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Keywords:

  • adults;
  • community health;
  • focus groups;
  • rural/remote

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Aims:  To investigate community health patients' impressions of care planning and their relationship with allied health professionals in a rural town in Western Australia.

Methods:  Focus groups were conducted followed by a survey to identify patients' opinions on care planning and their relationships with health professionals.

Results:  Focus groups and a survey identified that patients generally had positive attitudes towards their experiences with community-based allied health professionals. Participants identified some of the attributes that they valued in allied health professionals. Many participants (39%) believed that they had a partnership with the health professional and also valued having a shared decision-making power with the health professional (46%); however, 17% identified that they would prefer the health professional to assume more of the decision-making power.

Conclusions:  More work is needed to create a health culture in which patients want to manage their own health and can develop a relationship with their health professional that allows them to achieve this.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Chronic diseases account for 80% of the burden of disease in Australia. At least one-third of this burden can be attributed to modifiable lifestyle factors such as poor diet, smoking and lack of exercise.1 Enabling people to make lifestyle changes needs to be at the centre of health-care delivery in Australia. When a patient and health professional form a successful partnership they can identify goals that are tailored to the patient's individual needs. This ideology underpins the National Chronic Disease Strategy 2006.1 One of the key principles of the strategy is to achieve person-centred care and optimise self-management. The key action areas of the strategy include patient self-management. Possible advantages of a self-management model of care include: increased patient satisfaction through having ‘ownership’ over their health care, decreased pressure on health resources and improved health outcomes due to increased patient commitment to goals.2

In recognition of the need to modify the health-care environment, Australia's governments commenced trials of coordinated care in 19973 and the Enhanced Primary Care (EPC) package was introduced in 1999. EPC is an Australian Federal Government program that encourages general practitioners (GPs) to generate multidisciplinary care plans for patients with chronic diseases and to refer patients to allied health professionals.4–6

Care planning was introduced into one of the regions of the Western Australian Country Health Service-South West (WACHS-SW) in late 2007 as a quality improvement activity. It also meets the EQuIP4 (2006) accreditation standard 1.1.2; care is planned and delivered in partnership with the consumer/patient to achieve the best possible outcomes.7 Previously there was no standard and easily identifiable approach to care planning within the region. To address this, representatives from each community health team within the region formed a project group which developed the format of a care plan. Each care plan was to have the agreement of the patient, to specify timelines, resources and responsibilities, and to list goals/problems and strategies to achieve the goals. Allied health practitioners were encouraged to use a patient-centred approach towards goal setting.

Wagner et al.,8 in their discussion of factors that improve chronic illness care, highlighted the need to improve relevant skills of team members through the use of training methods. Practitioners working within the study region of WACHS-SW have been supported to attend training in chronic disease self-management programs. These have included the ‘Lorig Model’, developed at Stanford University,9 which delivers group education to patients, and the ‘Flinders Model’3 that trains health professionals to work individually with patients to develop health goals. Neither of these models were appropriate to use in our community health centre—the Lorig model was designed for group education and not for use with individuals. Furthermore, the model requires that a health consumer be part of the team and there was no one available to take this role. The Flinders process is lengthy which makes it impractical to use for all patients attending the community health centre. The Family Partnerships Training Program is a UK program that has been adapted for the Australian setting and provides health professionals with supervised training in developing effective therapeutic partnerships with their patients. This training program was piloted in the study region in 200910 and was attended by around half of the practitioners working within this region.

While there is an extensive literature on chronic care management, there are limited publications that have addressed the patients' views, and some of these have been disease specific.11 We were keen to gain an insight into patients' views on the changes to provision of health care in our community health centre and thus the purpose of the current study was to evaluate the care plan from the perspective of patients and also to explore patients' views on their relationship with their health professional.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Study participants were recruited from a database of patients who had care plans. Allied health professionals in the study region were instructed to create a care plan for all of their patients. An audit showed that there was poor compliance with the use of care plans as only 40% of patients had one. This limited the number of patients who could be recruited for the study.

