Gemmae M. Fix

The Role of Patients’ Explanatory Models and Daily-Lived Experience in Hypertension Self-Management

ABSTRACTBACKGROUNDUncontrolled hypertension remains a significant problem for many patients. Few interventions to improve patients’ hypertension self-management have had lasting effects. Previous work has focused largely on patients’ beliefs as predictors of behavior, but little is understood about beliefs as they are embedded in patients’ social contexts.OBJECTIVEThis study aims to explore how patients’ “explanatory models” of hypertension (understandings of the causes, mechanisms or pathophysiology, course of illness, symptoms and effects of treatment) and social context relate to their reported daily hypertension self-management behaviors.DESIGNSemi-structured qualitative interviews with a diverse group of patients at two large urban Veterans Administration Medical centers.PARTICIPANTS (OR PATIENTS OR SUBJECTS)African-American, white and Latino Veterans Affairs (VA) primary care patients with uncontrolled blood pressure.APPROACHWe conducted thematic analysis using tools of grounded theory to identify key themes surrounding patients’ explanatory models, social context and hypertension management behaviors.RESULTSPatients’ perceptions of the cause and course of hypertension, experiences of hypertension symptoms, and beliefs about the effectiveness of treatment were related to different hypertension self-management behaviors. Moreover, patients’ daily-lived experiences, such as an isolated lifestyle, serious competing health problems, a lack of habits and routines, barriers to exercise and prioritizing lifestyle choices, also interfered with optimal hypertension self-management.CONCLUSIONSDesigning interventions to improve patients’ hypertension self-management requires consideration of patients’ explanatory models and their daily-lived experience. We propose a new conceptual model — the dynamic model of hypertension self-management behavior — which incorporates these key elements of patients’ experiences.

Barriers to patient portal access among veterans receiving home-based primary care: a qualitative study

Electronic, or web‐based, patient portals can improve patient satisfaction, engagement and health outcomes and are becoming more prevalent with the advent of meaningful use incentives. However, adoption rates are low, particularly among vulnerable patient populations, such as those patients who are home‐bound with multiple comorbidities. Little is known about how these patients view patient portals or their barriers to using them.

Delivering PACT-Principled Care: Are Specialty Care Patients Being Left Behind?

ABSTRACTBACKGROUNDWith the reorganization of primary care into Patient Aligned Care Teams (PACT) teams, the Veteran Affairs Health System (VA) aims to ensure all patients receive care based on patient-centered medical home (PCMH) principles. However, some patients receive the preponderance of care from specialty rather than primary care clinics because of the special nature of their clinical conditions. We examined seven VA (HIV) clinics as a model to test the extent to which such patients receive PCMH-principled care.OBJECTIVETo examine the extent to which HIV specialty care in VA conforms to PCMH principles.DESIGNQualitative study.PARTICIPANTSForty-one HIV providers from seven HIV clinics and 20 patients from four of these clinics.APPROACHWe conducted semi-structured interviews with HIV clinic providers and patients about care practices and adherence to PCMH principles. Using an iterative approach, data was analyzed using both a content analysis and an a priori, PCMH-principled coding strategy.KEY RESULTSPatients with HIV receive varying levels of PCMH-principled care across a range of VA HIV clinic structures. The more PCMH-principled HIV clinics largely functioned as PCMHs; patients received integrated, coordinated, comprehensive primary care within a dedicated HIV clinic. In contrast, some clinics were unable to meet the criteria of being a patient’s medical home, and instead functioned primarily as a place to receive HIV-related services with limited care coordination. Patients from the less PCMH-principled clinics reported less satisfaction with their care.CONCLUSIONSEven in a large, integrated healthcare system, there is wide variation in patients’ receipt of PCMH-principled care in specialty care settings. In order to meet the goal of having all patients receiving PCMH-principled care, there needs to be careful consideration of where primary and specialty care services are delivered and coordinated. The best mechanisms for ensuring that patients with complex medical conditions receive PCMH-principled care may need to be tailored to different specialty care contexts.

