efrat shadmi, phd the cheryl spencer department of nursing

Efrat Shadmi, PhDThe Cheryl Spencer Department of NursingFaculty of Social Welfare and Health SciencesHaifa UniversityMount Carmel 31905, IsraelPhone: (972) 48288012Email: eshadmi@univ.haifa.ac.il

ONCOLOGY PATIENTS' EXPERIENCE AT THE INTERFACE

BETWEEN HOSPITAL AND COMMUNITY CARE: A MIXED

METHOD INVESTIGATION

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

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)

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

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

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”

Methods - Qualitative

Focus groups: Patients, Staff Nurses, Head Nurses, Nurse Coordinators, Social Workers, Medical Administrators

Semi-structured interviews: Physicians, Regional health plan managers

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

Results: Focus Groups and Interviews

Themes:

(1) Responsibility for care

(2) Administrative and bureaucratic burden

(3) Informal routes of communication

(4) Cultural barriers

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)

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)

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)

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)

Results: SurveyPatient Characteristics

Total

422

Hebrew

207

Russian 94

Arabic 121

Age 58.961.163.152.0

Gender: Female54%55%54%55%

SF-12: Physical Health

34.736.232.034.1

SF-12: Mental Health

36.637.140.133.3

Low Education20%9%2%53%

Low Economic24%20%22%32%

Patients’ Relationship with their Primary Care Physician (PCP)

TotalHebrewRussianArabic

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%

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

Primary Care Physician Discussed Hospital Discharge Summary with the

Patient

72

91 92

40

50

60

70

80

90

100

Perc

ent

Hebrew

Russian

Arabic

* *

* P value from Chi2 test ≤ 0.001

Patients' Assessment of Primary Care

20

30

40

50

60

70

80

90

100

Access Knowledge Integration Communication Interpersonal Trust

Mea

n S

cale

Sco

re

Hebrew Russian Arabic

PCAS Scales

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

AccessKnowledgeIntegrationCommunicationInterpersonalTrust

Age0.040.24**0.080.100.030.15

Gender (female)1.00-1.93-1.60-1.560.350.51

Russian-5.00*-7.81**-9.60**-13.14†-15.78†-5.92*

Arabic14.88†14.75†8.82**6.83*7.75*7.05**

SF-12: Physical Health

0.140.05-0.01-0.03-0.020.18*

SF-12: Mental Health0.100.130.130.160.150.16*

Educ: High-School 1.045.051.180.380.504.63

Educ: Diploma2.315.781.333.451.995.59

Educ: ≥ BA2.412.491.55-1.370.840.64

Econ level: Average3.732.280.893.502.872.29

Econ level: ≥ Good-0.25-0.110.74-0.161.782.08

Sick fund: Maccabi2.614.062.734.176.06*5.00*

Sick fund: Other3.577.64*6.89*4.309.20**7.55**

Patient Assessment of Transition from Hospital

72.975

80.9

50

60

70

80

90

100

Mea

n CT

M S

cale

Sco

re

Hebrew

Russian

Arabic

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. errorP value

Age0.020.090.865

Gender (female)2.992.130.161

Russian-1.362.890.638

Arabic6.493.100.037

SF-12: Physical Health0.040.100.698

SF-12: Mental Health0.270.080.001

Education: High School -2.573.370.445

Education: Diploma2.353.850.542

Education: BA-1.893.780.618

Discharge unit -Medical-1.213.180.704

Discharge unit - Surgical2.912.340.214

Discharge unit - Other-1.774.710.707

PCP discussed discharge letter with patient8.112.620.002

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

Discussion (cont.)

Limitations: Generalizability Cross-sectional study

Next steps: Understanding cultural barriers The role of caregiver support

Thank you!

شكرا

Спасибо

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