Patient-centered care through internal and external participation in medical rehabilitation

Mirjam Körner

Department of Medical Psychology and Medical Sociology, University of Freiburg, Freiburg, Germany;.

DOI: 10.4236/health.2013.56A2008                

Abstract

Patient-centeredness is one of the most important quality and outcome criteria in health care. Health care organizations are continually searching for approaches that will enable them to establish sustainable patient-centeredness in their daily practice. Existing approaches frequently focus on interaction between patient and health care professional (external participation). However, this is often not sufficient; other elements, such as good teamwork among the health care professionals (internal participation), are also essential. The model of integrated patient-centeredness differentiates between these two participations forms, both of which are explored from a patient and health care professional perspective in our study. The aim of the study was to confirm the model from the viewpoint of staff and patients. To this end we conducted a multi-center cross-sectional study consisting of a patient and staff survey to assess internal and external participation and patient-centeredness. A total of 15 rehabilitation clinics were involved, with 272 staff members and 536 patients included in the final analysis. Although evaluation was positive (mainly slightly above the middle of the scale), there was potential for improvement for both types of participation. Internal and external rating differed between patients and health care staff, with the first group assessing internal significantly better and external lower than the second group. The low to middle correlation of both types, as well as the correlation and regression with patient-centeredness, confirmed the model of integrated patient-centeredness. The model underlines the importance of both participation forms for patient-centeredness, as well as their interdependence. Further studies are needed in order to verify the impact of internal and external participation, as well as that of further possible dimensions of patient-centeredness, on clinical and functional outcome criteria.

Keywords

Patient-Centeredness; Participation; Rehabilitation; Shared Decision-Making; Teamwork

1. INTRODUCTION

Patient-centeredness is one of the most important quality and outcome criteria in health care. There are different concepts of the dimensions of patient centeredness [1-7]. Some focus only on the patient and physician and their interaction [5-7], while other broader concepts take into account structural and organizational aspects such as access to care, coordination and continuity, information technology, interprofessional teamwork etc. [2,4,8,9].

The model of integrated patient-centeredness [8] differentiates between internal and external patient-centeredness in order to consider patient-health care professional interaction as well as organizational aspects. External patient-centeredness can thereby be described as a patient relationship focused on patient needs and preferences and with the primary aim of enabling patient expectations. In contrast, internal patient-centeredness refers to in-house conditions, e.g. interprofessional teamwork or clinic culture, that enable delivery of a continuous strategy aimed at the expectations of patients (external clients) [9]. The key feature of both forms is participation (see Figure 1).

External participation is defined as patient participation in decision-making, e.g. treatment planning, goal setting in the patient-professional encounter. The “shared decision-making (SDM)” approach is promoted as the ideal interaction model for implementing external par-

Figure 1. Model of integrated patient-centeredness [8,9].

ticipation in patient-professional interaction [10-12]. Shared decision-making can be defined as sharing medical and personal information in a reciprocal communication flow, discussing of wishes, options and preferences, and a mutual deliberation and decision-making process with the patient [13-16]. Expected effects of SDM are, for example, higher compliance, treatment acceptance and patient satisfaction, improved functional status, higher quality of life and improvement in medication adherence, as well as a reduction of decision conflicts, anxiety and medication costs [17-24]. Most patients who have to make a healthcare decision prefer SDM [25,26].

Internal participation can be defined as patient-centered interprofessional teamwork within the clinic. It focuses on communication, coordination, cooperation, respect and climate within the interprofessional team in the patient treatment planning and process. Medical rehabilitation in Germany mostly takes place as in-patient measures in special rehabilitation clinics. This treatment is based on a holistic approach and requires different health care professionals working together in a team. The teamwork process brings these different professions, assessments and evaluations together to obtain a holistic view of the patients’ problems. Teamwork is therefore a key feature of the work in medical rehabilitation and a precondition for effective patient treatment [27-30]. Effective teamwork is accompanied by enhancement of treatment outcomes [31-33], reduction of morbidity [34], increase in patient [31,32] and employee [35] satisfaction and reduction of costs [32,33].

The model of integrated patient-centeredness is the first to combine both participation forms as the main dimensions. The aim of the study was to confirm this model by assessing staff and patient perception of internal and external participation, interdependence of these two elements, and whether there is an association with patient-centeredness.

2. METHODS

The study formed a part of the larger research project “Development and evaluation of a shared decisionmaking training program in medical rehabilitation”, funded as part of the German grant program “Chronic illness and patient orientation”, and was supported by the German Federal Ministry of Research and Education and the German Statutory Pension Insurance Scheme. The study was approved by the Ethics Committee of the University of Freiburg in Germany.

Twenty-two in-patient medical rehabilitation clinics in southwest Germany originally expressed interest in the study; of these, fifteen took part in the patient and staff survey. Each clinic determined a contact person (mostly senior physician or psychologist) responsible for the study process: all surveys were then sent to this contact person, who distributed them to the patients and health care professionals in the treatment team.

Inclusion criteria for patients were: chronic disease(s), treatment in inpatient rehabilitation, age > 18 years, sufficient German language abilities, no cognitive impairments and signed informed consent.

