Satisfaction with hospital at home care

OBJECTIVES: To examine differences in satisfaction with acute care between patients who received treatment in a physician-led substitutive Hospital at Home program and those who received usual acute hospital care. DESIGN: Survey questionnaire of participants in prospective, nonrandomized clinical trial. SETTING: Three Medicare-managed care health systems and a Department of Veterans Affairs Medical Center. PARTICIPANTS: Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis, 84 of whom were treated in Hospital at Home and 130 in the acute care hospital. INTERVENTION: Treatment in a Hospital at Home model of care that substitutes for treatment in an acute care hospital. MEASUREMENTS: A 40-question survey measuring nine domains of care for patients and a 37-question survey measuring eight domains of care for family members. RESULTS: A higher proportion of patients were satisfied with treatment in Hospital at Home than with the acute care hospital in eight of nine domains, and this difference was statistically different in four domains. Hospital at Home patients were more likely than acute hospital patients to be satisfied with their physician (adjusted odds ratio (AOR) = 3.84, 95% confidence interval (CI) = 1.32-11.19), comfort and convenience of care (AOR = 6.52, 95% CI = 1.97-21.56), admission processes (AOR = 5.90, 95% CI = 2.21-5.76), and the overall care experience (AOR = 2.98, 95% CI = 1.08-8.21). Family members of patients treated in Hospital at Home were also more likely to be satisfied with multiple domains of care. CONCLUSION: Hospital at Home care was associated with greater satisfaction than acute hospital inpatient care for patients and their family members. These findings support further dissemination of the Hospital at Home care model.     

Living with Advanced Chronic Obstructive Pulmonary Disease: A Qualitative Interview Study with Patients and Informal Carers

Abstract

The disease trajectory in chronic obstructive pulmonary disease (COPD) is characterised by a progressive decline in overall function, loss of independence and reduction of health-related quality of life. Although the symptom burden is high and care is often demanding, patients’ and informal carers’ experiences in living with advanced COPD are seldom described. This study sought to explore patients’ and informal carers’ experiences in living with advanced COPD and to understand their awareness about palliative care provision in advanced COPD. About 20 patients and 20 informal carers were recruited in a respiratory care service in Southern Switzerland. Semistructured individual interviews with participants were conducted on clinic premises and audio-recorded. Interviews lasted between 35 and 45?min. Data were analysed using thematic analysis.

Living day to day with COPD, psychosocial dimension of the disease and management of complex care were the main themes identified. Patients and informal carers reported a range of psychological challenges, with feelings of guilt, discrimination and blame. Most of the participants had no knowledge of palliative care and healthcare services did not provide them with any information about palliative care approaches in advanced COPD. The reported psychological challenges may influence the relationship between patients, informal carers and healthcare professionals, adding further complexity to the management of this long-term condition. Further research is needed to explore new ways of managing complex care in advanced COPD and to define how palliative care may be included in this complex care network.     

Clinic Services for Persons with AIDS: Experience in a High-Prevalence State

OBJECTIVE: To profile characteristics of clinics caring for persons with advanced HIV infection. DESIGN AND SETTING: Survey of clinic directors in New York State. PARTICIPANTS: Newly diagnosed Medicaid-enrolled AIDS patients in New York state in federal fiscal years 1987-1992 (n = 6,184) managed by 62 HIV specialty, 53 hospital-based general medicine/primary care, 36 community-based primary care, and 28 other clinics. MEASUREMENTS AND MAIN RESULTS: Telephone survey about clinic hours, emphasis on HIV, staffing, procedures, and directors' rating of care. Estimates of the number of newly diagnosed, Medicaid-enrolled AIDS patients treated in surveyed clinics were obtained from claims data. We found that community-based clinics were significantly more likely to have longer hours, a physician on call, or to accommodate unscheduled care than were hospital-based general medicine/primary care or other types of clinics. Compared with HIV specialty clinics, general medicine/primary care clinics were less likely to have HIV-specific care attributes such as a director of HIV care (98% vs 72%), multidisciplinary conferences on HIV care (83% vs 32%), or a standard initial HIV workup (90% vs 70%). Of general medicine/primary care clinics, most (83%) were staffed by residents and fellows compared with only 68% of HIV or 25% of community-based clinics (p < .001). General medicine/primary care clinics were less likely than community-based clinics to perform Pap smears (75% vs 94%) or to have case managers on payroll (21% vs 81%). CONCLUSIONS: In this sample of clinics, hospital-based general medicine/primary care clinics managing the care of Medicaid enrollees with AIDS appeared to have more limited hours and availability of specific services than HIV specialty or community-based clinics.     

