocol based, but now we are reducing that number. ‘How many times would you like? When? Whom would you like to see?’” (GP1)
“I will always explain why the protocol or standard says that a certain choice is best, but I do respect the patient's choice. As long as I have pointed out to the patient what the possible risks might be.” (NP3)
Information and education
“I always ask the patients what they like; I can give information verbally or in a letter so that they can read it again later. I also ask them how they look for information themselves. One patient goes neurotically through all the forums, while another thinks you cannot look anything up on the internet. Then I tell them that it is good to use different sources of information, but that they have to assess the value of those sources. Some patients can do that and others cannot. So, I often help them to determine where to find relevant information.” (GP4)
“Patients do not know how to see if their values are good, but now there are smileys. An LDL of 2.5 comes with a green smiling face. And the patient is invited to email if it is orange or red. And if they want to email anyway, even when it is green, that is all right, if they still want confirmation. I think that is pretty much the future.” (NP3)
“Just the values, they do not understand of course. And they are not to blame, because those sugar values are developed internationally, and I find that difficult too. So, I try to show in graphs what happens, but not only with the sugar, also with the blood pressure or weight. And you can put two graphs together and then say ‘okay, your weight has risen, but your sugar rises along with it. When the weight goes down, the sugar goes down as well.’ So then one can see what is happening there. And that is a lot of fun actually.” (NP6)
“I think that for some patients, things do become a habit, insulin therapy for example. Then it is wise to repeat it once more. Because you often assume that people know it all, that is also the case when using an inhaler with a spacer, for example. Now I often hand out again the leaflet that says how to do it. Then I will go through it briefly. And then they say ‘oh, I don’t actually do it like that,’ or they do not know that they have to clean the puffer as well. Even though they have done it like that for years, I just say it again.” (NP8)
Access to care
“The people who I see always leave here with a new appointment. And if someone for example cancels an appointment through the assistant, they get a reminder; or if they don't show up, I call them. And if they do not answer, I send them a letter. At the time of their checkup every two months we monitor whether they are back in the picture again; if not, they will receive another reminder. And once every three months we also get an overview from the healthcare service provider, which also keeps track of when people are in danger of getting lost to follow-up.” (NP2)
“Telephone consultations are not just for my own convenience, but for both sides. If patients come here just to tell me something which takes two minutes, it is also annoying for the patient. And for me it just takes the same time when I can help them over the phone. I ask them sometimes: ‘you can come here, but we can also do it over the phone.’ We leave the choice up to the patient. Only a new blood pressure measurement, well, that is not possible over the phone.” (NP3)
“Some patients find it [consultation by email] very pleasurable. Other patients really just want the personal contact, either by phone or physically.” (GP5)
“To the annoyance of the assistants, our phone is always open. We could switch on the answering machine, but we do not want to. Even at lunchtime the phone is answered and we monitor it every day. Daily at five o’clock, I get a list with the day's waiting times. And once every week we have a meeting about the telephone times and we would like to see that more than 90% is answered within two minutes. The emergency line is always within 30 seconds.” (GP4)
“It helps to inform patients about the waiting times. When people see how long it takes, they know where they stand.” (NP9)
Physical comfort
“I think that physical comfort has always been a goal in primary care. And as a nurse practitioner, you pay a lot of attention to what kind of obstacles patients experience as a result of their condition. And that is often somatically oriented, i.e., focused on physical comfort.” (NP2)
“Physical comfort often looms large in the patient's perception. That's what bothers them the most, so when they visit for check-ups, the first thing they say is 'I am in pain.' This is also much more important to them than all kinds of other factors that may be much worse compared to the pain. But they feel the pain now and that must be resolved now as well.” (GP4)
“There are a number of things that you ask by default, such as 'how short of breath have you been?,' 'does the cough bother you?,' 'does it interfere with your social contacts?.' But also, the questions to diabetics: 'Are your injections comfortable enough?,' 'Are your materials suitable?,' 'Do you sleep well?.' A lot is about physical comfort.” (NP2)
“We just have got everything brand new. We tested a lot of chairs, and we have got half of them with cushions and half without. All very washable, because people very quickly find it dirty. Everything is built according to the latest requirements; everything is easily accessible for wheelchairs, everything is height adjustable; for example, the examination table goes from very low to very high. All aisles are wide, and also in the corners there are special recesses for stretchers. The ambulance entrance is completely on a straight line that is the shortest possible route. The walking routes are such that people enter and leave as quietly as possible. And the partition at the reception desk is there so that others cannot see who they need to visit, be it a psychologist or a doctor. And next to the desk, there is also a special room, so that people cannot listen in, and if something private is asked at the desk. That is a soundproof room so they can get the results there. And of course, the large toilet facility for the disabled. And at the back of the toilet a hatch to deposit urine samples, so no one can see that you turn in pee.” (GP4)
“We have addressed the privacy issue, and in particular that you can overhear others. At first, the phone calls were audible in the waiting room, but after installing a glass wall this was a lot less.” (NP2)
