Patient-Centered Narrative Interviewing Impact on Perceptions of Primary Care Clinicians
Section I: Clinical Problem <ul><li>Problems with a Provider-Centered Approach </li></ul><ul><ul><li>To Err is Human  and ...
Section II: Clinical Solution <ul><li>Components of Evidence-Based Patient-Centered Interviewing </li></ul><ul><li>Patient...
Components of Evidence-Based Patient-Centered Interviewing <ul><li>Skills Used Simultaneously </li></ul><ul><ul><li>Rappor...
Patient-Centered Interviewing in a Narrative Mode <ul><li>History and basic concepts </li></ul><ul><li>Application in Pati...
Section III:  Project Implementation <ul><li>Purpose </li></ul><ul><ul><li>Conduct a project using consultants to intervie...
Section III:  Project Implementation <ul><li>Overall Design and Objectives </li></ul><ul><li>Provide a process for the PCP...
Section III:  Project Implementation <ul><li>Outcomes Evaluated </li></ul><ul><ul><li>PCP perceptions of patient’s conditi...
Section III:  Project Implementation <ul><li>Training Approach and Method </li></ul><ul><ul><li>12-week period from Januar...
Section III:  Project Implementation <ul><ul><ul><li>Intervention and Data Collection </li></ul></ul></ul><ul><ul><ul><ul>...
Section IV:  Project Evaluation <ul><li>Results </li></ul><ul><ul><li>Participant Characteristics (n=16) </li></ul></ul><u...
Section IV:  Project Evaluation <ul><li>Results </li></ul><ul><ul><li>Sites (n=16) </li></ul></ul><ul><ul><ul><li>44% Prim...
Section IV:  Project Evaluation <ul><li>Results </li></ul><ul><ul><li>Diagnostic range: </li></ul></ul><ul><ul><li>psychia...
Value of Interview Information to the PCP
Section IV:  Project Evaluation <ul><li>Results </li></ul><ul><ul><ul><li>Positive Value of information provided to PCP </...
Section IV:  Project Evaluation <ul><li>Results </li></ul><ul><ul><ul><li>Positive Value of information provided to PCP </...
PCP Understanding of Patient Condition/Situation Changed
Information Changed Diagnostic Impression:
Information Changed Treatment Options:
Information Changed Treatment Options:
Section IV:  Project Evaluation <ul><li>Results </li></ul><ul><ul><li>Outcomes </li></ul></ul><ul><ul><ul><li>PCP percepti...
Change in PCP Frustration
Section IV:  Project Evaluation <ul><li>Results </li></ul><ul><ul><ul><li>PCP frustration </li></ul></ul></ul><ul><ul><ul>...
Section IV:  Project Evaluation <ul><li>Results </li></ul><ul><ul><ul><li>Differences between clinician and interviewer as...
Section IV:  Project Evaluation <ul><li>Analysis </li></ul><ul><ul><li>Participants and Sites </li></ul></ul><ul><ul><ul><...
Section IV:  Discussion –  lessons learned <ul><ul><li>Would clinicians involved in this project want to do it again?  </l...
Section V: Next Steps <ul><li>CQI and EBP – ideal application </li></ul><ul><ul><li>Problem with Patient Preferences & Sha...
Section V: Next Steps <ul><li>This project’s iterative development history </li></ul><ul><li>Directions forward: </li></ul...
Section VI: Implications for Advanced Practice Nursing <ul><li>Concurrence with Nursing Theory </li></ul><ul><li>Concurren...
Concurrence with Nursing Theory <ul><li>Newman’s Health as Expanding Consciousness (HEC) </li></ul><ul><ul><li>Meaning & E...
Concurrence with Nursing Theory <ul><li>Ways of Knowing </li></ul><ul><ul><li>Patterns </li></ul></ul><ul><ul><ul><li>Empi...
Concurrence with DNP Competencies <ul><li>Independent Practice </li></ul><ul><li>Scientific Foundation </li></ul><ul><li>L...
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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

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  • 4
  • Impact of Patient-Centered Narrative Interviews on Primary Care Providers

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

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