efrat shadmi, phd the cheryl spencer department of nursing
TRANSCRIPT
Efrat Shadmi, PhDThe Cheryl Spencer Department of NursingFaculty of Social Welfare and Health SciencesHaifa UniversityMount Carmel 31905, IsraelPhone: (972) 48288012Email: [email protected]
ONCOLOGY PATIENTS' EXPERIENCE AT THE INTERFACE
BETWEEN HOSPITAL AND COMMUNITY CARE: A MIXED
METHOD INVESTIGATION
Acknowledgements
Team: The Rambam Medical Center, Haifa: Admi, H., PhD,
RN; Muller, E. MSN, RN. The Department of Family Medicine, Clalit Health
Services, Haifa and the Western Galilee: Reis, S. MD, MHPE ; Naveh, N. MD; Ungar, L. PhD; Kaffman, M. MD
Funding: The Israel National Institute for Health Policy and Health Services Research
Background
Oncology patients experience breakdowns in care when transitioning across care settings Uncertainty about the division of responsibility
between GPs and specialists (Stalhammar et. al., Scand J Prim Health Care, 1998)
Substantial deficits in communication and information transfer between hospital-based physicians and primary care physicians (Farquhar et. al., Eur J Cancer Care, 2005)
Background
Disparities in cancer care among minority groups Communication barriers, lack of cultural
competence from providers, differences in health beliefs (Elkan et. al., Eur J Cancer Care, 2007)
Disparities in cancer care across care transitions
Aims
To examine differences in the experience of oncology patients at the transition between hospital and community care, according to cultural/ethnic subgroups, and to identify factors that promote or hinder seamless transitions
Setting Haifa and North Israeli region
~ 38% Arab Israelis; ~13% Immigrants from former Soviet Union
Health care: Regional Oncology
Center – Rambam Hospital Receive primary care at
four “Sick Funds”
Methods - Qualitative
Focus groups: Patients, Staff Nurses, Head Nurses, Nurse Coordinators, Social Workers, Medical Administrators
Semi-structured interviews: Physicians, Regional health plan managers
Methods -Quantitative
Patients discharged from hospital in prior 2-12 weeks
Self administered survey in Hebrew, Arabic, and Russian Primary Care Assessment Survey (PCAS) / Safran,
D.G., Medical Care, 1998 Care Transition Measure (CTM) / Coleman, E. In J Integr
Care, 2002 SF-12 V.2 Demographics
Results: Focus Groups and Interviews
Themes:
(1) Responsibility for care
(2) Administrative and bureaucratic burden
(3) Informal routes of communication
(4) Cultural barriers
Responsibility for Care
“There is a feeling that the patient doesn’t know who to turn to. Patients often call us with questions the nurses or doctors in their primary clinic should have answered” (Hospital Nurse)
“The primary care physician prefers to send his patient to the hospital even for minor reasons, which results in added burden to the system and the patient. The primary care physician is present but absent” (Hospital physician)
Administrative and bureaucratic burden
“Once a letter from the primary care physician was enough. Today the process is much more complicated. First we need to send a letter, that needs to be signed by a physician, which then needs to be authorized by a special committee. This all takes time and there are many opportunities for breakdowns” (Nurse coordinator)
Informal routes of communication
“It depends whom you know. If you have personal connections with a physician then you feel you can call in and contribute to the care plan and receive information about your patient. If not, you depend on the patient and the completeness and accuracy of information in the electronic medical record” (Community Physician)
Cultural barriers
“The only doctors we had a problem with are those who immigrated from Russia (former Soviet Union – ES). We speak Hebrew, but when a Russian doctor explained something to us we had to ask the Nurse to explain again.” (Patient)
Results: SurveyPatient Characteristics
Total
422
Hebrew
207
Russian 94
Arabic 121
Age 58.961.163.152.0
Gender: Female54%55%54%55%
SF-12: Physical Health
34.736.232.034.1
SF-12: Mental Health
36.637.140.133.3
Low Education20%9%2%53%
Low Economic24%20%22%32%
Patients’ Relationship with their Primary Care Physician (PCP)
TotalHebrewRussianArabic
When I have a health problem I usually see my PCP (vs. oncologist)
91%89%90%92%
I would recommend my PCP to a friend or family member
84%82%72%89%
Coordination Across Care Settings
83% visited PCP after hospitalization 97% of patients had provided a hospitalization
summary letter to the PCP 83% discussed summary letter recommendations
with PCP
Primary Care Physician Discussed Hospital Discharge Summary with the
Patient
72
91 92
40
50
60
70
80
90
100
Perc
ent
Hebrew
Russian
Arabic
* *
* P value from Chi2 test ≤ 0.001
Patients' Assessment of Primary Care
20
30
40
50
60
70
80
90
100
Access Knowledge Integration Communication Interpersonal Trust
Mea
n S
cale
Sco
re
Hebrew Russian Arabic
PCAS Scales
Patient Characteristics Associated With High Quality Primary Care
(PCAS -Patient Reports)
Comparison categories: Hebrew Language; Elementary School education; Economic level: poor; Sick Fund: Clalit *P<0.05; ** p<0.01, † p<0.001
AccessKnowledgeIntegrationCommunicationInterpersonalTrust
Age0.040.24**0.080.100.030.15
Gender (female)1.00-1.93-1.60-1.560.350.51
Russian-5.00*-7.81**-9.60**-13.14†-15.78†-5.92*
Arabic14.88†14.75†8.82**6.83*7.75*7.05**
SF-12: Physical Health
0.140.05-0.01-0.03-0.020.18*
SF-12: Mental Health0.100.130.130.160.150.16*
Educ: High-School 1.045.051.180.380.504.63
Educ: Diploma2.315.781.333.451.995.59
Educ: ≥ BA2.412.491.55-1.370.840.64
Econ level: Average3.732.280.893.502.872.29
Econ level: ≥ Good-0.25-0.110.74-0.161.782.08
Sick fund: Maccabi2.614.062.734.176.06*5.00*
Sick fund: Other3.577.64*6.89*4.309.20**7.55**
Patient Assessment of Transition from Hospital
72.975
80.9
50
60
70
80
90
100
Mea
n CT
M S
cale
Sco
re
Hebrew
Russian
Arabic
Patient Characteristics Associated with High Quality Transition from Hospital
(CTM- Patient Reports)
Comparison categories: Hebrew Language; Elementary School education; Discharge unit – Oncology
β coefficient Stand. errorP value
Age0.020.090.865
Gender (female)2.992.130.161
Russian-1.362.890.638
Arabic6.493.100.037
SF-12: Physical Health0.040.100.698
SF-12: Mental Health0.270.080.001
Education: High School -2.573.370.445
Education: Diploma2.353.850.542
Education: BA-1.893.780.618
Discharge unit -Medical-1.213.180.704
Discharge unit - Surgical2.912.340.214
Discharge unit - Other-1.774.710.707
PCP discussed discharge letter with patient8.112.620.002
Discussion Barriers are mainly due to organizational and
system-level characteristics and factors that promote seamless care are related to specific physician-level practices
Deciphering minority quality of care issues: Arabic speaking patients report a better care experience Russian speaking patients face significant cultural and
language barriers Performing coordinating activities (such as
discussing discharge recommendations with patient) is associated with better ratings of the transition
Discussion (cont.)
Limitations: Generalizability Cross-sectional study
Next steps: Understanding cultural barriers The role of caregiver support
Thank you!
شكرا
Спасибо
תודה