13. transición hospital comunidad

8/14/2019 13. transicin hospital comunidad

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Hospitalecommunity interface: A qualitative study on patients with

cancer and health care providers experiences

Hanna Admi a,*, Ella Muller a, Lea Ungar b, Shmuel Reis b,e, Michael Kaffman b,c,Nurit Naveh b,c, Efrat Shadmi d

a Nursing Division, Rambam Health Care Campus, P.O.B. 9602, Haifa 31096, Israelb Department of Family Medicine, Clalit Health Services, Haifa District, Israelc Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israeld Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israele Faculty Development Unit, Bar Ilan University, Faculty of Medicine in the Galilee, Safed, Israel

Keywords:

Cancer patients

Oncology health care providers

Health care system barriers

Hospitalecommunity interface

Qualitative design

Care continuity

a b s t r a c t

Background:Patients with cancer must deal with complex and fragmented healthcare systems in addi-

tion to coping with the burden of their illness. To improve oncology treatment along the care continuum,

the barriers and facilitators for streamlined oncologic care need to be better understood.

Purpose:This study sought to gain insight into the hospitalecommunity interface from the point of view

of patients with cancer, their families, and health care providers on both sides of the interface i.e., the

community and hospital settings.

Methods and sample: The sample comprised 37 cancer patients, their family members, and 40 multi-

disciplinary health care providers. Twelve participants were interviewed individually and 65 took part in

10 focus groups. Based on the grounded theory approach, theoretical sampling and constant comparative

analyses were used.

Results:Two major concepts emerged: ambivalence and confusionand overcoming healthcare system

barriers.Ambiguity was expressed regarding the roles of health care providers in the community and inthe hospital. We identied three main strategies by which these patients and their families overcame

barriers within the system: patients and families became their own case managers; patients and health

care providers used informal routes of communication; and nurse specialists played a signicant role in

managing care.

Conclusions: The heavy reliance on informal routes of communication and integration by patients and

providers emphasizes the urgent need for change in order to improve coordinating mechanisms for

hospitalecommunity oncologic care.

2013 Elsevier Ltd. All rights reserved.

Introduction

Patients with cancer face a wide array of challenges in the

course of their care. In addition to dealing with disease symptoms,emotional stress, social and nancial pressures, and self-

management needs, patients often encounter a disarrayed

healthcare system and are charged with care navigation and

bureaucratic challenges. Care of patients with cancer is typically

provided across several settings, with a variety of providers

delivering various types of care at different stages, often with no

clear understanding of each others role(Stalhammar et al., 1998).

The difculties encountered by patients and their families in

navigating complex and fragmented healthcare systems have

been well documented in various healthcare systems worldwide(Berendsen et al., 2009;Farquhar et al., 2005). While barriers to

cancer care coordination are well acknowledged (Walsh et al.,

2010), to date, little is known of the mechanisms by which pa-

tients and their providers overcome system barriers to achieve

seamless cancer care.

Background

Uncertainty about the division of responsibility, poor commu-

nication among health care providers, and inadequate transfer of

information between hospital-based physicians and primary care

* Corresponding author. Tel.:972 4 8542395; fax: 972 4 8541696.

E-mail addresses: [email protected] (H. Admi), [email protected],

[email protected] (S. Reis).

Contents lists available at SciVerse ScienceDirect

European Journal of Oncology Nursing

j o u r n a l h o m e p a g e : w w w . e l s e v i e r .c o m / l o c a t e / e j o n

1462-3889/$ e see front matter 2013 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ejon.2013.02.005

