Providing Primary Care for HIV in the Context of Trauma: Experiences of the Health Care Team

BackgroundTrauma-informed health care for women living with human immunodeficiency virus (HIV) attends not only to HIV treatment, but also to the many common physical and emotional health consequences of trauma. One principle of providing trauma-informed care is the acknowledgement that working with a population that has experienced extensive trauma affects the team members who care for them in the clinic, as well as the interactions between those team members.MethodsTo understand the needs of one primary health care team, we conducted in-depth interviews with 21 providers, staff, and collaborators who provide care to patients within the clinic. We used symbolic interaction and grounded theory methods to examine how interactions unfold within the clinic and how they are influenced by trauma.ResultsThe clinic team serves a highly traumatized and vulnerable population. Within this context, interactions between clinic staff unfold and trauma surfaces, and power dynamics play out along the lines of professional hierarchy. Although power differences cause tension within the clinic, professional hierarchy also serves as an important division of labor in times of medical crises.ConclusionsClinic power dynamics may be influenced to improve the care environment for patients, and to realize a more effective and satisfying trauma-informed health care clinic for both patients and staff.     

Experiences of hospital-based multidisciplinary team meetings in oncology: An interview study among participating general practitioners

Background: Cancer care has become complex, requiring healthcare professionals to collaborate to provide high-quality care. Multidisciplinary oncological team (MDT) meetings in the hospital have been implemented to coordinate individual cancer patients’ care. General practitioners (GPs) are invited to join, but their participation is minimal.

Objectives: Aim of this study is to explore participating GPs’ perceptions of their current role and to understand their preferences towards effective role execution during MDT meetings.

Methods: In May to June 2014, semi-structured interviews (n?=?16) were conducted involving GPs with MDT experience in Belgium. The analysis was done according to qualitative content analysis principles.

Results: Attendance of an MDT meeting is perceived as part of the GP’s work, especially for complex patient care situations. Interprofessional collaborative relationships and the GP’s perceived benefit to the MDT meeting discussions are important motivators to participate. Enhanced continuity of information flow and optimized organizational time management were practical aspects triggering the GP’s intention to participate. GPs valued the communication with the patient before and after the meeting as an integral part of the MDT dynamics.

Conclusion: GPs perceive attendance of the MDT meeting as an integral part of their job. Suggestions are made to enhance the efficiency of the meetings.     

Hospice social workers’ perception of being valued by the interdisciplinary team and the association with job satisfaction

ABSTRACT

Being valued and respected by colleagues is an important contributor to job satisfaction in hospice and other health care settings. The purpose of this study was to examine how the perception of feeling valued by different members of the interdisciplinary team and interdependence of team members are related to hospice social workers’ job satisfaction. The study aims were to examine: (1) the degree to which hospice social workers feel valued by other members of the interdisciplinary team; and 2) whether this is associated with job satisfaction. A nonprobability sample of 203 hospice social workers completed an online survey assessing job satisfaction, perception of feeling valued by each of the professionals on the interdisciplinary hospice team, interdependence of team members, and professional and personal characteristics. The final regression model for intrinsic job satisfaction included feeling valued by doctors and by other social workers, and interdisciplinary interdependence. The final model for extrinsic job satisfaction did not include any of the perception of feeling valued by others on the interdisciplinary team, although interdependence and the number of social workers at the hospice were significant in this model. Reasons for the difference in these models and the practice and policy implications are discussed.     

Effects of Primary Care Team Social Networks on Quality of Care and Costs for Patients With Cardiovascular Disease

PURPOSE

Cardiovascular disease is the leading cause of mortality and morbidity in the United States. Primary care teams can be best suited to improve quality of care and lower costs for patients with cardiovascular disease. This study evaluates the associations between primary care team communication, interaction, and coordination (ie, social networks); quality of care; and costs for patients with cardiovascular disease.

METHODS

Using a sociometric survey, 155 health professionals from 31 teams at 6 primary care clinics identified with whom they interact daily about patient care. Social network analysis calculated variables of density and centralization representing team interaction structures. Three-level hierarchical modeling evaluated the link between team network density, centralization, and number of patients with a diagnosis of cardiovascular disease for controlled blood pressure and cholesterol, counts of urgent care visits, emergency department visits, hospital days, and medical care costs in the previous 12 months.