Patients and families experience with pharmacist care at cystic fibrosis foundation accredited clinics

Cystic fibrosis (CF) is a complex genetic, multiorgan disease. The CF Foundation (CFF) recommends a multidisciplinary team (physician, nurse, respiratory therapist, dietitian, physical therapist, social worker, mental health coordinator, clinic coordinator, and pharmacist) to work with patients and families. The objective of our study was to describe the impact of a pharmacist involved in the care of patients and families from their perspective. The CF Patient and Family Experience of Care (PFEC) is a voluntary, 50‐question telephonic or internet‐based survey designed to continuously collect information from patients and their families regarding their care experience. From August of 2017 through February of 2018, five questions were added to the internet survey to assess the impact of the pharmacist on the care experience. From the 666 respondents, 54% reported that a pharmacist was involved in their CF care. At two CF clinics designated as “full access” to a pharmacist, respondents reported a higher percentage of the CF–team discussed medications compared to those from three clinics designated as “limited access” to the pharmacist (95% vs 67%). Respondents in clinics with “full access” to a pharmacist were significantly more likely to get their medications refilled on time (78% vs 63%) and reported using fewer pharmacies to fill their medications. Pharmacist involvement in CF care may improve patient's access to medication and the ability to sustain use.     

Referral rates of patients with diabetes to secondary care are inversely related to the prevalence of diabetes in each primary care practice and confidence in treatment,not to HbA1c level

AimsTo determine the factors affecting the referral rates of patients with diabetes from primary care to secondary care.MethodsA study based on 66 GP surgeries in the Cardiff and Vale University Health Board (population: 515,581) was conducted. We included patients who had an established clinical diagnosis of diabetes (type 1 and type 2) from September 2017 to September 2018.HbA1c outcome data of GP surgeries were obtained from the Quality and Outcomes Framework (QOF) database published for 2018. Referral rates were obtained from the electronic referral database of Cardiff and Vale University Health Board over the same period, and this was adjusted according to the number of patients with diabetes in each GP surgery. Confidence level on the treatment of diabetes among GPs was assessed as a sub-study conducted in nine GP surgeries in the same area, using a self-administered questionnaire. Linear regression was undertaken to assess the relationship between adjusted referral rate and key factors which might influence prescribing rate.ResultsThe average adjusted referral rate to secondary care in one year was 4.23% of patients with diabetes in each GP surgery, with a wide variation of 1.24% to 16.28%. The average percentage of patients with diabetes with HbA1c < 59 mmol/mol was 63.17% (range: 43.19–76.23%). The average confidence score of GPs in treating diabetes was 67% and ranged from 50–85% in the sub-study. Referral rates correlated inversely with the numbers of patients with diabetes in each practice β = ?0.32; (95% CI ?0.57, ?0.08) p = 0.01, but there was no significant correlation with the HbA1c outcome β = ?0.13; (95% CI ?0.39, 0.12); p = 0.30. Borderline significant negative correlation was observed between referral rates and overall practice size β = ?0.23; (95% CI ?0.48, 0.02) p = 0.07.ConclusionsReferral rates of patients with diabetes to secondary care are determined by the number of patients with diabetes in each practice and confidence level in treatment, not by the overall practice size or HbA1c level. Ensuring quality training in diabetes care for primary care teams as well as the development of integrated diabetes care may be the best way to optimise the volume and appropriateness of referrals to secondary care.     

