Impact of Patient-Centered Narrative Interviews on Primary Care Providers
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Impact of Patient-Centered Narrative Interviews on Primary Care Providers

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Report on project conducted for clinical dissertation in DNP program

Report on project conducted for clinical dissertation in DNP program

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Impact of Patient-Centered Narrative Interviews on Primary Care Providers Impact of Patient-Centered Narrative Interviews on Primary Care Providers Presentation Transcript

  • Patient-Centered Narrative Interviewing Impact on Perceptions of Primary Care Clinicians
  • Section I: Clinical Problem
    • Problems with a Provider-Centered Approach
      • To Err is Human and Crossing the Quality Chasm
    • Problems with a Patient-Centered Approach
      • Identifying the Essential Elements of Patient-Centered Interviewing
      • Making the Personal Transformation
  • Section II: Clinical Solution
    • Components of Evidence-Based Patient-Centered Interviewing
    • Patient-Centered Interviewing in a Narrative Mode
  • Components of Evidence-Based Patient-Centered Interviewing
    • Skills Used Simultaneously
      • Rapport building and the relationship maintenance
      • Mindful practice
      • Topic tracking
      • Acknowledging social or emotional clues with empathy
    • Skills Used Sequentially
      • Up-front, collaborative agenda setting
      • Exploring the patient’s perspective
      • Co-creating a plan
  • Patient-Centered Interviewing in a Narrative Mode
    • History and basic concepts
    • Application in Patient-Centered Interviewing Skills
      • Rapport building and the relationship maintenance
      • Mindful practice
      • Topic tracking
      • Acknowledging social or emotional clues with empathy
      • Up-front, collaborative agenda setting
      • Exploring the patient’s perspective
      • Co-creating a plan
  • Section III: Project Implementation
    • Purpose
      • Conduct a project using consultants to interview patients and provide information to their medical providers, and evaluate its impact and suitability as a small test of change in order to improve and expand this approach to improving patient-centered care in primary care settings.
    • Rationale and Assumptions
      • PCPs likely employ medical model; provider-centered approach
      • PCPs unlikely to seek training but may be open to others performing services
  • Section III: Project Implementation
    • Overall Design and Objectives
    • Provide a process for the PCP to identify frustrating and/difficult patients.
    • Collect quality and adequate biopsychosocial data using the patient-centered narrative interviewing process.
    • Organize and effectively present this case to the PCP.
    • Assess changes in the clinical decision-making, level of frustration, and other general perceptions of the PCP.
    • Evaluate information for the purposes of modifying the approach in order to improve its value and acceptability.
    • Determine how, when, and where to re-implement and/or expand the implementation of this project the future.
  • Section III: Project Implementation
    • Outcomes Evaluated
      • PCP perceptions of patient’s condition, diagnosis and treatment plans
      • Value of information provided to PCP
      • PCP frustration
      • Differences between clinician and interviewer assessments of patient problems
    • Setting
      • Contracted w/ UCSF; preceptors established
      • Student roles and expectations established
  • Section III: Project Implementation
    • Training Approach and Method
      • 12-week period from January through April,
      • Approx. 10 hours of classroom instruction and 30 hours of reading, practice, and other assignments.
      • Methods of instruction included
        • assigned articles,
        • viewing videos,
        • participating in discussions,
        • developing individual and group create presentations,
        • performing and rating each other’s practice.
        • Final check-out
      • https: //moodle . ucsf . edu/course/view . php ?id=821
  • Section III: Project Implementation
        • Intervention and Data Collection
          • PCPs invited
          • Patients selected; Clinician Problem Assessment form completed
          • Interviews performed; and Interviewer Problem Assessment form completed
          • Cases presented
          • Information discussed
          • Surveys completed,
          • Forms collected and submitted
  • Section IV: Project Evaluation
    • Results
      • Participant Characteristics (n=16)
        • Profession
          • MD 6%
          • PA 12%
          • NP 81%
            • FNP 31%
            • ANP 44%
            • PNP 6%
        • Medical + Psychiatric Scope- 31%
  • Section IV: Project Evaluation
    • Results
      • Sites (n=16)
        • 44% Primary Care only
          • VA, CHC, Pvt practice, HMO, elder care
        • 31% Psych is primary
          • PES, Psych hospitals
        • 25% PC + Psych
          • Correctional center, mobile van, community care, residential care
  • Section IV: Project Evaluation
    • Results
      • Diagnostic range:
      • psychiatric conditions - substance abuse, bipolar disorder, anxiety, depression and suicide attempt, schizoaffective disorder, psychotic disorder, somatization disorder, schizophrenia, dementia,
      • medical conditions - chronic back pain, stomach pain, celiac disease, cellulitis, hypertension, dyslipidemia, emphysema, arthritis, gastroesophageal reflux disease, medication side effects, asthma
  • Value of Interview Information to the PCP
  • Section IV: Project Evaluation
    • Results
        • Positive Value of information provided to PCP
          • 100% (48%+ 52%++)
          • Characteristics attributed to information:
            • 50% encouraging
            • 31% hopeful
            • 12% enthusiastic
            • 6% ambivalent
            • 3% indifferent
          • Readiness to make change:
            • Confidence: 83% very, 17% somewhat
