Easier Said Than Done: Healthcare Professionals’ Barriers to the Provision of Patient-Centered Primary Care to Patients with Multimorbidity

Patient-centered care (PCC) has the potential to entail tailored primary care delivery according to the needs of patients with multimorbidity (two or more co-existing chronic conditions). To make primary care for these patients more patient centered, insight on healthcare professionals’ perceived PCC implementation barriers is needed. In this study, healthcare professionals’ perceived barriers to primary PCC delivery to patients with multimorbidity were investigated using a constructivist qualitative design based on semi-structured interviews with nine general and nurse practitioners from seven general practices in the Netherlands. Purposive sampling was used, and the interview content was analyzed to generate themes representing experienced barriers. Barriers were identified in all eight PCC dimensions (patient preferences, information and education, access to care, physical comfort, emotional support, family and friends, continuity and transition, and coordination of care). They include difficulties achieving mutual understanding between patients and healthcare professionals, professionals’ lack of training and education in new skills, data protection laws that impede adequate documentation and information sharing, time pressure, and conflicting financial incentives. These barriers pose true challenges to effective, sustainable PCC implementation at the patient, organizational, and national levels. Further improvement of primary care delivery to patients with multimorbidity is needed to overcome these barriers.

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Transformation of primary care during the COVID-19 pandemic: experiences of healthcare professionals in eight European countries

British Journal of General Practice ◽

10.3399/bjgp.2020.1112 ◽

2021 ◽

pp. BJGP.2020.1112

Author(s):

Marta Wanat ◽

Melanie Hoste ◽

Nina Gobat ◽

Marilena Anastasaki ◽

Femke Boehmer ◽

...

Keyword(s):

Primary Care ◽

Secondary Care ◽

Healthcare Professionals ◽

Care Delivery ◽

Practical Training ◽

Structured Interviews ◽

New Ways Of Working ◽

Primary Care Delivery ◽

Local Primary Care ◽

Remote Care

Background: Primary care has a crucial role in responding to the COVID-19 pandemic as the first point of patient care and gatekeeper to secondary care. Qualitative studies exploring the experiences of healthcare professionals during the COVID-19 pandemic have mainly focused on secondary care. Aim: To understand the experiences of European PCPs working during the first peak of the COVID-19 pandemic. Design and Setting: An exploratory qualitative study, using semi-structured interviews in primary care in England, Belgium, the Netherlands, Ireland, Germany, Poland, Greece and Sweden, between April and July 2020. Method: Interviews were audio recorded, transcribed and analysed using a combination of inductive and deductive thematic analysis techniques. Results: Eighty interviews were conducted with PCPs. PCPs had to make their own decisions on how to rapidly transform services in relation to COVID-19 and non-COVID-19 care. Despite being overwhelmed with guidance, they often lacked access to practical training. Consequently, PCPs turned to their colleagues for moral support and information to try to quickly adjust to new ways of working, including remote care, and deal with uncertainty. Conclusion: PCPs rapidly transformed primary care delivery despite a number of challenges. Representation of primary care at policy level and engagement with local primary care champions will facilitate easy and coordinated access to practical information on how to adapt services, ongoing training and access to appropriate mental health support services for PCPs. Preservation of autonomy and responsiveness of primary care are critical to preserve the ability for rapid transformation in any future crisis of care delivery.

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Integrating nurse practitioners into primary care: policy considerations from a Canadian province

BMC Family Practice ◽

10.1186/s12875-020-01318-3 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Stacey Black ◽

Raad Fadaak ◽

Myles Leslie

Keyword(s):

Primary Care ◽

Nurse Practitioners ◽

Care Delivery ◽

Primary Care System ◽

Structured Interviews ◽

Primary Care Delivery ◽

Key Stakeholders ◽

The Status ◽

Practice Opportunities ◽

Care System

Abstract Background The integration of nurse practitioners (NPs) into primary care health teams has been an object of interest for policy makers seeking to achieve the goals of improving care, increasing access, and lowering cost. The province of Alberta in Canada recently introduced a policy aimed at integrating NPs into existing primary care delivery structures. This qualitative research sought to understand how that policy – the NP Support Program (NPSP) – was viewed by key stakeholders and to draw out policy lessons. Methods Fifteen semi-structured interviews with NPs and other stakeholders in Alberta’s primary care system were conducted, recorded, transcribed and analyzed using the interpretive description method. Results Stakeholders predominantly felt the NPSP would not change the status quo of limited practice opportunities and the resulting underutilization of primary care NPs in the province. Participants attributed low levels of NP integration into the primary care system to: 1) financial viability issues that directly impacted NPs, physicians, and primary care networks (PCNs); 2) policy issues related to the NPSP’s reliance on PCNs as employers, and a requirement that NPs panel patients; and 3) governance issues in which NPs are not afforded sufficient authority over their role or how the key concept of ‘care team’ is defined and operationalized. Conclusions In general, stakeholders did not see the NPSP as a long-term solution for increasing NP integration into the province’s primary care system. Policy adjustments that enable NPs to access funding not only from within but also outside PCNs, and modifications to allow greater NP input into how their role is utilized would likely improve the NPSP’s ability to reach its goals.