European Journal of Oncology Nursing 17 (2013) 528e535
mailto:[email protected]:[email protected]:[email protected]://www.sciencedirect.com/science/journal/14623889http://www.elsevier.com/locate/ejonhttp://dx.doi.org/10.1016/j.ejon.2013.02.005http://dx.doi.org/10.1016/j.ejon.2013.02.005http://dx.doi.org/10.1016/j.ejon.2013.02.005http://dx.doi.org/10.1016/j.ejon.2013.02.005http://dx.doi.org/10.1016/j.ejon.2013.02.005http://dx.doi.org/10.1016/j.ejon.2013.02.005http://www.elsevier.com/locate/ejonhttp://www.sciencedirect.com/science/journal/14623889http://crossmark.crossref.org/dialog/?doi=10.1016/j.ejon.2013.02.005&domain=pdfmailto:[email protected]:[email protected]:[email protected]


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physicians (PCPs), constitute preventable breaches in care

(Farquhar et al., 2005;Sada et al., 2011). A recent qualitative study

identied six barriers to effective cancer care coordination:

confusion regarding roles and responsibilities of the health care

team, lack of multidisciplinary team meetings, lack of continuity in

transitioning across care settings, inadequate communication be-

tween specialists and primary care providers, inequitable access to

health services, and scarce professional resources (Walsh et al.,

2010). In addition, several studies have addressed communication

gaps, uncertainty about divisions of responsibility, and differences

in professional strategies of cancer management between PCPs and

oncologists (Babington et al., 2003; Barnes et al., 2000; Smeenk

et al., 2000;Klabunde et al., 2009).

While current literature acknowledges the deciencies in cancer

care integration, little is known on howpatients and their providers

manage their care across providers and care settings. This study

aims to ll this gap by examining the experiences of patients, their

families, and health care providers from community as well as

hospital settings.

Methods

This qualitative study is part of a larger study aimed at investi-

gating the factors inuencing the nature and quality of cancer care

at the hospitalecommunity interface (Shadmi et al., 2010). The

theoretical orientation for this qualitative study was based on

grounded theory, which develops a theory about phenomena of

interest from a corpus of data. Grounded theory is a complex iter-

ative process consisting of a series of steps, which after careful data

analysis, generates a theory (Glaser and Strauss, 1967; Lingard et al.,

2008;Strauss and Corbin, 2008).

Sampling

A purposive sampling method was employed to select partici-

pants, which included patients, their family members, and multi-disciplinary health care providers. Participants were selected for

the purpose of exploring their experiences with care provided in

both the hospital and the community care settings. The settings for

this study included oncology units and day care clinics in both

hospital and primary care clinics.

The eligibility criteria of patients and their family members

were: (1) a diagnosis with any type of cancer, (2) over 18 years of

age, (3) able to speak and understand Hebrew (4) agreement to

participate in focus groups or one-on-one interviews. Patients were

excluded if they met hospice care criteria or end-stage disease to

protect them from unwarranted emotional and physical exhaustion

at this point in their lives.

The health care staff participants were selected for their ability

to conrm or challenge the emerging theory. They represented amultidisciplinary team from the community and the hospital

health care sites. They all had extensive clinical and managerial

experience in the eld of oncology and agreed to participate in

focus groups or personal interviews. All interviewees were willing

to share from experiences within their context. Individual in-

terviews and focus groups were used in this study to increase the

probability of credible ndings and interpretations (Lincoln and

Guba, 1985).

Cycles of simultaneous data collection and analysis were

conducted where analysis informed the next cycle of data

collection. Sample sizes were determined based on ongoing data

collection, analysis and renement. Recruitment of participants

continued until data had reached saturation (Lingard et al.,

2008).

Data collection

Five focus groups that included patients and their families were

conducted. Each group comprisedve to eight members. Four focus

groups were conducted within a hospital setting among hospital-

ized and day care patients, and one within the community in a

primary care clinic. All potential participants were approached and

recruited voluntarily by local health care personnel. Patients and

their family members were asked about their community, hospital,

and transitional care experiences.

Triangulation technique is used to improve credibility of nd-

ings and interpretations (Lincoln and Guba, 1985). In this study we

used three modes of triangulation: multiple and different modes of

sources, methods and investigators. A mixed data collection

approach allowed for both proliferation of ideas (focus group) and

condentiality of in-depth personal interviews. Depth of perspec-

tive was made possible by involving several investigators from

different disciplines; their examination of the ndings as a group

helped avoid interpretive bias.

