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How do you evaluate patient access to care? What action can you take to assess retention at your clinic? What are your strategies to keep patients retained in care?
Posted by HEALTHQUAL|Apr 10, 2012|14 COMMENTS
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Dear all
thanks for the informative forum; i am not sure about the topic currently under discussion but mine is on awarding best performance site/s. is there any of the Healthqual particicipating countries that are conducting any initiatives to award best performing sites? if so; kindly provide some guidance in terms of the assesment tool to describe the selection criteria or any other relevant information that will help our program to do this objectively and effectively. HIVqual-namibia is planning to carry out this exercise for the 1st time in 2013
Counting on your usual peer learning collaboration
best wishes,
claudia
namiibia
I recently attended a physician communication training to improve patient-physicain interactions in office/hospital settings. The health care provider need to develop skills for effective patient comunication that leads to trust. Communications is key.
Surafel K Gebreselassie, MD
Ohio, USA
So much of our attention is at the level of the health care system or carer and how it/they fail and I am sure this is important .. Poor counselling,aggressive, rude, disinterested health care workers,unfriendly support staff, stigma and discrimination ,long queues,dirty clinics obviously make the process of seeking care such an unpleasant experience it may impede patients being linked to care after a positive HIV diagnosis.
I however, am interested in the patients who ARE adherent ,who remain in care for years ,who cope with all the afore mentioned challenges.For want of a better word -PATIENT EFFICACY - what is needed for the patient to achieve this and how we as carers, foster this and measure it.
In truth,once patients are on ART and doing well ,visits to the health facility need only happen 3 or 4 times per year.
Patient ART clubs or community ART groups where patients join together and arrange that one patient accesses the clinic but collects pharmacy refills for a number of other patients are part of an advocacy strategy and reflect patient efficacy ; particularly as these groups are often self formed and maintained.
Patients who have fully disclosed their status, patients who belong to support and/or HIV advocacy groups, patients who maintain suppressed viral loads and good CD4 responses from year to year have taken full responsibility for the infection and their own management. Systems where patients are seen as passive recipients of services we design for them are unsustainable ; life long adherence to ART will require the patients taking the extra step to being the person in control.
Dr. Shanks Chakravarty-Zambia
The cardinal factors that determine ACCESS and RETENTION of PATIENTS UNDER CARE at any clinic, is based on RELATIONSHIP OF THE CARE PROVIDER WITH EACH INDIVIDUAL CLIENT ( I prefer to use the word Client as it does not portray the grimness of a SICKNESS whatever sickness it may be)
To understand the word RELATIONSHIP we have to delve a bit deeper into the MINDSET of the CARE PROVIDER and the CLIENT.
The MINDSET of the CARE PROVIDER should be, as has been clearly outlined in earlier discussions by colleagues, STRESS and FATIGUE FREE which is dependent on the following factors being more or less equally taken care of-
A- TAKE HOME SALARY-everyone works to earn a living to take good care of their families, so a decent ALL ENCOMPASSING WAGE is cardinal to keep your care provider on the top of his/her SERVICE PROVISION
B-If WAGE is a constraining issue, perks should be incorporated-Housing Allowance, Schooling Allowance, Telephone Bill Cushions, Electricity Bill Cushions etc.- WHY IS IT IN LOW SOCIO-ECONOMIC SETUPS, A WORKER IN A MOBILE COMPANY GETS MORE SALARY AND PERKS THAN THE POOR CARE GIVER WHO CAN CHANGE THE SOCIETY BY CARE AND CLIENT RETENTION IN PMTCT SET-UPs AND CONTRIBUTE TO A BETTER SOCIETY OF THE FUTURE???? In most circumstances, in these Socio Economic set-ups, RESPONSIBILITY TOWARDS ONE'S HEALTH AND RESPONSIBILITY TOWARDS PROPER HEALTH SERVICE DELIVERY HAS NEVER BEEN AND IS NEVER A PRIORITY- it is just one of the existing parameters of the Social Set-up.
