Impact of Patient-Centered Narrative Interviews on Primary Care Providers

Patient-Centered Narrative Interviewing

Impact on Perceptions of Primary Care Clinicians

Michael Terry 2

Section I: Clinical Problem

Problems with a Provider-Centered Approach To Err is Human and Crossing the Quality Chasm

Problems with a Patient-Centered Approach Identifying the Essential Elements of Patient-

Centered Interviewing Making the Personal Transformation

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Section II: Clinical Solution

Components of Evidence-Based Patient-Centered Interviewing

Patient-Centered Interviewing in a Narrative Mode

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Components of Evidence-Based Patient-Centered Interviewing Skills Used Simultaneously

Rapport building and the relationship maintenance Mindful practice Topic tracking Acknowledging social or emotional clues with

empathy

Skills Used Sequentially Up-front, collaborative agenda setting Exploring the patient’s perspective Co-creating a plan

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Patient-Centered Interviewing in a Narrative Mode History and basic concepts

Application in Patient-Centered Interviewing Skills Rapport building and the relationship maintenance Mindful practice Topic tracking Acknowledging social or emotional clues with empathy Up-front, collaborative agenda setting Exploring the patient’s perspective Co-creating a plan

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Section III: Project Implementation Purpose

Conduct a project using consultants to interview patients and provide information to their medical providers, and evaluate its impact and suitability as a small test of change in order to improve and expand this approach to improving patient-centered care in primary care settings.

Rationale and Assumptions PCPs likely employ medical model; provider-

centered approach PCPs unlikely to seek training but may be open to

others performing services

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Section III: Project ImplementationOverall Design and Objectives Provide a process for the PCP to identify frustrating

and/difficult patients. Collect quality and adequate biopsychosocial data using

the patient-centered narrative interviewing process. Organize and effectively present this case to the PCP. Assess changes in the clinical decision-making, level of

frustration, and other general perceptions of the PCP. Evaluate information for the purposes of modifying the

approach in order to improve its value and acceptability. Determine how, when, and where to re-implement and/or

expand the implementation of this project the future.

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Section III: Project Implementation Outcomes Evaluated

PCP perceptions of patient’s condition, diagnosis and treatment plans

Value of information provided to PCP PCP frustration Differences between clinician and interviewer

assessments of patient problems

Setting Contracted w/ UCSF; preceptors established Student roles and expectations established

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Section III: Project Implementation Training Approach and Method

12-week period from January through April, Approx. 10 hours of classroom instruction and 30

hours of reading, practice, and other assignments. Methods of instruction included

assigned articles, viewing videos, participating in discussions, developing individual and group create presentations, performing and rating each other’s practice. Final check-out

https://moodle.ucsf.edu/course/view.php?id=821










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Section III: Project Implementation

Intervention and Data Collection PCPs invited Patients selected; Clinician Problem Assessment form

completed Interviews performed; and Interviewer Problem

Assessment form completed Cases presented Information discussed Surveys completed, Forms collected and submitted

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Section IV: Project Evaluation Results

Participant Characteristics (n=16) Profession

MD 6% PA 12% NP 81%

FNP 31%

ANP 44%

PNP 6%

Medical + Psychiatric Scope- 31%

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Sites (n=16) 44% Primary Care only

VA, CHC, Pvt practice, HMO, elder care

31% Psych is primary PES, Psych hospitals

25% PC + Psych Correctional center, mobile van, community care,

residential care

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Diagnostic range:psychiatric conditions - substance abuse,

bipolar disorder, anxiety, depression and suicide attempt, schizoaffective disorder, psychotic disorder, somatization disorder, schizophrenia, dementia,

medical conditions - chronic back pain, stomach pain, celiac disease, cellulitis, hypertension, dyslipidemia, emphysema, arthritis, gastroesophageal reflux disease, medication side effects, asthma

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Value of Interview Information to the PCP

0

Somewhat10

Very

11

Info Value to PCP

Not at all 0

Somewhat 10

Very 11

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Positive Value of information provided to PCP 100% (48%+ 52%++) Characteristics attributed to information:

50% encouraging 31% hopeful 12% enthusiastic 6% ambivalent 3% indifferent

Readiness to make change: Confidence: 83% very, 17% somewhat Act within: 50% now, 33% <6 mo., 27% 30 days

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Positive Value of information provided to PCP Specifically helpful in these ways: “Helps me with overall understanding and treatment planning,” “To put a plan together that will anticipate the patient’s needs prior to

presenting with a health decline,” “Helpful in giving additional information and another perspective,” “Helped me think about the case from a broader perspective,” “Reinforced diagnostic impression,” “Mental health is as important as the medical issues presented,” “It gives me good insight into the patient’s behavior,” “This information made her more approachable and more

straightforward to deal with,” “Provided me with alternative insight and viewpoints on approach

and technique with his patient,” “Found impressions very helpful to my end decision,” “Knowing history of drug use will guide me in deciding interventions

for enhancing client motivation and self esteem.”

