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PATIENT-CENTEREDNESS in PHARMACIST PRACTICE: Filling a Foundation for What Counts to Patients

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PATIENT-CENTEREDNESS in PHARMACIST PRACTICE: Filling a Foundation for What Counts to Patients PATIENT-CENTEREDNESS IN PHARMACIST PRACTICE: Filling a foundation for what counts to patients A Dissertation submitted to the Faculty of the University of Minnesota by ANTHONY W. OLSON In Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Advisor: Jon C. Schommer, Ph.D. July 2020 Copyright 2020 by Anthony W. Olson Acknowledgments First and foremost, I owe thanks to the study participants whose willingness to share their time, insights, and lived experiences made this work possible. I am grateful for the financial and instructional support from the Peters Endowment for Pharmacy Practice and Innovation and the Agency for Healthcare Research (AHRQ) – Practice-based Research Methods Fellowship. I must also recognize Anne Burns, Ann Byre, and Brian Isetts for their significant contributions as key informants for identifying and recruiting study participants. Jon, you have my deepest thanks and utmost admiration for all you do and who you are. Thank you for steering me throughout this journey, especially on the trips to Neptune. The Academy is filled with strong intellects like yourself, but few possess your kindness and compassion. You made me a better researcher and, more importantly, a better person. Brian, I cannot overestimate your insightfulness, relentlessness, and remarkable ability to make things happen. Thank you for always being in my corner, helping me to meet the moment, and pushing me to make my best better. I’ll cherish of our stimulating conversations, lunch-hour basketball, and pep talk from Lombardi himself. Tim, I am enormously grateful for the invaluable example and mentorship you’ve provided me since 2011. I’ll always remember that it our choices, more than anything else that make us who we are. Your commitment to service is inspiring and I can’t imagine my path in pharmacy without your influence. Rajiv, I sincerely appreciate your invaluable perspectives and infectious enthusiasm. I always leave our meetings with an exciting new idea to explore, and I look forward to continuing to do so. Lisa, my gratitude to you extends well beyond your coding contributions to this project. You are a dear friend and respected colleague. To Bob, Ryan, Greg, Christy, Debbie, Bithia, Mahsa, Alina, Bethany, Arun, Meena, Suhak, Zack and all other my colleagues in the Social & Administrative Pharmacy program, thank you for making the years so memorable, enjoyable, and educational. I look forward to seeing where the future takes each one of us. To Alison, Amy, Angie, Anne, Anton, Barb, Bob, Caity, Carl, Caroline, Cassie, Cynthia, Dan, David, Don, Gardner, Grant, Jacob, Jared, Jason, Jess, Joel, John, Karen, Keri, Kerry, Kuei, Laura, Marsha, Mike, Molly, Olihe, Oscar, Paul, Penny, Phyllis, Randy, Raquel, Reid, Ron, Sarah, Sean, Steve, Theo, Tom, Wade, Wendy, and Yee, a special thanks to each of you for providing a specific and unique contribution of knowledge, skill, motivation, and/or resource necessary to reach this goal. iii Dedication This dissertation is dedicated to my wife Tawny, my mother Deb, my father William, my sister Anna, and my daughter Audrey. You mean everything to me and this accomplishment is as much yours as it is mine. iv Abstract Background: There is general agreement among nearly all healthcare stakeholders that team-based, ‘Patient-Centered Care’ (PCC) is essential to successful prevention and management of chronic disease as well as the promotion of health and well-being. However, there is ambiguity and divergent thinking about the explicit meaning of the ‘Patient-Centeredness’ (PC) theoretical construct that informs PCC. Contemporary PC research has focused on identifying the commonalities of PC conceptualizations across healthcare populations (e.g., age, disease), settings (e.g., outpatient, inpatient), and professions (e.g., Medicine, Nursing) to reflect the interprofessional and team-based nature of contemporary healthcare practice. The Joint Commission of Pharmacy Practitioners’ “Pharmacists’ Patient Care Process” (PPCP) places PCC at the center of its model but provides little detail about the meaning of PC. A well-articulated conceptualization of PC is a necessary precursor for ensuring fidelity in the measurement, practice, and evaluation of team-based PCC provided by pharmacists with patients. Objectives: This study aims to (1) uncover how PC is defined and conceptualized in care provided by pharmacists with patients and (2) describe, interpret, and compare patient preferences and expectations of PC in care provided by pharmacists with patients. Methods: This study used a qualitative directed content analysis design. Data were collected using