Interview guide

All focus groups and interviews took place during 2008. Focusgroups and interviews were led by seven researchers (three nurses,

three physicians, and one social worker) using complete topic

guided open-ended questions. For the study purposes we devel-

oped three sets of interviewguides, each oneaddressed to a specic

group of participants from both the community and the hospital:

patients and their families, health care personnel, and policy de-

cision makers. Each interview guide included questions in accor-

dance to the study aim tailored to the unique perspective of the

different participants. Examples of questions to patients included:

What do you do when you are at home and realize you have a

health problem? Who is managing your care at present? How

would you describe the types of care you received from your PCP?

What types of care do you receive from the oncology unit?

Initial grand tour questions were designed to promote opendiscussion and specic probes were pre-designed for subsequent

stages of the interview. Health care providers were asked: How do

you view the relationships at present between the PCP, oncologist,

and oncology nurse? In your opinion, what should be the PCPs

involvement during hospitalization of oncology patients under

their responsibility? What obstacles/difculties do you face in the

communityehospital interface at present? In your opinion, what

should be done to ensure continuity of care?

Each session lasted 60e90 min. All interviews were audio-

recorded and transcribed verbatim.

Analysis

Based on the grounded theory approach, purposive samplingand constant comparative analysis were used (Glaser and Strauss,

1967). All interview and focus group transcripts were reviewed

line by line to search for coding, themes, concepts, and propositions

that emerged from the data.

Four evaluative criteria (credibility, transferability, depend-

ability, and conrmability) for judging the rigor of qualitative in-

quiries were applied to increase trustworthiness of the analysis

process (Lincoln and Guba, 1985). To increase credible ndings, all

transcribed interviews were analyzed independently by at least

three of the researchers, followed by peer debrieng. Reections on

thedata and interpretations were discussed until consensus and

saturation of emerging themes were achieved. Theoretical sam-

pling continued, and the topical guide for interviews and focus

groups was modi

ed after initial analysis.

H. Admi et al. / European Journal of Oncology Nursing 17 (2013) 528e535 529


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Ethical considerations

Study approval was obtained from the institutional review

board of Rambam Health Care Campus. Informed consent was ob-

tained from participants prior to interviews or participation in a

focus group. To assure condentiality, all personal identifying in-

formation was removed from the transcripts prior to analysis.

Results

A total of 37 patients and their family members, and 40 health

care providers (physicians, nurses, social workers and administra-

tive assistances) participated in this study (Table 1). Thirteen phy-

sicians participated in the study. A focus group was conducted with

eight PCPs; personal interviews were conducted with ve oncolo-

gists in hospital and community settings. Sixteen nurses (head

nurses, oncology nurse specialists and senior nurses at the hospital;

community urban and rural nurses) participated in the study; 13

participated in two focus groups and three participated in personal

in-depth interviews. Five hospital social workers participated in a

focus group. Six administrators in the eld of oncology were also

included.

Two major categories emerged from analysis of the patient andprovider transcripts: Ambivalence and confusion and over-

coming healthcare system barriers.

Ambivalence and confusion

Perceptions of patients and family members

The attitudes of patients toward providers reected the gap

between patient needs and expectations of the healthcare system

and actual experience. When relating to the PCP, patients often

shared different experiences. Patients expected their PCP to show

personal interest in them when they get sick and while hospital-

ized. One patient, for example, shared his expectations from

the PCP:

I think the PCP needs to be involved and show interest. When you

nd out that you are ill you feel alone. As if you fall into a pit.

There is much loneliness. The PCP should call you and help and

not wait for my phone call. He doesnt callto ask how I feel and isnt

interested in my situation

Focus Group (FG) 5, Community, Patient 3

Another patient shared a completely different experience:

My PCP knows everything about me. He accompanies me and I

feel I am his patient every minute.