“Learning about this aspect was really an experience. Sometimes you come across people who are very fat and are supposed to sit in such a small chair, but then say 'I will just stand here.' Now I realize it is not a comfortable chair for them.” (NP8)
Coordination of care within the GP practice
“We would like to use each other's expertise. So, for example, an assistant walks into my office at lunchtime to ask me about a patient. Like, ‘would you like to help me determine how I could deal with this issue?’” (NP2)
“It is very important for me to see what the GP has written down. When someone comes for a consultation, I check in advance what has happened to that person since the last time I saw the patient. That may be on a completely different level, but all the information, including that from the consultations with the GP, is important.” (NP2)
“We also verify all phone calls with the assistants: everyone who called today is on the authorization list. Other practices do not do that, because they say 'but I trust my assistants.' I do trust my assistants, because we have really good assistants, but even still, things are not always as they should be.” (GP4)
“The cooperation with the general practitioners is fine. We casually enter each other's rooms or I schedule a brief telephone consultation, and there is a structured low-threshold team meeting with the general practitioners and also with the assistants. They do not have anything to do with chronic care, but they do plan the appointments and receive patients.” (NP9)
“I always prepare my agenda; I check all the results in advance or any items I already promised I would discuss. Every morning we go through all that. Every day we have a start-of-day meeting with the whole team. And also with the assistants present. Details about patients or the practice are discussed there.” (NP3)
Continuity and transition among healthcare disciplines
“It is nice that when you are worried about something you can ask 'gosh think along, do you have any other points of view?’ That you just start thinking along from your own expertise. Because a psychologist might think very differently from a psychiatrist and a nurse practitioner.” (GP7)
“In cooperation with the district nursing service, we get a much better understanding of what the most profound problems are for a patient in a home situation. Sometimes this is not necessarily pain or shortness of breath, but for example, no good contact with the children anymore or loneliness or no daytime activities at all, or that the house is neglected. And that way you can take a much broader look at what that patient needs.” (GP5)
“The other professionals do not literally see the information in our system. However, they can communicate through our chain information system. This is an automation system for communicating with chain partners. And you can open up bits of information and close up bits of information, so that only relevant information goes to the healthcare professional who needs it.” (GP1)
“We start by making a care plan and then the various disciplines are complementing. Various people may well contribute something. I myself, a doctor, a geriatrics specialist, and also home care can contribute something. It is solution focused, but also thinking along. That's how we try to complete the picture.” (NP2)
“We are really trying to work together with professionals in the neighborhood. So, we do not go to someone on the other side of town, because that does not work.” (NP8)
“I must say that the lines with the district nurses and the paramedics are actually very short, because here in a village you actually know everyone. We meet once a month in a home team meeting where we also specifically highlight the vulnerable patients.” (GP5)
Emotional support
“It is a well-known fact that if people with diabetes are very emotional or stressed, then those sugar values can go up.” (NP8).
“Someone with severe COPD and rheumatism can be very limited in his mobility. Such a patient can also become very sad. Therefore, I think that a lot of people also find a sense of support and comfort important. Sometimes patients really develop depression. Of course, you must talk about that too.” (GP5)
“Yes, any chronic care protocol includes a section on how the patient experiences his illness, how he deals with it. So, it is part of it. It's just a tricky part. Because sometimes it can take a lot of time to go into it deeply.” (GP1)
“We have different mental health nurse practitioners, with different backgrounds. On purpose actually. So that for certain cases we have the option to better assess who suits whom. We have both a man and a woman. We have a psychologist, a social worker, and we have a psychiatric nurse.” (GP7)
“There are a number of people with COPD here who work out with the physiotherapists twice a week in a group, and get a lot of emotional support from it. From the other people in the group, but also from the physiotherapist. It just shows that everyone finds support in something or with someone else. As long as there is enough variety, so that people eventually end up somewhere where they feel supported.” (GP5)
Family and friends
“We know that patients spend less than 1% of their time here in the consulting room and spend much more time at home with family and friends.” (GP5)
“Family needs to come along to the consultation as well and be educated in order to understand why something is important. Someone with heart failure, for example, should not eat salt. But then the food does not taste good. So, then I explain to the family member who is cooking what it means if he/she always adds salt to the food, and that this can lead to a hospital visit. It is also a matter of great ignorance in the family.” (GP4)
Experiences of patients with multimorbidity with PCC improvement
Dimension | n | Score (mean ± standard deviation) | T0 vs. T1 | |||
---|---|---|---|---|---|---|
T0 | T1 | t | df | p | ||
Overall | 110 | 3.90 ± 0.49 | 4.03 ± 0.43 | 2.66 | 109 | 0.005 |
Patient preferences | 134 | 4.05 ± 0.61 | 4.07 ± 0.56 | 0.44 | 133 | 0.332 |
Physical comfort | 118 | 3.96 ± 0.59 | 4.07 ± 0.49 | 1.80 | 117 | 0.037 |
Coordination of care | 116 | 3.97 ± 0.61 | 4.06 ± 0.52 | 1.51 | 115 | 0.068 |
Emotional support | 123 | 3.55 ± 0.74 | 3.73 ± 0.69 | 2.35 | 122 | 0.010 |
Access to care | 130 | 4.12 ± 0.57 | 4.10 ± 0.49 | -0.54 | 129 | 0.296 |
Continuity and transition | 87 | 4.05 ± 0.59 | 4.21 ± 0.51 | 2.37 | 86 | 0.010 |
Information and education | 133 | 3.97 ± 0.56 | 4.00 ± 0.46 | 0.54 | 132 | 0.294 |
Family and friends | 42 | 3.72 ± 1.07 | 4.08 ± 0.76 | 2.20 | 41 | 0.017 |