Patients’ understanding of shared decision-making in a mental health setting: The importance of the patient-provider relationship

Shared decision making is a fundamental component of patient-centered care and has been linked to positive health outcomes. Increasingly, researchers are turning their attention to shared decision making in mental health; however, few studies have explored decision making in these settings from patients’ perspectives. We examined patients’ accounts and understanding of shared decision making. We analyzed interviews from 54 veterans receiving outpatient mental health care at a Department of Veterans Affairs Medical Center in the United States. Although patients’ understanding of shared decision making was consistent with accounts published in the literature, participants reported that shared decision making goes well beyond these components. They identified the patient–provider relationship as the bedrock of shared decision making and highlighted several factors that interfere with shared decision making. Our findings highlight the importance of the patient–provider relationship as a fundamental element of shared decision making and point to areas for potential improvement

Social capital and burnout among mental healthcare providers

Background: Provider burnout is a critical problem in mental health services. Contributing factors have been explicated across three domains: personal, job and organizational characteristics. Of these, organizational characteristics, including workplace environment, appear to be particularly important given that most interventions addressing burnout via the other domains (e.g. bolstering personal coping skills) have been modestly effective at best. Aims: This study builds on previous research by using social capital as a framework for the experience of work social milieu, and aims to provide a richer understanding of how workplace social environment might impact burnout and help create more effective ways to reduce burnout. Methods: Providers (n = 40) taking part in a larger burnout intervention study were randomly selected to take part in interviews regarding their workplace environment and burnout. Participant responses were analyzed thematically. Results: Workplace social milieu revolved around two primary themes: workplace social capital in provider burnout and the protective qualities of social capital in cohesive work teams that appear to mitigate burnout. Conclusions: These results imply that work environments where managers support collaboration and social interaction among work teams may reduce burnout

Factors influencing patients’ preferences and perceived involvement in shared decision making in mental health care

Background: Although research has suggested that patients desire to participate in shared decision-making, recent studies show that most patients take a passive role in their treatment decisions. The discrepancy between patients’ expressed desire and actual behaviors underscores the need to better understand how patients perceive shared decision-making and what factors influence their participation. Aims: To investigate patients’ preferences and appraisals of their involvement in treatment decisions. Methods: Fifty-four qualitative interviews were conducted with veterans receiving outpatient mental health care at a U.S. Veterans Affairs Medical Center. Interviews were analyzed using thematic analysis. Results: Participants outlined several factors that influence their preferences and involvement in treatment decisions. These include the patient–provider relationship, fear of being judged, perceived inadequacy, and a history of substance abuse. Conclusion: Patients’ preferences and willingness to engage in shared decision-making fluctuate over time and are context dependent. A better understanding of these factors and a strong patient–provider relationship will facilitate better measurement and implementation of shared decision-making

Veterans’ perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication

Objectives Drawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication. Methods We interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach. Results Participants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers’ fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication. Conclusion Our findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans

Characterizing health care utilization following hospitalization for a traumatic brain injury: a retrospective cohort study

Objective: The purpose of this study was to characterize health services utilization among individuals hospitalized with a traumatic brain injury (TBI) 1-year post-injury. Methods: Using a retrospective cohort design, adult patients (n = 32, 042) hospitalized with a traumatic brain injury between 2005 and 2014 were selected from a statewide traumatic brain injury registry. Data on health services utilization for 1-year post-injury were extracted from electronic medical and administrative records. Descriptive statistics and logistic regression were used to characterize the cohort and a subgroup of superutilizers of health services. Results: One year after traumatic brain injury, 56% of participants used emergency department services, 80% received inpatient services, and 93% utilized outpatient health services. Superutilizers had ≥3 emergency department visits, ≥3 inpatient admissions, or ≥26 outpatient visits 1-year post-injury. Twenty-six percent of participants were superutilizers of emergency department services, 30% of inpatient services, and 26% of outpatient services. Superutilizers contributed to 81% of emergency department visits, 70% of inpatient visits, and 60% of outpatient visits. Factors associated with being a superutilizer included sex, race, residence, and insurance type. Conclusions: Several patient characteristics and demographic factors influenced patients’ healthcare utilization post-TBI. Findings provide opportunities for developing targeted interventions to improve patients’ health and traumatic brain injury-related healthcare delivery

Patients’ and caregivers’ perspectives on healthcare navigation in Central Indiana, USA after brain injury