FG 3, Hospital, Patient 2

Table 1

Participants (patients, families and health care providers) according to data collection methods and interviewers.

1.1 Patients & families

Group no. No. of participants Participant characteristics Site Interviewer/Researchera

Focus groups

1 6 Patients & familiesb Hospital 1, 2

2 8 Patients & families Hospital 1, 2

3 5 Patients Hospital 7

4 7 Patients & families Hospital 7

5 8 Patients Community 3, 5

Total: 34 patients & familiesIn-depth personal interviews

1 1 Patient Community 6 MD



Total: 3 Patients

Total: 37 patients & families

1.2 Health care providers

Group no. No. of participants Participant characteristics Site Interviewer/Researchera

Focus groups

1 7 Oncology senior nurses Hospital 1, 2

2 6 Oncology nurse specialists Hospital 1, 2

3 5 Oncology social workers Hospital 1, 2

4 5 Oncology administrative assistants Hospital 1, 2

5 8 Primary care physicians Community 3, 5

Total: 31 health care providersIn-depth personal interviews

1 1 Medical director oncology division Hospital 1, 2 RN, RN

2 1 Medical director radiation unit Hospital 7, 2 RN, RN

3 1 Director of medical review (Physician) Hospital 1, 2 RN, RN

4 1 Medical review (Nurse) Hospital 1, 2 RN, RN

5 1 District medical director of oncology Community 4, 5 MD, MD

6 1 District medical director, HMO Community 4,5 MD, MD

7 1 Head nurse, rural clinic Community 3 SW

8 1 Head nurse, urban clinic Community 3 SW

9 1 Administrative assistant, urban clinic Community 3 SW

Total: 9 health care providers

Total: 40 health care providers

a Interviewer/Researcher: 1. RN, PhD: Director of Nursing, Rambam Health Care Campus (RHCC), Haifa. 2. RN, MA: Director of Oncology Nursing Division, RHCC, Haifa. 3.

SW, PhD: Social Worker, Department of Family Medicine, HMO, Haifa. 4e6. MD; Department of Family Medicine, HMO & Ruth and Bruce Rappaport, Faculty of Medicine,

Technion-Israel Institute of Technology, Haifa. 7. RN, PhD: Nurse Researcher, RN, Department of Nursing, University of Haifa.b

Overall,

ve spouses participated in three focus groups.

H. Admi et al. / European Journal of Oncology Nursing 17 (2013) 528e535530
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An issue that was raised by the some of the patients was that the

PCPs knowledge about oncology diseases was inadequate:

There is no point in turning to the primary care team. They know

nothing about oncology patients. My PCP doesnt know anything

about my diseases. Even when I ask him to send me to the ER he

sends me to a central community clinic.


Another patient stated how he knows to differentiate between

expectations from the PCP and the oncologist:

If its a simple matter that is not related directly to my oncologic

disease I consult my PCP. If for example I feel weakness Illrst turn

to my PCP. Based on my experience, my PCP is reliable and if he

doesnt know what is the reason for my complaint he will always

send me to a specialist doctor.


Patients were frustrated with having to nd their way between

the various providers; they were stressed by the bureaucratic

requirement to refer to their PCP before any specialist. In addition,

patients struggled with ambivalence; although frustrated because

of the lack of availability of their PCP, they still wanted closer

contact with them. In the words of one of the hospitalized

participants:

When you have a problem you must go directly to the emergency

room or to the oncologist. What can the family physician do? He is

not available. He is in the community clinic only twice a week. He is

my doctor, he knows me personally for years and he cares about

me. I can call him and sometimes he calls.


Over time, patients with cancer learn what to expect from their

PCP. They view the PCP as their personal physician who knows

them intimately, is a resource for general basic health care, and

sometimes serves as an administrator. Patients also becamefamiliar with the rules and regulations of the healthcare system. In

the following example, one patient expressed frustration that her

family doctor had to take on the role of administrator at the

expense of providing quality treatment.

