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Featured researches published by Nora Mueller.


Journal of General Internal Medicine | 2012

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

Barbara G. Bokhour; Ellen S. Cohn; Dharma E. Cortés; Jeffrey L. Solomon; Gemmae M. Fix; A. Rani Elwy; Nora Mueller; Lois A. Katz; Paul Haidet; Alexander R. Green; Ann M. Borzecki; Nancy R. Kressin

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.


Journal of Health Psychology | 2012

Habits and routines in the daily management of hypertension.

Ellen S. Cohn; Dharma E. Cortés; Gemmae M. Fix; Nora Mueller; Jeffery L. Solomon; Barbara G. Bokhour

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.


American Journal of Psychiatric Rehabilitation | 2014

Impact of Stigma on Veteran Treatment Seeking for Depression

Stephanie Rodrigues; Barbara G. Bokhour; Nora Mueller; Natalie S. Dell; Princess E. Osei-Bonsu; Shibei Zhao; Mark E. Glickman; Susan V. Eisen; A. Rani Elwy

The Veterans Health Administration (VHA) mandates annual depression screening in primary care; however, veterans often delay seeking treatment after screening positive, which can increase the severity and impact of depression. This mixed-methods study examined the association between stigma and treatment utilization among veterans (N = 271) in primary care with a positive depression screen. A subsample of veterans (n = 23) participated in a semistructured interview to qualitatively explore the social and cultural contexts of treatment utilization for depression. Treatment utilization data based on Healthcare Effectiveness Data and Information Set (HEDIS) guidelines were obtained by chart review 3 months following the positive screen date. Logistic regression indicated a lack of evidence that stigma was associated with treatment utilization. However, grounded thematic analysis suggested that stigma negatively influenced perceptions of depression and treatment utilization for some veterans. Four themes emerged: (1) depression is weakness; (2) depression is an unwanted label; (3) depression is normal; and (4) overcoming stigma. Evidence from interviews suggests that stigma may play a larger role in decisions about treatment seeking, which was not quantitatively evident. Addressing the psychosocial ramifications of stigma for depression may help minimize treatment lapses and maximize treatment seeking among veterans who screen positive for depression in primary care.


Health Expectations | 2018

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

Gemmae M. Fix; Carol VanDeusen Lukas; Rendelle E. Bolton; Jennifer N. Hill; Nora Mueller; Sherri L. LaVela; Barbara G. Bokhour

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.


Medical Care | 2016

Using Mixed Methods to Examine the Role of Veterans' Illness Perceptions on Depression Treatment Utilization and HEDIS Concordance.

A. Rani Elwy; Mark E. Glickman; Barbara G. Bokhour; Natalie S. Dell; Nora Mueller; Shibei Zhao; Princess E. Osei-Bonsu; Stephanie Rodrigues; Craig M. Coldwell; Tu A. Ngo; James Schlosser; Melanie J. Vielhauer; Paul A. Pirraglia; Susan V. Eisen

Background:Although depression screening occurs annually in the Department of Veterans Affairs (VA) primary care, many veterans may not be receiving guideline-concordant depression treatment. Objectives:To determine whether veterans’ illness perceptions of depression may be serving as barriers to guideline-concordant treatment. Research Design:We used a prospective, observational design involving a mailed questionnaire and chart review data collection to assess depression treatment utilization and concordance with Healthcare Effectiveness Data and Information Set guidelines adopted by the VA. The Self-Regulation Model of Illness Behavior guided the study. Subjects:Veterans who screened positive for a new episode of depression at 3 VA primary care clinics in the US northeast. Measures:The Illness Perceptions Questionnaire-Revised, measuring patients’ perceptions of their symptoms, cause, timeline, consequences, cure or controllability, and coherence of depression and its symptoms, was our primary measure to calculate veterans’ illness perceptions. Treatment utilization was assessed 3 months after the positive depression screen through chart review. Healthcare Effectiveness Data and Information Set (HEDIS) guideline-concordant treatment was determined according to a checklist created for the study. Results:A total of 839 veterans screened positive for a new episode of depression from May 2009–June 2011; 275 (32.8%) completed the survey. Ninety-two (33.9%) received HEDIS guideline-concordant depression treatment. Veterans’ illness perceptions of their symptoms, cause, timeline, and controllability of depression predicted receiving guideline-concordant treatment. Conclusions:Many veterans are not receiving guideline-concordant treatment for depression. HEDIS guideline measures may not be assessing all aspects of quality depression care. Conversations about veterans’ illness perceptions and their specific needs are encouraged to ensure that appropriate treatment is achieved.


Journal of Medical Internet Research | 2018

Patient Centeredness in Electronic Communication: Evaluation of Patient-to-Health Care Team Secure Messaging.

Timothy P. Hogan; Tana M. Luger; Julie E. Volkman; Mary Rocheleau; Nora Mueller; Anna M. Barker; Kim M. Nazi; Thomas K. Houston; Barbara G. Bokhour

