PATIENT CENTERED CARE FOR GERIATRIC PATIENTS: INFORMATION EXPERT PROVIDERS USE TO MAKE PATIENT CENTERED CARE DECISIONS

Purpose: Patient Centered Care (PCC) is a central value in medicine, on par with safety, effectiveness, and equity.  Central components of PCC are thought to be recognizing the patient as a whole person, developing a partnership between the clinician and patient, fostering a climate of shared decision making, and promoting positive clinical experiences.  The PCC process may be more difficult with patients who are less activated and more fragile.  Our aim was to understand the decisions expert providers make and information needs providers have when they deliver PCC to geriatric patients.

Method: We conducted a cognitive work analysis with 10 expert providers working in Veteran’s Affairs primary care clinics.  A modified version of Rasmussen’s decision ladder approach was used to map the cognitive work of decision making involved in providing PCC to geriatric patients. This model of eliciting mental models was used because it focuses on information needs in relationship to goals. The interview included questions about typical or prototypical work situations in primary care as well as questions about a specific patient for whom the provider thought a PCC approach was important.  Transcripts were de-identified and analyzed by investigators using ATLAS.TI.  An iterative approach to analysis was used to identify provider decision processes and strategies regarding PCC.

Results:  Providers did not generally differentiate PCC from any other patient care. When prompted with questions addressing PCC domains (patient as a whole person, partnership, fostering shared decision making) providers indicated that a decision to engage more deeply in PCC processes was made when there were indications that a patient (1) had low health literacy, (2) had poor adherence, (3) had experienced a change in functional status, (4) there were discrepant reports from the patient and other information sources (such as from patient family members), and (5) was not adequately supported by their social network for independent living.

Conclusion: A basic definition of PCC is not apparent from these expert provider interviews,  suggesting that PCC is not particularly well integrated into practice.  Providers need access to information about patient attributes, status changes, and social context to support their practice of PCC suggesting implications for information displays that can foster PCC for geriatric patients.