C-To Incorporate (paid for if possible) activities that promote a healthier LIFESTYLE, thus a HEALTHIER MINDSET-Encourage CARE PROVIDERS to take up basic minimum Aerobic sessions-45-50 MINUTES THRICE WEEKLY MINIMUM, at work or after work within or nearby campus possibly and also ensure ENOUGH REST -it is VITAL to have an ACTIVE MINDSET- In the States whilst in curriculum, most health professionals are encouraged to take up sports like golf (Its great for the MIND)
D-Other tools of encouragement that will promote a healthy competition, amongst CARE PROVIDERS to deliver a consistent personalised service to clients- AWARDS, STUDY SCHOLARSHIPS, PROMOTIONS, FINANCIAL RETRIBUTION etc
E-PROVIDE ALL TOOLS required to ensure SAVING TIME with ALL LEVELS of CARE GIVERS- everyone should have access to DETERMINE HIV1&2 strip tests, as widely as Pregnancy Strip tests, so that a Screening Test can be carried out at any point in time, quickly and efficiently under any given situation-this will save problems of long waiting times and confidentiality, in Public Health Service provisions-EVEN CD4 counters should be provided to more outlets so that one can have quick CD4 runs and start on ART-
LETS ALWAYS KEEP ONE CLEAR GOAL-REACHING EACH AND EVERY MEMBER OF OUR SOCIETY AND ENSURE PROFESSIONAL UPTAKE OF CLIENTS, PERSONALISED CARE PROVISION AND PERSONALISED FOLLOW THROUGH TILL A MINIMUM OF TWO YEARS
I am of the OPINION that with the above factors looked into, in most HEALTH SERVICE OUTLETS, it will get your SERVICE PROVIDER ROCKING.
Now to delve deeper into the MINDSET OF THE CLIENT. Below is what I have gathered in my years of experience in the Zambian SOCIAL SET-UP.
A TYPICAL CLIENT IS-
A- A lady from age group of 14-30, VERY SINGLE AND VERY PREGNANT AND mostly POSITIVE-
we have to understand WHY?????- REASONS may be FALSE PROMISES, SECURITY OF HOOKING THE MAN FINANCIALLY WITH A BABY, PROOF OF FERTILITY, VICTIM OF HIT AND RUN OR INCEST OR FORCED SEX, INDECENT BEHAVIOR IN TEENAGERS, PEER PRESSURE, HIGH SCHOOL SEX, etc. etc.- in most cases despite all PUBLIC MEDIA working 24/7 WITH PICTURE MESSAGES of SAFE-SEX, it is common practice to have live sex without TESTING EACH PARTNER on "HE LOOKS FINE" philosophy, with reasons above.....
I will give three examples that I have seen in the last two weeks-
CLIENT 1- 15 years SCHOOLGIRL from BOARDING SCHOOL, from well to do socio economic background, history of UN-PROTECTED SEX with 4 PARTNERS, in different time frames, VERY PREGNANT but NOT POSITIVE- was counseled thoroughly, made to understand how lucky she was, MTP carried out and made to take steps to positive progressive steps for future- FOLLOW UP ENSURED INVOLVING MOTHER AND FRIENDS!!
CLIENT 2- 29 years SINGLE HAIR DRESSER, MULTI-PARTNERS, VERY PREGNANT and VERY POSITIVE with a CD4 count of 4,- ART started immediately, MTP carried out immediately and patient COUNSELED thoroughly though she was mentally not stable and requested the status to be hidden from parents, personalised FOLLOW UP ensured involving family
CLIENT 3- 25 years SINGLE HOTEL worker, VERY PREGNANT with PID and VERY POSITIVE-CD4 was 61, counseled, ART started, on observation for elective MTP, personalised FOLLOW UP ensured involving Family members
INFERENCE from all these examples is AS OUTLINED ABOVE, and also having a surplus of single "available" women, the RATE OF INFECTIVITY is still predominantly HIGH and also WITH HIGH VIRAL LOADS AND LOW CD4.
So it is very important to understand the MIND-SET, to ensure that THE CARE GIVER while counseling is able to break SOCIAL FACTORS and BELIEFS, as above and INJECT A CLEAR SENSE OF SELF-RESPECT AND RESPONSIBILITY-HEALTH WISE, in each client and subsequent CHILD BIRTH- it is a very difficult GOAL but IT HAS TO BE DONE TO THE BEST POSSIBLE CAPACITY to ENSURE CHANGE OF MIND-SET
Thus PERSONALISATION AND A CLEAR UNDERSTANDING OF EACH CLIENT'S SOCIAL PERSPECTIVE IS VITAL!!
B- The ATMOSPHERE OF A HEALTH SERVICE OUTLET- let's face it- WHAT DISSUADES MOST CLIENT'S TO CONTINUOUS UPTAKE as my colleagues above have mentioned, IS THE GLOOMY, DISMAL, WITH AN ODOUR OF TERMINAL ILLNESS AND DEATH LOOMING IN THE ATMOSPHERE TYPICAL OF MOST PUBLIC OUTLETS. Then one has to deal with long waiting hours, disgruntled un-enthusiastic almost robot like health workers, who make the client feel more sick than they are. And finally the VISUAL IMPACT OF TERMINALLY ILL HIV PATIENTS, who completely demoralise the client's FAITH ON THE POSSIBLE EFFICACY OF ART AND THUS EMBRACE THE TERMINAL VERDICT!!