Background As information and communication technology is becoming more widely implemented across health care organizations, patient-provider email or asynchronous electronic secure messaging has the potential to support patient-centered communication. Within the medical home model of the Veterans Health Administration (VA), secure messaging is envisioned as a means to enhance access and strengthen the relationships between veterans and their health care team members. However, despite previous studies that have examined the content of electronic messages exchanged between patients and health care providers, less research has focused on the socioemotional aspects of the communication enacted through those messages. Objective Recognizing the potential of secure messaging to facilitate the goals of patient-centered care, the objectives of this analysis were to not only understand why patients and health care team members exchange secure messages but also to examine the socioemotional tone engendered in these messages. Methods We conducted a cross-sectional coding evaluation of a corpus of secure messages exchanged between patients and health care team members over 6 months at 8 VA facilities. We identified patients whose medical records showed secure messaging threads containing at least 2 messages and compiled a random sample of these threads. Drawing on previous literature regarding the analysis of asynchronous, patient-provider electronic communication, we developed a coding scheme comprising a series of a priori patient and health care team member codes. Three team members tested the scheme on a subset of the messages and then independently coded the sample of messaging threads. Results Of the 711 messages coded from the 384 messaging threads, 52.5% (373/711) were sent by patients and 47.5% (338/711) by health care team members. Patient and health care team member messages included logistical content (82.6%, 308/373 vs 89.1%, 301/338), were neutral in tone (70.2%, 262/373 vs 82.0%, 277/338), and respectful in nature (25.7%, 96/373 vs 33.4%, 113/338). Secure messages from health care team members sometimes appeared hurried (25.4%, 86/338) but also displayed friendliness or warmth (18.9%, 64/338) and reassurance or encouragement (18.6%, 63/338). Most patient messages involved either providing or seeking information; however, the majority of health care team member messages involved information provision in response to patient questions. Conclusions This evaluation is an important step toward understanding the content and socioemotional tone that is part of the secure messaging exchanges between patients and health care team members. Our findings were encouraging; however, there are opportunities for improvement. As health care organizations seek to supplement traditional encounters with virtual care, they must reexamine their use of secure messaging, including the patient centeredness of the communication, and the potential for more proactive use by health care team members.


BMC Health Services Research | 2018

How can healthcare organizations implement patient-centered care? Examining a large-scale cultural transformation

Barbara G. Bokhour; Gemmae M. Fix; Nora Mueller; Anna M. Barker; Sherri L. LaVela; Jennifer N. Hill; Jeffrey L. Solomon; Carol VanDeusen Lukas

BackgroundHealthcare organizations increasingly are focused on providing care which is patient-centered rather than disease-focused. Yet little is known about how best to transform the culture of care in these organizations. We sought to understand key organizational factors for implementing patient-centered care cultural transformation through an examination of efforts in the US Department of Veterans Affairs.MethodsWe conducted multi-day site visits at four US Department of Veterans Affairs medical centers designated as leaders in providing patient-centered care. We conducted qualitative semi-structured interviews with 108 employees (22 senior leaders, 42 middle managers, 37 front-line providers and 7 staff). Transcripts of audio recordings were analyzed using a priori codes based on the Consolidated Framework for Implementation Research. We used constant comparison analysis to synthesize codes into meaningful domains.ResultsSites described actions taken to foster patient-centered care in seven domains: 1) leadership; 2) patient and family engagement; 3) staff engagement; 4) focus on innovations; 5) alignment of staff roles and priorities; 6) organizational structures and processes; 7) environment of care. Within each domain, we identified multi-faceted strategies for implementing change. These included efforts by all levels of organizational leaders who modeled patient-centered care in their interactions and fostered willingness to try novel approaches to care amongst staff. Alignment and integration of patient centered care within the organization, particularly surrounding roles, priorities and bureaucratic rules, remained major challenges.ConclusionsTransforming healthcare systems to focus on patient-centered care and better serve the “whole” patient is a complex endeavor. Efforts to transform healthcare culture require robust, multi-pronged efforts at all levels of the organization; leadership is only the beginning. Challenges remain for incorporating patient-centered approaches in the context of competing priorities and regulations. Through actions within each of the domains, organizations may begin to truly transform to patient-driven care.


Journal of Patient Experience | 2018

Providers’ Perceptions of Barriers to Optimal Communication With Patients During the Postcolonoscopy Experience:

Travis Hyams; Barbara A. Curbow; Juliette Christie; Nora Mueller; Evelyn King-Marshall; Shahnaz Sultan; Thomas J. George

Introduction: Colonoscopy screening is an effective method of detecting and preventing colorectal cancer. Standard procedure for most colonoscopies (98%) is to use conscious sedation, which can cause short-term cognitive impairment postprocedure, including communication difficulties. In this study, we explored providers’ (gastroenterology doctors and nurses) perceptions of the barriers to optimal communication with patients immediately following colonoscopy. Methods: We conducted interviews with 61 providers across 5 clinical configurations. Interviews were transcribed and coded with NVivo version 11 software. Results: Themes emerged regarding barriers to optimal provider–patient communication postcolonoscopy: patient barriers (sedation and patient characteristics), caregiver barriers, and system characteristics. Conclusions: Providers’ perceived barriers to communication are an important topic to study. They endorsed, in particular, interventions that target the postcolonoscopy time frame when patients may still be sedated, but providers must convey important discharge and follow-up instructions.


Patient Education and Counseling | 2016

“It is just another test they want to do”: Patient and caregiver understanding of the colonoscopy procedure

Evelyn C. King-Marshall; Nora Mueller; Amy B. Dailey; Tracy E. Barnett; Thomas J. George; Shahnaz Sultan; Barbara A. Curbow


Healthcare | 2015

Provider perspectives on and experiences with engagement of patients and families in implementing patient-centered care

Sara M. Locatelli; Jennifer N. Hill; Barbara G. Bokhour; Laura Krejci; Gemmae M. Fix; Nora Mueller; Jeffrey L. Solomon; Carol VanDeusen Lukas; Sherri L. LaVela

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A. Rani Elwy

Edith Nourse Rogers Memorial Veterans Hospital

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Stephanie Rodrigues

University of Massachusetts Medical School

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