Patient Experiences with Coordination of Care: The Benefit of Continuity and Primary Care Physician as Referral Source

BACKGROUND  Coordination across a patient’s health needs and providers is important to improving the quality of care. OBJECTIVES  (1) Describe the extent to which adults report that their care is coordinated between their primary care physician (PCP) and specialists and (2) determine whether visit continuity with one’s PCP and the PCP as the referral source for specialist visits are associated with higher coordination ratings. DESIGN  Cross-sectional study of the 2007 Health Tracking Household Survey. PARTICIPANTS  A total of 3,436 adults with a PCP and one or more visits to a specialist in the past 12 months. MEASUREMENTS  Coordination measures were patient perceptions of (1) how informed and up to date the PCP was about specialist care received, (2) whether the PCP talked with the patient about what happened at the recent specialist visit and (3) how well different doctors caring for a patient’s chronic condition work together to manage that care. RESULTS  Less than half of respondents (46%) reported that their PCP always seemed informed about specialist care received. Visit continuity with the PCP was associated with better coordination of specialist care. For example, 62% of patients who usually see the same PCP reported that their PCP discussed with them what happened at their recent specialist visit vs. 48% of those who do not usually see the same PCP (adjusted percentages, p < 0.0001). When a patient’s recent specialist visit was based on PCP referral (vs. self-referral or some other source), 50% reported that the PCP was informed and up to date about specialist care received (vs. 35%, p < 0.0001), and 66% reported that their PCP discussed with them what happened at their recent specialist visit (vs. 47%, p < 0.0001). CONCLUSIONS  Facilitating visit continuity between the patient and PCP, and encouraging the use of the PCP as the referral source would likely enhance care coordination.     

Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs

Persons with continuous complex care needs frequently require care in multiple settings. During transitions between settings, this population is particularly vulnerable to experiencing poor care quality and problems of care fragmentation. Despite how common these transitions have become, the challenges of improving care transitions have received little attention from policy makers, clinicians, and quality improvement entities. This article begins with a definition of transitional care and then discusses the nature of the problem, its prevalence, manifestations of poorly executed transitions, and potentially remediable barriers. Necessary elements for effective transitions are then presented, followed by promising new directions for quality improvement at the level of the delivery system, information technology, and national health policy. The article concludes with a proposed research agenda designed to advance the science of high-quality transitional care.     

Communication problems for patients hospitalized with chest pain

In many settings, primary care physicians have begun to delegate inpatient care to hospitalists, but the impact of this change on patients' hospital experience is unknown. To determine the effect on physician-patient communication of having the regular outpatient physician (continuity physician) continue involvement in hospital care, we surveyed 1,059 consecutive patients hospitalized with chest pain. Patients whose continuity physicians remained involved in their hospital care were less likely to report communication problems regarding tests (20% vs 31%, p = .03), activity after discharge (42% vs 51%, p = .02), and health habits (31% vs 38%, p = .07). In a setting without a designated hospitalist system, communication problems were less frequent among patients whose continuity physicians were involved in their hospital care. New models of inpatient care delivery can maintain patient satisfaction but to do so must focus attention on improving physician-patient communication.     

Use of the accident and emergency department by patients with diabetes.

As part of a District-based audit of diabetes care all attendances (of diabetic and non-diabetic patients) at a local Accident and Emergency department were monitored over a 3-month period. A total of 9505 attendances took place of which 62 (0.7%) were by people with diabetes. This was no different from the expected number of attendances (61.5) based on the rates seen in non-diabetic individuals. Of these 62 attendances, 20 (by 15 individuals) were directly related to diabetes (hypoglycaemia 17, hyperglycaemia 1, for supplies of insulin or equipment 2). When these diabetes-specific attendances were removed from the total, the number of attendances (42) was significantly (p = 0.004) less than that expected. Diabetic males aged 0-19 years attended significantly more often than non-diabetic individuals of the same age but this excess was solely attributable to diabetes.     