This project was conducted in two stages: focus groups (September and October 2008) and a survey (November and December 2008). Focus groups were held as the first part of the study in order to canvass the range of opinions held by patients and to ensure that the survey incorporated the concepts that were identified by the focus group participants as being significant. Although both children and adults receive services at the community health centre, only adults were included in this study. The study received ethics approval from the Curtin University Human Research Ethics Committee. The study was also approved by the Director of the region's Population Health Unit. All study participants gave informed consent to participate in the study.

Forty-five subjects were randomly selected and six of these chose not to participate. Three people could not be contacted. Six people who agreed to attend did not. A total of 29 people participated in focus groups (participation rate of 64%). Of the people who participated in the focus groups, 66% were women. Four focus groups were held and one individual was interviewed separately.

Focus groups were recorded using a digital voice recorder and were transcribed. EH categorised the data into general themes. EH identified the themes that arose most often and those themes that generated conflicting responses from participants.

A survey was generated based on the major themes that emerged during the focus groups. The survey aimed to look at patients' satisfaction with their health goals, health professionals and the power balance in their relationship with the health professional. The draft survey was distributed to assess applicability and legibility to 12 health allied health professionals and to four patients of community health. These patients were each in a different age bracket and consisted of two women and two men. The final survey was distributed in person or posted to all 80 adult patients who had attended appointments at the community health centre between October and December 2008. They were provided with a stamped, addressed envelope to return the survey. A box was also placed at community health for survey returns.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

The participants were asked about their general attitudes towards the care plan, goal setting, making health decisions and their relationship with their health professional. These questions were based on the National Service Framework for Long-Term Conditions Quality Requirements12 and CanChild's Family-Centred Service Checklist for Families.13

The major themes that were discussed in the focus groups were the attributes that participants valued in health professionals, the value of having choices in health care and whether the participants were achieving their health goals.

During the focus groups, participants were keen to talk about the negative experiences they had with health professionals. Many of the negative experiences had happened years before and involved GPs, specialists and private practising health professionals. The negative experiences involved health professionals making insulting personal remarks, being kept waiting by health professionals, not being listened to, and health professionals taking personal phone calls during consults. In all of these cases, the participants described feeling unimportant and belittled by the health professional:

“He (the health professional) was an arrogant so and so. It was like he was more interested in how much he was earning and didn't care how much pain I was in.”

The participants expressed positive experiences with health professionals. Participants described their best interactions with health professionals who showed that they understood what they were going through:

“It was like the [heath professional] knew how difficult it was to have to say ‘no’ to certain foods. It was like she had been through that.”

“We like [the health professional] because he cares about older people. He is older so he understands how to look after older people.”

The participants also agreed that they are more likely to follow the advice given by a health professional that they liked and felt comfortable with.

“If you clash with your health professional. If you don't agree you won't do what you are being told.”

The focus group participants described some of the attributes they valued in health professionals. These are listed in Table 3.

One of the contentious topics that came up in focus groups was how many choices participants wanted in their health care. Some participants described wanting choice about which health professional they could see. If they had a negative experience with a health professional they would not go back to her/him. However, once they trusted a health professional they said they were happy to follow her/his advice and wanted the health professional to make the choices.

Participants agreed that receiving information and education from the health professional was valuable. However, they differed in their views about how prescriptive they wanted that education to be:

“I would have liked a diet that I could follow exactly. It would have been easier . . . especially when I am busy.”

“You've got to do what you are told [by the health professional] or you suffer the consequences.”

Other participants valued being able to make their own health choices:

“The [health professional] doesn't live with me so I am going to have to work out what I do for myself when I get home.”

I think you both have to work together. You know how you feel, you know what you've done.

Discussion regarding whether people had achieved health-care goals showed that some people had been successful in achieving their goals and others had not. Those who had not achieved their goals generally attributed this to the fact that the solution to the problem was beyond the scope of the health professional (i.e. chronic pain that could not be solved through physiotherapy). Some others felt that they had some success but not as much as they would have liked. Of the people who had succeeded, some attributed it to following the advice of the health professional:

“I knew I wanted to get the results so I followed the instructions. I wouldn't have lost the weight if I hadn't.”

