Exploring the Patient and Staff Experience With the Process of Primary Care

Elizabeth J. Brown; Shreya Kangovi; Christopher Sha; Sarah Johnson; Casey Chanton; Tamala Carter; David T. Grande

doi:10.1370/afm.1808

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Table 1

Participant Characteristics (N = 51)

Characteristic	Value
Practice staff (n=30)
Female, No. (%)	29 (97)
Race, No. (%)
Black	14 (47)
White	11 (37)
Asian	2 (7)
Other	3 (10)
Age, mean (SD), y	46 (11.1)
Practice site, No. (%)
Federally qualified health center	11 (37)
Academic practice	19 (63)
Job title, No. (%)
Administrator/Practice manager	4 (13)
Call Center/Front desk/Scheduler	7 (23)
Medical assistant	2 (7)
Physician	3 (10)
Nurse	7 (23)
Other (psychologist, nutritionist, case manager, social worker, pharmacist)	6 (20)
Patients (n=21)
Female, No. (%)	12 (57)
Black race, No. (%)	20 (95)
Age, mean (SD), y	50 (10.0)
Emergency department visits in 6 months prior, mean (range), No.	5.4 (0–20)
Insurance type, No. (%)
Medicaid	9 (43)
Uninsured	8 (38)
Dually eligible (Medicare/Medicaid)	3 (14)
Diagnoses, No. (%)
Hypertension	13 (65)
Hyperlipidemia	10 (50)
Diabetes	9 (40)
Mental illness/Addiction	8 (40)
Obesity	8 (40)
Congestive heart failure	6 (29)
Asthma/chronic obstructive pulmonary disease	5 (20)

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Table 2

Examples of Key Findings by Step in the Primary Care Process

	Previsit	Visit			Postvisit

Key Finding	Scheduling Appointments	Check-in	Rooming	Clinician Visit	Laboratory and Imaging
Information flow	Reason for visit not always clearly communicated or understood, leading to patients getting visit scheduled for something that could have been dealt with over the telephone	Changes to addresses or insurance information need to be updated in multiple places	Problems identified by MAs during screening not always seen by physician	Medication lists frequently not reconciled appropriately because patients assume the computer is correct	Laboratory orders not entered correctly or did not print, which causes confusion or errors when patient goes to laboratory
Alignment of goals and expectations	Open-access scheduling can conflict with patient’s need to be able to plan ahead	Patients frustrated with not being seen when late, even when public transportation issues were the cause	MAs caught between need to keep flow moving and increasing number of screening questions they are expected to ask	Patients have multiple concerns, and clinicians may be willing to address only 1 or 2 or prioritize chronic disease management	Prior authorization requirements of insurance companies conflict with patient and clinician desire for rapid access to needed tests
Personal relationships	Knowing which patients will have trouble scheduling follow-up can help care coordinators decide whom to schedule in advance	Patients feel comfortable with front desk staff whom they have known for many years	Patients more likely to discuss true reason for visit with staff they know well	Trust between patients and clinicians develops with time	Walking patients to laboratory prevents them from leaving before having tests completed

MA=medical assistant.

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Supplemental Appendix

Supplemental Appendix. Interview guides

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The Article in Brief

Exploring the Patient and Staff Experience With the Process of Primary Care

Elizabeth J. Brown , and colleagues

Background Surveys of patient experiences usually target Medicare and privately insured populations, leaving the lowest socioeconomic status patients' voices under-represented. This is the first qualitative study to assess the experience of both low income, chronically ill patients and the clinic staff who care for them during each step of the primary care process.

What This Study Found There are areas of agreement and tension between the needs and preferences of high-risk patients and staff in the primary care setting. Two major challenges frequently get in the way of an effective visit: 1) information flow, despite systems that are intended to improve communication and 2) misaligned goals and expectations among patients, clinicians and staff members. Personal relationships are highly valued by patients and staff.

Implications

The authors conclude that when considering how to improve the care of vulnerable patients, it is important to focus on improving information flow, aligning goals and expectations, and developing personal relationships.