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.
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TL;DR: It is argued that knowledge translation is a potentially effective tool for engaging Indian healthcare providers in the delivery of high quality geriatric care.
Abstract: Despite a rapidly aging population, geriatrics - the branch of medicine that focuses on healthcare of the elderly - is relatively new in India, with many practicing physicians having little knowledge of the clinical and functional implications of aging. Negative attitudes and limited awareness, knowledge or acceptance of geriatrics as a legitimate discipline contribute to inaccessible and poor quality care for India's old. The aim of this paper is to argue that knowledge translation is a potentially effective tool for engaging Indian healthcare providers in the delivery of high quality geriatric care. The paper describes India's context, including demographics, challenges and current policies, summarizes evidence on provider behaviour change, and integrates the two in order to propose an action plan for promoting improvements in geriatric care.
34 citations
Cites background from "Primary Care for Elderly People Why..."
...Physicians in the US experience difficulty in caring for the elderly because of administrative burden, medical complexity, and interpersonal challenges; researchers suggest that changes in the care delivery system and medical education are required [49]....
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TL;DR: For instance, this paper investigated the perceptions of older adults among undergraduate social work and criminal justice students (N = 228), with moderately ageist attitudes in general toward older adults and controlling for ethno-cultural identification and previous gerontology education.
Abstract: This study investigated perceptions of older adults among undergraduate social work and criminal justice students (N = 228). With moderately ageist attitudes in general toward older adults and controlling for ethno-cultural identification and previous gerontology education, there were significant differences in the perceptions of social work and criminal justice students in ten of twelve dependent variables. These significant variables included perceptions of elders as unmotivated and parsimonious, perceptions of elders as attractive, perceptions of elders as useful, perceptions of elders' health, perceptions of elders' ability to drive, perceptions of elders as romantic, willingness to be with elders, willingness to work with elders if the job required it, perceptions of elders' right to suicide, and perceptions of elders engaging in sexual behaviors. While generally ageist in perspective, there were not significant differences between the two students groups regarding their perceptions of elder...
31 citations
Cites background from "Primary Care for Elderly People Why..."
...These portrayals of aging as a social drain often appear to be linked with the expenditures of Medicare and Social Security (Adams et al., 2002)....
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TL;DR: The home visitation programme did not have major shortcomings in itself, but the delivery offered room for improvement, and general practices received useful tools to redesign their care delivery from reactive towards proactive care.
Abstract: Population ageing fosters new models of care delivery for older people that are increasingly integrated into existing care systems. In the Netherlands, a primary-care based preventive home visitation programme has been developed for potentially frail community-dwelling older people (aged ≥75 years), consisting of a comprehensive geriatric assessment during a home visit by a practice nurse followed by targeted interdisciplinary care and follow-up over time. A theory-based process evaluation was designed to examine (1) the extent to which the home visitation programme was implemented as planned and (2) the extent to which general practices successfully redesigned their care delivery. Using a mixed-methods approach, the focus was on fidelity (quality of implementation), dose delivered (completeness), dose received (exposure and satisfaction), reach (participation rate), recruitment, and context. Twenty-four general practices participated, of which 13 implemented the home visitation programme and 11 delivered usual care to older people. Data collection consisted of semi-structured interviews with practice nurses (PNs), general practitioners (GPs), and older people; feedback meetings with PNs; structured registration forms filled-out by PNs; and narrative descriptions of the recruitment procedures and registration of inclusion and drop-outs by members of the research team. Fidelity of implementation was acceptable, but time constraints and inadequate reach (i.e., the relatively healthy older people participated) negatively influenced complete delivery of protocol elements, such as interdisciplinary cooperation and follow-up of older people over time. The home visitation programme was judged positively by PNs, GPs, and older people. Useful tools were offered to general practices for organising proactive geriatric care. The home visitation programme did not have major shortcomings in itself, but the delivery offered room for improvement. General practices received useful tools to redesign their care delivery from reactive towards proactive care, but perceived barriers require attention to allow for sustainability of the home visitation programme over time.
31 citations
TL;DR: PAS was strongly predictive of beneficiary experience beyond case-mix adjustment, and more confident respondents (active and complacent) give higher ratings of their care and providers, suggesting that they have more favorable experiences.
Abstract: Background: Patient activation status (PAS) can be identified using the Medicare Segmentation Screening Tool, a 2-item measure assessing patients' health skills and motivation to participate in their own care. Objective: To determine whether PAS is predictive of Medicare beneficiary health care experiences with health providers and insurance plans after case-mix adjustment. Research Design: Linear regression models examined the association between PAS and evaluations of care after case-mix adjustment in observational cross-sectional data. Subjects: 236,322 Medicare beneficiaries with at least one prescription medication responding to the Medicare Segmentation Screening Tool items on the 2007 Medicare Consumer Assessment of Healthcare Providers and Systems Survey. Measures: Four-category patient activation category; 11 patient-reported evaluations of health care and providers and 2 self-reported immunization measures. Results: PAS was strongly predictive of beneficiary experience beyond case-mix adjustment. Even after case-mix adjustment, active beneficiaries consistently reported the most positive experiences, followed by complacent beneficiaries, with differences of 0.2 to 0.4 standard deviations for 4 of 5 composite measures of patient experience (P < 0.05). Adjusted immunization rates for flu and pneumonia were highest for active beneficiaries, followed closely by high-effort beneficiaries. The rates for these 2 segments were 10 percentage points higher than for complacent and passive beneficiaries. Conclusions: PAS may be an important determinant of health care experiences. More confident respondents (active and complacent) give higher ratings of their care and providers, suggesting that they have more favorable experiences. Respondent motivation (high for active and high effort) seems to be a factor in receiving preventive care.
30 citations
TL;DR: How the physical plant, people, workflow management, and community linkages in a primary care practice can be restructured to better serve vulnerable elders is discussed.
Abstract: With the impending surge in the number of older adults, primary care clinicians will increasingly need to manage the care of vulnerable elders Caring for vulnerable elders is complex because of their wide range of health goals and the interdependence of medical care and community supports needed to achieve those goals In this article, we identify ways a primary care practice can reorganize to improve the care of vulnerable elders We begin by identifying important outcomes for vulnerable elders and three key processes of care (communication, developing a personal care plan for each patient, and care coordination) needed to achieve these outcomes We then describe two delivery models of primary care for vulnerable elders – co-management, and augmented primary care Finally, we discuss how the physical plant, people, workflow management, and community linkages in a primary care practice can be restructured to better serve these patients
29 citations
References
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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)....
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