However this can be possibly eradicated if all levels of care givers are aware of the NEGATIVE IMPACT of a PUBLIC OUTLET and CREATE A MORE VIBRANT, COMPASSIONATE AND POSITIVE "FULL OF HOPE AND HEALTHY LIFE" ATMOSPHERE IN A MORE PERSONALISED SET UP- the PMTCT AND VCT AND ART outlets in any setup should have very vibrant colours (Colours and Human Psyche go hand in hand together). Also these rooms should NOT BE named as PMTCT/ART/VCT centers but part of routine hospital ANC / CHECK UP facilities- just like you would decorate your up-coming baby's room-THERE SHOULD BE A GREAT ATMOSPHERE, GOOD SMELL, LIGHT MUSIC IF POSSIBLE, TV AND FRIENDLY CARE GIVERS, who understand the essentials of PERSONALISED CARE AND UNDERSTANDING
C-All CARE GIVERS MUST INTERACT in every possible way with CLIENT to INSTILL A STRONG SENSE OF RESPONSIBILITY TOWARDS PERSONAL HEALTH- IF WE INSTILL A STRONG SENSE OF PERSONAL RESPONSIBILITY IN WOMEN OF CHILD BEARING AGE, we will climb a huge mountain, AS ALL CHANGES CAN START WITH THE WOMEN WHO WILL "FORCE" THEIR MALE PARTNERS in the same sense of responsibility-THUS ENSURING both break-through into active male participation and follow through !!
These are my humble observations and no matter how impossible the GOAL may be IT IS MOST DEFINITELY ACHIEVABLE if we tackle each minute segment piece by piece, always supporting the CARE GIVER to be ABLE ENOUGH to SUPPORT THE CLIENT and have a personal interaction with as many clients as possible.
I rest my case-hope my contribution will be of help!!
I couldn't agree more with Dr.Shankah regarding patient retention into care.The service provider's attitude is fundamental to patient retention success.Thank you for your elaborate input.There is also concern regarding client's personal sense of responsibility when some shift from clinic to clinic for whatever reason but fail to move with transfer out documents making it hard for the former service provider to make follow up thus reporting them as being lost to follow up.This also results from incentives provided to patients from public health facilities in form of food or cash by some NGO'S as they rush to commence more patients into care and treatment.
Patient waiting time and consultation time are tools we use to determine the level of patients access to care. Dwindling number of health care providers and increasing number of new patient intake are key factors leading to high doctor -patient ratio which invariably affect access to quality care. The number of those lost to follow up determines our level of patient retention. Continuous counselling and support group activity help to address the socio-economic challenges that often lead to patient withdrawing from treatment.
We invite each of you to share your strategies, experiences and insights on retention in HIV care. After joining the discussion, please visit our retention special collection on the QI Learning page where you will find a tool box of helpful resources on this topic.
Since the implementation of Quality improvement methodology in health care system in Haiti, great leaders have been discovered both among members of the care team that the department heads and even the Executive Directors.
An example, in a very frequented site of Port-au-Prince, it was noted that less than 40% of patients seen were tested for HIV, resulting in a low rate of new enrollments in care. The head of VCT/ART department asked the different clinics to learn from patients the reasons for their refusal to be tested. This survey was conducted informally by providers of the different clinics. The majority of patients complained of waiting too long when they had to go to counseling and then to the lab to get tested after having been seen in consultation and return to the counseling service for the test result. Often they were returned given the long queue. In order to overcome this problem, the department head , after brainstorming session with different actors in the chain of care, applied the opt-out strategy by putting the whole structure for screening in all clinics after a pilot experience on a small scale for a week. Patients were able to be tested before even being seen in consultation. His leadership helped to motivate the most reluctant. This has allowed the screening for HIV of 85% of the population frequenting the institution in the following month and enrollment in care nearly 60% of those tested positive. In this same institution, Medical and Executive directions have also demonstrated exemplary leadership in ensuring the training of all employees on HIV / AIDS, according to the needs of each class. This has lead to a better provider-patient relationship, an improvement of the adherence of the patients in care.
