Perspectives on chronic illness care in the Southern region. Fiona Doolan-Noble, Robin Gauld; Debra Waters & Sophia Leon de la Barra.

Transcription

1 Perspectives on chronic illness care in the Southern region Fiona Doolan-Noble, Robin Gauld; Debra Waters & Sophia Leon de la Barra.

2 Aim To study the organisation and coordination of chronic illness care in the Southern region from the perspective of the patient and primary care health professionals.

3 Context 1. Chronic illness is the leading cause of morbidity and mortality in New Zealand; 2. People with chronic conditions are significantly more likely to use primary health care services; 3. Chronic conditions contribute the major share of inequalities in life expectancy; 4. All General Practices have the ability to provide additional GP and PN time to patients with chronic care needs enrolled in the governmentfunded Care Plus programme, for which General Practices receive additional funding; 5. Currently little is known about how General Practices actively coordinate services for chronic care patients.

4 Phases of the study 1 Literature search to identify and appraise: Questionnaires for survey Information on the use of diaries as data collection tools 2 Identification of samples: Health professional sample comprised 335 GPs and 302 PNs Random sample of 500 patients enrolled under Care Plus 3 4 Data collection and analysis of surveys Identification of diary participants Distribution of dairies Monitoring of participants progress over 2 months Collection of diaries; data entered into NVivo10 and analysed 5 Synthesis of quantitative and qualitative findings

5 Modified Patient Assessment of Chronic Illness Care (M-PACIC) Survey tool

6 Characteristics of GP and PN responders Variable Frequency Percent Practice nurse % General practitioner % Female % Male % Multiple practice % Solo practice % Practice locations Central Otago/Lakes % Southland/Gore/Invercargill % Dunedin/Clutha/North Otago %

7 Patient characteristics Variable Frequency Percent Male % Female % Age Mean (SD) Range 71.5 years (12.5) years Ethnicity Maori % NZE % Samoan 2 0.8% Cook Island Maori 2 0.8% Chinese 1 0.4% Other 6 2.4%

8 Self rated health scores Self rated health Frequency Percent Excellent 4 1.6% Very good % Good % Fair % Poor % There was an inverse statistically significant relationship between selfrated health and age (P=0.043)

9 Findings

10 Satisfied you are doing a good job organising care Delivery system Q2: feel satisfied that you are doing a good job organising their care Male Count % Female Count % A little of the time Some of the time Most of the time Always % 19.1% 76.6% 4.3% % 38.3% 55.3% 0% Total % % P=0.022

11 Comparison of mean scores between health professionals and patients Patient activation score * Delivery system score Goal setting score * Problem solving score * Follow up score * Cultural sensitivity score * Overall mean PN Mean Std D GP Mean Std D Pts Mean Std D * = P value of <0.001

12 Thematic analysis of text data Frustrations Challenges to chronic care management Patient challenges; Time; Lack of continuity and linkages; Misunderstanding. Enablers of chronic care management Teamwork; Care plus s role in CCM. Areas identified for improvement

13 Frustrations Health professionals In an ideal world we might say that all of these things are important and that this type of care (follow up) should be provided. However, this is not an ideal world and we do the best we can, within the time and financial constraints. M GP We live in a far from perfect world. Our resources to provide care are limited and the demands upon services are great. In a perfect world we would be able to do a lot more, and to a higher standard. M GP Patients I would like to be treated as a whole person, not just a particular problem like a pain somewhere. Being sent to a specialist is Ok but my whole self is affected by whatever is being treated. Often my Care Plus visit does not deal with everything. My doctor is good but tends to get stuck on one problem when other things are bugging me as well. F78 yrs I feel like medical care deals with the immediate problem presented to the doctor, but a long term holistic approach is needed to seek solutions to improve my quality of life. F 75 yrs

