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Efrat Shadmi, PhD
The Cheryl Spencer Department of Nursing
Faculty of Social Welfare and Health Sciences
Haifa University
...
Acknowledgements
 Team:
 The Rambam Medical Center, Haifa: Admi, H., PhD,
RN; Muller, E. MSN, RN.
 The Department of Fa...
Background
 Oncology patients experience breakdowns in
care when transitioning across care settings
 Uncertainty about t...
Background
 Disparities in cancer care among minority
groups
 Communication barriers, lack of cultural
competence from p...
Aims
 To examine differences in the experience
of oncology patients at the transition
between hospital and community care...
Setting
 Haifa and North Israeli region
 ~ 38% Arab Israelis; ~13% Immigrants from
former Soviet Union
 Health care:
 ...
Methods - Qualitative
 Focus groups: Patients, Staff Nurses,
Head Nurses, Nurse Coordinators, Social
Workers, Medical Adm...
Methods -Quantitative
 Patients discharged from hospital in prior 2-12
weeks
 Self administered survey in Hebrew, Arabic...
Results: Focus Groups and
Interviews
 Themes:
(1) Responsibility for care
(2) Administrative and bureaucratic burden
(3) ...
Responsibility for Care
 “There is a feeling that the patient doesn’t know
who to turn to. Patients often call us with
qu...
Administrative and
bureaucratic burden
 “Once a letter from the primary care
physician was enough. Today the process
is m...
Informal routes of
communication
 “It depends whom you know. If you have
personal connections with a physician
then you f...
Cultural barriers
 “The only doctors we had a problem with are
those who immigrated from Russia (former
Soviet Union – ES...
Results: Survey
Patient Characteristics
Total
422
Hebrew
207
Russian
94
Arabic
121
Age 58.9 61.1 63.1 52.0
Gender: Female ...
Patients’ Relationship with their Primary
Care Physician (PCP(
Total Hebrew Russian Arabic
When I have a health
problem I ...
Coordination Across Care
Settings
 83% visited PCP after hospitalization
 97% of patients had provided a hospitalization...
Primary Care Physician Discussed
Hospital Discharge Summary with the
Patient
72
91 92
40
50
60
70
80
90
100
Percent
Hebrew...
Patients' Assessment of Primary
Care
20
30
40
50
60
70
80
90
100
Access Knowledge Integration Communication Interpersonal ...
Patient Characteristics Associated With
High Quality Primary Care
(PCAS -Patient Reports(
Comparison categories: Hebrew La...
Patient Assessment of Transition from
Hospital
72.9
75
80.9
50
60
70
80
90
100
MeanCTMScaleScore
Hebrew
Russian
Arabic
Patient Characteristics Associated with High
Quality Transition from Hospital
(CTM- Patient Reports(
Comparison categories...
Discussion
 Barriers are mainly due to organizational and
system-level characteristics and factors that
promote seamless ...
Discussion (cont.(
 Limitations:
 Generalizability
 Cross-sectional study
 Next steps:
 Understanding cultural barrie...
Thank you!
‫ا‬‫ر‬‫ك‬‫ش‬
Спасибо
‫ה‬‫ד‬‫ו‬‫ת‬
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  • Add – what is missing form lit that this study adds. Look at proposal
    Even disruptions in pain management have been reported - J Pain Symptom Manage. 2005 May;29(5):433-4. Problematic discharge from hospital for patients prescribed opioids for cancer pain. Mercadante S, Girelli D, Casuccio A.
    As there are known cultural issues around cancer communication (Surbone A. , Cultural aspects of communication in cancer care.
    Recent Results Cancer Res. 2006;168:91-104. Review), understanding cultural differences across the care continuum is imperative
  • Elkan R, Avis M, Cox K, Wilson E, Patel S, Miller S, Deepak N, Edwards C, Staniszewska S, Kai J. The reported views and experiences of cancer service users from minority ethnic groups: a critical review of the literature. Eur J Cancer Care (Engl). 2007 Mar;16(2):109-21. Review.
    And – insufficient evidence on barriers across the care continuum for different ethnic groups.
  • Rambam - Number of hospital beds
  • Convenience sample
    Sample – original CTM instructions 14-28 days
    Medical Care article 6-12 weeks
  • H- 49%; R – 22%; A - 29%
    For example – 50.6 % of total sample reported that pain interferes quite a bit to extremely in their daily lives.
    Low educ – elementary school
    Low econ – poor-v.poor
  • 66% of patients had a referral letter from PCP when hospitalized – 61% Hebrew, only 47% Russian, 76% Arabic
    It should be noted that we did not examine appropriateness and reason for hospitalization nor urgency.
    Visit PCP after hospitalization – H 77%; R – 91%, A - 86%
    83% visited PCP after hospitalization – 73% H; 86% R; 84% A
  • Given that there was a PCP visit
  • Prior work showed a CTM average of:
    1. 70 (Coleman EA, Parry C, Chalmers SA, Chugh A, Mahoney E. The central role of performance measurement in improving the quality of transitional care. Home Health Care Serv Q. 2007;26(4):93-104.)
    2.
  • ** The CTM was designed as a care transition measure rather than a discharge planning g measure, thus our results may be indicative of its validity as such a measure and highlights the importance of viewing the care process as continuous rather that episodic.
