First Advisor

Hyeyoung Woo

Term of Graduation

Winter 2021

Date of Publication

3-10-2021

Document Type

Dissertation

Degree Name

Doctor of Philosophy (Ph.D.) in Sociology

Department

Sociology

Language

English

Subjects

Veterans -- Medical care, Patient-centered health care, Primary health care, Chronically ill -- Medical care, United States Department of Veterans Affairs

DOI

10.15760/etd.7520

Physical Description

1 online resource (v, 113 pages)

Abstract

Home Based Primary Care (HBPC) is an interdisciplinary care model involving comprehensive primary care services for patients with chronic illness who are unable to access clinic-based care. The largest HBPC program in the United States is run by the Department of Veterans Affairs (VA) and provides team-based primary care service to Veterans with complex, chronic conditions. The VA HBPC model includes primary care visits from a physician, nurse practitioner, or physician assistant, nurse care management, service coordination by a social worker, mental health services from a social worker or psychologist, nutrition counseling from a dietician, and help with medication management. In both VA and non-VA settings, HBPC has demonstrated success in improving patient and system outcomes. It is largely unknown how and in what circumstances HBPC positively impacts patients' health outcomes but may be related to the integration of long-term services and supports, strong patient-provider relationships, and highly functioning interprofessional teams. Thus, the specific aims of this study are: 1) explore how HBPC providers understand and address concurrent medical and social needs; 2) examine the ways in which providers in the VA HBPC program understand and manage their relationships with patients with respect to patient power and decision-making; and 3) investigate HBPC team function and coordination between clinic-based primary care physicians. Aims 1 and 2 are qualitative studies and Aim 3 utilizes an explanatory mixed-methods design. Data collected for Aims 1 and 2 are based on 14 semi-structured interviews with HBPC providers and 6 field observations of HBPC team meetings. Data collected for Aim 3 involves a cross-sectional survey administered to 33 HBPC providers and 10 semi-structured interviews with clinic-based primary care providers. Additionally, data from the HBPC provider interviews is used for Aim 3. For Aims 1 and 2, an exploratory, content-driven approach and analytic expansion approach, respectively, is used for data analysis. For Aim 3, survey data is used to assess the strength of relational coordination within HBPC teams and between HBPC teams and clinic-based primary care providers and staff, while qualitative data from semi-structured interviews with HBPC providers and clinic-based providers are used to explicate survey results. Findings from this study drive three main conclusions. First, having the home visit component of VA HBPC gives providers unparalleled insight into the impact that overlapping medical and social complexity has on HBPC patients. The home visit combined with the flexible nature of HBPC programming allows for providers to directly address patients' care needs. Second, HBPC providers experience relationship boundary challenges stemming from patient's social isolation and the mutual emotional attachments that form between patients and providers. However, HBPC providers have developed individual and team-based strategies to address these challenges. Third, HBPC teams are highly functioning when it comes to intra-team collaboration and care coordination, but they have substantial gaps in the coordination of patient care activities with clinic-based primary care providers and staff. This gap has caused confusion and frustration over the role of HBPC and what types of patients HBPC should serve and reveals a need for increased horizontal communication between HBPC teams and clinic-based primary care providers and staff. These findings provide evidence for the development of future studies that investigate the wider impact that these care patterns may have on patient care outcomes. Additionally, these findings provide data for health policies targeted towards patients with complex medical and social care needs.

Rights

In Copyright. URI: http://rightsstatements.org/vocab/InC/1.0/ This Item is protected by copyright and/or related rights. You are free to use this Item in any way that is permitted by the copyright and related rights legislation that applies to your use. For other uses you need to obtain permission from the rights-holder(s).

Persistent Identifier

https://archives.pdx.edu/ds/psu/35126

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