Preliminary needs assessment of mobile technology use for healthcare among homeless veterans

Background. Homeless veterans have complex healthcare needs, but experience many barriers to treatment engagement. While information technologies (IT), especially mobile phones, are used to engage patients in care, little is known about homeless veterans’ IT use. This study examines homeless veterans’ access to and use of IT, attitudes toward health-related IT use, and barriers to IT in the context of homelessness. Methods. Qualitative interviews were conducted with 30 homeless veterans in different housing programs in Boston, MA, ranging from emergency shelters to supportive transitional housing that allow stays of up to 2 years. Interviews were conducted in person, audio recorded and then transcribed. Three researchers coded transcripts. Inductive thematic analysis was used. Results. Most participants (90%) had a mobile phone and were receptive to IT use for health-related communications. A common difficulty communicating with providers was the lack of a stable mailing address. Some participants were using mobile phones to stay in touch with providers. Participants felt mobile-phone calls or text messages could be used to remind patients of appointments, prescription refills, medication taking, and returning for laboratory results. Mobile phone text messaging was seen as convenient, and helped participants stay organized because necessary information was saved in text messages. Some reported concerns about the costs associated with mobile phone use (calls and texting), the potential to be annoyed by too many text messages, and not knowing how to use text messaging. Conclusion. Homeless veterans use IT and welcome its use for health-related purposes. Technology-assisted outreach among this population may lead to improved engagement in care.

Understanding the context of patient experiences in order to explore adherence to secondary prevention guidelines after heart surgery.

After coronary artery bypass surgery, many patients do not incorporate healthy behaviors into their postoperative lifestyle or enroll in cardiac rehabilitation, key aspects of secondary prevention. This qualitative study examined patients’ post-coronary artery bypass surgery experiences to explore barriers in adhering to dietary and activity guidelines. We conducted semi-structured, in-depth interviews with 30 male patients from a military veteran’s hospital, using emergent, thematic analysis to identify experiences that led to poor adherence. Results were grouped according to barriers to diet, activities, and enrolling in cardiac rehabilitation. Overall, understandings of postoperative health, priorities that diverged from guidelines, and the context of household members and other health conditions impacted postoperative health behaviors. Many participants were familiar with secondary prevention guidelines. However, postoperative perceptions of health as well as the context of recovery influenced self-management. Providers must consider a patient’s context when discussing secondary prevention. Venues such as cardiac rehabilitation may provide an opportunity to improve adherence to secondary prevention guidelines by expanding available class times, engaging patients’ household members, or tailoring recommendations to also address other health conditions.

Use of the Blue Button Online Tool for Sharing Health Information: Qualitative Interviews With Patients and Providers.

Background Information sharing between providers is critical for care coordination, especially in health systems such as the United States Department of Veterans Affairs (VA), where many patients also receive care from other health care organizations. Patients can facilitate this sharing by using the Blue Button, an online tool that promotes patients’ ability to view, print, and download their health records. Objective The aim of this study was to characterize (1) patients’ use of Blue Button, an online information-sharing tool in VA’s patient portal, My HealtheVet, (2) information-sharing practices between VA and non-VA providers, and (3) how providers and patients use a printed Blue Button report during a clinical visit. Methods Semistructured qualitative interviews were conducted with 34 VA patients, 10 VA providers, and 9 non-VA providers. Interviews focused on patients’ use of Blue Button, information-sharing practices between VA and non-VA providers, and how patients and providers use a printed Blue Button report during a clinical visit. Qualitative themes were identified through iterative rounds of coding starting with an a priori schema based on technology adoption theory. Results Information sharing between VA and non-VA providers relied primarily on the patient. Patients most commonly used Blue Button to access and share VA laboratory results. Providers recognized the need for improved information sharing, valued the Blue Button printout, and expressed interest in a way to share information electronically across settings. Conclusions Consumer-oriented technologies such as Blue Button can facilitate patients sharing health information with providers in other health care systems; however, more education is needed to inform patients of this use to facilitate care coordination. Additional research is needed to explore how personal health record documents, such as Blue Button reports, can be easily shared and incorporated into the clinical workflow of providers.