RESULTS

Teams with dense interactions among all team members were associated with fewer hospital days (rate ratio [RR] = 0.62; 95% CI, 0.50–0.77) and lower medical care costs (−$556; 95% CI, −$781 to −$331) for patients with cardiovascular disease. Conversely, teams with interactions revolving around a few central individuals were associated with increased hospital days (RR = 1.45; 95% CI, 1.09–1.94) and greater costs ($506; 95% CI, $202–$810). Team-shared vision about goals and expectations mediated the relationship between social network structures and patient quality of care outcomes.

CONCLUSIONS

Primary care teams that are more interconnected and less centralized and that have a shared team vision are better positioned to deliver high-quality cardiovascular disease care at a lower cost.     

A Case Study Using The Discipline with a Clinical Team

SUMMARY

Health care delivery in hospitals and clinics promotes an interdisciplinary team approach. This article presents the use of The Discipline though the involvements of the chaplain as part of the Infectious Disease team as together they addressed the inherent spirituality of one HIV/AIDS patient. This narrative recounts the unfolding events of the patient's life and describes the use of The Discipline during a very difficult time period for the patient and the staff. The experience can serve as a model for other health care teams who must manage difficult, deteriorating patients.     

Development and psychometric testing of the patient participation in bedside handover survey

IntroductionWhen handover is conducted at the patient''s bedside, active patient participation can be encouraged, which may improve the safety and quality of care. There is a need for valid and reliable tools to measure patient perceptions of participation in bedside handover, to ensure the rising number of implementation and improvement efforts are consistently and effectively evaluated. The aim of this study is to systematically develop and evaluate the psychometric properties of a self‐report survey to measure patients'' perceptions of participation in bedside handover.MethodsIn Phase 1, our team developed a conceptual framework and item pool (n = 130). In Phase 2, content validity was assessed with four health consumers, four nurses and four researchers. Next, 10 current hospital inpatients tested the survey for end‐user satisfaction. In Phase 3, 326 inpatients completed the survey, allowing exploratory factor analysis, reliability analyses and convergent/divergent validity analyses to occur.ResultsPhase 1 and 2 resulted in a 42‐item survey. In Phase 3, 321 surveys were available for analysis. Exploratory factor analysis revealed a three‐factor solution, with 24 items, which matched our conceptual framework. The three factors were: ‘Conditions for patient participation in bedside handover’, ‘Level of patient participation in bedside handover’ and ‘Evaluation of patient participation in bedside handover’. There was strong evidence for factor reliability and validity. Additionally, the correlation between factors was strong.ConclusionThis study furthers our conceptual understanding by showing that nurse facilitating behaviours are a strong precursor for patient participation and perceived handover outcomes, justifying the need for nursing training. A robust survey has been developed to measure patient perceptions of participation in bedside handover, which can effectively evaluate this approach to care. Engaging consumers and nurses as research team members was invaluable in ensuring that the survey is acceptable for end‐users.Patient or Public ContributionA health consumer and nurse partnered as members of the research team from study inception to dissemination.     

Relación clínica y problemas éticos en atención primaria,São Paulo,Brasil

ObjectivesMain Objective: to identify ethical problems in primary care according to nurses’ and doctors’ perceptions. Secondary Objective: to know ethical issues of patient-professional relationships in primary care.DesignSynthesis to integrate and reinterpret primary results of qualitative studies.SettingPrimary healthcare centers, Sao Paulo, SP, Brazil.Participants and/or contextIncidental sample of 34 nurses and 36 medical doctors working in primary healthcare centers selected by convenience.MethodsIndividual, semi-structured interviews to identity situations considered as sources of ethical problems. The sample is socially representative of primary care health centers and professionals. Data collection assured discourse saturation. Hermeneutic-dialectical discourse analysis was used to study the results.ResultsPatient-professional relationships and team work were the main sources of ethical problems. The most important problems were patient information, privacy, confidentiality, interpersonal relationship, linkage and patient autonomy. These issues reflect the recent changes in clinical relation ships and show the peculiarities of primary care with its continuous care which lasts a long time. Healthcare involves multiprofessional team work in the midst of the patient claims for autonomy. Good care of patients needs requires a relationship based on communication and cooperation, and includes feelings and values, with communication skills.ConclusionsEthical problems in primary care are common situations. For quality and humane primary care the relationship should consist of dialogue, trust and cooperation.     

