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Beyond an Academic Exercise: Expanding the Role of Student Home Visit Programs to Evaluate Patients’ Experience of Care
Kate Richards, MD; Maya Wolpert Bauer, MD; W. Suzanne Eidson-Ton, MD, MS; Ulfat Shaikh, MD, MPH, MS
ABSTRACT
Purpose: Bringing the patient’s voice into quality improvement is a critical step in promoting patient-centered care. Patient feedback is often gathered in surveys, but numerical data do not always convey patient priorities. Although resource-intensive, patient interviews are an effective way to identify strategies to improve care.
Methods: UC Davis first-year medical students completed three home visits, including one in which they administered an open-ended quality improvement (QI) questionnaire. Students reflected on their patients’ answers and submitted a one to two page de-identified narrative. We collected 102 narratives for analysis. Themes were identified and patient feedback was summarized.
Results: 264 quotes were abstracted from 102 essays and coded by content analysis into thematic categories describing ideal healthcare based on the National Academy of Medicine’s quality domains: Patient-Centered (120), Equitable (50), Efficient (30), Effective (24), Timely (21), and Safe (19). Themes abstracted from the narratives identified the patients’ values and priorities, most commonly patient-centered care (46% of the quotes). Emotional support, trust, and respect for patients’ values were especially appreciated within the theme of patient-centered care. Equitable care, including for age, ethnicity, and socioeconomic status, was also highly prioritized (19%). Fewer patients mentioned efficiency, effectiveness, timeliness, or safety.
Conclusion: Medical student home visit narratives provided valuable qualitative data on patients’ experiences of care. Our patient feedback highlights how critical patient-centeredness is to excellent medical care. The specific examples and patient-generated solutions from the narratives will be used to develop more targeted quality improvement initiatives. The effectiveness of these initiatives in changing clinician behavior and hospital practices can then be evaluated.
BACKGROUND
Quality improvement research is driven by data from patients to develop targeted interventions to enhance healthcare delivery, outcomes, and the patient experience.
This data can be gathered through surveys and narratives. Multiple-choice surveys are frequently used to quickly collect consumer reactions, but close-ended questions do not always capture important patient concerns nor do they motivate clinicians to change. While surveys such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) provide crucial feedback, valuable contextual information can be lost.[1] Other barriers include declining response rates and long intervals between data collection and interpretation.[2] Although resource-intensive, patient narratives complement surveys by highlighting the patient’s voice, which is especially valuable in complex situations such as adverse events and incident disclosures.[3],[4],[5] The National Health Service (NHS) has long utilized patient and caregiver interviews to understand patient priorities and to develop successful strategies to improve the patient’s experience of care.[6] In the US, patient narratives are also frequently employed to elicit more meaningful and complete patient feedback.[7],[8] Allowing patients to answer open-ended questions enables interviewers and clinicians to understand “what really matters” to patients, fostering the design of more nuanced initiatives aimed at meeting patients’ needs.
Home visits provide a rich educational opportunity for patients, medical students, and clinicians, wherein perspectives can be elicited and responded to in real time. Home visits are used worldwide to teach medical students about patient care[9], enhance inter-professional training[10], expose students to chronic disease management[11], and improve health outcomes[12]. They have not been widely used to systematically gather patient input. Our literature review of more than 50 studies suggests that most home visit programs focus on the visiting student’s experience, with only a few incorporating the patient’s perspective. We were unable to identify publications that utilized patient feedback obtained during home visits to inform quality improvement (QI) measures.
Student home visits could be a novel approach to understanding barriers to care, perceived weaknesses in the healthcare system, and propose QI measures. Patients may be more comfortable expressing their opinions in the familiar environment of their own homes, allowing more opportunity to elaborate on their concerns and share recommendations for clinical QI.
Since 2004, UC Davis medical students have conducted home visits in the Doctoring course (basic clinical skills training), where they hear first-hand accounts from patients about barriers to care, personal experiences, and proposed solutions. Following their visits, the students write reflection essays summarizing the feedback generated by their patients. The objectives of our qualitative study were to: (1) categorize patients’ recommendations in the home visit reflections using the National Academy of Medicine’s Six Aims for Quality Care (Safe, Patient-centered, Efficient, Effective, Timely, and Equitable)[13] and (2) identify opportunities to improve patients’ experience of care and inform quality care goals in the UC Davis Health System.
