Research: The Wife Caregiver of the Prostate Cancer Patient at Home

July, 2014

I am pleased to share the Abstract of the doctoral dissertation of Mary Beth O'Brien, Ph.D., who recently completed research regarding the wife caregiver to the prostate cancer patient.

Abstract

Wife Caregiver Experiences in the Prostate Cancer Patient at Home

by

Mary Elizabeth O’Brien

MSN, Catholic University, 1982

BSN, Alderson-Broaddus College, 1974

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Health Services

Walden University

August 2014

Abstract

The purpose of this qualitative case study was to explore the experiences of wife caregivers of patients diagnosed with prostate cancer cared for in the home rather than in a medical facility. The focus was on understanding their experiences using Lawton’s Appraisal of Caregiving Scale interview schedule and one open-ended question. Guided by systems theory and stress theory, this study examined the caregiving demands, whether these demands reduced the quality of life for the wives, and whether caregivers have sufficient information to care for their husbands at home. Twenty wife caregivers were asked to describe their specific personal experiences. The data sources analyzed were the demographic matrix, the interview schedule using the Likert scale, and the one open-ended question. Findings revealed that the wife caregivers and their husbands with older age, more education, or more years of marriage were less burdened by the demands of caregiving, and this responsibility did not appear to affect their quality of life. However, the wives acknowledged needing more information to provide adequate care for the husbands when at home. The implications for social change for health care professionals in understanding the wives’ caregiving experiences might reveal a new dimension in caregiving and contribute to the social change dynamic of care for both the prostate cancer patient and his caregiver.

Responding to Disaster | West Virginia Water Contamination

Responding to Disaster | West Virginia Water Contamination

Complete credit to H&HN and author Fran Atkinson.  Used in Class Discussion.
REH

H&HN Daily

Seven Steps to Engaging Your Hospital Staff

01.09.14 by Fran Atkinson, Anne S. Klein

Kennedy Health System senior leaders and front-line staff created a consistent message about their organization and set mutual expectations for interacting with patients and the community.

Kennedy Health System in Cherry Hill, N.J., faced a challenge: Patient satisfaction scores were below the system's goals. And Kennedy's senior team was not sure what front-line staff members were telling patients and others outside the hospital about Kennedy, its services, its care and its commitment to the community.

In addition, the senior team recognized they needed to create a consistent messaging platform with other key audiences, both internal and external. What messages should the senior staff communicate to physicians and others within the health system? What messages should the nursing staff communicate to patients? Moreover, what messages should advertisements and marketing materials communicate to the outside world? Who is Kennedy? What does Kennedy stand for?

Working with a public relations firm specializing in health care communications, the senior team at Kennedy Health System obtained feedback from executives and employees. The goal was to frame messaging that would unite the executive team and the employees in their perception of Kennedy as different from other health systems in the area.

Here's how we did it, and how you can do it, too:

Step 1: Interview executives to establish a benchmark. We began by interviewing 15 senior leaders individually. We wanted to know what they thought were the most vital messages to impart to patients and others. What were Kennedy's strengths; what were the differentiators? As a community-based hospital, what did the senior leaders think were the most compelling messages to focus on, and what were the challenges to be overcome?

There was agreement that the three hospitals in the system were the first step to health care services in the area: When patients come to the hospital, Kennedy clinicians care for them directly and may arrange for them to receive additional health services upon discharge from the hospital. Kennedy's senior team was proud of the primary care physician network; the warm, comfortable hospital environment; and the staff. But there were many questions about whether staff were happy to be part of the Kennedy family. We would find out.

Step 2: Invite employees to participate. We convened four focus groups: non-executive managers, nurses, and two other groups from Kennedy's three hospitals as well as ambulatory services. We wanted to know if the members of these groups had the same thoughts about the hospital, its quality of care and its offerings.

Step 3: Listen to what employees say. We were happy to learn that employees were proud to be a part of the Kennedy family. They believed they provided excellent care. They were eager to know what to say to patients and even to their own families and friends. But we discovered there was a disconnect between what the senior leadership team discussed and communicated among themselves and what they communicated down the line. For example, senior managers liked positioning Kennedy as the "front door" to health care. When we discussed this concept with employees, they were not as enthusiastic. A simple change to using the term "gateway" to health care left employees feeling positive about their contribution to the health system's messaging and empowered by the organization's position in the marketplace. The focus groups opened up communication and made a world of difference.

Step 4: Incorporate what you learn. The research identified common themes all employees agreed upon that ultimately shaped the key messages and talking points: sense of community, culture and vision, quality of care outcomes, and patient satisfaction. The final messages and talking points encompassed Kennedy's vision for health care delivery and distinguished Kennedy from other area hospitals and health systems.

