Date of Award

January 2018

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Andre N. Sofair

Abstract

Objectives: To study communication in medicine within the context of readmission rates and patient satisfaction, by assessing 1) the perspectives of primary care physicians (PCPs) and home care nurses (HCNs) on why older adults are readmitted to the hospital within 30 days of discharge, and 2) patient perceptions regarding the implementation and value of bedside rounding.

Design: Two studies were performed independently. 1) A qualitative study consisting of PCPs and HCNs of patients readmitted to the hospital within 30 days of discharge home. 2) A concurrent mixed methods study consisting of patients admitted to the inpatient medicine service who participated in bedside rounds.

Materials and Methods: 1) Semi-structured open-ended qualitative phone interviews, and 2) qualitative in-person interviews followed by surveys including 5-item Likert scales and open-ended written responses. For qualitative analyses, interviews were repeated until thematic saturation was achieved.

Results: 1) While PCPs and nurses both mentioned disease progression and multi-morbidity as contributors to readmissions, nurses further described other psychosocial factors like home environment and patient motivation. PCPs often ascribed responsibility for the readmissions to specialists, hospitalists, and emergency physicians. Nurses expressed frustration about the lack of both communication and working relationships between them and PCPs. 2) Patients described positive attributes of bedside rounds: meeting the medical team and understanding more about their illness. Although patients enjoyed undivided attention from physicians, distractions included too many participants in rounds, confusion about roles, and unclear expectations about the goal of rounds. Physicians sought to use patient-centered language, but 53% of patients stated that medical jargon was still used. Male patients reported a statistically significant improvement in their understanding about the plan for the day and borderline significance regarding knowing who was responsible for their care compared to female patients.

Conclusion: Communication between HCNs and PCPs, and between patients and hospital teams can be improved. There should be an explicit agreement on roles, responsibilities, and coordination among all providers caring for a patient. Moreover, well-conducted, patient-centered bedside rounds greatly enhance patient-physician rapport and foster patient understanding and satisfaction.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 06/27/2019

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