Making a Difference: Practicing Patient-Centered Care. Laurel E. Radwin, RN, Ph.D. OBJECTIVES

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1 Making a Difference: Practicing Patient-Centered Care Laurel E. Radwin, RN, Ph.D. Research Health Scientist Center for Healthcare Outcomes and Innovation Research (CHOIR) Boston Veteran Administration Health Care System OBJECTIVES Discuss patients perspectives on patient centered care. Explore how measuring patient-centered care may credit nursing s contribution to such care and its outcomes. 1

2 Respect for patient preferences Coordinated care Communication Information/ Education Comfort/ Emotional support Inclusive Family/Friends Continuity of Care Six Aims of Health Care System Safe, Efficient, Equitable, Timely, Effective PATIENT-CENTERED Patient-Centered Care Care that is respectful of and responsive to individual patient preferences, needs, and values and [ensures] that patient values guide all clinical decisions (IOM, 2001, p. 40) 2

3 Patients in the qualitative studies (including nursing) described patient centered care: Individualized Being involved in decision-making Clinicians know patients as persons with health beliefs Rapport Respectful Involved family and friends (Sofaer and Firminger, 2005) Oncology Patient s Perceptions of Quality Nursing Care Radwin, L., Research in Nursing & Health, , Quality Nursing Care Attributes Patient as PARTNER Patient treated as INDIVIDUAL CARING approach ATTENTIVE manner RAPPORT established 3

4 Quality Nursing Care Attributes PROFESSIONAL KNOWLEDGE used CONTINUITY COORDINATED care Quality Nursing Care Outcomes SENSE OF WELL-BEING trust optimism authenticity FORTITUDE INDIVIDUALIZATION Tailored to patient particulars preferences feelings and perceptions impact of illness preferred coping strategies and approaches 4

5 INDIVIDUALIZATION "I did not ever feel as if I was a 'breast cancer patient' I was a young professional who was being treated for breast cancer. Who had her own set of special needs and peculiarities [that my nurse] was sensitive and aware of and integrated into the treatment plan" (Informant 11). PARTNERSHIP Inclusive decision-making Honoring patient's skills knowledge appraisals conclusions PARTNERSHIP Negative Case I ve got a bad history when it comes to [central] lines. But trying to convince somebody that I had some idea what I was talking about. I said, That lump was not there 15 minutes ago. And believe me after having breast cancer, I can tell you every lump, bump, nook and cranny and they just said it doesn't happen (Informant 2). 5

6 RAPPORT Human connection Patient knows nurse RAPPORT It's not just that cut, cold, clinical relationship, You're the patient and I'm here to take care of you. Okay let's see that arm. Let's see the incision. Okay that's done. Goodbye. [The nurses are] human beings. They connect with you, they talk. [It s] forming a bond with this person (Informant 10). A few additional considerations about PCC itself Includes shared decision-making Can be affected by system factors For best measurement, should be considered as stand alone separate from system factors 6

7 Patient Engagement/Shared Decision- Making as part of PCC Nursing Alliance for Quality Care white paper on patient engagement Partnership for Patients patient and family engagement tools AHRQ information on patient engagement National Quality Forum report on personcentered care and outcomes Understand that health care system characteristics can affect nursing patientcentered care Nurse Dose/Nursing Human Capital Education, nurse hours per patient day, specialty knowledge (Sidani et al. 2010; Bartel et al. 2014) 7

8 Caveat: PCC definitions are beginning to include health care system characteristics along with the process characteristic Understand what is being defined and measured Respect for patient preferences Emotional support Physical comfort Involvement of family, friends Information, education, communication PATIENT CENTERED MEDICAL HOME (PCMH) Coordination Continuity Transitions Access to care Rathert et al., 2012 OBJECTIVE 2: Explore how measuring patientcentered care may credit nursing s contribution to such care and its outcomes Several considerations about outcomes: Proximal and Distal Wellness and Disease-Related Effects of PCC as stand alone OR PCC as part of PCMH 8

9 Research findings about outcomes Individualization consistently resulted in better Patient-reported outcomes (PRO/PROMIS) SOWB Satisfaction In some studies, individualization resulted in Fewer rehospitalizations Fewer disease-related symptoms (Rather et al., 2012) Morbidity and Mortality PCC decision-making has been shown to improve health care outcomes (Weiner, et al., 2013) Shown to improve patients' health status (Stewart, et al., 2000; Anderson, 2002), lessen patients' symptom burden (Little, et al., 2001). Encourages patients to adhere to treatment (Beck, et al., 2002). Cost Reduce the chance of misdiagnosis (DiMatteo, 1998). Reduce underuse and overuse of medical care (Berry, et al., 2003). Reduce the number of diagnostic tests and referrals (Little, et al., 2001). May increase providers' costs, especially in the short run (Bechel, et al., 2000). 9

10 To whom are outcomes attributed? Has implications for PCC measures what specific questions are asked 2002 study of PCC for hospitalized cardiac patients and post-dc events (Fremont et al., 2002) Consumer Assessment Of Health Providers and Systems (CAHPS) Family of Measures Health Plans Clinician and Group Hospital Experiences of Care and Outcomes (ECHO) Hospice Nursing Home Home Health Surgical Care Dental and others Challenge to consider when measuring PCC Do we measure nursing s contributions exclusively? As inherent when referencing staff? Or in nursing specific items in specific surveys? 10

11 During this hospital stay, how often did nurses listen carefully to you? During this hospital stay, how often did nurses show respect for what you had to say? During this hospital stay, how often did nurses explain things in a way you could understand? During this hospital stay, how often did nurses treat you with courtesy and respect? During this hospital stay, how often did you feel nurses really cared about you as a person? During this hospital stay, how often did doctors listen carefully to you? During this hospital stay, how often did doctors show respect for what you had to say? During this hospital stay, how often did doctors explain things in a way you could understand? During this hospital stay, how often did doctors treat you with courtesy and respect? During this hospital stay, how often did you feel doctors really cared about you as a person? From CAHPS Medication Knowledge Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? 11

12 From CAHPS - Outcomes Pain During this hospital stay, how often was your pain well controlled? During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? DC Readiness During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? Analyses to explain how much of these outcomes are attributable to nursing and to medical care indicate.. A systematic review of instruments measuring patients perceptions of patient-centered nursing care 12

13 Responsiveness (comprised attentiveness, caring, rapport items) The nurse meets patient needs in a caring, attentive manner The nurses comforted me when I needed it (Radwin et al., 2003) Individualization (comprised individualization, partnership items) The nurse personalizes care to the patient s feelings, preferences, and desired level of involvement The nurses knew how to help me when things were bothering me Coordination (comprised coordination, continuity items) The nurse promotes communication among other nurses and the patient The nurses arranged for the same nurses to care for me regularly 13

14 Proficiency The nurse provides knowledgeable and skillful care. The nurses knew how to care for someone with my condition. In Summary Patient Centered Care defined based on research. Outcomes associated with PCC Measurement options include national and local measures. Measurement with a purpose Conclusions Understand what you want to measure and why. Nursing specific, PCC more generally Understand system effects on PCC and its associated outcomes Consider a specific measure for performance improvement purposes 14

15 Questions? 15