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Making care more patient centered; experiences of healthcare professionals and patients with multimorbidity in the primary care setting

BMC Family Practice ◽

10.1186/s12875-021-01420-0 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Sanne Jannick Kuipers ◽

Anna Petra Nieboer ◽

Jane Murray Cramm

Keyword(s):

Primary Care ◽

Nurse Practitioners ◽

Care Setting ◽

Healthcare Professionals ◽

Primary Care Setting ◽

Care Delivery ◽

Care Needs ◽

Patient Centered ◽

Improvement Program ◽

Improvement Programs

Abstract Background The present study describes how primary care can be improved for patients with multimorbidity, based on the evaluation of a patient-centered care (PCC) improvement program designed to foster the eight PCC dimensions (patient preferences, information and education, access to care, physical comfort, coordination of care, continuity and transition, emotional support, and family and friends). This study characterizes the interventions implemented in practice as part of the PCC improvement program and describes the experiences of healthcare professionals and patients with the resulting PCC delivery. Methods This study employed a mixed-methods design. Semi-structured interviews were conducted with nine general practitioners and nurse practitioners from seven primary care practices in Noord-Brabant, the Netherlands, that participated in the program (which included interventions and workshops). The qualitative interview data were examined using thematic analysis. A longitudinal survey was conducted with 138 patients with multimorbidity from these practices to assess perceived improvements in PCC and its underlying dimensions. Paired sample t tests were performed to compare survey responses obtained at a 1-year interval corresponding to program implementation. Results The PCC improvement program is described, and themes necessary for PCC improvement according to healthcare professionals were generated [e.g. Aligning information to patients’ needs and backgrounds, adapting a coaching role]. PCC experiences of patients with multimorbidity improved significantly during the year in which the PCC interventions were implemented (t = 2.66, p = 0.005). Conclusion This study revealed how primary PCC can be improved for patients with multimorbidity. It emphasizes the importance of investing in PCC improvement programs to tailor care delivery to heterogenous patients with multimorbidity with diverse care needs. This study generates new perspectives on care delivery and highlights opportunities for its improvement according to the eight dimensions of PCC for patients with multimorbidity in a primary care setting.

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Staff Perceptions of Implementation of a Team-Based Model of Patient-Centered Primary Care

The International Journal of Person Centered Medicine ◽

10.5750/ijpcm.v4i4.456 ◽

2015 ◽

Vol 4 (4) ◽

pp. 244-250

Author(s):

Sherri L LaVela ◽

Jennifer N Hill

Keyword(s):

Primary Care ◽

Team Building ◽

Organizational Factors ◽

Care Staff ◽

Health Care Staff ◽

Structured Interviews ◽

Implementation Barriers ◽

Patient Centered ◽

Optimal Care ◽

Team Based Care

Objectives. Patient-Aligned Care Teams (PACTs) aim to reorganize primary care by putting the patient at the center of the care team that includes family and health care staff; embodying patient-centered care (PCC). Team members share information, and work together in a synergistic, supportive way to provide optimal care based on mutually negotiated goals to meet patient needs. Our objective was to evaluate the process, barriers, and facilitators to implementing PACT as part of a VA quality improvement effort.Study Design/Methods. Semi-structured interviews were conducted, transcribed verbatim and analyzed with constant comparative techniques using constructs from implementation and organizational frameworks. Respondent demographic and position-level data were also collected. Data were collected in 2013.Results. A purposive sample of 35 key leaders and staff involved in implementing and/or participating in PACT at VA facilities participated. Implementation barriers included: failure to gain staff buy-in for PACT early on and to alleviate existing concerns about time and resources, incongruent performance measurement, and lack of defined role/responsibilities. Implementation facilitators included: training and engaging staff in PCC delivery and support for team-building.Conclusions. Team-based approaches to care have strong literature support; less is known about implementation. This study provides insight into the implementation of team-based care. Implementation of a team-based care model should include staff preparation and support (awareness, education, and encouragement) in advance. Once implemented, continued attention to team-building efforts and staff engagement are needed for sustainability. Healthcare organizations must understand and address multiple organizational factors to successfully implement team-based care that leads to systemic and sustainable PCC delivery.