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PCP Understanding of Patient Condition/Situation Changed

Unchanged4

Somewhat12

Definitely5

Changed Understanding

Unchanged 4

Somewhat 12

Definitely 5

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Information Changed Diagnostic Impression:

11

8

2

0

2

4

6

8

10

12

Changed Dx

Not at all 11

Somewhat 8

Definitely 2

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Information Changed Treatment Options:

Not at all3

Somewhat13

Definitely5

Changed Tx

Not at all 3

Somewhat 13

Definitely 5

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Information Changed Treatment Options:

11

89

6

4

0

6

Changed Tx Type

Approach 11

Sequence 8

Referral 9

Rx 6

Eval 4

Test 0

Other 6

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Outcomes PCP perceptions of patient’s condition,

diagnosis and treatment plans Condition/Situation: 81% (57% + 24% ++) Dx: 48% (38% + 9%++) vs. 52% - Tx: 86% (62% + 24% ++) vs. 14% - Areas:

29% general approach 21% sequence/timing 24% referrals 16% Rx 11% further eval/testing

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Change in PCP Frustration

Unchanged10

More1

Less10

0

1

2

3

4

5

6

7

8

9

10

Change in PCP Frustration

Unchanged More Less

Unchanged 10

More 1

Less 10

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PCP frustration Less: 48% Unchanged 48% More 4% Reasons: Lack of responsibility for actions, manipulative behaviors, medication seeking behaviors, attention seeking behaviors, “needy patient,” chronic pain problems, refusal of care, refusal of referrals patient lack of insight, evasiveness, lack of motivation, Multiple comorbid conditions, high level of complexity, complex patient but

limited time, non-adherence, noncompliant, “says one thing and does another,” inconsistency of information provided, demanding, controlling, frequency of service use, “irritable and difficult to communicate with,” patient distrust of system, evasiveness, “hyperactive and hyper verbal patient,”, “poor temper,” somatization

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Differences between clinician and interviewer assessments of patient problems

PCP: medical dx + biopsyhosocial problems Primary care dx + psychiatric dx

Interviewer: Co-morbidity & co-occurring disorders Situational elaboration Patient’s perspective on problem

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Section IV: Project Evaluation Analysis

Participants and Sites Over 80% NPs Over-representation of psychiatric diagnoses and settings Substantial mental health expertise in PCPs

Outcomes PCP perceptions of patient’s condition, diagnosis and

treatment plans Treatment > Diagnosis change is expected Scale and Direction of treatment changes unanticipated

Value of information provided to PCP Highly appreciated and committed to action

PCP frustration Similar to expectations based on literature

Differences between clinician and interviewer assessments of patient problems

Overlap of biomedical & biopsychosocial approach Condition elaboration; fostered acceptability

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Section IV: Discussion – lessons learned

Would clinicians involved in this project want to do it again? Would they take advantage of other opportunities to use

consultants in similar ways? As a result of this experience, are any of them interested in

pursuing this kind of training themselves? Should be provided routinely? What patients do they feel would

benefit from this approach? When might this approach be considered to be essential? Did a nursing background of the interviewer affect the results? Did the nursing background of the PCP have an effect? If this project were repeated in strictly outpatient primary care

medical clinics, would we see the same results? Did interviewers actually perform patient-centered narrative

interviewing as trained?

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Section V: Next Steps

CQI and EBP – ideal applicationProblem with Patient Preferences & Shared

Medical Decision-MakingSimilar problems as biomedical +

biopsychosocial intersection

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Section V: Next Steps

This project’s iterative development history Directions forward:

Repeat with lessons-learnedExpand to PCP training approachEvolve to Primary Behavioral Health

Consultation Services

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Section VI: Implications for Advanced Practice Nursing

Concurrence with Nursing Theory

Concurrence with DNP Competencies

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Newman’s Health as Expanding Consciousness (HEC)Meaning & Emergent PatternsDialectic & Transforming PresenceShared Narrative

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Ways of KnowingPatterns

Empiric (Positivist), logico-scientific, biomedical approach

Aesthetic, narrative, biopsychosocial approach

Relationship Independent Dependent Interdependent

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Concurrence with DNP Competencies Independent Practice Scientific Foundation Leadership Quality Practice Inquiry Technology & Information Literacy Policy Health Delivery System Ethics

Impact of Patient-Centered Narrative Interviews on Primary Care Providers

Health & Medicine

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