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Journal ArticleDOI

Multidisciplinary care: Experience of patients with complex needs

TL;DR: Perceptions of the diabetic patients' experience of multidisciplinary care, in particular their perceptions, perceived barriers and facilitators, showed that patients found it inconvenient to be referred to many health professionals because of multiple physical and psychosocial barriers.
Abstract: The rapidly increasing prevalence of diabetes with its high morbidity and mortality raises the need for an integratedmultidisciplinaryservicefromhealthcareprovidersacrosshealthsectors.Theaimofthisstudywastoexplorethe diabetic patients' experience of multidisciplinary care, in particular their perceptions, perceived barriers and facilitators. Thirteenpatientswithtype-2diabetesadmittedtotheemergencydepartmentofalocalhospitalinNSWwereinterviewedand completed a demographic questionnaire. Results showed that patients found it inconvenient to be referred to many health professionals because of multiple physical and psychosocial barriers. Separate sets of instructions from different health professionalswereoverwhelming,confusingandconflicting.Lackofadedicatedcoordinatorofcare,followupandsupport forself-managementfromhealthprofessionalswerefactorsthatcontributedtopatients'challengesinbeingactivelyinvolved in their care. The presence of multiple co-morbidities made it more difficult for patients to juggle priorities and 'commitments' to many health professionals. In addition, complex socioeconomic and cultural issues, such as financial difficulties, lack of transport and language barriers, intensified the challenge for these patients to navigate the health system independently.Fewpatientsfeltthathavingmanyhealthprofessionalsinvolvedintheircareimprovedtheirdiabetescontrol. Communicationamongthemultidisciplinarycareteamwasfragmentedandhadanegativeeffectonthecoordinationofcare. The patients' perspective is important to identify the problems they experience and to formulate strategies for improving multidisciplinary care for patients with diabetes.

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Journal ArticleDOI
TL;DR: The objectives of this work were to study the structure of the vegetative body of Lophophytum mirabile subsp.
Abstract: The objectives of this work were to study the structure of the vegetative body of Lophophytum mirabile subsp. bolivianum (Wedd.) B. Hansen, to analyze the change on roots of Anadenanthera colubrina var. cebil (Griseb.) Altschul when they are infected by this parasitic plant, and to identify the anatomical changes produced by that parasitism. L. mirabile subsp. bolivianum plants are formed by a spheroidal-narrower underground vegetative body or tuber, that externally has a dark warty surface;epidermis, stomata or trichomes are lacking. The central matrix of tuber consists of reserving parenchyma and vascular bundles. Parasitic cells located at the level of root cambium initiate the tuber formation. On the infected root of A. colubrina var. cebil , the identity of radial and axial growth of the secondary system are lost. This leads to the formation of xylem loops that affect the xylem transport and root development, which stops length growth and develops a woody gall. Infection of L. mirabile subsp. bolivianum causes profound anatomical changes in timber developing of A. colubrina var. cebil , which favor the parasite success.

2 citations

Journal ArticleDOI
TL;DR: The needs and wishes of people with type 2 diabetes, and specialist and primary care teams regarding optimal diabetes care are identified to explore how to better support people with diabetes in a metropolitan healthcare service in Australia.
Abstract: Globally, type 2 diabetes care is often fragmented and still organised in a provider‐centred way, resulting in suboptimal care for many individuals. As healthcare systems seek to implement digital care innovations, it is timely to reassess stakeholders' priorities to guide the redesign of diabetes care. This study aimed to identify the needs and wishes of people with type 2 diabetes, and specialist and primary care teams regarding optimal diabetes care to explore how to better support people with diabetes in a metropolitan healthcare service in Australia.

2 citations

Journal ArticleDOI
TL;DR: Specific associations showed specific associations that could lead in improvements in CDPM delivery, contributing to the understanding of the complex mechanisms of chronic disease management and support.
Abstract: Background The purpose of this research was to explore the predictive factors (patient-related and intervention-related) of effects of an interdisciplinary and patient-centered chronic disease prevention and management (CDPM) intervention in an adult population with chronic diseases seen in primary healthcare (PHC). Methods This work presents the secondary analysis of data from the PR1MaC project, a pragmatic randomized controlled trial of an intervention involving the integration of canadian CDPM services in PHC. The main outcomes were dichotomic substantive improvement in the eight domains of the Health Education Impact Questionnaire (heiQ) measured at baseline and three months. Included in the multivariate analysis were the independent variables related to patient characteristics: age, gender, education, family income, marital status, multimorbidity, having healthy eating habits at baseline, doing sufficient physical activity at baseline; and those related to the intervention: duration of intervention, number of health professionals involved, health professionals working in consensus and number of risk factors aimed by the intervention objectives. Results A group of 160 patients (84 male; mean age 52.7 ± 11.5 years) from the intervention arm was considered. Multivariate logistic regression analysis showed that being younger, being single and having a higher family income is associated with improvement in Emotional Wellbeing. Having healthy eating habits and a limited number of patient-fixed objectives is associated with improvement in the Constructive Attitudes and Approaches. Also, being younger, longer intervention duration and consensus of the professionals is associated with improvement in the Health Services Navigation. An increasing intervention duration is associated with improvement in the Positive and Active Engagement in Life. Finally, increasing number of professionals is associated with improvement in the Skills and Techniques Acquisition. Conclusion The results showed specific associations that could lead in improvements in CDPM delivery, contributing to the understanding of the complex mechanisms of chronic disease management and support.