Little research has documented the experiences of patients with traumatic brain injury (TBI) and their caregivers in navigating health systems for TBI care. In this qualitative study, we conducted semi-structured interviews with 62 participants (34 patients with moderate or severe TBI and 28 caregivers) from Central Indiana. Data were collected from January to September 2016 and analysed using a constructivist grounded theory approach. Participants discussed three significant challenges about navigating health services for TBI care: lack of support for care navigation, financial barriers, and communication barriers. Participants described how navigating outpatient healthcare services for TBI remains complex and emphasised the need for ongoing care navigation support throughout the care continuum. They detailed the long-term financial burden of TBI including high treatment costs, limited insurance coverage, and the emotional toll that financial stress has on their ability to navigate healthcare services for ongoing TBI-related needs. They also discussed how ineffective patient–provider communication and lack of reliable, timely and comprehensive health information about TBI limited their engagement in and navigation of TBI health services. Findings suggest that persons with TBI and their caregivers need ongoing support to manage the long-term impacts of TBI. Efforts to provide care coordination and navigation to patients with TBI and their families are urgently needed to facilitate greater access to care, effective healthcare navigation and improved health outcomes

The Relationship Between Race, Patient Activation, and Working Alliance: Implications for Patient Engagement in Mental Health Care

This study explored the relationship between race and two key aspects of patient engagement—patient activation and working alliance—among a sample of African-American and White veterans (N = 152) seeking medication management for mental health conditions. After adjusting for demographics, race was significantly associated with patient activation, working alliance, and medication adherence scores. Patient activation was also associated with working alliance. These results provide support for the consideration of race and ethnicity in facilitating patient engagement and patient activation in mental healthcare. Minority patients may benefit from targeted efforts to improve their active engagement in mental healthcare

Communicating with providers about racial healthcare disparities: The role of providers’ prior beliefs on their receptivity to different narrative frames

Objective Evaluate narratives aimed at motivating providers with different pre-existing beliefs to address racial healthcare disparities. Methods Survey experiment with 280 providers. Providers were classified as high or low in attributing disparities to providers (HPA versus LPA) and were randomly assigned to a non-narrative control or 1 of 2 narratives: “Provider Success” (provider successfully resolved problem involving Black patient) and “Provider Bias” (Black patient experienced racial bias, which remained unresolved). Participants' reactions to narratives (including identification with narrative) and likelihood of participating in disparities-reduction activities were immediately assessed. Four weeks later, participation in those activities was assessed, including self-reported participation in a disparities-reduction training course (primary outcome). Results Participation in training was higher among providers randomized to the Provider Success narrative compared to Provider Bias or Control. LPA participants had higher identification with Provider Success than Provider Bias narratives, whereas among HPA participants, differences in identification between the narratives were not significant. Conclusions Provider Success narratives led to greater participation in training than Provider Bias narratives, although providers’ pre-existing beliefs influenced the narrative they identified with. Practice implications Provider Success narratives may be more effective at motivating providers to address disparities than Provider Bias narratives, though more research is needed

Consumer and Relationship Factors Associated with Shared Decision-Making in Mental Health Consultations

Objective: This study explored the association between shared decision making and consumers’ illness management skills and consumer-provider relationships. Methods: Medication management appointments for 79 consumers were audio recorded. Independent coders rated overall shared decision making, minimum level of shared decision making, and consumer-provider agreement for 63 clients whose visit included a treatment decision. Mental health diagnoses, medication adherence, patient activation, illness management, working alliance, and length of consumer-provider relationships were also assessed. Correlation analyses were used to determine relationships among measures. Results: Overall shared decision making was not associated with any variables. Minimum levels of shared decision making were associated with higher scores on the bond subscale of the Working Alliance Inventory, indicating a higher degree of liking and trust, and with better medication adherence. Agreement was associated with shorter consumer-provider relationships. Conclusions: Consumer-provider relationships and shared decision making might have a more nuanced association than originally thought

Veterans Affairs Providers' Beliefs About the Contributors to and Responsibility for Reducing Racial and Ethnic Health Care Disparities

Purpose: Providers' beliefs about the causes of disparities and the entities responsible for addressing these disparities are important in designing disparity-reduction interventions aimed at providers. This secondary analysis of a larger study is aimed at evaluating perceptions of providers regarding the underlying causes of racial health care disparities and their views of who is responsible for reducing them. Methods: We surveyed 232 providers at 3 Veterans Affairs (VA) Medical Centers. Results: Sixty-nine percent of participants believed that minority patients in the United States receive lower quality health care. Most participants (64%) attributed differences in quality of care for minority patients in the VA health care system primarily to patients' socioeconomic status, followed by patient behavior (43%) and provider behaviors (33%). In contrast, most participants believed that the VA and other health care organizations (75%) and providers (70%) bear the responsibility for reducing disparities, while less than half (45%) believed that patients were responsible. Among provider-level contributors to disparities, providers' poor communication was the most widely endorsed (48%), while differences in prescribing of medications (13%) and in provision of specialty referrals (12%) were the least endorsed. Conclusions: Although most providers in the study did not believe that providers contribute to disparities, they do believe that they, along with health care organizations, have the responsibility to help reduce them. Interventions might focus on directly offering providers concrete ways that they can help reduce disparities, rather than focusing on simply raising awareness about disparities and their contributions to them