Others described that their success related to the fact that they had made the choice to make changes:

“I got a general idea from the dietitian's plan but I wanted to do my own with healthy food that I like. I have done the hard work.”

“Fifty-six completed surveys were received (response rate of 70%). The survey had more responders from the younger age groups in comparison to the general population of community health patients (see Table 1). Seventy percent of survey participants indicated that their condition was long term or chronic (likely to last more than 6 months). Fourteen per cent of participants indicated that their health condition was short-term and 16% indicated that they were not sure.”

Table 1.  Participant demographics
AgeSelected for focus groupParticipated in focus groupParticipated in surveyTotal patients community health Oct 2008
18–293 (7%)2 (7%)7 (12%)25 (9%)
30–394 (9%)3 (10%)11 (20%)21 (7%)
40–499 (20%)5 (17%)6 (11%)27 (9%)
50–5912 (27%)8 (28%)10 (18%)45 (15%)
60–698 (18%)5 (17%)12 (22%)57 (20%)
70–795 (11%)4 (14%)7 (12%)66 (23%)
80–892 (4%)2 (7%)3 (5%)40 (14%)
90+2 (4%)0 (0%)0 (0%)9 (3%)
Total452956290
Number with chronic diseaseData not available26 (90%)39 (70%) 

The participants were asked to use a Likert scale (1–10) to indicate their perception of the power balance in the relationship. The range of the scale is outlined below.

  • • 
    1: the health professional is in charge: he/she sets health goals for you and organises the management of your health
  • • 
    5: there is a partnership between you and the health professional: you share information and negotiate health goals and the management plan for your health
  • • 
    10: you are totally in charge: you tell the health professional what you want done. You choose all your own health goals and how to manage your health.

Participants had the option of marking the scale between these descriptions. The participants were also asked to use the same scale to describe what they perceived was the ideal power balance between the health professional and the patient. The responses to these questions are summarised in Table 2.

Table 2.  Current relationship with the health professional compared with the participant's ideal relationship with the health professional
Response on Likert scaleNumber of participants (current relationship)Number of participants (ideal relationship)
 1 (Health professional is in charge)1 (2%)3 (5%)
 23 (5%)3 (5%)
 36 (11%)7 (13%)
 45 (9%)2 (4%)
 5 (Partnership between patient and health professional)22 (39%)26 (47%)
 64 (7%)6 (11%)
 75 (9%)3 (5%)
 85 (9%)0
 93 (5%)3 (5%)
10 (Patient is in charge)2 (4%)3 (5%)
Total5656

The median response for the current and the ideal relationships was 5. Thirty-nine per cent of the participants rated their current relationship with the health professional as a partnership and 46% indicated that a partnership was the ideal relationship. Forty-eight per cent of participants gave the same rating on the scale for their current and ideal power balance with the health professional, indicating that they were happy with the current power balance in the relationship. Thirty per cent of the participants gave a lower rating to their ideal power balance than their current power balance, indicating that they would like less power in the relationship with their health professional.

Participants were asked to identify the three most important attributes in a health professional. Four participants (7%) left this blank and 17 participants (30%) ranked all of the attributes equally. Thirty-five participants (63%) answered as instructed. Their responses are reported in Table 3. The majority (71%) indicated that health professionals providing accurate information was one of their top three attributes. Health professionals having good listening skills was the next highest rated attribute with 63% of participants rating it in their top three.

Table 3.  Survey participants rating of health professional attributes
AttributePercentage of participants that ranked this in the ‘top 3’ attributes (%)
Providing accurate information71
Good listening skills63
Having enough time for the patient57
Seeing the patient as an individual37
Having a non-judgemental attitude34
Speaking in normal English (not medical jargon)29
Good non-verbal communication6
Building up trust over many years3

In the survey, participants were asked to indicate whether they were happy with their health professional using a Likert scale. Sixty-three per cent of participants indicated that they were very happy with their health professional, 30% indicated that they were fairly happy, 4% indicated that they were neither happy nor unhappy and 4% indicated that they were very unhappy with the health professional.