Physicians, nursing staff, therapists of the psychosocial department (such as psychotherapists, social workers, art, occupational and music therapists), and therapists of the physiological department (such as physiotherapists, masseurs, sport, exercise and nutrition therapists, dieticians) constitute the medical rehabilitation teams and were included in the staff survey.

All surveys were anonymous and participation was optional for patients as well as for staff members. After completing the survey the patients put it and the signed letter of consent in the envelope provided and returned it to the study coordinator, who collected the envelopes and sent them back to us. The staff sent the questionnaire direct to our research team in a pre-paid addressed envelope.

2.1. Instruments

The questionnaire pack for the patients and for the staff contained standardized questionnaires. Table 1 provides an overview of assessment required for this study.

The 9-item Shared Decision-Making Questionnaire (SDM-Q-9) [36] is a standardized brief patient-report instrument for assessing shared decision-making. It is psychometrically tested and can be used for the measurement of external participation from the patient’s perspective. The questionnaire contains nine five-step items, relating to the nine steps of the SDM model [36]. The authors of the instruments recommend compiling a standardized total value over the nine items, which is calculated by multiplying the mean of all items by 20/9, giving a range of 0 (no participation) to 100 (maximal par-

Table 1. Assessment of internal and external participation as well as patient-centeredness.

ticipation) [36]. The total score should not be calculated if two or more items are missing. We used a slightly modified version, replacing “physician” in the nine questions with “health care professional” and not asking for a specific decision-making situation, and therefore captured involvement in decision-making in a more general manner. The psychometrical criteria in our study were checked and were comparable with those in the original version.

The 9-item Shared Decision-Making Questionnaire doctor version (SDM-Q-9 doc) [37] was also modified to assess external participation, or rather the implementation of SDM from the health care professional perspective. Calculation of the standardized total value is identical to the SDM-Q-9 (see above). Psychometric properties of the adapted instrument were tested with the sample and were also comparable with the original SDM-Q9 doc [37].

The Internal Participation Scale (IPS) [38] was developed in this study in order to measure interprofessional patient-centered participation from a patient and staff perspective. The scale can be used for both groups, and consists of six items on climate, communication, coordination of treatment, coordination of professionals, cooperation and respect. The item scales have four steps and range from 1 (does not apply at all) to 4 (fully applies). The raw scores were also transformed to a standardized value range from 0 (minimal participation) to 100 (maximal participation) in order to compare internal and external participation. The main psychometric criteria were tested and are acceptable to excellent [38].

The global item of patient-centeredness (“In my point of view the clinic is patient-centered”) is assessed on a five-point Likert scale (1 = fully applies, 2 = generally applies, 3 = undecided, 4 = does not generally apply, 5 = does not apply at all), or the professionals can also tick “I can’t judge this”.

In the patient survey, “patient satisfaction” was used as a surrogate parameter to measure patient-centeredness, applying the established and validated “Questionnaire on Patient Satisfaction” [39,40]. This instrument is a selfrating instrument for inpatient settings designed on the basis of the American “Client Satisfaction Questionnaire CSQ-8” [41]. Based on eight 4-point Likert-scaled items (e.g., “Did you receive the type of treatment that you wished?”), the questionnaire assessed general patient satisfaction [41]. High scale values mark high patient satisfaction.

2.2. Data Analysis

Prior to data entry, quality was tested by verification of random samples, the items were further checked for plausibility, and missing data analysis was performed. Questionnaires with more than 30% of items unanswered (missing data) were excluded.

The survey data were evaluated with the IBM Statistical Package for Social Science (SPSS Version 21). Descriptive statistics, t-Test for paired samples (comparing internal and external participation within the staff or patient survey) and univariate analysis of variance with the factor “group” (patient or staff) and dependent variable “participation” (internal or external) were used for data analysis. Bivariate correlation coefficient between internal and external participation and patient-centeredness were calculated to judge interdependence and association with patient-centeredness in general. Additionally, a linear regression analysis checked the impact of internal and external participation on patient-centeredness.

3. RESULTS

3.1. Samples

A total of N = 1419 questionnaires were distributed to patients, with N = 662 completed and returned (response rate = 46.6%). After missing data analysis, a total of 536 complete data sets were included. Table 2 provides a description of the patient sample.

The average age of the patient sample was 52.7 years (range 18 - 90, SD = 13.7), with more men (62.3%) than women (36.9%) participating, and mostly Germans (93%). While 43.5% registered a low educational level, 33% had reached a medium and 19.8% a high level. Almost half of the patients were employed, 24.6% were retired and 17.2% were unemployed. Nearly two thirds of the patients were treated in somatic rehabilitation clinics (64.6%) and slightly more than one third in psychosomatic rehabilitation clinics (34%).

Of 661 questionnaires allotted to health care professionals in the rehabilitation teams, 275 came back (rate of return: 41.6%). Three questionnaires were excluded as a result of missing data analysis (more than 30% in the whole questionnaire), giving a total of 272 staff surveys for the analysis.

Table 3 displays the sample characteristics of the staff survey. In contrast to the patient sample, more females (60.3%) than males (34.6%) participated here. About two

Conflicts of Interest

The authors declare no conflicts of interest.

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