The role of comorbidities in patients’ hypertension self-management

Objective We sought to understand barriers to hypertension self-management in patients with hypertension and comorbidities. Methods We conducted semi-structured, qualitative interviews with 48 patients with uncontrolled hypertension and at least one comorbidity to learn about beliefs and behaviors that might affect hypertension self-management. Using a grounded theory strategy, we analyzed interview transcripts detailing patients’ hypertension self-management behaviors vis-à-vis a framework including Explanatory Models—a patient’s understanding of the pathophysiology, cause, course, treatment, and severity of an illness, such as hypertension. Results We identified four factors that interfered with hypertension self-management. (1) Interdependence: Participants saw hypertension as interconnected to their comorbidities and subsequently had difficulty separating information about their illnesses. (2) Low priority: Compared to other conditions, participants assigned hypertension a lower priority. (3) Conflicts: Participants struggled with conflicts between hypertension self-management practices and those for comorbidities. (4) Managing multiple medications: Polypharmacy led to patients’ confusion and concern about taking medications as prescribed. Discussion Participants did not experience hypertension as a discreet clinical condition; rather, they self-managed hypertension concurrently with other conditions, leading to a breakdown in hypertension self-management. We provide strategies to address each of the four barriers to better equip providers in addressing their clinically salient concerns.

Habits and routines in the daily management of hypertension.

Two purposive case studies illustrate the role of habits and routines in illness management and how they are addressed in the clinical encounter. We argue habits and routines are related, but distinct constructs, and that by overlooking habits and routines, providers may be missing key opportunities to influence behaviour change. Utilization of ‘habit-changing’ professionals or health coaches who have the opportunity to communicate with patients on a regular basis in their daily living environment is proposed.

Patient-centred care is a way of doing things: How healthcare employees conceptualize patient-centred care

Patient‐centred care is now ubiquitous in health services research, and healthcare systems are moving ahead with patient‐centred care implementation. Yet, little is known about how healthcare employees, charged with implementing patient‐centred care, conceptualize what they are implementing.

Evaluating broad-scale system change using the Consolidated Framework for Implementation Research: challenges and strategies to overcome them

ObjectiveThe objective of this paper is to demonstrate the utility of the CFIR framework for evaluating broad-scale change by discussing the challenges to be addressed when planning the assessment of broad-scale change and the solutions developed by the evaluation team to address those challenges. The evaluation of implementation of Patient-centered Care and Cultural Transformation (PCC&CT) within the Department of Veterans Affairs (VA) will be used as a demonstrative example. Patient-Centered Care (PCC) is personalized health care that considers a patient’s circumstances and goals. The Department of Veterans Affairs (VA) is working towards implementing PCC throughout its healthcare system, comprised of multiple interventions with a singular long-term goal of cultural transformation, however little is known about the factors influencing its implementation. This paper discusses the issues that arose using CFIR to qualitatively assess the factors influencing implementation of cultural transformation.ResultsApplication of CFIR to this broad-scale evaluation revealed three strategies recommended for use in evaluating implementation of broad-scale change: (1) the need for adapted definitions for CFIR constructs (especially due to new application to broad-scale change), (2) the use of a mixed deductive-inductive approach with thematic coding to capture emergent themes not encompassed by CFIR, and (3) its use for expedited analysis and synthesis for rapid delivery of findings to operational partners. This paper is among the first to describe use of CFIR to guide the evaluation of a broad-scale transformation, as opposed to discrete interventions. The processes and strategies described in this paper provide a detailed example and structured approach that can be utilized and expanded upon by others evaluating implementation of broad-scale evaluations. Although CFIR was the framework selected for this evaluation, the strategies described in this paper including: use of adapted definitions, use of mixed deductive-inductive approach, and the approach for expedited analysis and synthesis can be transferred and tested with other frameworks.