Ninety-four per cent of participants indicated that they had specific health goals to work on after they had seen the health professional. Participants were asked to rank their confidence in achieving their goals on a Likert scale of 1–10 (median = 7.9). According to the Stanford Chronic Disease Self-Management Program,14 a goal is appropriate if people rank their confidence in achieving it above 7. Of the survey participants who remembered they had goals (n = 53), 83% ranked their confidence in achieving them at 7 or above. However, there was a weak correlation between the participants' overall happiness with their health professional and their confidence in achieving their health goals.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References

Our community health centre within WACHS began using care planning to promote a self-management model of patient care in 2008. The present study aimed to investigate patients' perceptions of their health professionals and of the care planning process, in particular whether patients believe they have the power to make decisions about their health and whether they want this power. Previous studies evaluating care planning in a community setting have primarily looked at ways in which the uptake of care planning can be increased by health professionals4,15 or have evaluated the care plans that are part of chronic disease self-management programs.3,9 The patients' views of the care plan have not been evaluated in the study region until now.

Focus groups were used to generate patient discussion about health professionals and care planning. The focus groups discussed a number of attributes that were valued in the health professional. The survey was used to identify which of these are most important to patients. Several of the participants gave an equal rating to all attributes. This may be because the survey instructions were misunderstood or that participants valued all attributes and did not wish to choose the ‘top three’. Health professionals can enhance their relationship with patients by being aware of all of the attributes listed in Table 3. Patients particularly valued accurate information, good listening skills and time spent by health professionals. Focus groups indicated strongly that participants believed that they were more likely to achieve health goals when they liked their health professionals. In contrast, the survey showed that there was only a very weak correlation between overall happiness with the health professional and confidence in achieving health goals. However, the study did not investigate whether the patients actually did achieve these goals. The attributes highlighted in this study have been noted previously. O'Hair,16 reporting on the literature at that time, noted that consumers prefer providers who demonstrate involvement. Haidet et al., in their analysis of patients' illness narratives,17 alluded to a lost opportunity by physicians who do not recognise that they are embedded in their patients' narratives. Again this suggests that a level of health professional engagement is needed by patients.

The discussion regarding the power balance in the health relationship in focus groups revealed that there were diverse opinions regarding the ‘ideal’ power balance. While many (46%) valued having a partnership with the health professional, there are still patients who want the health professional to make the decisions for them (5%). The fact that 17% of patients indicated that they want less control of the health decision-making process than they currently have does raise the question of whether it is appropriate to be encouraging patients to take control of their health care. In a critique of self-management programs, Newbould et al.18 identify that participants in self-management programs are self-selected. They tend to be educated and self-motivated. They conclude that not all people with chronic diseases will respond to self-management strategies. Greenhalgh19 also agrees that the self-management approach is not applicable to all people.

With this in mind, should health professional be identifying those patients who do not want to have the power in the health relationship and adopt a different approach in the delivery of health care to them? Do we continue to encourage patients to take more control of their health care? It is possible that as patients become more accustomed to working in a partnership model they may become more accepting of it. It is likely that each patient's personal narrative would have an impact on the level of control they considered desirable, for example, a Dutch study (Schoot et al.20) reported the theme of participants regarding themselves in an equal position to the nurses and nurses' aids involved in their tailored care. The patients in this study had a chronic illness or disability and viewed experience-based knowledge as a component of their equality.

The circumstances of this study may have influenced the outcomes. The groups were facilitated by one of the community health professionals. Participants may have felt uncomfortable making criticisms of the health service in front of their health professional. Another factor affecting study validity was that the study population was younger than the general population of the study region's community health patients. It is likely that older people will have different attitudes towards their relationship with their health professional. One of the reasons for this is that study participants were selected from the population of patients who had care plans. Medical record audits show that the physiotherapy and dietetic departments had a better compliance with the use of the care plan than other allied health professions. The group of patients seeing the dietitian and the physiotherapists may have been demographically different from the general community health patient population. In addition, several older people (above 85 years) declined to participate.