            • Act within: 50% now, 33% <6 mo., 27% 30 days
  • Section IV: Project Evaluation
    • Results
        • Positive Value of information provided to PCP
          • Specifically helpful in these ways:
          • “ Helps me with overall understanding and treatment planning,”
          • “ To put a plan together that will anticipate the patient’s needs prior to presenting with a health decline,”
          • “ Helpful in giving additional information and another perspective,”
          • “ Helped me think about the case from a broader perspective,”
          • “ Reinforced diagnostic impression,”
          • “ Mental health is as important as the medical issues presented,”
          • “ It gives me good insight into the patient’s behavior,”
          • “ This information made her more approachable and more straightforward to deal with,”
          • “ Provided me with alternative insight and viewpoints on approach and technique with his patient,”
          • “ Found impressions very helpful to my end decision,”
          • “ Knowing history of drug use will guide me in deciding interventions for enhancing client motivation and self esteem.”
  • PCP Understanding of Patient Condition/Situation Changed
  • Information Changed Diagnostic Impression:
  • Information Changed Treatment Options:
  • Information Changed Treatment Options:
  • Section IV: Project Evaluation
    • Results
      • Outcomes
        • PCP perceptions of patient’s condition, diagnosis and treatment plans
          • Condition/Situation: 81% (57% + 24% ++)
          • Dx: 48% (38% + 9%++) vs. 52% -
          • Tx: 86% (62% + 24% ++) vs. 14% -
          • Areas:
            • 29% general approach
            • 21% sequence/timing
            • 24% referrals
            • 16% Rx
            • 11% further eval/testing
  • Change in PCP Frustration
  • Section IV: Project Evaluation
    • Results
        • PCP frustration
          • Less: 48% Unchanged 48% More 4%
          • Reasons:
          • Lack of responsibility for actions,
          • manipulative behaviors, medication seeking behaviors,
          • attention seeking behaviors, “needy patient,”
          • chronic pain problems,
          • refusal of care, refusal of referrals
          • patient lack of insight, evasiveness, lack of motivation,
          • Multiple comorbid conditions, high level of complexity, complex patient but limited time,
          • non-adherence, noncompliant,
          • “ says one thing and does another,” inconsistency of information provided,
          • demanding, controlling,
          • frequency of service use,
          • “ irritable and difficult to communicate with,” patient distrust of system,
          • evasiveness, “hyperactive and hyper verbal patient,”, “poor temper,”
          • somatization
  • Section IV: Project Evaluation
    • Results
        • Differences between clinician and interviewer assessments of patient problems
          • PCP:
            • medical dx + biopsyhosocial problems
            • Primary care dx + psychiatric dx
          • Interviewer:
            • Co-morbidity & co-occurring disorders
            • Situational elaboration
            • Patient’s perspective on problem
  • Section IV: Project Evaluation
    • Analysis
      • Participants and Sites
        • Over 80% NPs
        • Over-representation of psychiatric diagnoses and settings
        • Substantial mental health expertise in PCPs
      • Outcomes
        • PCP perceptions of patient’s condition, diagnosis and treatment plans
          • Treatment > Diagnosis change is expected
          • Scale and Direction of treatment changes unanticipated
        • Value of information provided to PCP
          • Highly appreciated and committed to action
        • PCP frustration
          • Similar to expectations based on literature
        • Differences between clinician and interviewer assessments of patient problems
          • Overlap of biomedical & biopsychosocial approach
          • Condition elaboration; fostered acceptability
  • Section IV: Discussion – lessons learned
      • Would clinicians involved in this project want to do it again?
      • Would they take advantage of other opportunities to use consultants in similar ways?
      • As a result of this experience, are any of them interested in pursuing this kind of training themselves?
      • Should be provided routinely? What patients do they feel would benefit from this approach?
      • When might this approach be considered to be essential?
      • Did a nursing background of the interviewer affect the results?
      • Did the nursing background of the PCP have an effect?
      • If this project were repeated in strictly outpatient primary care medical clinics, would we see the same results?
      • Did interviewers actually perform patient-centered narrative interviewing as trained?
  • Section V: Next Steps
    • CQI and EBP – ideal application
      • Problem with Patient Preferences & Shared Medical Decision-Making
      • Similar problems as biomedical + biopsychosocial intersection
  • Section V: Next Steps
    • This project’s iterative development history
    • Directions forward:
      • Repeat with lessons-learned
      • Expand to PCP training approach
      • Evolve to Primary Behavioral Health Consultation Services
  • Section VI: Implications for Advanced Practice Nursing
    • Concurrence with Nursing Theory
    • Concurrence with DNP Competencies
  • Concurrence with Nursing Theory
    • Newman’s Health as Expanding Consciousness (HEC)
      • Meaning & Emergent Patterns
      • Dialectic & Transforming Presence
      • Shared Narrative
  • Concurrence with Nursing Theory
    • Ways of Knowing
      • Patterns
        • Empiric (Positivist), logico-scientific, biomedical approach
        • Aesthetic, narrative, biopsychosocial approach
      • Relationship
        • Independent
        • Dependent
        • Interdependent
  • Concurrence with DNP Competencies
    • Independent Practice
    • Scientific Foundation
    • Leadership
    • Quality
    • Practice Inquiry
    • Technology & Information Literacy
    • Policy
    • Health Delivery System
    • Ethics