Geneva medical students increasingly identify primary care physicians as role models after introduction of a compulsory clerkship

BackgroundRole modelling is recognised as an important element in career choice. In strongly hospital-based medical education settings, students identify few primary care physicians as positive role models, which might impact their career plans and potentially contribute to primary care workforce shortage. At Geneva Faculty of Medicine (Switzerland), a compulsory final-year clerkship in primary care practices was introduced to strengthen primary care teaching in the curriculum.ObjectivesTo assess the proportion of graduating students identifying a primary care physician as positive role model, before and after the introduction of the clerkship.MethodsCross-sectional survey in four consecutive classes of graduating medical students one year before and three years after the introduction of the clerkship. The main outcome measure was the proportion of students in each class citing a primary care physician role model. Comparisons were analysed using Pearson’s Chi-square test and one-way ANOVA.ResultsThe total sample included 505 students. The proportion of students recalling a primary care physician role model increased steadily from 8% (before introduction of the clerkship) to 13, 16, and 21%, respectively, at 1, 2 and 3 years after the introduction of the clerkship (p = 0.03).ConclusionOur exploratory study suggests that introducing a compulsory primary care clerkship may have contributed to increasing the visibility of primary care physicians as role models. Future research should explore primary care physicians’ awareness of role modelling and its contribution to career choices.     

St Joseph's Community Health Centre model of community-based interdisciplinary health care team education

As our reliance on interdisciplinary health care teams for meeting the multidimensional needs of the community becomes greater, new interdisciplinary education programmes and learning experiences are needed to educate students and health care professionals to become better team players. The St Joseph's Community Health Centre (SJCHC) model of community-based interdisciplinary health care team education was developed with support from McMaster University and the Educational Centre for Aging and Health's Clinical Teaching Unit Without Walls. The SJCHC model is structured as one 3-h session each week for eight consecutive weeks and is an elective learning experience for students. Six to eight senior health, social science and other health-related students work with two group facilitators as a team on discussion theme topics: team dynamics; role issues and professional values; collaboration and conflict; communication, leadership and power; client-centred goal-oriented care; and consumerism issues. The success and impact of the SJCHC model has been measured by several primary and secondary outcomes outlined in the Charting the Outcomes of Educational and Clinical Approaches (COECA) model.     

Factors associated with professional satisfaction in primary care: Results from EUprimecare project

Background: Given the importance of primary care to healthcare systems and population health, it seems crucial to identify factors that contribute to the quality of primary care. Professional satisfaction has been linked with quality of primary care. Physician dissatisfaction is considered a risk factor for burnout and leaving medicine.

Objectives: This study explored factors associated with professional satisfaction in seven European countries.

Methods: A survey was conducted among primary care physicians. Estonia, Finland, Germany and Hungary used a web-based survey, Italy and Lithuania a telephone survey, and Spain face to face interviews. Sociodemographic information (age, sex), professional experience and qualifications (years since graduation, years of experience in general practice), organizational variables related to primary care systems and satisfaction were included in the final version of the questionnaire. A logistic regression analysis was performed to assess the factors associated with satisfaction among physicians.

Results: A total of 1331 primary care physicians working in primary care services responded to the survey. More than half of the participants were satisfied with their work in primary care services (68.6%). We found significant associations between satisfaction and years of experience (OR?=?1.01), integrated network of primary care centres (OR?=?2.8), patients having direct access to specialists (OR?=?1.3) and professionals having access to data on patient satisfaction (OR?=?1.3). Public practice, rather than private practice, was associated with lower primary care professional satisfaction (OR?=?0.8).

Conclusion: Elements related to the structure of primary care are associated with professional satisfaction. At the individual level, years of experience seems to be associated with higher professional satisfaction.     