Our hypothesis is that home visits are a rich source of qualitative data that could be used to develop actionable QI initiatives. In particular, we hypothesize that patient-centered care will be the aim mentioned most in the home visit reflections, and that the reflections will contain useful information to understand patients’ experience of care.
METHODS
In 2013-2014, 102 first-year medical students each conducted three home visits in the Doctoring course with patients from the UC Davis Health System, student-run clinics, and volunteer faculty clinics. On the third home visit, students interviewed their patients using a semi-structured open-ended QI questionnaire (Appendix A). Students were then instructed to submit a one to two page de-identified narrative reflection of their patients’ responses regarding positive and negative aspects of their health care experience and their patients’ suggestions for improvement.
Qualitative data was evaluated using content analysis through creation of a coding sheet based on the National Academy of Medicine’s Six Aims for Quality Care (Appendix B). Further refinement of the codes was based on the American Hospital Association’s Quality Goals.[14] Two researchers independently reviewed narratives and abstracted quotes from every narrative into the coding sheet by content analysis. Discrepancies were reconciled by consensus with a third researcher. Themes were identified and patient feedback was summarized.
RESULTS
264 quotes were abstracted from 102 essays.
Patient-Centered (46% of quotes): Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
Respect for patients’ values, preference, and expressed needs
“He said he appreciates how his doctor takes his opinions into consideration when creating a treatment plan for him.”
Coordination and integration of care
“Even though his doctor is not directly involved in his specialty care, his doctor keeps tabs on his situation, and the patient reaches out to this doctor first with questions. He is grateful that his doctor is mindful of his overall health.”
Information, communication, and education
“Her physician takes time to answer her questions in the office or over the phone and makes her feel acknowledged.”
Physical comfort
“She did talk about firing one doctor. …He kept his back to her and remained facing away from her as she tried to ask him questions.”
Emotional support
“She loves her current doctors, because they are people-oriented, excellent communicators, and interact with her on a human level. …She looks for a human connection and care more than answers and solutions to medical questions.”
Trust
“The patient said he must be able to trust a physician not to judge him. …There are some patients who hide their illnesses from their families and yet they share this with their physicians.”
Relationship
“For the patient, continuity of care and a relationship with her physician is the most crucial thing to good quality care. ...The patient sometimes sees different doctors and says it’s hard to have a good relationship with just one visit.”
“He values the personal relationship he has developed with his physician. His doctor takes time to discuss non-medical issues and share his own family photographs, which helps the patient trust him more.”
Equitable (19%): Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
Ability
“The clinic did not have sufficient interpreters to meet the needs of their mute and deaf patients.”
Age
“She often feels like physicians and nurses do not want to put up with her because she is older. She believes that the providers find her stubborn, slow, and unintelligent… She said to assume elders are capable of understanding until you are given evidence that they are not.”
Gender/Age
“She guessed her urologist was unaccustomed to dealing with female patients, or he assumed she was senile because of her age.”
Ethnicity
“She mentioned that she had experienced racism and unequal treatment because of her skin color and that she was treated like a child who did not understand and was talked down to.”
Education
“He felt that he didn’t really have an advocate… Doctors forget the immense knowledge gap and power dynamic between them and their patients.”
Geographic location
“She described the inconvenience of driving to Roseville for her husband’s surgery since neither of them drive on the freeway.”
Disease
“The HIV-positive patient started sharing about the time a doctor he visited refused to touch him.”
Socioeconomic
“As an undocumented worker, he was surprised that he was able to have healthcare paid for and was provided a social worker to help him through his illness.”
Efficient (11%): Avoiding waste, including waste of equipment, supplies, and energy.
Time
“She travels over 1.5 hours to West Sacramento from Woodland for dialysis treatment 3 times per week.”
Cost
“Their insurance didn’t cover a specific medication the patient’s husband needed so he could breathe without fits of coughing, and they had to pay for it out-of-pocket with their savings.”
Continuity of Care
“He states that in the last 10 months he’s seen four different providers, and often new physicians order redundant tests, which wastes time and resources.”
Information Sharing
“She wants doctors to maintain continuity and make sure that information flows continuously between doctors. When physicians don’t review a patient’s notes, information is lost, and she has to bring notes and reminders with her to get proper care.”