This study explored a range of patient views regarding care planning and their expectations of health professionals. Future studies could measure the participants' self-management ability using a tool such as the Client Health Questionnaire.4 Future evaluation of this model of care planning could investigate whether the way the care plan is delivered has an influence on the patients' satisfaction with the health care they receive. The care plan could be developed to enable patients to identify the power balance they desire to have with their health professional. Investigating whether patients' views on care planning change as they become more accustomed to care planning would also be valuable.

Health professionals who are using care planning in our community health centre are providing a service that is valued by their patients. Most patients also believe that their health professionals are working in partnership with them, sharing decision-making power in setting health goals. However, not all patients see a shared power balance as desirable. More work is needed to create a health culture in which patients want to manage their own health and can develop a relationship with their health professional that allows them to achieve this.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  • 1
    National Health Priority Action Council (NHPAC). National Chronic Disease Strategy. Canberra: Department of Health and Ageing, 2006.
  • 2
    Hook M. Partnering with patients—a concept ready for action. J Adv Nurs 2006; 56: 13343.
  • 3
    Battersby M, Harvey P, Mills AP et al. SA plus: a controlled trial of a statewide application of a generic model of chronic illness care. Millbank Q 2007; 85: 3767.
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    Newland J, Zwar N. General practice and the management of chronic conditions: where to now? Aust Fam Physician 2006; 35: 1619.
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    Francis C, Feyer A, Smith B. Implementing chronic disease self-management in community settings: lessons from Australian demonstration projects. Aust Health Rev 2007; 31: 499509.
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    Martin C, Peterson C. Improving chronic illness care: revisiting the role of care planning. Aust Fam Physician 2008; 37: 1614.
  • 7
    The Australian Council of Healthcare Standards. EquIP4 Accreditation Standard 1.1.2. July 2006.
  • 8
    Wagner EH, Austin BT, Davis C, Hindmarsh M, Scaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff 2001; 20: 6478.
  • 9
    Lorig KR, Sobel DS, Stewart AL, Brown BW, Ritter P, Gonzales VM. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care 1999; 37: 514.
  • 10
    Jackiewicz S. Evaluation of Family Partnership Training in Western Australia 2001–2003. Perth: Telethon Institute for Child Health Research, 2004.
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    Ockleford E, Shaw R, Willars J, Dixon-Woods M. Education and self-management for people newly diagnosed with type 2 diabetes: a qualitative study of patients' views. Chronic Illn 2008; 4: 2837.
  • 12
    NHS Modernisation Agency. Good Care Planning for People with Long-Term Conditions. London: National Health Service, 2005.
  • 13
    Law M, Rosenbaum P, King G et al. Family Centred Service—A Checklist for Families. CanChild Centre for Childhood Disability Research, McMaster University. 2003; 18: 48.
  • 14
    Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M. Living a Healthy Life with Chronic Conditions. Denver, CO: Bull Publishing Company, 2000.
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    Jayasuriya P, Roach S, Bailey L, Shaw E. Self management for chronic disease: an introduction. Aust Fam Physician 2001; 30: 91316.
  • 16
    O'Hair D. Research traditions in provider-consumer interaction: implications for cancer cure. Patient Educ Couns 2004; 50: 58.
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    Haidet P, Kroll TL, Sharf B. The complexity of patient participation: lessons learned from patients' illness narratives. Patient Educ Couns 2006; 62: 3239.
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    Newbould J, Taylor D, Bury M. Lay-led self-management in chronic illness: a review of the evidence. Chronic Illn 2006; 2: 24961.
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    Greenhalgh T. Chronic illness: beyond the expert patient. Br Med J 2009; 338: 62931.
  • 20
    Schoot T, Proot I, ter Meulen R, de Witte L. Recognition of client values as a basis for tailored care: the view of Dutch expert patients and family caregivers. Scand J Caring Sci 2005; 19: 16976.