Validating Domains of Patient Contextual Factors Essential to Preventing Contextual Errors: A Qualitative Study Conducted at Chicago Area Veterans Health Administration Sites.

PURPOSE: "Patient context" indicates patient circumstances and characteristics or states that are essential to address when planning patient care. Specific patient "contextual factors," if overlooked, result in an inappropriate plan of care, a medical error termed a "contextual error." The myriad contextual factors that constitute patient context have been grouped into broad domains to create a taxonomy of challenges to consider when planning care. This study sought to validate a previously identified list of contextual domains. METHOD: This qualitative study used directed content analysis. In 2014, 19 Department of Veterans Affairs (VA) providers (84% female) and 49 patients (86% male) from two VA medical centers and four outpatient clinics in the Chicago area participated in semistructured interviews and focus groups. Topics included patient-specific, community, and resource-related factors that affect patients' abilities to manage their care. Transcripts were analyzed with a previously identified list of contextual domains as a framework. RESULTS: Analysis of responses revealed that patients and providers identified the same 10 domains previously published, plus 3 additional ones. Based on comments made by patients and providers, the authors created a revised list of 12 domains from themes that emerged. Six pertain to patient circumstances such as access to care and financial situation, and 6 to patient characteristics/states including skills, abilities, and knowledge. CONCLUSIONS: Contextual factors in patients' lives may be essential to address for effective care planning. The rubric developed can serve as a "contextual differential" for clinicians to consider when addressing challenges patients face when planning their care.

Perceptions of Chronic Illness Care Among Veterans With Multiple Chronic Conditions.

OBJECTIVES: Given the burden of multiple chronic conditions (MCCs) in the Veterans Affairs (VA) Health Care System, understanding perspectives of Veterans with MCC is essential to evaluate chronic care and ensure that care and quality improvement efforts align with patient needs. The purpose of this study was to use the Patient Assessment of Chronic Illness Care (PACIC) instrument to examine perceptions of chronic care among Veterans with MCC. METHODS: We conducted a nation-wide, cross-sectional mailed survey. Study inclusion criteria were Veteran patients with MCC who receive care from eight VA facilities. The survey included questions on patient demographics, recent hospital or doctor visits, and the PACIC instrument. Chronic condition and health care utilization data were extracted from VA administrative databases. RESULTS: The sample (n = 3,519) was mostly male; average age was 68.1 years. Mean PACIC summary score was 3.05 (standard deviation [SD] = 1.12). Respondents achieved higher scores (favorable perceptions) in the Delivery System Design and Patient Activation subscales, and lowest scores (unfavorable perceptions) in the Follow-up/Coordination subscale. Characteristics associated with higher scores included non-white race, recent VA doctor visit, and high school or less education. CONCLUSIONS: Perceptions of chronic care were high; however, quality improvements are needed to enhance care continuity and coordination.

Do perceptions of family-centered care differ in older and younger family/caregivers of U.S. veterans?

INTRODUCTION: Family-centered care (FCC) involves partnering with patients and family/caregivers ("caregivers"), engaging them in decisions, and providing support. FCC may be measured across 3 dimensions: respect, collaboration, and support and needs likely vary by caregiver age. The objective was to examine and compare caregiver perceptions of FCC by age. METHOD: We mailed surveys to family/caregivers of Veterans. We collected demographics and measured respect, collaboration, and support using the Family-Centered Care Survey (FCCS). We calculated mean values and conducted bivariate comparisons, dichotomized by caregiver age (≥60 vs. <60), of demographics and FCC constructs. We completed thematic analysis on open-ended text. RESULTS: Caregivers (n = 2,111) aged ≥60 versus <60 were more likely to be spouses (81% vs. 62%, p < .0001) and White (74% vs. 50%, p < .0001). Overall FCC subscales values were high: respect (3.30), collaboration (3.07), and support (2.99). Older caregivers reported higher respect (3.36 vs. 3.22, p < .001), collaboration (3.12 vs. 2.98, p < .0001), and support (3.06 vs. 2.88, p < .0001). Qualitative analysis revealed collaboration, communication, hospital climate, and physical environment as important to FCC and supplemented quantitative findings on age. Examples highlighted both positive perceptions of FCC and areas of concern, such as feeling "unheard" and "like I am bothering providers," and needing "more comfortable seating" and "better parking." DISCUSSION: Caregivers perceived high FCC levels at VA facilities, reporting highest on respect and lowest on support. Older caregivers perceived better FCC compared with younger caregivers. Several concerns identified can be used to target improvements to FCC including: improved support, collaboration between patient/family/provider, and climate/environmental enhancements. (PsycINFO Database Record