1 citations


Cites background from "Multidisciplinary care: Experience ..."

  • ...As identified by other authors, disorganized and fragmented services constituted barriers for patients, such as confusion and feelings of being overwhelmed by the process [42]....

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Journal ArticleDOI
TL;DR: In this paper, the authors explored factors that underpin decisions to seek emergency department (ED) care for chronic noncancer pain in patients identifying as culturally and linguistically diverse (CALD) or Australian born.
Abstract: OBJECTIVE This study explored factors that underpin decisions to seek emergency department (ED) care for chronic noncancer pain in patients identifying as culturally and linguistically diverse (CALD) or Australian born. DESIGN AND METHODS This mixed-methods study was underpinned by the Behavioral Model of Health Services Use conceptual framework. Consenting consecutive patients attending the ED for a chronic pain condition were recruited to a CALD (n = 45) or Australian-born (n = 45) cohort. Statistical comparisons compared the demographic, pain, health literacy, and episode of care profiles of both cohorts. Twenty-three CALD and 16 Australian-born participants consented to an audio-recorded semi-structured interview (n = 24) or focus group (n = 5 focus groups) conducted in their preferred language. Interviews were translated and transcribed into English for analysis using applied thematic analysis, guided by the conceptual framework. Data were triangulated to investigate the patterns of ED utilization and contributing factors for both cohorts. RESULTS ED attendance was a product of escalating distress, influenced by the degree to which participants' perceived needs outweighed their capacity to manage their pain. This interaction was amplified by the presence of predisposing factors, including constrained social positions, trauma exposure, and biomedical health beliefs. Importantly, experiences varied between the two cohorts with higher degrees of pain catastrophizing, lower health literacy, and greater social challenges present for the CALD cohort. CONCLUSION This study highlights the role contextual factors play in amplifying pain-related distress for CALD and Australian-born patients with chronic pain. The findings support a need for health care providers to recognize features of higher vulnerability and consider streamlining access to available support services.

1 citations

Journal ArticleDOI
TL;DR: The majority of patients indicated that attendance at the joint medical-surgical clinical made them feel less anxious about their disease, provided consistent messages regarding their care and minimised the number of trips made to hospital.
Abstract: Background Joint medical-surgical inflammatory bowel disease clinics allow simultaneous patient assessment by both a gastroenterologist and surgeon. However, patient perceptions of dual clinician p...
References
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Journal ArticleDOI
TL;DR: The CCM is described, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process are described, to guide quality improvement.
Abstract: The growing number of persons suffering from major chronic illnesses face many obstacles in coping with their condition, not least of which is medical care that often does not meet their needs for effective clinical management, psychological support, and information. The primary reason for this may be the mismatch between their needs and care delivery systems largely designed for acute illness. Evidence of effective system changes that improve chronic care is mounting. We have tried to summarize this evidence in the Chronic Care Model (CCM) to guide quality improvement. In this paper we describe the CCM, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process.

3,215 citations

Journal ArticleDOI
TL;DR: The challenge is to organize these components into an integrated system of chronic illness care, which can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care.
Abstract: Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.

2,805 citations


"Multidisciplinary care: Experience ..." refers background in this paper

  • ...The Chronic Care Model (CCM) describes six elements that are essential for improving the quality of care for patients with chronic disease (Wagner et al. 1996)....

    [...]

Journal ArticleDOI
24 Jul 2002-JAMA
TL;DR: Inadequate health literacy may contribute to the disproportionate burden of diabetes-related problems among disadvantaged populations and efforts should focus on developing and evaluating interventions to improve diabetes outcomes among patients with inadequate health literacy.
Abstract: ContextHealth literacy is a measure of patients' ability to read, comprehend, and act on medical instructions. Poor health literacy is common among racial and ethnic minorities, elderly persons, and patients with chronic conditions, particularly in public-sector settings. Little is known about the extent to which health literacy affects clinical health outcomes.ObjectivesTo examine the association between health literacy and diabetes outcomes among patients with type 2 diabetes.Design, Setting, and ParticipantsCross-sectional observational study of 408 English- and Spanish-speaking patients who were older than 30 years and had type 2 diabetes identified from the clinical database of 2 primary care clinics of a university-affiliated public hospital in San Francisco, Calif. Participants were enrolled and completed questionnaires between June and December 2000. We assessed patients' health literacy by using the short-form Test of Functional Health Literacy in Adults (s-TOFHLA) in English or Spanish.Main Outcome MeasuresMost recent hemoglobin A1c (HbA1c) level. Patients were classified as having tight glycemic control if their HbA1c was in the lowest quartile and poor control if it was in the highest quartile. We also measured the presence of self-reported diabetes complications.ResultsAfter adjusting for patients' sociodemographic characteristics, depressive symptoms, social support, treatment regimen, and years with diabetes, for each 1-point decrement in s-TOFHLA score, the HbA1c value increased by 0.02 (P = .02). Patients with inadequate health literacy were less likely than patients with adequate health literacy to achieve tight glycemic control (HbA1c ≤7.2%; adjusted odds ratio [OR], 0.57; 95% confidence interval [CI], 0.32-1.00; P = .05) and were more likely to have poor glycemic control (HbA1c ≥9.5%; adjusted OR, 2.03; 95% CI, 1.11-3.73; P = .02) and to report having retinopathy (adjusted OR, 2.33; 95% CI, 1.19-4.57; P = .01).ConclusionsAmong primary care patients with type 2 diabetes, inadequate health literacy is independently associated with worse glycemic control and higher rates of retinopathy. Inadequate health literacy may contribute to the disproportionate burden of diabetes-related problems among disadvantaged populations. Efforts should focus on developing and evaluating interventions to improve diabetes outcomes among patients with inadequate health literacy.

