Primary Care for Elderly People Why Do Doctors Find It So Hard
TL;DR: Much of the difficulty participants experienced could be facilitated by changes in the health care delivery system and in medical education, and the voices of these physicians and the model resulting from the analysis can inform change.
Abstract: Purpose: Many primary care physicians find caring for elderly patients difficult. The goal of this study was to develop a detailed understanding of why physicians find primary care with elderly patients difficult. Design and Methods: We conducted in-depth interviews with 20 primary care physicians. Using an iterative approach based on grounded theory techniques, a multidisciplinary team analyzed the content of the interviews and developed a conceptual model of the difficulty. Results: Three major domains of difficulty emerged: (i) medical complexity and chronicity, (ii) personal and interpersonal challenges, and (iii) administrative burden. The greatest challenge occurred when difficulty in more than one area was present. Contextual conditions, such as the practice environment and the physician’s training and personal values, shaped the experience of providing care and how difficult it seemed. Implications: Much of the difficulty participants experienced could be facilitated by changes in the health care delivery system and in medical education. The voices of these physicians and the model resulting from our analysis can inform such change.
Citations
More filters
TL;DR: Older adults still experience frustrating obstacles when trying to access CBPHC, and identified barriers and facilitators of improved system integration aligned well with current literature and Wagner's Chronic Care Model.
Abstract: Older persons are often poorly served by existing models of community-based primary health care (CBPHC). We sought input from clients, informal caregivers, and health care providers on recommendations for system improvements.
50 citations
TL;DR: Findings show that PCPs recognize the limits of the cure paradigm and articulate a caring, more holistic model that addresses the psychosocial needs of dementia patients.
Abstract: The symbolic framework guiding primary care physicians’ (PCPs) practice is crucial in shaping the quality of care for those with degenerative dementia. Examining the relationship between the cure and care models in primary care offers a unique opportunity for exploring change toward a more holistic approach to health care. The aims of this study were to (a) explore how PCPs approach the care of patients with Alzheimer’s disease (AD), and (b) describe how this care unfolds from the physicians’ perspectives. This was a cross-sectional study of 40 PCPs who completed semistructured interviews as part of a dementia caregiving study. Findings show that PCPs recognize the limits of the cure paradigm and articulate a caring, more holistic model that addresses the psychosocial needs of dementia patients. However, caring is difficult to uphold because of time constraints, emotional burden, and jurisdictional issues. Thus, the care model remains secondary and temporary.
47 citations
Cites background from "Primary Care for Elderly People Why..."
...biomedical fields often talk about the “management” of its symptoms, mainly to occur in primary care settings (Adams et al., 2002; Boustani et al., 2005; Boustani, Peterson, Hanson, Harris, & Lohr, 2003; Boustani, Sachs, & Callahan., 2007; Hinton, Franz, & Friend, 2004; Hogan, 2008; Olafsdóttir, Foldevi, & Marcusson, 2001; Vickrey et al., 2006)....
[...]
...…nature of dementia, researchers in U.S. biomedical fields often talk about the “management” of its symptoms, mainly to occur in primary care settings (Adams et al., 2002; Boustani et al., 2005; Boustani, Peterson, Hanson, Harris, & Lohr, 2003; Boustani, Sachs, & Callahan., 2007; Hinton, Franz, &…...
[...]
TL;DR: The emergency department represents a potential opportunity for screening at-risk patients for AAA and emergency ultrasound is a fast and accurate method for identifying patients with AAA who may benefit from follow-up or intervention.
Abstract: Objective: Abdominal aortic aneurysm (AAA) is a deadly but often clinically silent disease. Patients at increased risk are elderly men with risk factors for vascular disease who may not have adequate screening through primary care. We sought to examine the prevalence and feasibility of screening for AAA in at-risk patients presenting for unrelated complaints using emergency physician–performed bedside ultrasound. Methods: At-risk patients presenting with unrelated complaints were screened for AAA by emergency physician–performed ultrasound. Scan was rated as complete, limited, or inadequate, and time to complete scan noted. Patients with identified AAA were provided with appropriate follow-up and were followed to look at confirmatory imaging and clinical course. Results: A total of 179 patients were screened, with 12 AAAs discovered (6.7%; 95% confidence interval, 3.9%-11.4%). Average time to perform the screening ultrasound was 141 ± 135 seconds. Average discrepancy between emergency ultrasound and formal imaging was 3.9 mm. Of 12 (92%) patients, 11 were followed up, with repair recommended in 3 patients. Conclusion: The emergency department represents a potential opportunity for screening at-risk patients for AAA. Emergency ultrasound is a fast and accurate method for identifying patients with AAA who may benefit from follow-up or intervention. © 2008 Elsevier Inc. All rights reserved.
46 citations
Cites background from "Primary Care for Elderly People Why..."
...Geriatric patients represent one of these vulnerable populations and may have particular barriers to primary care and screening [19]....
[...]