It really bothers me that she has to be an administrator, because

that takes away from the time she has to deal with important

matters. She shouldght for getting the medications I need. She has

to negotiate for everything related to my cancer. She does it for me,

with a lot of respect, but this is an extraordinary waste of the time

of a high quality doctor.

FG 5, Community, Patient 2

Patients accorded great importance to maintaining continuity of

care and communication between providers on both sides of theinterface. Most referred to the present lack of such communication,

as indicated by this patient:

There needs to be connections between the family doctor and the

hospital. Ive never heard of such. I havent heard of a physician in

the hospital calling a family doctor. This doesnt happen.


Most patients interviewed expressed a desire for their family

doctor to take on the role of an integrator of care. One woman

explained the rationale behind this:

My expectations from my family doctor are that she will be an

integrator for the disease. Theres an oncologist, a hematologist, a

pain specialist. From my side, its totally acceptable that she (my

family doctor) should tell me that this is something she does not

know. She knows me not only in regard to the illness, but also from

my personality. She sees the whole picture. She sees me as a

whole human being.

FG5, Community, Patient 4

Although patients understood the limitations of their PCP, they

also expressed expectations for personal interest and communi-

cation that were sometimes unfullled. This was exemplied by

their repeated expectation that the PCP would call or visit during

the hospitalization.

Our ndings revealed disappointment among patients. They felt

they were at the mercy of a bureaucratic system. There was no

overall integrated plan for their management nor was there con-

tinuity of care, resulting in wasted time and energy. Patients were

aware of health care providers difculties, such as overload and

high turnover among oncology specialists, lack of oncologic

expertise among family doctors, and bureaucratic constraints.

Nevertheless, most of these patients were not sympathetic to the

limitations of the healthcare system, and expressed bitterness and

frustration. They expected guidance and coordination, ongoing

communication between providers, and to be treated as whole

human beings. Most patients looked to the family doctor to fulll

the role of case manager and coordinator of care, advocating on

their behalf within the healthcare system, and serving as the pri-

mary advocate for personal and medical problems.

Perceptions held by community-based providers

Community-based providers (policymakers, PCPs, nurses, and

oncologists) acknowledged difculties in communication amongst

themselves, as well as vis-a-vis hospital providers. This was espe-

cially striking against a backdrop of conviction that communication

was essential for maintaining care continuity and addressing pa-

tient needs within the broader context of their health history,

family, and socio-cultural background.

Most community providers perceived the PCP as a case manager,i.e., a coordinator of all providers, the patients advocate, and the

quintessential connection throughout all stages of treatment, and

across all care sites.

A medical administrator of the regional health maintenance

organization summarized the situation:

In the end, the responsibility for the oncology patient is on the

family doctor.

Interview, Community, Medical director 6

A PCP described her view of her role as a case manager and

patient advocate:

I always say that as their doctor, I will accompany them, and it

doesnt matter which station in oncology they reach, we continue

to be together; that means that there is no disconnect between the

patient and myself. This is something that occurs at one point in

time during a patients lifetime, during which I will stay by him; I

continue to be his doctor.

FG 5, Community, Physician 1

Interviewees differed in their perceptions of the reasons and

responsible agents for fragmentation in the healthcare system. As

expected, providersroles affected their views. For instance, in the

words of the head of the oncology service in the community:

Oncologists suffer greatly from lack of time. Therefore family

doctors must conduct follow-up of oncology patients; only that



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healthcare system as their experience with cancer care unfolds.

They expressed anger, confusion, and frustration at being tossed

around within the constraints of the healthcare system. In contrast,

they conveyed appreciation, respect, and gratitude toward health

care providers.

Among both community and hospital providers the general un-

certainty concerning the essence of their roles and responsibilities is

compounded by the absence of established communication pro-

cesses. Health care providers must deal with administrative and

organizational matters beyond their professional expertise.

Overcoming healthcare system barriers

Three main strategies by which different stakeholders have

overcome barriers, gaps, and confusion within the healthcare sys-

tem were identied. Some patients and family members became

their own case managers and emissaries. Another strategy was for

both patients and providers to use informal communication routes.