Effective (9%): Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.
Social Determinants of Health and Social Support
“The patient felt that social situation plays a large role in his health and having family or friends involved in his health care could help immensely.”
"The patient noted that a program that provides complex patients like himself with a stable living situation, longitudinal care, and intensive case management would be incredibly helpful.”
Evidence-Based Care
“The patient appreciates that his doctor modifies his practices and exhibits flexibility as treatment ideals have evolved. He thinks that the ability to adapt to new facets of medicine is an essential quality for any physician.”
Self-Efficacy
“She talked about how she didn’t want to follow doctors’ orders at diagnosis, but when she overcame her self-defeating thoughts and began treatment, she improved.”
Creating a Practical Plan
“She laughed when she was told to walk in her neighborhood, because this was not actionable or practical for her. Her neighborhood is too dangerous.”
Access
“A recurring topic was that the CARES clinic is overcrowded since it became a primary care center.”
Systems Improvement
“She expressed frustration that neither her teacher nor her parents identified her symptoms, and said the healthcare system should play a greater role in schools to catch problems that may not be addressed in the home.”
Timely (8%): Reducing waits and sometimes harmful delays for both those who receive and those who give care.
Reducing Waiting Time
“He appreciates that wait times for appointments have decreased, and that patients are notified if the doctor is running late.”
“She states that the doctors are always quick and available to respond, especially through email, which makes it much more convenient.”
Reducing Delays
“She was critical about the amount of time she had to wait for referrals to specialists. …Finding ways to cut referral times between specialists would expedite when patients can receive their next phase of care.”
“He was misdiagnosed as having some sort of calcification, which was ignored for many years so he was not properly diagnosed with fibrosis…He felt disappointed that out of the numerous doctors he saw, no one really offered up a second opinion or suggested follow-up.”
Safe (7%): Avoiding injuries to patients from the care that is intended to help them.
Communication
“She demanded that they recheck the dosage on her husband’s painkillers, and it turned out that the hospital was giving him four times too much. Each time a different member of the health care team came by, they changed the dosage. The patient’s wife believes the team should have communicated better, and listened to her input.”
Loss of Trust
“Her new physician forced her to switch her medication which she was perfectly happy taking. The new medication caused her to vomit incessantly and become ill. This experience not only reinforced her distrust in healthcare, but also provided her with ‘care’ that harmed her.”
DISCUSSION
Our study of 102 diverse patient narratives demonstrates that home visits conducted by medical students are a unique opportunity to quantitatively and qualitatively obtain patient input for QI initiatives to improve the patients’ experience of care. While the home visit narratives identified thematic values and priorities, they also included perceived strengths, areas for improvement, and patient-generated solutions for the health system.
Almost half (46%) of the quotes were about patient-centeredness, which is fundamental to the patients’ experience of care. Patients particularly appreciated physicians who provided emotional support, created a relationship, built trust, and demonstrated respect for patients’ values. Repeatedly, patients stated that these are the characteristics they value most in their physicians.
Equitable care (19%) was also prioritized. Patients described experiences of both fair and unfair treatment due to ability, age, gender, ethnicity, education, geographic location, disease, and socioeconomic status. Many patients noted they felt comfortable talking to the medical student about their experiences with systemic and salient disparities within healthcare that they could not summarize on a survey or during an encounter with a physician.
Regarding efficiency (11%), patients noted that continuity and information-sharing reduced cost and waste because unnecessary tests were not reordered. Continuity of care extended into other realms as well, including safety, timeliness, and patient-centeredness. Patients felt continuity improved safety and reduced waiting time because the doctor knew the risks for the patient, and did not have to retake each patient’s history, respectively. Continuity of care was also thought to increase patient-centeredness with long-lasting relationships.
Patients were concerned that the effectiveness (9%) of medical care is limited by lack of access to primary care, the under-utilization of community resources, and over-use of emergency departments and free clinics. They noted that social support improves the effectiveness of their care because having help from friends, family, and the community increases their ability to handle complex diseases and treatments.
Timeliness was mentioned in 8% of patient quotes. Most patients agreed that appointment wait times are shorter, although sometimes there are long delays for specialty referrals. Being accessible to patients by email between visits and notifying patients of long appointment wait times are simple measures that improved patients’ perception of timely care.