1,732 citations

Journal ArticleDOI
TL;DR: In this article, the authors explored the impact of depressive symptoms in primary care patients with diabetes on self-care, adherence to medication regimens, functioning, and health care costs.
Abstract: Background Depression is common among patients with chronic medical illness. We explored the impact of depressive symptoms in primary care patients with diabetes on diabetes self-care, adherence to medication regimens, functioning, and health care costs. Methods We administered a questionnaire to 367 patients with types 1 and 2 diabetes from 2 health maintenance organization primary care clinics to obtain data on demographics, depressive symptoms, diabetes knowledge, functioning, and diabetes self-care. On the basis of automated data, we measured medical comorbidity, health care costs, glycosylated hemoglobin (HbA 1c ) levels, and oral hypoglycemic prescription refills. Using depressive symptom severity tertiles (low, medium, or high), we performed regression analyses to determine the impact of depressive symptoms on adherence to diabetes self-care and oral hypoglycemic regimens, HbA 1c levels, functional impairment, and health care costs. Results Compared with patients in the low-severity depression symptom tertile, those in the medium- and high-severity tertiles were significantly less adherent to dietary recommendations. Patients in the high-severity tertile were significantly distinct from those in the low-severity tertile by having a higher percentage of days in nonadherence to oral hypoglycemic regimens (15% vs 7%); poorer physical and mental functioning; greater probability of having any emergency department, primary care, specialty care, medical inpatient, and mental health costs; and among users of health care within categories, higher primary (51% higher), ambulatory (75% higher), and total health care costs (86% higher). Conclusions Depressive symptom severity is associated with poorer diet and medication regimen adherence, functional impairment, and higher health care costs in primary care diabetic patients. Further studies testing the effectiveness and cost-effectiveness of enhanced models of care of diabetic patients with depression are needed.

1,491 citations

Journal ArticleDOI
TL;DR: The extent to which primary care physicians working in a public hospital assess patient recall and comprehension of new concepts during outpatient encounters was measured and the association between physicians' application of this interactive communication strategy and patients' glycemic control was examined.
Abstract: Background Patients recall or comprehend as little as half of what physicians convey during an outpatient encounter. To enhance recall, comprehension, and adherence, it is recommended that physicians elicit patients' comprehension of new concepts and tailor subsequent information, particularly for patients with low functional health literacy. It is not known how frequently physicians apply this interactive educational strategy, or whether it is associated with improved health outcomes. Methods We used direct observation to measure the extent to which primary care physicians working in a public hospital assess patient recall and comprehension of new concepts during outpatient encounters, using audiotapes of visits between 38 physicians and 74 English-speaking patients with diabetes mellitus and low functional health literacy. We then examined whether there was an association between physicians' application of this interactive communication strategy and patients' glycemic control using information from clinical and administrative databases. Results Physicians assessed recall and comprehension of any new concept in 12 (20%) of 61 visits and for 15 (12%) of 124 new concepts. Patients whose physicians assessed recall or comprehension were more likely to have hemoglobin A1clevels below the mean (≤8.6%) vs patients whose physicians did not (odds ratio, 8.96; 95% confidence interval, 1.1-74.9) (P= .02). After multivariate logistic regression, the 2 variables independently associated with good glycemic control were higher health literacy levels (odds ratio, 3.97; 95% confidence interval, 1.09-14.47) (P= .04) and physicians' application of the interactive communication strategy (odds ratio, 15.15; 95% confidence interval, 2.07-110.78) (P Conclusions Primary care physicians caring for patients with diabetes mellitus and low functional health literacy rarely assessed patient recall or comprehension of new concepts. Overlooking this step in communication reflects a missed opportunity that may have important clinical implications.

1,139 citations


"Multidisciplinary care: Experience ..." refers background in this paper

  • ...This requires tailored, active, long-term support and regular follow up from health professionals (Schillinger et al. 2003)....

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