Finally, nurse specialists played a signicant role in managing care.

The patient with cancer as a case manager and emissary

Once patients and family members learn how the healthcare

system functions, either through their own experience or through

others, they frequently assumed responsibility for managing their

own care; many even became their own case managers. One pa-

tients wife expressed how exhausting this can be:

The running around between the family doctor, the hospital, and

the social security ofce is very difcult. I used to be a ghter but

not anymore, I gave up, the burden is so heavy and you dont know

how to navigate your own energy.

FG 2, Hospital, family member

When patients were asked to whom they turn when facing a

health problem while at home, the common answer was that their

decision making is based on the specic problem. A typical reply tothis question is exemplied by one hospitalized patient:

I decide to whom to turn according to the problem. If it has to do

with my surgery I refer to the surgeon. If I have a simple problem

that is not related to the oncological disease, I contact my family

doctor. When I cant dene the problem, for example, weakness, I

also contact my family doctor. From my experience, my family

doctor is conscientious and when he doesnt have specic knowl-

edge, which he doesnt always have, he refers me to specialists.


During hospitalization the two healthcare systems, community

and hospital, are perceived as disconnected, and the patient be-

comes the link between them.

One patient who was hospitalized a number of times com-mented about the interface between hospital and community

doctors:

I arrived at the hospital on my own, it was at night.. until I was

discharged, I had no connection with my PCP since he cant help me

when Im hospitalized, but showing interest sometimes helps.

When I wasdischarged, I brought himthe discharge letter. I became

the expert in this eld. I think that a doctor should receive infor-

mation from a doctor, since in any case when I leave the hospital I

am in his [the PCPs] hands.

Interview, Hospital, Patient 1

Frequently, patients and their family members initiated contact

with PCPs, updating them so as to maintain treatment according to

oncological instructions, and to preserve channels of personal

communication, but without expecting medical expertise.

Informal routes of communication

In a number of instances, patients succeeded in advancing their

care through the use of personal relations, either by relying on

acquaintances within the system or by establishing a good personal

rapport with a provider.

In the words of one patient:

A patient with cancer must have connections, otherwise he gets

lost in fairyland: go there, come back, wait, and so on.


An experienced doctor shared:

It all depends on the relationships youhad before with your cancer

patient; if you had a good relationship with him, and he was

connected to you, then afterwards, when he is in the hospital, he

will expect you to continue the connection.


Doctors, nurses, administrative managers, and secretaries

repeatedly emphasized the importance of personal relations for

shortening waiting times for scheduling therapy, tests, and

appointments.

A PCP explained:

It depends on whom you know. If you have personal relations with

a physician then you feel you can call and contribute to the care

plan, and receive information about your patient. If not, you

depend on thecancerpatient andthe completeness and accuracy of

information in the electronic medical record.


A nurse in a rural clinic (kibbutz) described how personal re-

lations help with care management:

I made connection with two particular nurses, and with another

one, relating to a patient with cancer who had passed away. We

were all the time in touch. I had their phone numbers, and they had

mine. From the moment that they saw me, and knew who they

were talking to, they were with me, since we both wanted to suc-

ceed. Its a common goal, and we must work together e this

changed everything. When the patient died, I called the hospital to

tell them, and to thank them.

Interview, Community, nurse 7

These examples demonstrate a shared model of care among

health care providers, based on informal personal communication,

within a system that has no inherent solutions for transitioning

across health care settings.

Management of care by a hospital nurse specialist

Cancer patients and health care providers alike noted that the

oncological nurse specialist played a signicant role in managing

health care.

One cancer patient explained:

With every problem that arises, I refer to the nurse at the hospital,

she always solves the problem professionally and efciently.

Once when my immune system was showing deterioration, the

nurse told me to go to the hospital. I was in fact hospitalized. The

rst thing that comes to my mind is to get to the hospital or to call.