Journal Article•
TL;DR: The Seniors Collaborative Care Program used an interprofessional, shared-care, geriatric model and allowed for a short referral time and easy access, which might allow seniors to remain in their environment of choice.
Abstract: Problem addressed Family physicians provide most of the care for the frail elderly population, but many challenges and barriers can lead to difficulties with fragmented, ineffective, and inefficient services. Objective of program To improve the quality, efficiency, and coordination of care for the frail elderly living in the community and to enhance geriatric and interprofessional skills for providers and learners. Program description The Seniors Collaborative Care Program used an interprofessional, shared-care, geriatric model. The feasibility of the program was evaluated through a pilot study conducted between November 2008 and June 2009 at Stonechurch Family Health Centre, part of the McMaster Family Health Team. The core team comprised a nurse practitioner, an FP, and a registered practical nurse. Additional team members included a pharmacist, a dietitian, a social worker, and a visiting geriatrician. Twenty-five seniors were evaluated through the pilot program. Patients were assessed within 5 weeks of initial contact. Patients and practitioners valued timely, accessible, preventive, and multidisciplinary aspects of care. The nurse practitioner’s role was prominent in the program, while the geriatrician’s clinical role was focused efficiently. Conclusion The family health team is ideally positioned to deliver shared care for the frail elderly. Our model allowed for a short referral time and easy access, which might allow seniors to remain in their environment of choice.
43 citations
TL;DR: The findings suggest that CMs and geriatricians collaborated well from the start and throughout the care management process, and the dynamics of the collaboration process develop in three phases: initiating relationships, developing real two-way collaboration, and developing interdisciplinary teamwork.
Abstract: Purpose The purpose of the study was to understand better the clinical collaboration process among primary care physicians (PCPs), case managers (CMs), and geriatricians in integrated models of care. Methods We conducted a qualitative study with semistructured interviews. A purposive sample of 35 PCPs, 7 CMs, and 4 geriatricians was selected in 2 integrated models of care for frail elderly patients in Canada and France: System of Integrated Care for Older Patients of Montreal and Coordination of Care for Older Patients of Paris. Data were analyzed using a grounded theory approach. Findings The dynamics of the collaboration process develop in three phases: (1) initiating relationships, (2) developing real two-way collaboration, and (3) developing interdisciplinary teamwork. The findings suggest that CMs and geriatricians collaborated well from the start and throughout the care management process. Real collaboration between the CMs and the PCPs occurred only later and was mostly fostered by the interventions of the geriatricians. PCPs and geriatricians collaborated only occasionally. Implications The findings provide information about PCPs' commitment to the integrated models of care, the legitimization of the CM's role among PCPs, and the appropriate positioning of geriatricians in such models.
41 citations
Cites background from "Primary Care for Elderly People Why..."
..., 2006) and that PCPs find caring for this population difficult (Adams et al., 2002)....
[...]
References
More filters
TL;DR: The Nature of Qualitative Inquiry Theoretical Orientations Particularly Appropriate Qualitative Applications as mentioned in this paper, and Qualitative Interviewing: Qualitative Analysis and Interpretation Enhancing the quality and credibility of qualitative analysis and interpretation.
Abstract: PART ONE: CONCEPTUAL ISSUES IN THE USE OF QUALITATIVE METHODS The Nature of Qualitative Inquiry Strategic Themes in Qualitative Methods Variety in Qualitative Inquiry Theoretical Orientations Particularly Appropriate Qualitative Applications PART TWO: QUALITATIVE DESIGNS AND DATA COLLECTION Designing Qualitative Studies Fieldwork Strategies and Observation Methods Qualitative Interviewing PART THREE: ANALYSIS, INTERPRETATION, AND REPORTING Qualitative Analysis and Interpretation Enhancing the Quality and Credibility of Qualitative Analysis
31,305 citations
TL;DR: In this article, the authors discuss the uses of literature and open coding techniques for enhancing theoretical sensitivity of theoretical studies, and give guidelines for judging a grounded theory study.
Abstract: Introduction Getting Started Theoretical Sensitivity The Uses of Literature Open Coding Techniques for Enhancing Theoretical Sensitivity Axial Coding Selective Coding Process The Conditional Matrix Theoretical Sampling Memos and Diagrams Writing Theses and Monographs, and Giving Talks about Your Research Criteria for Judging a Grounded Theory Study
28,999 citations
Journal Article•
TL;DR: The Nature of Qualitative Inquiry Theoretical Orientations Particularly Appropriate Qualitative Applications as mentioned in this paper, and Qualitative Interviewing: Qualitative Analysis and Interpretation Enhancing the quality and credibility of qualitative analysis and interpretation.
22,714 citations
21,313 citations
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
"Primary Care for Elderly People Why..." refers background in this paper
...In the area of practice organization, a number of interventions to facilitate primary care of chronically ill elders have been proposed and a few have been studied (Boult, Boult, Morishita, Smith, & Kane, 1998; Leveille et al., 1998; Schraeder, Shelton, & Sager, 2001; Netting & Williams, 2000; Wagner et al., 1996)....
[...]