“The More They Know, the Better Care They Can Give”: Patient Perspectives on Measuring Functional Status in Primary Care

Abstract

BACKGROUND: Despite its importance to care and outcomes for older adults, functional status is seldom routinely measured in primary care. Understanding patient perspectives is necessary to develop effective, patientcentered approaches for measuring function, yet we know little about patient views on this topic. OBJECTIVE: To examine patient and caregiver perspectives on measuring activities of daily living (ADLs) and instrumental ADLs (IADLs). DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: Twenty-eight patients aged 65 or older and five caregivers in primary care clinics at one Veterans Affairs Medical Center. APPROACH: We conducted interviews to elicit patient and caregiver perspectives on the importance of measuring function, including preferences for method of screening and assessment, wording of questions, and provider communication style. We analyzed interviews using qualitative thematic analysis. KEY RESULTS: We identified several themes related to measuring function in primary care. First, most participants reported that measuring function is part of quality, holistic care. However, a minority of participants noted that discussing function, especially IADLs, was not medically relevant. Second, in terms of preferences for measuring function, participants noted that interdisciplinary approaches to measuring function are optimal and that face-to-face assessment is most "intimate" and can prompt reflection on one's limitations. However, some participants indicated that self-assessment is less invasive than inperson assessment. Third, participants had varied preferences regarding communicating about function. Participants noted that asking about difficulty with activities versus need for help are distinct and complementary concepts and that providing context is essential when discussing sensitive topics such as functional decline.CONCLUSIONS: Most patients and caregivers reported that measuring function was important, preferred faceto-face assessment, and emphasized the importance of providing context when asking about function. These findings suggest that incorporating patient and caregiver preferences for measuring function can improve satisfaction and experience with functional assessment in primary care.

Using multiple qualitative methods to inform intervention development: Improving functional status measurement for older veterans in primary care settings

“…Four phases of analysis contributed to intervention development (Fig 1 ); additional methodologic details for developing process maps and analyzing PCP and patient interviews were previously published [53,54,57].…”

“…This medical center had routine, standardized processes in place for measuring functional status in primary care, allowing us to elicit patient feedback on these existing processes. We stratified recruitment by functional status (reported by PCPs), race/ethnicity, and gender [52,54]. For patients with cognitive impairment who were unable to provide informed consent but assented to participate, we obtained surrogate consent and recruited caregivers to participate.…”

“…Third, we used an inductive approach to qualitative thematic analysis of patient interviews to understand experience with and preferences for measurement [54,63]. We serially reviewed transcripts and developed and applied inductive codes.…”

Improving measurement of functional status among older adults in primary care: A pilot study

“…The development of the intervention and details of the intervention components have been previously described in detail [30]. The intervention was designed to incorporate patient and clinician preferences for functional status measurement and to address barriers to previous measurement approaches (Fig 1) [22,29]. The four components included: (1) an interprofessional educational session; (2) routine, standardized functional status measurement; (3) screening by nurses and follow-up PCP assessment when impairments were identified; and (4) electronic tools and templates to facilitate screening and assessment.…”

“…We identified provider-and system-level barriers to routine functional status measurement in primary care, including time pressures, cumbersome tools, and the perception that measurement would not be used to inform care [21,22]. We also identified patient preferences for measurement of functional status, including face-to-face screening, asking questions about both difficulty and need for help with daily activities, and providing context when asking potentially sensitive questions about function [29]. These findings informed the development of a multi-component intervention to improve measurement of functional status in VA primary care clinics…”