We have her cell phone number.




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A nurse specialist at the hospital described her experience and

perspective:

I shorten processes in medical committees through my connec-

tions with people in the system and with other nurse specialists in

different organizations. We exchange information and help in any

way we can, with the belief that the patients benet is above all

other considerations.

FG 1, Hospital, Nurse 3

The nurse specialists role was considered very important; she

navigates between functionaries to ensure continuity of care, to

provide support, and to help overcome administrative and

bureaucratic barriers.

Discussion

This study adds to the accumulating knowledge about conti-

nuity of care in transitions between hospital and community health

care, from the perspective of patients with cancer and their family

members, as well as multidisciplinary health care providers across

settings. Our ndings revealed signicant deciencies in continuityand integration, unclear division of responsibilities, ambiguous

denitions of professional roles, and a lack of established means of

communication across care settings. The study ndings indicate

that patients with cancer and health care providers have similar

views on the types of challenges patients encounter at the interface

between community and hospital care (Fig. 1).

Recently, six United States professional medical organizations

developed consensus principles and standards to address gaps in

the transition of care (Snow et al., 2009). The consensus highlights

the inherent challenges in current health systems, each with its

unique characteristics, yet all characterized by varying types of

fragmentation. Our study highlights the efforts made by cancer

patients their providers and the solutions they nd to overcome

barriers within the system in order to achieve effective care inte-

gration. A common nding was that often nurse coordinators or the

PCP, assumes the vital role of coordinating information and ser-

vices. Yet formal coordinating roles are often not clearly dened or

systematic, and patients and family members often assume

informal roles of care coordinators. The coordinators role in over-

coming bureaucratic, communication, and structural gaps emerged

as a signicant contributor to seamless care. Additionally, informal

routes of communication (even between providers) were

mentioned as effective means of overcoming fragmentation in care.

Several recent studies (Campbell et al., 2010;Farrell et al., 2011;

Lee et al., 2011;OToole et al., 2009) support our ndings. A quali-

tative Australian study of cancer care coordination concludes that

having a key contactperson is essential for effective care coordi-

nation, the organization of services, information sharing, and for

upholding an ongoing therapeutic relationship (Walsh et al., 2011).

The need for involvement of primary care providers was also

evident from the results of our previous quantitative study, where

91% of the cancer patients reported that when they have a health

problem they consult their PCP (Shadmi et al., 2010). The ndings of

this study emphasize the importance of increased PCP involvementin advanced cancer patient care, and nurses critical roles in care

integration for reducing barriers to care.

Limitations

This study was limited to one district in the northern part of

Israel and conducted in only one oncology center. In addition, the

diagnoses and severity of the participantsdiseases varied and may

have inuenced their experiences with the healthcare system.

Implications for policy and practice

Findings of the current study should encourage policymakers to

initiate implementation of structural and procedural changes and

redesign professional role denitions. Extending the roles of nurses

and PCPs to include clinical leadership and coordinators of care

across the community and tertiary settings may promote compre-

hensive and continuous care for oncology patients.

Further development of communication strategies (e.g. personal

contact, electronic communications, and scheduled meetings), as

well as linking structures (e.g. assignment of a designated patient

navigator), is crucial for optimizing quality and continuity of care

and for maintaining inter-professional work, for the benet of for

cancer patients, health professionals, and the healthcare system.

Finally, the applicability of the results of this study to other

healthcare systems cannot be ignored. While cultural and bureau-

cratic systems may differ, our research adds to the growing body of

evidence, making it clear that coordination and communication

problems should notbe ignored. The interface between community

and hospital settings merits careful examination to determine areas

of improvement.

Conicts of interest

None declared.

Acknowledgment

This study was funded by a grant from the Israeli National

Institute of Health Policy and Health Services Research number R/

2005/2006.Fig. 1. The hospitale

community interfaced

theoretical framework.

H. Admi et al. / European Journal of Oncology Nursing 17 (2013) 528e535534


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13. transición hospital comunidad

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