Primary care team working in Ireland: a qualitative exploration of team members’ experiences in a new primary care service

Team working is an integral aspect of primary care, but barriers to effective team working can limit the effectiveness of a primary care team (PCT). The establishment of new PCTs in Ireland provides an excellent opportunity to explore team working in action. The aim of this qualitative study was to explore the experiences of team members working in a PCT. Team members (n = 19) from two PCTs were interviewed from May to June 2010 using a semi‐structured interview guide. All interviews were audio‐recorded and transcribed. Data were analysed using NVivo (version 8). Thematic analysis was used to explore the data. We identified five main themes that described the experiences of the team members. The themes were support for primary care, managing change, communication, evolution of roles and benefits of team working. Team members were generally supportive of primary care and had experienced benefits to their practice and to the care of their patients from participation in the team. Regular team meetings enabled communication and discussion of complex cases. Despite the significant scope for role conflict due to the varied employment arrangements of the team members, neither role nor interpersonal conflict was evident in the teams studied. In addition, despite the unusual team structure in Irish PCTs – where there is no formally appointed team leader or manager – general issues around team working and its benefits and challenges were very similar to those found in other international studies. This suggests, in contrast to some studies, that some aspects of the leadership role may not be as important in successful PCT functioning as previously thought. Nonetheless, team leadership was identified as an important issue in the further development of the teams.     

Association between Women Veterans' Experiences with VA Outpatient Health Care and Designation as a Women's Health Provider in Primary Care Clinics

BackgroundWomen veterans comprise a small percentage of Department of Veterans Affairs (VA) health care users. Prior research on women veterans' experiences with primary care has focused on VA site differences and not individual provider characteristics. In 2010, the VA established policy requiring the provision of comprehensive women's health care by designated women's health providers (DWHPs). Little is known about the quality of health care delivered by DWHPs and women veterans' experience with care from these providers.MethodsSecondary data were obtained from the VA Survey of Healthcare Experience of Patients (SHEP) using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient-centered medical home (PCMH) survey from March 2012 through February 2013, a survey designed to measure patient experience with care and the DWHPs Assessment of Workforce Capacity that discerns between DWHPs versus non-DWHPs.FindingsOf the 28,994 surveys mailed to women veterans, 24,789 were seen by primary care providers and 8,151 women responded to the survey (response rate, 32%). A total of 3,147 providers were evaluated by the SHEP-CAHPS-PCMH survey (40%; n = 1,267 were DWHPs). In a multivariable model, patients seen by DWHPs (relative risk, 1.02; 95% CI, 1.01–1.04) reported higher overall experiences with care compared with patients seen by non-DWHPs.ConclusionsThe main finding is that women veterans' overall experiences with outpatient health care are slightly better for those receiving care from DWHPs compared with those receiving care from non-DWHPs. Our findings have important policy implications for how to continue to improve women veterans' experiences. Our work provides support to increase access to DWHPs at VA primary care clinics.     

Variation in Hospice Experiences by Care Setting for Patients With Dementia

ObjectivesUse of hospice care among patients with dementia has been steadily increasing. Our objectives were to characterize quality of hospice care experiences among decedents who had a primary diagnosis of dementia and their caregivers and investigate differences across settings of hospice care.DesignWe analyzed Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey data from caregiver respondents whose family members received hospice care.Setting and ParticipantsData from 96,845 caregiver respondents whose family members had a primary diagnosis of dementia and died in 2017 or 2018 while receiving hospice care in 2829 hospices.MethodsWe calculated quality measure scores overall and stratified by setting, adjusting for mode of survey administration and differences in case mix, and examined variability in hospice-level scores among decedents with dementia.ResultsMean quality measure scores ranged from 69.0 (Getting Hospice Care Training) to 90.9 (Getting Emotional Support). Measure scores varied significantly across settings, with caregivers of decedents who received care in a nursing home (NH), acute care hospital (ACH), or assisted living facility (ALF) consistently reporting poorer quality of care. Hospice-level scores varied substantially, with a wide range between the 10th and 90th percentiles of hospice performance (eg, 25 points).Conclusions and ImplicationsThere are important opportunities to improve hospice care for patients with dementia and their caregivers, particularly with respect to caregiver training, symptom management, and across all dimensions within the NH, ACH, and ALF settings. Variability in care experiences across hospices, as well as long lengths of stay for those with dementia, highlight the importance of informed and timely hospice referral.     

