Falls remain a major geriatric problem, and the search for new solutions continues. We investigated how existing fall prevention technology was experienced within nursing home nurses' environment and workflow. Our NIH-funded study in an American nursing home was followed by a cultural learning exchange with a Dutch nursing home. We constructed two case reports from interview and observational data and compared the magnitude of falls, safety cultures, and technology characteristics and effectiveness. Falls were a high-magnitude problem at the US site, with a collectively vigilant safety culture attending to non-directional audible alarms; falls were a low-magnitude problem at the NL site which employed customizable, infrared sensors that directed text alerts to assigned staff members' mobile devices in patient-centered care culture. Across cases, 1) a coordinated communication system was essential in facilitating effective fall prevention alert response, and 2) nursing home safety culture is tightly associated with the chosen technological system.
Background: Provider recognition of level of functioning may be suboptimal in the dialysis setting, and this lack of recognition may lead to less patient-centered care. We aimed to assess whether delivery of an app-based, individualized functioning report would improve patients' perceptions of patient-centeredness of care.
Methods: In this pre-post pilot study at three outpatient dialysis facilities in metropolitan Atlanta, an individualized functioning report - including information on physical performance, perceived physical functioning, and community mobility - was delivered to patients receiving hemodialysis (n = 43) and their providers. Qualitative and quantitative approaches were used to gather patient and provider feedback to develop and assess the report and app. Paired t test was used to test for differences in patient perception of patient-centeredness of care (PPPC) scores (range, 1 = most patient-centered to 4 = least patient-centered) 1 month after report delivery.
Results: Delivery of the reports to both patients and providers was not associated with a subsequent change in patients' perceptions of patient-centeredness of their care (follow-up vs. baseline PPPC scores of 2.35 vs. 2.36; P > 0.9). However, patients and providers generally saw the potential of the report to improve the patient-centeredness of care and reacted positively to the individualized reports delivered in the pilot. Patients also reported willingness to undergo future assessments. However, while two-thirds of surveyed providers reported always or sometimes discussing the reports they received, most (98%) participating patients reported that no one on the dialysis care team had discussed the report with them within 1 month.
Conclusions: Potential lack of fidelity to the intervention precludes definitive conclusions about effects of the report on patient-centeredness of care. The disconnect between patients' and providers' perceptions of discussions of the report warrants future study. However, this study introduces a novel, individualized, multi-domain functional report that is easily implemented in the setting of hemodialysis. Our pilot study provides guidance for improving its use both clinically and in future pragmatic research studies, both within and beyond the dialysis population.
Background: Knowing how chronic kidney disease (CKD) patients talk about their encounters with providers (i.e., their discourse) can inform the important clinical goal of engaging patients in their chronic disease self-management. The aim of this study was to analyze patient discourse on ongoing CKD monitoring encounters for health communication strategies that motivate patient engagement. Methods: Passages regarding CKD monitoring from 6 focus group transcripts on self-management with a total of 30 participants age ≥ 70 years from the Atlanta Veterans Affairs Renal Clinic across three different CKD trajectories (stable, linear decline, and non-linear) were extracted. These passages were examined using three-stage critical discourse analysis (description, interpretation, explanation) for recurring patterns across groups. Results: Focus group participants were an average age of 75.1, 96.7% male, and 60% Black. Passages relating to CKD monitoring (n = 55) yielded predominantly negative communication themes. Perceived negative communication was characterized through a patient discourse of unequal exchange, whereby engaged patients would provide bodily fluids and time for appointments and continued to wait for meaningful, contextualized monitoring information from providers and/or disengaged providers who withheld that information. However, some encounters were depicted as helpful. Perceived positive communication was characterized by a patient discourse of kidney protection, whereby patients and providers collaborate in the mutual goal of preserving kidney function. Conclusions: Patient perceived an unequal exchange in CKD monitoring encounters. This perception appears rooted in a lack of easily understandable information. By accessing the positive discourse of protecting the kidneys (e.g., through eGFR level) vs. the discourse of damage (e.g., serum creatinine level), healthcare professionals can clarify the purpose of monitoring and in ways that motivate patient engagement in self-management. Patients being monitored for CKD progression may best be supported through messaging that conceptualizes monitoring as kidney protection and provides concrete contextualized information at each monitoring encounter.