Palliative Access Through Care at Home: Experiences with an Urban, Geriatric Home Palliative Care Program

The aging of the U.S. population has resulted in a large number of persons with multiple, chronic illnesses and gradual functional decline. Many older adults with these conditions are homebound and have great difficulty accessing medical care. They are also more likely to suffer from unaddressed symptoms and end-of-life care needs. Certain groups, such as African-American patients and patients with dementia, are even less likely to access palliative care and hospice services. Although the informal caregivers attending to such persons may become overwhelmed without adequate support, palliative care, which covers a broad population, is an optimal way to address many of these needs. This article describes a unique, urban, home-based geriatrics palliative care program (Palliative Access Through Care at Home (PATCH)) designed to address some of these unmet needs. After 1 year of providing service, a mixed-methods study consisting of chart review, telephone interviews, and face-to-face interviews was conducted to assess caregiver expectations of and satisfaction with the program. Caregivers for the elderly, mostly African-American patients, more than half of whom had dementia, were overall very satisfied with their experience, despite the large amount of time necessary to provide the care that patients required. Themes extracted during qualitative analysis were the desire to remain at home, the need for easy access to a practitioner specializing in geriatrics and palliative medicine, and the challenges of transitions of care. PATCH was able to address many of these needs and provide high levels of caregiver satisfaction.     

Relationship of medical home quality with school engagement and after-school participation among children with asthma

Objectives: To examine the relationship between medical home quality and measures of daily life experiences among children with asthma. Methods: A nationally representative sample of children from the 2007 National Survey of Children's Health (NSCH), aged 6–17 years (n = 6357), who have asthma was used to assess the relationship of a quality medical home and its features with their daily life experiences. Five medical home features – access, continuity, comprehensiveness, family-centered care, and coordination of care – were examined individually and in total in relation to measures of school engagement (missed school days, parents contacted about problems with the child, repeating a grade since kindergarten) and after-school activity participation (physical activity, sports participation, and community service or volunteer work). Results: Before and after adjustment for personal characteristics, health insurance status, family environment, neighborhood variables, and asthma severity, total medical home score was associated with more days exercised [beta (B) = 0.10, p < .05] and a greater likelihood of having performed community service or volunteer work [odds ratio (OR) = 1.16, CI: 1.02–1.31]. Additionally, the medical home features of access, comprehensiveness, and family-centered care remained favorably associated with three of the six measures of school engagement and after-school activity participation, even after adjustment. Conclusion: Medical home quality – particularly the features of access, comprehensiveness, and family-centered care – is positively associated with the daily life experiences of children with asthma. Working to enhance these aspects of primary care might be one place to start in improving the management of children's chronic conditions and their quality of life.     

Association of Communication Between Hospital-based Physicians and Primary Care Providers with Patient Outcomes

BACKGROUND  Patients admitted to general medicine inpatient services are increasingly cared for by hospital-based physicians rather than their primary care providers (PCPs). This separation of hospital and ambulatory care may result in important care discontinuities after discharge. We sought to determine whether communication between hospital-based physicians and PCPs influences patient outcomes. METHODS  We approached consecutive patients admitted to general medicine services at six US academic centers from July 2001 to June 2003. A random sample of the PCPs for consented patients was contacted 2 weeks after patient discharge and surveyed about communication with the hospital medical team. Responses were linked with the 30-day composite patient outcomes of mortality, hospital readmission, and emergency department (ED) visits obtained through follow-up telephone survey and National Death Index search. We used hierarchical multi-variable logistic regression to model whether communication with the patient’s PCP was associated with the 30-day composite outcome. RESULTS  A total of 1,772 PCPs for 2,336 patients were surveyed with 908 PCPs responses and complete patient follow-up available for 1,078 patients. The PCPs for 834 patients (77%) were aware that their patient had been admitted to the hospital. Of these, direct communication between PCPs and inpatient physicians took place for 194 patients (23%), and a discharge summary was available within 2 weeks of discharge for 347 patients (42%). Within 30 days of discharge, 233 (22%) patients died, were readmitted to the hospital, or visited an ED. In adjusted analyses, no relationship was seen between the composite outcome and direct physician communication (adjusted odds ratio 0.87, 95% confidence interval 0.56 – 1.34), the presence of a discharge summary (0.84, 95% CI 0.57–1.22), or PCP awareness of the index hospitalization (1.08, 95% CI 0.73–1.59). CONCLUSION  Analysis of communication between PCPs and inpatient medical teams revealed much room for improvement. Although communication during handoffs of care is important, we were not able to find a relationship between several aspects of communication and associated adverse clinical outcomes in this multi-center patient sample. This paper was presented at the Society for General Internal Medicine Annual Meeting in April 2006.