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Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care

Health Services Research ◽

10.1111/1475-6773.13246 ◽

2020 ◽

Vol 55 (2) ◽

pp. 178-189 ◽

Cited By ~ 3

Author(s):

Chuan‐Fen Liu ◽

Paul L. Hebert ◽

Jamie H. Douglas ◽

Emily L. Neely ◽

Christine A. Sulc ◽

...

Keyword(s):

Primary Care ◽

Quality Of Care ◽

Nurse Practitioners ◽

Care Delivery ◽

Primary Care Delivery ◽

Utilization Cost

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The Need for Co-Creation of Care with Multi-Morbidity Patients—A Longitudinal Perspective

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17093201 ◽

2020 ◽

Vol 17 (9) ◽

pp. 3201

Author(s):

Sanne J. Kuipers ◽

Anna P. Nieboer ◽

Jane M. Cramm

Keyword(s):

Primary Care ◽

Healthcare Professionals ◽

Care Delivery ◽

Well Being ◽

Satisfaction With Care ◽

Care Needs ◽

Primary Care Delivery ◽

Care Practices ◽

Primary Care Practices ◽

Multimorbid Patients

Background: Primary care delivery for multimorbid patients is complex, due to single disease–oriented guidelines, complex care needs, time constraints and the involvement of multiple healthcare professionals. Co-creation of care, based on the quality of communication and relationships between healthcare professionals and patients, may therefore be valuable. This longitudinal study investigates the relationships of co-creation of care to physical and social well-being and satisfaction with care among multimorbid patients in primary care. Methods: In 2017 and 2018, longitudinal surveys were conducted among multimorbid patients from seven primary care practices in Noord-Brabant, the Netherlands (n = 138, age = 73.50 ± 9.99). Paired sample t-tests and multivariate regression analyses were performed. (3) Results: Co-creation of care improved significantly over time (t = 2.25, p = 0.026), as did social well-being (t = 2.31, p = 0.022) and physical well-being (t = 2.72, p = 0.007) but not satisfaction with care (t = 0.18, p = 0.858). Improvements in co-creation of care from T0 to T1 were associated with social well-being (B = 0.157, p = 0.002), physical well-being (B = 0.216, p = 0.000) and satisfaction with care (B = 0.240, p = 0.000). (4) Conclusions: Thus, investment in co-creation of care by primary care practices may lead to better outcomes for multimorbid patients.

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Patients’ and clinicians’ perspectives on the primary care consultations for acute respiratory infections during the first wave of the COVID-19 pandemic: an eight-country qualitative study in Europe

BJGP Open ◽

10.3399/bjgpo.2021.0172 ◽

2022 ◽

pp. BJGPO.2021.0172

Author(s):

Marta Wanat ◽

Melanie Eugenie Hoste ◽

Nina Helene Gobat ◽

Marilena Anastasaki ◽

Femke Böhmer ◽

...

Keyword(s):

Primary Care ◽

Qualitative Study ◽

Respiratory Infections ◽

Care Delivery ◽

European Countries ◽

Structured Interviews ◽

Delivery Of Care ◽

Primary Care Delivery ◽

The Impact ◽

Remote Consultations

BackgroundThe impact of the COVID-19 pandemic on patients’ and clinicians’ perceptions of healthcare-seeking behaviour and delivery of care is unclear. The pandemic accelerated the use of remote care and understanding its benefits and drawbacks may inform its implementation during this and future healthcare emergencies.AimTo explore patients’ and primary care professionals’ (PCPs) experiences of primary care delivery in the first wave of the pandemic.Design & settingQualitative study using semi-structured interviews in primary care in eight European countriesResultsWe conducted 146 interviews with 80 PCPs and 66 patients consulting for respiratory tract infection (RTI) symptoms, in eight European countries (England, Ireland, Belgium, the Netherlands, Greece, Poland, Sweden and Germany). Data was collected between April and July 2020 and analysed using thematic analysis. We found that patients accepted telemedicine when PCPs spent time to understand and address their concerns, but a minority preferred in-person consultations. PCPs felt that remote consultations created emotional distance between themselves and patients, and they reported having to manage diverse COVID-19-related medical and social concerns.ConclusionRemote consultations for RTI symptoms may be acceptable long-term if both groups are happy to use this format but it is important that PCPs take time to address patients’ concerns and provide safety-netting advice.

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