Johane Johnny Bautule, ARV NURSE PRESCRIBER, Thamaga Botswana. I think there are number of issues pertaining to patient retention 1. PATIENTS REASONS. Socioeconomic reasons: budget should cater for check ups and may be better foods and care to self than before. Mental health challenges, esp depression; most patients get depression from being HIV positive due to adjustment in their lives. Have to explain reasons for frequent hospital visits to colleagues at work. Meeting other sick patients, which leads to fear of outcome of disease, esp that patients are not used to seeing seriously sick patients. 2.HEALTH SYSTEM ISSUES. Long queues, esp in developing countries; lack of reagents and equipments hence patients having to return on another date for bleedings; lack of skills, wholestick approach by health workers, not only focusing on HIV.
Solomie Jebessa , MD,senior pediatrics HIV program officer, Kampala , Uganda
Retention to care in HIV clinics depend on :
1- Patient - health worker interaction : unfriendly communications will repel the patients from the clinics
2- Access/distance to the health institution- if the health institution is far the patient may delay to come and eventually will even stop the patient from coming because of financial reason
3- Stigma and discrimination : if there is stigma the patient may fail to come for fear of being stigmatized by the community
4- Poor Health condition / being bed ridded
5- Lack of support - familial , social , financial
6- Ignorance about the disease process
7- Adherence fatigue
8- Cultural / religious advices- or misconceptions
Thanks
Hi Dr. Solomie, Thank you for your post!
I think you have hit on several major groups of reasons for patients who fail to be retained in clinic. Patient reasons, health care systems reasons and structural reasons, such as transportation, etc. Let’s begin the discussion by looking at the systems issues. What do you think we can do to ensure respectful and warm communication between patients and providers?
I want to share an experience from the US healthcare system that might be of interest. As you may know, our medical residents (in training) used to work constantly – they might stay up all night and continue to work through the next day straight until evening – without a wink of sleep. About 10 years ago, reforms were made, and now medical residents work far more reasonable hours and get more sleep! When I act as a consultant on the medical ward now, I notice that residents are far more friendly – to each other and to their patients. This raises an obvious issue – when health care workers are confronted by stresses (fatigue, hunger, overwhelmed) they can easily become unwelcoming or even rude. Given the high volume of patients, do you think the providers are stressed? Why are some providers professional in the face of challenges while others break down? What do you think can be done to systematically improve the interaction between patients and providers to keep patients in care? I Look forward to your thoughts (and to others’ responses)!
- Elvin
Thanks for the opportunity I am given to post new comment .
First of all as you have already spelled out , work load is the main cause for health care providers to be impatient for their patients so it will be good to distribute the work load equally among other work mates .
The reason why some health workers are tolerant and why others are not , may be a matter of nature, spiritual tranquility and may be also good social life .
Others may be demoralized because of lack of support from other work mates , family or society , and most importantly in many African countries because of low payment of health workers .
so to improve patient - health worker interaction :
1- the health worker skill should be built and social life should be improved
2 Health workers should be paid what they deserve in relation to the work they are doing
3-The health care providers should also give attention and should improve their interaction skill with their patients
Sometimes, even with an adequate salary, the health worker may, by his attitude, discourage the patient to addhere to treatment. It is important that the health worker has a sense of belonging within the institution where he works and he feels that his work is appreciated by his superiors. The supervisor or manager must ensure harmony between employees and recognize the efforts of his colllaborateurs ( awards etc..).
It is equally important for the health worker to be aware of the mental state of the patients. For this, some institutions in Haiti organize seminars for the care team in which role playings are accomplished by the participants, mimicking different situations that patients and providers may be confronted to. This has helped the care team better understand the patients' needs and reality.
On the patient's side, support groups are availble in most haitian sites for patients and their family. A buddy system has also helped with adherence to treatment. Most sites also have Field workers who go in the community and visit the patients at home and also call them when they miss an appointment. Emphasis has been made on educating the community using the media and also by having educational kiosks during public events ( church meetings,carnival, Block parties etc..)
Thank you both for sharing your perspectives. I agree that economic and resource considerations are very important and workers need to make a fair wage. On the other hand, by definition, working in the public health sector and in resource limited settings, I think that the level of compensation may always fall perhaps short of ideal expectations. So even as we work on this, other strategies have to be considered as well. I think Dr. Jasmin raised an important point, leadership at the front lines is critical. Leadership means that there is someone in charge who understands the dynamics between providers and patients and also can influence the providers. Perhaps this is something that we can share lessons with – do you know any great leaders who direct the attitude and activities of the clinic in a patient-centered way? Dr. Jasmin, do you have any examples from Haiti or Dr. Jebessa from Uganda? Another theme here is that community is also very important – patients must play their part too. It might be very helpful for there to be a formal mechanism with which the clinics and providers can capture the patient perspective and act on it to strengthen retention in care. Can I ask whether anyone has had any experience with patient satisfaction surveys? If so, what were the findings? If not, what do you think of this concept?
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