Research: Annals of Family Medicine

Process Matters in Primary Care Delivery to Vulnerable Patients

August 07, 2015 02:54 pm Sheri Porter

New research published in the July/August 2015 issue of Annals of Family Medicine suggests that low-income patients with multiple health issues -- and staff members at primary care clinics where those patients receive care -- have something in common.

[Staff member with couple, shaking man's hand]

Namely, neither group is entirely satisfied with the process of clinical encounters, beginning with the patient's first phone call to make an appointment.

Authors of the article(, titled "Exploring the Patient and Staff Experience With the Process of Primary Care," noted that patient experience, as a measure of patient centeredness, "has become increasingly important in assessments of primary care quality."

However, patient-experience surveys have been offered almost exclusively to Medicare and privately insured patients, "leaving the voices of patients in the lowest socioeconomic status underrepresented," said the authors.

Researchers sought to correct that omission by conducting patient and staff interviews in three primary care clinics in Philadelphia using "open-ended" interview guides that encouraged study participants to "speak freely and in their own words about each step of the primary care process."

Story Highlights
  • Research recently published in the Annals of Family Medicine highlights how the process of primary care delivery affects patients and primary care clinic staff members.
  • Authors noted that in previous studies, the voices of patients at the lowest socioeconomic levels were underrepresented; therefore, they conducted patient and staff interviews in three Philadelphia clinics that primarily served low-income and uninsured patients.
  • Authors concluded that improving information flow, aligning goals and expectations, and developing personal relationships could improve the experience of both patients and staff.

Between August 2012 and March 2013, interviewers spoke with 21 patients with chronic illnesses who were either uninsured or Medicaid beneficiaries. Interviews also were conducted with 30 clinic staff members -- including physicians, nurses, practice managers and front desk personnel -- who worked at either the one federally qualified health center or one of two academically affiliated clinics included in the study.

Authors ascertained that the primary care process included three stages (pre-visit, visit and post-visit) and five steps within those stages: scheduling appointments, checking patients in, rooming patients, spending time with a clinician, and completing laboratory and imaging tests.

Interviews conducted with clinic staff and patients revealed three issues that impacted all stages of a primary care episode. Authors concluded that improving information flow, aligning goals and expectations, and developing personal relationships could improve the experience of both patients and staff.

Information Flow

The study results highlighted how complications and misunderstandings arose when communication failed. For instance, wrote the authors, "Many patients said that when they left a message for their physician, the calls were frequently not returned or the important information in the message was lost."

Other areas of concern included insufficient information hand-offs from the medical assistant to the physician after patient rooming. For instance, during rooming, medical assistants completed required screenings for issues such as falls or depression but reported that there was not always a clear way to transmit that information to the physician.

"Staff indicated that the sheer volume of information in the electronic health record can obscure some of the important details," said the authors.

And nearly all staff members recognized that patients sometimes left the clinic before getting lab tests and other additional services that had been ordered or before scheduling a follow-up appointment.

"Technology, in particular, was a frustration," said researchers, and that frustration was tied to both human error and system malfunction.

Patients weren't always happy with medical technology, either, and especially didn't appreciate having to repeat their health history multiple times since they expected it be included in their electronic health record.

"You should already know what's going on," said one patient. "You've got a big screen in front of you; you have my whole life history since I was 4 in there."

Goals and Expectations

"For many patients, expectations of having their immediate concern fully resolved conflicts with clinicians' desire to maximize opportunities to address chronic health conditions," wrote the authors.

For instance, one patient presented with back pain and then reported: "We barely discussed my back … He wanted to talk about blood pressure medication and then my pharmacy that I go to."

According to researchers, conflict also arose because of other mixed expectations -- the patient's desire to have multiple concerns dealt with in a single visit and the clinician's opinion that the patient is trying to squeeze too many issues into a single visit. "So, that can lead to conflict …the time constraints on both ends," said one physician.

Personal Relationships

Authors noted that a "personalized touch stood out as a positive" and was identified as such by both patients and staff.

"Patients said they were more satisfied and more likely to be open with a physician who knows them well," wrote the authors.

Clinic staff members said the ability to identify patients and know a little bit about their circumstances was helpful from their standpoint, too. "Just from seeing the patients daily and getting to know my patients, I know who needs what," said one front desk staff member.

"The length of the relationship, however, is not the only thing that facilitates a positive relationship or helps develop trust," wrote the authors. A staff person's job title and gender were also mentioned as factors "affecting with whom patients feel comfortable sharing certain information," said researchers.

Author Q&A

Corresponding author and family physician Elizabeth Brown, M.D., M.S.H.P., is a member of the Robert Wood Johnson Clinical Scholars Program at the University of Pennsylvania in Philadelphia. In an interview with AAFP News, Brown dug a little deeper into the significance of the research team's findings. Here are some excerpts from that discussion.

Q. Why is this study important at this time?

A. The importance of primary care is being recognized across our health care system. Everyone is talking about primary care redesign. As we think about how to change the system, it's important to systematically assess what is working, what isn't, and for whom. The patient population that we focused on, those who are low-income and are chronically ill, needs a primary care system that works for them to help lower the risk of poor health outcomes.

Q. Were you surprised by any of the study findings?

A. I was particularly interested in the ways that people think about information flow. We have a variety of systems to document information, such as electronic medical records and electronic lab ordering, but that doesn't mean the information is available in the ways people expect it to be, or when they think they need it.

Q. Why should family physicians have an interest in this topic?

A. One of the most important parts of this study was that we asked everyone involved in care: physicians, patients, medical assistants, nurses, front desk staff, etc. We showed that those different perspectives matter -- there are some things everyone agrees on, but we shouldn't take that for granted. This study was done in an urban area, in clinics that care for largely underserved populations. However, many of the themes, such as information flow and personal relationships, are likely applicable to many settings.

Q. What's the single most important takeaway for family physicians to remember?

A. Not everyone sees every step or interaction in the same way, so as we think about problems and solutions, everyone's input is important.

Q. Where would you like to see the research go next?

A. I think this work comes at a time when we are really critically thinking about how to maximize the potential of our primary care system. People are experimenting with more virtual visits and electronic communications, changing roles for nurses and other members of the care team, and other really new and innovative ideas. Continuing to ask these important questions about how we are transferring information, assessing and aligning goals, and developing personal relationships as we develop new care delivery models will be key.

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