Patient perspectives on quality of care for depression and anxiety in primary health care teams: A qualitative study

BackgroundWidespread policy reforms in Canada, the United States and elsewhere over the last two decades strengthened team models of primary care by bringing together family physicians and nurse practitioners with a range of mental health and other interdisciplinary providers. Understanding how patients with depression and anxiety experience newer team‐based models of care delivery is essential to explore whether the intended impact of these reforms is achieved, identify gaps that remain and provide direction on strengthening the quality of mental health care.ObjectiveThe main study objective was to understand patients’ perspectives on the quality of care that they received for anxiety and depression in primary care teams.MethodsThis was a qualitative study, informed by constructivist grounded theory. We conducted focus groups and individual interviews with primary care patients about their experiences with mental health care. Focus groups and individual interviews were recorded and transcribed verbatim. Grounded theory guided an inductive analysis of the data.ResultsForty patients participated in the study: 31 participated in one of four focus groups, and nine completed an individual interview. Participants in our study described their experiences with mental health care across four themes: accessibility, technical care, trusting relationships and meeting diverse needs.ConclusionGreater attention by policymakers is needed to strengthen integrated collaborative practices in primary care so that patients have similar access to mental health services across different primary care practices, and smoother continuity of care across sectors. The research team is comprised of individuals with lived experience of mental health who have participated in all aspects of the research process.     

Hospice medical directors: a survey of one state

IntroductionLittle research exists regarding hospice medical directors (HMD). This project describes the HMD’s background and training, clinical roles, and current function within the hospice organization and their interdisciplinary groups.MethodsA survey was mailed to each licensed hospice that was also a member of the state hospice association in one state. Thirty-one HMDs from 31 hospice programs (40% response rate) in one state responded.ResultsFindings show that the role of the HMD in this state is primarily part-time and filled by primary care physicians. Most HMDs report being satisfied with their positions. No more than one third belong to any one professional association and no physician in this survey was certified in palliative care by the American Board of Medical Specialties. The role for most of these HMDs centers around their clinical contribution to the team.DiscussionDespite the 2008 revisions in the regulations, the HMD roles still vary across hospices, and requirements regarding the specialty, training, and education for physicians are not specified. Professional associations for HMDs should target these part-time physicians in an effort to build a comprehensive organization represented by all types of HMDs.ConclusionThe part-time nature of HMDs has important implications for professional organizations and policy makers. Palliative care certification and continuing education opportunities need to be made available to these physicians. Additionally, new changes requiring face-to-face visits for recertification should consider the part-time nature of HMD work and the difficulties that the requirement will have in both cost for the hospice and access to primary care in rural areas.     

Accessibility of primary care physician practice sites in South Carolina for people with disabilities

BackgroundQuality and level of health care provided for people with disabilities at primary care physician's offices can be drastically impacted by the level of accessibility of the practice. The study goal was to assess the accessibility of primary care physician practices sites in South Carolina for people with mobility or sensory disabilities.MethodsPrimary care offices were contacted through two different networks, and 68 agreed to a modified accessibility assessment. Prior to each visit, practice characteristics were gathered. The rehabilitation engineer assessed the sites for 93 specific accessibility items using a tape measure, inclinometer, and weight scale. The survey items were taken from the American with Disabilities Act Accessibility Guidelines (ADAAG).ResultsThe level of accessibility varied substantially; the average practice was deemed adequate on 70% of the items assessed. The strongest predictor of overall accessibility was the year of construction or most recent renovation. Hospital-owned buildings were significantly more accessible (P = 0.04) when controlling for year built. Key aspects of accessibility that were often lacking included car- and van-accessible parking, lever door handles, clear floor space and grab bars in the restroom, TTY telephone or a hearing aid–compatible telephone, wheelchair accessible scale, and an adjustable-height examination table.ConclusionThe accessibility of primary care practice sites in South Carolina is suboptimal. Research is needed to identify effective approaches for encouraging primary care practices to make their practices fully accessible.