  • It is worthwhile to note that when we examined the effect of giving the PCP the discharge letter – it did not influence the CTM ratings (i.e., it is not the mere existence of the letter, rather the discussion that “does the trick”
    The effect of PCP discussion – supported by literature on the effect of interventions to explain discharge receommendations (e.g., - Hughes LC, Hodgson NA, Muller P, Robinson LA, McCorkle R. Information needs of elderly postsurgical cancer patients during the transition from hospital to home. J Nurs Scholarsh. 2000;32(1):25-30. )
  • Limitations – response rate 63% - those who were sickest are not included, may bias results.
    Examining unmet needs – mental health and pain management
  • Transcript of "Efrat Shadmi, PhD The Cheryl Spencer Department of Nursing"

    1. 1. Efrat Shadmi, PhD The Cheryl Spencer Department of Nursing Faculty of Social Welfare and Health Sciences Haifa University Mount Carmel 31905, Israel Phone: (972) 48288012 Email: eshadmi@univ.haifa.ac.il ONCOLOGY PATIENTS' EXPERIENCE AT THE INTERFACE BETWEEN HOSPITAL AND COMMUNITY CARE: A MIXED METHOD INVESTIGATION
    2. 2. 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
    3. 3. 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)
    4. 4. 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
    5. 5. 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
    6. 6. 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”
    7. 7. Methods - Qualitative  Focus groups: Patients, Staff Nurses, Head Nurses, Nurse Coordinators, Social Workers, Medical Administrators  Semi-structured interviews: Physicians, Regional health plan managers
    8. 8. 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
    9. 9. Results: Focus Groups and Interviews  Themes: (1) Responsibility for care (2) Administrative and bureaucratic burden (3) Informal routes of communication (4) Cultural barriers
    10. 10. 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)
    11. 11. 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)
    12. 12. 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)
    13. 13. 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)
    14. 14. Results: Survey Patient Characteristics Total 422 Hebrew 207 Russian 94 Arabic 121 Age 58.9 61.1 63.1 52.0 Gender: Female 54% 55% 54% 55% SF-12: Physical Health 34.7 36.2 32.0 34.1 SF-12: Mental Health 36.6 37.1 40.1 33.3 Low Education 20% 9% 2% 53% Low Economic 24% 20% 22% 32%
    15. 15. Patients’ Relationship with their Primary Care Physician (PCP( Total Hebrew Russian Arabic 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%
    16. 16. 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
    17. 17. Primary Care Physician Discussed Hospital Discharge Summary with the Patient 72 91 92 40 50 60 70 80 90 100 Percent Hebrew Russian Arabic * * * P value from Chi2 test ≤ 0.001
    18. 18. Patients' Assessment of Primary Care 20 30 40 50 60 70 80 90 100 Access Knowledge Integration Communication Interpersonal Trust MeanScaleScore Hebrew Russian Arabic PCAS Scales
    19. 19. 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 Access Knowledge Integration Communication Interpersonal Trust Age 0.04 0.24** 0.08 0.10 0.03 0.15 Gender (female) 1.00 -1.93 -1.60 -1.56 0.35 0.51 Russian -5.00* -7.81** -9.60** -13.14† -15.78† -5.92* Arabic 14.88† 14.75† 8.82** 6.83* 7.75* 7.05** SF-12: Physical Health 0.14 0.05 -0.01 -0.03 -0.02 0.18* SF-12: Mental Health 0.10 0.13 0.13 0.16 0.15 0.16* Educ: High-School 1.04 5.05 1.18 0.38 0.50 4.63 Educ: Diploma 2.31 5.78 1.33 3.45 1.99 5.59 Educ: ≥ BA 2.41 2.49 1.55 -1.37 0.84 0.64 Econ level: Average 3.73 2.28 0.89 3.50 2.87 2.29 Econ level: ≥ Good -0.25 -0.11 0.74 -0.16 1.78 2.08 Sick fund: Maccabi 2.61 4.06 2.73 4.17 6.06* 5.00* Sick fund: Other 3.57 7.64* 6.89* 4.30 9.20** 7.55**
    20. 20. Patient Assessment of Transition from Hospital 72.9 75 80.9 50 60 70 80 90 100 MeanCTMScaleScore Hebrew Russian Arabic
    21. 21. 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. error P value Age 0.02 0.09 0.865 Gender (female) 2.99 2.13 0.161 Russian -1.36 2.89 0.638 Arabic 6.49 3.10 0.037 SF-12: Physical Health 0.04 0.10 0.698 SF-12: Mental Health 0.27 0.08 0.001 Education: High School -2.57 3.37 0.445 Education: Diploma 2.35 3.85 0.542 Education: BA -1.89 3.78 0.618 Discharge unit -Medical -1.21 3.18 0.704 Discharge unit - Surgical 2.91 2.34 0.214 Discharge unit - Other -1.77 4.71 0.707 PCP discussed discharge letter with patient 8.11 2.62 0.002
    22. 22. 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
    23. 23. Discussion (cont.(  Limitations:  Generalizability  Cross-sectional study  Next steps:  Understanding cultural barriers  The role of caregiver support
    24. 24. Thank you! ‫ا‬‫ر‬‫ك‬‫ش‬ Спасибо ‫ה‬‫ד‬‫ו‬‫ת‬
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