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Great Expectations: The Primary Care Experience of Low-Income, Chronically Ill Patients

Hopefully, we’ve alPt Staff blog photol had the experience of being a patient who leaves a doctor appointment feeling like we’ve been heard, we’ve received attentive care, and we know what the next steps are. However, some of us have probably also experienced a less-than-stellar visit to our primary care doctor’s office, where we leave feeling frustrated, confused and with remaining questions. And it’s not just patients who can feel dissatisfied with a doctor visit… staff members can also share these feelings. It’s a terrible feeling, and one that can be exacerbated when low-income, chronically ill patients are involved.

While researchers have previously looked at how high-risk patients perceive their care, a new study led by researchers at the Perelman School of Medicine at the University of Pennsylvania and published in the Annals of Family Medicine, explores how low-income, chronically ill patients and the staff who care for them experience the primary care process. 

“If you break down a visit to the doctor's office, it involves several steps and quite a few people, including patients, front desk staff, medical assistants and others,” said the study’s lead author Elizabeth J. Brown, MD, a Robert Wood Johnson Foundation Clinical Scholar and a fellow in Penn's Leonard Davis Institute of Health Economics (LDI). “We asked each of the people involved about how each of those steps works, from the first call to the office through follow-up, and how it might be different in an ideal world.”

The study consisted of interviews with 21 uninsured or Medicaid patients with multiple chronic illnesses, such as diabetes or high blood pressure, (putting them at high risk for poor health outcomes like repeat hospitalizations) as well as 30 primary care staff who interacted with them. The patients and staff were asked a variety of questions about the entire experience and there were three main themes that emerged.

First, the flow of information is not always ideal, both between the people involved, and from one step to the next. For example, when patients are put into exam rooms, information needs to be given from the patient to the medical assistant, and then from the medical assistant to the physician.

Second, the goals and expectations of the patients, staff members and physicians involved are not always aligned at each step. When that happens, there is potential for frustration and dissatisfaction. For example, one physician in the study said, “I think sometimes the patients may not feel like their concerns are addressed, and I think sometimes a provider may feel like the patient has too many things that they want to have addressed in one visit.”

Finally, the researchers found that having a personal relationship or individualized attention can help overcome some of these challenges for everyone involved. For example, multiple staff members in the study suggested that an after-visit escort through checkout would make it less likely that patients leave the clinic before completing all of their follow up steps (like scheduling a follow-up appointment or getting lab work done).

“Our study suggests that while we are redesigning the ways that we deliver primary care, we need to consider how patients, physicians and staff members’ goals may differ, and how changing the way we do things may affect the development of personal relationships or the feeling of personalized care,” said Brown. “We need to consider the information that each person feels is important, and the ways that they prefer to send and receive that information.”

As people experiment with more virtual doctor visits and electronic communications, changing roles for nurses and other members of the care team, and other innovative ideas to improve health care delivery, Brown says it will be key to continue asking these important questions about how we are transferring information, assessing and aligning goals, and developing personal relationships.

Evaluating and improving patient and staff experiences are fundamental to a successfully evolving health care system.

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