GPs' approaches to documenting stigmatising information: a qualitative study.

BACKGROUND: Complete medical documentation is essential for continuity of care, but the competing need to protect patient confidentiality presents an ethical dilemma. This is particularly poignant for GPs because of their central role in facilitating continuity. AIM: To examine how GPs manage medical documentation of stigmatising mental health (MH) and non-MH information. DESIGN AND SETTING: A qualitative sub-study of a factorial experiment with GPs practising in Massachusetts, US. METHOD: Semi-structured interviews (n = 128) were audiorecorded and transcribed verbatim. Transcripts were coded and analysed for themes. RESULTS: GPs expressed difficulties with and inconsistent strategies for documenting stigmatising information. Without being asked directly about stigmatising information, 44 GPs (34%) expressed difficulties documenting it: whether to include clinically relevant but sensitive information, how to word it, and explaining to patients the importance of including it. Additionally, 75 GPs (59%) discussed strategies for managing documentation of stigmatising information. GPs reported four strategies that varied by type of information: to exclude stigmatising information to respect patient confidentiality (MH: 26%, non-MH: 43%); to include but restrict access to information (MH: 13%, non-MH: 25%); to include but neutralise information to minimise potential stigma (MH: 26%, non-MH: 29%); and to include stigmatising information given the potential impact on care (MH: 68%, non-MH: 32%). CONCLUSION: Lack of consistency undermines the potential of medical documentation to efficiently facilitate continuous, coordinated health care because providers cannot be certain how to interpret what is or is not in the chart. A proactive consensus process within the field of primary care would provide much needed guidance for GPs and, ultimately, could enhance quality of care.

Care transitions from the hospital to home for patients with mobility impairments: patient and family caregiver experiences.

PURPOSE: Our study described patient and caregiver experiences with care transitions following hospital discharge to home for patients with mobility impairments receiving physical and occupational therapy. METHODS: The study was a qualitative longitudinal interview study. Interviews were conducted at 2 weeks, 1 month, and 2 months post discharge. Participants were men, Caucasian, between 70 and 88 years old, and had either a medical or surgical diagnosis. RESULTS: Breakdowns in communication in four domains impacted continuity of care and patient recovery: (a) Poor communication between patients and providers regarding ongoing care at home, (b) Whom to contact post discharge, (c) Provider response to phone calls following discharge, and (d) Provider-provider communication. DISCUSSION AND CONCLUSIONS: Improved systems are needed to address patient concerns after discharge from the hospital, specifically for patients with mobility impairments. Better communication between patients, hospital providers, and home care providers is needed to improve care coordination, facilitate recovery at home, and prevent potential adverse outcomes.

Implementation challenges and functional outcome predictors for elder community-based disability prevention programs.

BACKGROUND AND PURPOSE: Strategies to foster elder well-being and reduce long-term care costs include efficacious community disability prevention programs. However, it is often difficult to replicate clinical trials into real-world practice settings. We (a) compared replication and clinical trial functional changes, (b) compared replication and clinical trial program structures and processes of care, and, additionally, (c) examined how replication client and site features are associated with function. METHODS: We used secondary longitudinal data on 719 elder clients, and primary data through interviews with nurses, social workers, and site managers for the replication, and compared this to original trial data. We analyzed associations between baseline self-efficacy and functional outcomes and between site features and functional outcomes using multivariate and logistic models for the replication. RESULTS: Replication functional outcome changes were lower and structures and processes were less intense than in the original clinical trial. Baseline client higher self-efficacy positively influenced 12-month function, and smaller sites and urban sites had better functional outcomes than larger sites and rural sites for the replication. DISCUSSION AND CONCLUSION: Exploring systemic strategies for using available resources to improve research translation is essential. In addition, practitioners need to focus on client self-efficacy enhancement techniques, which may be more important in replication studies to improve function.

Association between mental health conditions and rehospitalization, mortality, and functional outcomes in patients with stroke following inpatient rehabilitation.