Only 7% of patient quotes discussed safety concerns. Patients felt that lapses in safety resulted from a lack of communication and led to mistrust in the medical system. Patients asked for better coordination within the health teams to prevent errors and for more personalized education from their doctors about what to expect from treatments.
Overall, this study showed that medical students are able to elicit, summarize, and learn from patient narratives, and perhaps can apply these narratives to drive QI. These essays provided rich, contextual data that can be used to complement survey data to inform and develop targeted QI initiatives.
Limitations: Semi-structured open-ended guides are often used to elicit narratives,4,5 but create inconsistency in the questions asked. In this pilot study, the QI questionnaire was broad to allow a natural conversation directed by the patient, but the methods are not reproducible. Also, the patient narratives were written by students which may introduce error, so direct patient quotes and summaries were used to best reflect the patients’ sentiments. Furthermore, patients’ ability and willingness to be interviewed in their home presents an inherent selection bias. In addition, to ensure that all first-year medical students were able to participate, patients were from a variety of settings and often made comparisons between different health systems. While this provides a diverse sample of narratives, not all of the patients’ experiences were directly applicable to the UC Davis Health System.
Recommendations for Future Directions: For future research, a structured protocol, such as that tested in “Breaking Narrative Ground,” 8 would be helpful to generate more specific, formalized feedback. Because this study introduces medical students to quality improvement topics, hearing the patients’ stories first-hand may inspire student-driven QI research. Future studies will be done using the patient feedback gathered in this study to develop, implement, and track QI initiatives, and to evaluate the effectiveness of these initiatives in changing clinician behavior and hospital practices.
COMPETING INTERESTS
The authors declare no competing interests.
REFERENCES
[1] Davies E & Cleary P. “Hearing the patient’s voice? Factors affecting the use of patient survey data in quality improvement.” Quality & Safety in Health Care. 2005 Dec;14(6):428-32.
[2] Kahn KL, et al. Methodological challenges associated with patient responses to follow-up longitudinal surveys regarding quality of care. Health Services Research. 2003 Dec;38(6 Pt 1):1579-98.
[3] Iedema R, et al. “Patients’ and family members’ views on how clinicians enact and how they should enact incident disclosure: the ‘100 patient stories’ qualitative study.” BMJ. 2011 July; 25 (343): 4423.
[4] ledema R, et al. "Patients' and family members' experiences of open disclosure following adverse events." Int. J. Qual Health Care. 2008. Dec; 20(6):421-32.
[5]Duclos CW, et al. “Patient perspectives of patient-provider communication after adverse events.” Int J Qual Health Care. 2005 Dec;17(6):479-86.
[6] Wilcock P, Brown GC, Bateson J, et al. “Using patient stories to inspire quality improvement within the NHS Modernization Agency collaborative programmes.” Journal of Clinical Nursing. 2003 May;12(3):422-30.
[7] Schlesinger M, et al. “Using Patient-Reported Information to Improve Clinical Practice.” Health Serv Res. 2015 Dec;50 Suppl 2:2116-54.
[8] Grob, R. “Breaking Narrative Ground: Innovative Methods for Rigorously Eliciting and Assessing Patient Narratives.” Health Serv Res. 2016 Jun;51 Suppl 2:1248-72.
[9] Puvanendran R, Vasanwala FF, Kamei RK, et al. “What do medical students learn when they follow patients from hospital to community? A longitudinal qualitative study.” Med Educ Online. 2012;17.
[10] Wheeler BK, Powelson S, Kim JH. “Interdisciplinary clinical education: implementing a gerontological home visiting program.” Nurse Educ. 2007 May-Jun;32(3):136-40.
[11] LoFaso VM, Breckman R, Capello CF, et al. “Combining the creative arts and the house call to teach medical students about chronic illness care.” J Am Geriatr Soc. 2010 Feb;58(2):346-51.
[12] Liang En W, Koh GC, Lim VK. “Caring for underserved patients through neighborhood health screening: outcomes of a longitudinal, interprofessional, student-run home visit program in Singapore.” Acad Med. 2011 Jul;86(7):829-39.
[13] Institute of Medicine (IOM). 2001. Crossing the Quality Chasm. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press.
[14] American Hospital Association. Quality Goals. 2015. Retrieved from http://www.aha.org/advocacy-issues/quality/background.shtml.