Step 5: Evaluate other communication tools, too. We evaluated presentations, social media content, surveys, memos, magazines, newsletters, patient information and other documents our organization produces. To ensure that all communications would be consistent, we conducted an audit of nearly 90 internal and external documents. Similar to the messaging research, the publications audit revealed opportunities to improve consistency in messaging for internal and external communications.

Step 6: Achieve CEO buy-in. Reviewing the findings from the focus groups and the publications audit, the CEO saw firsthand how improved consistency in messaging and branding could help him achieve his vision for the health system. He approved the changes immediately. The rollout happened quickly, because the recommendations made sense.

Step 7: Roll out the changes. We wanted to get employees excited about their role in relaying important messaging to patients by creating buzz about the findings. After all, the staff helped us by providing input. One week after presenting the research results, the Kennedy communications team began holding a series of briefing meetings to introduce the new key message platform to departmental managers and implement the recommendations from the publications audit. The key messages set Kennedy apart from its competitors and are now used both internally as the foundation for employee communications and externally as the foundation for executive presentations.

The nursing staff were trained on the messaging strategy so their behaviors reflected what they were saying. Nurses are taught to respond and communicate the "why" of statements. They are taught to be "in the moment" and to listen carefully and respond quickly to a patient's concern or request. A system of "bundled" actions was implemented that included regular rounding in patient rooms, along with scripted messaging which is delivered in a consistent manner.

Key Lessons from Kennedy's Journey

The process of engaging employees to assist in message development is a critical step in defining the persona of your hospital and health system. Teaching middle managers the necessity of being good communicators is a vital step in the process. And reinforcing the message by teaching consistent behaviors is essential in positioning your hospital and health system and distinguishing it from its competitors.

As Kennedy has learned, no hospital can afford to ignore good internal communications.

Fran Atkinson is the vice president of marketing at Kennedy Health System in Cherry Hill, N.J. Anne S. Klein is the founder and president of Anne Klein Communications Group LLC in Mount Laurel, N.J.

Predictions for 2014 with complete credit to H&HN Daily and author… Paul Keckley.
1/6/2014 Dr. Robert E. Hoye

H&HN Daily

What to Expect in 2014

01.06.14 by Paul Keckley

From declining reimbursements to narrow networks, hospital leaders face some daunting challenges this year. Paul Keckley takes a look at the biggest trends that are likely to shape the field.

Entering 2014, key elements in the external environment for hospitals are clear …

• Medicare will continue to cut reimbursement to hospitals. The Congressional Budget Office has forecast total health spending to increase 6 percent in 2014 vs. 4 percent annually for the past three years. But on a per capita basis, Medicare will be flat (vs. 0.4 percent in 2013) as a result of the sequester and expanded enrollment in the program.

• Medicaid will expand dramatically. Through mid-December, new enrollment in Medicaid via HealthCare.gov tops 900,000. At the same time, 26 states are expanding enrollment in sync with the Affordable Care Act. For hospitals, the Medicaid payer mix will increase exponentially, cutting into already stretched operating margins. Complicating matters, private health plans are lining up to convert Medicaid to managed care for states — a huge growth engine for their investors premised on lower payments to hospitals and limits on access to specialists.

• Employers will be active shoppers. Three in four employers will limit employee choices of local hospitals and doctors via high-deductible plans that offer narrower networks of hospitals and doctors. They’ll push for hospital price transparency and use reference pricing to base their payments. With the employer mandate delayed to 2015 and health spending spiking up, cost will be the employer’s issue. Some will play; others will pay the penalty and walk away. Hospital direct-contracting with employers, therefore, will be based on competitive pricing and a willingness to share risk for improved value in specific high-volume, high-cost clinical categories like joint replacement and open-heart surgery. Employers in certain industries and markets will contract for services with nonlocal hospitals and physicians to garner a value advantage.

• Medical device and drug companies will make new deals with hospitals. Drug and device manufacturers will pursue gain-sharing arrangements with hospitals that protect their volumes, wholesale margins and share of mind with physicians. As a result, the hospital supply chain will be re-engineered as manufacturers look for deals, which will face intensified scrutiny from regulators and the media as incentives must not induce unnecessary utilization or unusual financial gain to the parties.

• Bad debt will increase as margins from patient care will shrink. Hospitals will see increased severity of their patient populations, fewer with commercial coverage, and tougher negotiations with private insurers. Medicare will expand its policy of site-neutral reimbursement for outpatient tests and services, further cutting margins. The compound impact of slower-than-expected uptake of coverage via Healthcare.gov, reluctance in states to expand Medicaid, medical inflation anticipated at 3 percent, higher cost of capital and intensified competition means thinner margins in core patient care businesses and increased reliance on diversified businesses and unrestricted gifts to institutions.