14 Challenges to chronic care management Health professionals Patient challenges The patient will want their funny mole, turned ankle looked at, in the same slot you have earmarked for their chronic condition. (They think it is just a repeat of my pills). Hospital specialists in outpatient clinics can dodge the above by saying, ask your GP about that. F GP Time Time constraints have a large impact on helping the client organise their care. F PN Misunderstandings While patients value what I say, if it is backed up by the GP, then they really value it. F PN Time Patients Under the Care Plus programme too much emphasis is put on time and the lack of it. A lot of things are going on for me but every time, we ll deal with it next time, and it never gets done. F 62 yrs Misunderstandings Too often a visit to the doctor s results only in time with the practice nurse, with no doctor consultation. This leaves a feeling of, if they don t care why should I? M 81yrs

15 Challenges to chronic care management contd Health professionals Lack of continuity and care linkages Patients Lack of continuity and care linkages We don t always know about appointments with other health professionals. F PN I encourage groups if available in the area, but often not available. F PN I feel the uncertainty of what doctor I will see next time I visit makes it very hard to build up a good working relationship with them. In X we have had numerous doctors here, none of which stay long enough to build up a rapport with which makes it very hard. M 75 yrs.

16 Enablers of chronic care management Health professionals Depending on the condition/s other team members include: pharmacists, continence nurse, Arthritis/Alzheimer s/parkinson foundations, cardiac or pulmonary rehabilitation etc. F GP We use the Care Plus booklet (to provide written list) and the nurse will discuss and document exercise goals etc. I provide them with a written list of their medication changes and annotate the script so the chemist knows what changes I have made. F GP

17 Enablers of chronic care management Health professionals Care Plus We send out three month recall letter to Care Plus patients inviting them to come in for a Care Plus visit at a reduced fee of $15. We alternate GP/PN (same ones) which provides continuity of care and builds relationships. Patients can phone their nurse case manager between visits if concerned. F PN Patients Care Plus I visit my doctor 3 monthly. At this time we discuss any problems or if any other treatment is required. M 86 years

18 Areas for improvement Health professionals I probably should ask them if they ever have difficulty understanding information provided to them related to their medical condition/s. F GP Re show them how what they do to take care of themselves influences their condition, I should start to tell them. F PN Ask them how their chronic illness affects their life, I should definitely ask more often. F GP

19 Strengths and limitations Strengths Reference group guided study approach; Mixed methodology; Researchers did not have institutional proximity to the evaluated process and had received independent funding; The survey findings reflect the findings from other surveys. Limitations No access to health professional personal contact details at practice therefore unable to personalise approach; Health professional response rate; Common challenges in evaluating chronic disease management approaches e.g. lack of an evaluation culture.

20 Summary General practitioners and practice nurses in the Southern Region consider they provide the components of chronic care management described in the PACIC some or most of the time. Patients consider they receive these components of chronic illness care, a little or some of the time. The comments included in survey responses provide a potential understanding of the differences in perceptions between patients and providers of primary care. Key areas to address were identified: patient activation, care coordination and continuity of care

21 Acknowledgements All survey responders Well Dunedin Trust for funding the study

22 References Vrijhoef HJ. Berbee R. Wagner EH. Steuten LM. Quality of integrated chronic care measured by patient survey: identification, selection and application of most appropriate instruments. Health Expectations. 12(4):417-29, 2009 Dec. Carryer J, Budge C, Hansen C, Gibbs K. Modifying the PACIC to assess provision of chronic illness care: An exploratory study with primary health care nurses. Journal of Primary Health Care. 2010;2(2): Bonevski, B., Magin, P., Horton, g., Foster, M., Girgis, A. Response rates in GP surveys trialing two recruitment stategies. Australian Family Physician 2011; 40(6): Kenealy T, Docherty B, Sheridan N, Gao R. Seeing patients first: creating an opportunity for practice nurse care? Journal of Primary Health Care 2010;2(2): ) Knai C, Nolte E, Brunn M, Elissen A, Conklin A, Pedersen J, et al. Reported barriers to evaluation in chronic care: Experiences in six European countries. Health Policy. 2013;110: Edwards P, Roberts I, Clarke M, DiGuiseppi C, Pratap S, Wentz R, et al. Increasing response rates to postal questionnaires: systematic review. British Medical Journal [Internet] /06/2013; 324(18th May):[9 p.].