semi-structured, in-depth interviews from a key-informant nominated sample of patients and pharmacists spread over nine U.S. states and three types of outpatient care settings. All pharmacist study participants (n=9) were actively providing care services and had a minimum of 10,000 hours of experience providing care consistent with the PPCP. Patient study participants (n=6) were receiving care from pharmacists enrolled in the study and had multiple chronic conditions. The trustworthiness of the qualitative data collected was assessed using methods outlined by Guba & Krefting. Results: For Objective 1, analysis of the data and review of the pharmacy and broader PC literature yielded the “Team-based Outpatient Pharmacist Practice for Patient- Centeredness” (TOPPP) model, consisting of 13 concepts and seven conceptual groupings. A comparison between data provided by pharmacists and patients also showed high levels of agreement about the relative importance of each respective PC concept, with some differences. For Objective 2, data analysis revealed three patient archetypes related to PC preferences and expectations: ‘Partner,’ ‘Client,’ and ‘Customer.’ Discussion/Conclusion: The study’s first overarching finding is that PC in pharmacist practice is (a) broader in scope, (b) more granular in specificity and, (c) more connected to other healthcare disciplines than currently conceptualized. The study’s second overarching finding is that PC in pharmacist practice is achievable across outpatient care contexts, especially with careful recognition of the preferences and expectations of the patients participating in and receiving care. The findings from this study open numerous avenues for hypothesis generation and future research into PCC provided by pharmacists with patients about best practices, professional training, measurement validation, system design, value-based payment assessments, and remediation of care barriers. v Table of Contents Acknowledgments iii Abstract v List of Tables x List of Figures xii List of Acronyms xiv CHAPTER 1. INTRODUCTION 1 Problem Statement 1 Rationale & Significance 5 Research Question & Objectives 5 Definitions & Terms 7 CHAPTER 2. LITERATURE REVIEW 9 Search Strategy, Protocols, & Results 9 Overview of the Patient-Centeredness Literature 18 The Formative Origins of Patient Centeredness 20 Early Interpretations & Development of the Patient-Centeredness 22 Construct The Conceptualization of Patient-Centeredness in Medicine 22 The Conceptualization of Patient-Centeredness in Health Public Policy 32 The Conceptualization of Patient-Centeredness in Nursing 40 Comparisons of Patient-Centeredness in Medicine, Health Public 47 Policy, & Nursing Contemporary Patient-Centeredness Conceptualizations (2010- 51 Present) vi Scholl’s “Integrative Model of Patient-Centeredness” 55 The “Gothenburg Model of Person-Centred Care” 59 Summary of the Contemporary Patient-Centeredness Research Space 61 The Patient-Centeredness Literature Gap in Pharmacy 65 Patient-Centeredness in the Pharmaceutical Care Practice Model 66 Cipolle, Strand, & Morley’s Approach to Patient-Centeredness 67 Shoemaker & de Oliveira’s Patient-Centeredness through ‘Openness’ 76 “Utrecht’s Model for Patient-Centred Communication in the 79 Pharmacy” Kibicho & Owczarzak’s “Patient-Centered Pharmacy Services Model” 84 CHAPTER 3. METHODOLOGY 90 Inclusion & Exclusion Criteria 93 Data Privacy Considerations 94 Data Collection Procedures 95 Data Coding 100 Data Analysis Plan 103 3.1 Data Analysis Plan for Objective 1 104 3.2 Data Analysis Plan for Objective 2 106 3.3 Data Analysis Plan for Qualitative Trustworthiness 107 CHAPTER 4. RESULTS 111 4.1 Results for Objective 1 111 Biopsychosocial Perspective 124 Patient as a Unique Person 126 vii Care Mediators & Moderators 128 Patient-Pharmacist Relationship 133 Clinician Characteristics 137 Care Coordination & Integration 143 Macro Environment 145 The “Team-based Outpatient Pharmacist Practice for Patient- 153 Centeredness” Model 4.2 Results for Objective 2 156 Partner Archetype of Patient-Pharmacist Care Relationships 158 Client Archetype of Patient-Pharmacist Care Relationships 165 Customer Archetype of Patient-Pharmacist Care Relationships 171 4.3 Results for Qualitative Trustworthiness 175 Floyd (Iowa Patient) 180 Kate (Iowa Pharmacist) 181 Joan (California Patient) 184 Helen (California Pharmacist) 187 Viktor (Minnesota Patient) 188 Minnie (Minnesota Patient) 191 Goldie (Minnesota Pharmacist) 193 Aggie (Texas Patient) 195 Albert (Texas Pharmacist) 198 Madison (Virginia Patient) 200 Ronda (Virginia Pharmacist) 203 viii Gloria (Florida Pharmacist) 205 Miranda (North Carolina Pharmacist) 207 Brutus (Ohio Pharmacist) 209 Mary (Washington Pharmacist) 212 CHAPTER 5. DISCUSSION 215 5.1 Discussion for Objective 1 215 5.1a Patient & Pharmacist Comparisons of Patient-Centeredness 215 Concept Importance 5.1b Conceptualizing
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