• Insurers will play hardball with hospitals. Private insurance operators have had a good run since the ACA passed: Margins are strong even as enrollment shrank. They successfully passed through their costs of compliance with its new requirements in higher premiums, but those days are ending. Margins in their core business will shrink in coming years, prompting significant consolidation in the sector, and tougher negotiations with providers. For many plans, the gradual erosion in their group business will be replaced by strong retail and government businesses, but these growth markets bring lower operating margins to their businesses.Some insurers will seek to partner with hospitals via ACO agreements and narrow network agreements; others will compete directly with hospitals, acquiring medical practices and delivering outpatient services. And all expect the next few years to be challenging; thus, they’ll play hardball with hospitals — their primary target for health cost-reduction.

• Physicians will seek cover. Two-thirds of primary care and one-third of specialists currently depend on an exclusive relationship with a hospital for some or all of their incomes. Many of these are employed. But private health insurers and large medical groups are options for physicians seeking cover, and the terms of their deals dis-intermediate traditional hospital referral relationships. Medicare cuts and expansion of Medicaid enrollments will stress physicians forcing hospitals, in some cases, to make up the difference in lower payments to keep referral networks in tact.

Daunting as these seven are, many questions impacting hospital strategy remain unanswered going into 2014:

• Will Healthcare.gov and state exchanges be successful in reducing the ranks of the uninsured?
• Will private exchanges become the transitional bridge facilitating an employer’s transfer of financial risk to employees via high-deductible insurance programs?
• Will the results of key ACA demonstration and pilot programs — accountable care, patient-centered medical homes, et al. — justify their continuation or expansion?
• Will consumers push back from narrower networks of doctors and hospitals as insurers and employers advertise their advantages in prices, safety and quality?
• Will the political leaders in Red states not expanding their Medicaid programs change their minds?
• Will the Federal Reserve’s gradual easing of its inflation controls result in economic recovery that will not cause interest costs to soar?
• Will mergers among hospitals catch the ire of antitrust regulators?
• Will the backlash about the National Security Agency’s role in data-gathering activate public anxiety about the compromise of their personal health information?
• And what will happen in Campaign 2014 with 435 House seats, 33 Senate seats and 36 governors’ races to be decided? And how will changes in the composition of Congress and statehouses impact the ACA, budgets for Medicare and Medicaid, and more?

Against this backdrop, hospital leaders and boards must brace for the worst and hope for something better, and learn to live in uncertainty. The management dashboard, therefore, must carefully address these strategic imperatives:

Radical cost-reduction. Hospitals are labor-intense, capital-intense, and highly regulated at state and federal levels. In the immediate future, they’re also retailers for wellness, healthy living and over-the-counter self-care, managers of a professional network of physical and mental health providers, operators of long-term care services and facilities, and sponsors of health insurance plans sold to local and national employers and plans. Lowering operating costs across this complex system while deploying capital to targeted opportunities is key to survival: Core clinical programs must operate at Medicare rates. Diversified (non-third-party reimbursable) services must operate at levels that allow for value-based pricing. Radical cost-reduction will mean more than clinical program redesign and supply chain efficiency gains. It requires tough decisions about structure, people and processes, efficient acquisition of capital, and tough choices about which clinical services might be reduced or eliminated for institutional stability and sustainability.

Risk management. Hospitals must focus on three areas of risk: fraud, performance risk and payer-contracted risk. Fraud-related risk is well-understood and compliance efforts generally structured to avoid penalties. Performance risk — i.e., avoidable readmissions, overutilization of tests and procedures, medical error and safety — are nowhere near acceptable levels of preparedness in hospitals. And payer-contracted risk — i.e., the transition from volume to value via accountable care, medical homes and bundled payments et al. — is only modestly under way. The pace of the three is quickening, and the potential for revenue losses to competitors or penalties from regulators is increasing.

Physician alignment. Whether through employment or contractual means, exclusive relationships with a high-performing “group” of clinicians unafraid of risk, receptive to team-based delivery and accomplished in the use of clinical and administrative information technologies is the most difficult challenge facing hospitals. Clearly, transitioning from a facilitycentric brick-and-stick operating model to a regional care management organization with a wide scope of products and services requires physician input and active engagement. But conflicts with physicians take a toll: Physicians are increasingly dispassionate about their hospital loyalties. They want financial security and professional autonomy, and they’ll listen to any party that can deliver.

Growth. Scale in hospital operations is key. ‘Go big or get out’ is an imperative for most hospitals. Opportunities in adjacent sectors — like retail health, Medicare Advantage and population health — require new competencies that smaller, stand-alone players often are ill prepared to build or buy. And capital markets — lenders and investors — are skeptical about the sector’s ability to reinvent itself.

2014 is a pivotal year for hospitals. Boards and management must navigate the uncertainty while pursuing growth and re-engineering in their core business of patient care.

Paul H. Keckley is a health economist and leading expert on U.S. health reform and its impact. He recently retired as executive director for the Deloitte Center for Health Solutions, where he directed the center's nonpartisan studies that are prominently featured in congressional testimony and industry publications. His H&HN Daily column appears the first Monday of every month.