BACKGROUND: Limited evidence exists regarding the association of pre-existing mental health conditions in patients with stroke and stroke outcomes such as rehospitalization, mortality, and function. We examined the association between mental health conditions and rehospitalization, mortality, and functional outcomes in patients with stroke following inpatient rehabilitation. METHODS: Our observational study used the 2001 VA Integrated Stroke Outcomes database of 2162 patients with stroke who underwent rehabilitation at a Veterans Affairs Medical Center. Separate models were fit to our outcome measures that included 6-month rehospitalization or death, 6-month mortality post-discharge, and functional outcomes post inpatient rehabilitation as a function of number and type of mental health conditions. The models controlled for patient socio-demographics, length of stay, functional status, and rehabilitation setting. RESULTS: Patients had an average age of 68 years. Patients with stroke and two or more mental health conditions were more likely to be readmitted or die compared to patients with no conditions (OR: 1.44, p = 0.04). Depression and anxiety were associated with a greater likelihood of rehospitalization or death (OR: 1.33, p = 0.04; OR:1.47, p = 0.03). Patients with anxiety were more likely to die at six months (OR: 2.49, p = 0.001). CONCLUSIONS: Patients with stroke with pre-existing mental health conditions may need additional psychotherapy interventions, which may potentially improve stroke outcomes post-hospitalization.

Lay health mentors in community-based older adult disability prevention programs: provider perspectives.

In this study, we explored provider perspectives on the benefits of and implementation challenges in using lay health mentor peers in a community-based replication of an efficacious 12-month older adult disability prevention program. In addition, we describe the association of the mentor program with site features and program completion. We conducted semi-structured telephone interviews with nurses, social workers, and site managers and obtained primary data on site features and secondary data on program completion. Major themes included the importance of the health mentor program and implementation challenges. Sites with mentor programs were more likely to have older adults complete the program compared with sites without mentor programs. Rural, small, and less diverse sites were more likely to have health mentor programs than urban, large, and more diverse sites. Implications include a need to fund more lay health mentor programs, obtain adequate staffing including minority staff for health mentor support, and implement strategies to improve program efficiency.

Community-based disability prevention programs for elders: predictors of program completion.

Strategies to foster elder well-being and reduce long-term care costs include efficacious community disability prevention programs. Program completion remains an important barrier to their effectiveness. We examined the association between provider relationships and client variables, and program completion in senior centers. Our mixed methods design used secondary data for 719 clients and primary data through telephone interviews with 20 nurses, 23 social workers, and 18 site managers. Quantitative data showed that higher client baseline self-efficacy positively influenced completion and minority status negatively influenced completion. Qualitative data showed that higher focus on provider-client relationships was associated with high completion.

Nursing assistants' job commitment: effect of nursing home organizational factors and impact on resident well-being.

PURPOSE: The purpose of this study was to investigate (a) whether certified nursing assistants (CNAs) are more committed to nursing home jobs when they perceive their jobs as enhanced (greater autonomy, use of knowledge, teamwork), and (b) whether CNA job commitment affects resident satisfaction. DESIGN AND METHODS: A qualitative exploration of management philosophy and practice and of CNAs' views of their jobs in 18 Massachusetts nursing homes formed the basis for a survey administered to 255 CNAs in 15 homes. A quality-of-life questionnaire was administered to 105 residents. Logistic regression accounting for clustering estimated the effect of personal characteristics, satisfaction with tangible job rewards, and aspects of job design on CNAs' intent to stay in current jobs. A general linear model estimated the effect of job commitment on residents' satisfaction with their relationship to nursing staff. RESULTS: After we accounted for satisfaction with wages, benefits, and advancement opportunities, good basic supervision was most important in affecting CNAs' intent to stay in their jobs. Job enhancements were not significantly related to intent to stay. Residents were more satisfied with their relationships to nursing staff and their quality of life on units where a higher proportion of CNAs were committed to their jobs. IMPLICATIONS: The finding that greater job commitment of CNAs is associated with better quality of relationships and life for residents implies that better jobs lead to better care. Culture change transformation that increases CNA autonomy, knowledge input, and teamwork may not increase workers' commitment to jobs without improvements in basic supervision.