Long-standing physician-patient relationships are at the core of primary care.14
Many physician groups, including the American College of Physicians, the American Academy of Family Physicians, and the American Academy of Pediatrics, are embracing and promoting the notion of the ‘Patient-Centered Medical Home.’15
This model values an ongoing relationship with a personal physician trained to provide continuous and comprehensive care; care coordinated and integrated across the health care system, including the patient’s community; patients actively participating in decision-making; patients and families participating in quality improvement activities at the practice level; and improved access.15
In studying the perspectives of older adults whose clinic was closed, we have gained new insights into how attached patients can become to their ‘medical homes’ and how disruptive moving to a new medical home can be. This work builds on that of Casalino and colleagues who assessed the attitudes towards changes in practice structure from the perspective of the physician directors and administrators involved in making these decisions.16
In planning this study, we elected to focus on older patients and their reactions to the practice closure. Older individuals in this community are not affluent and have limited resources–making them a vulnerable cohort. Older patients are thought to be more loyal to their PCP and less likely to switch away from a PCP voluntarily.17–19
This study sheds light on the subject of how older patients balance the priorities of convenience and continuity in relation to their medical care.
Our findings suggest that when a change in care is forced upon patients (e.g., having to choose a new practice location or physician), thoughtful interventions to help with the transition are warranted. Although all patients received letters explaining the clinic closures and changes, one could argue that even more could have been done to help the patients to make well-informed decisions. Slide shows or pictures of the new clinic, informal ‘meet the physicians’ nights, tours or “open-houses” of the facilities, and designated forums for ‘questions and answers’ may have served to relieve concerns. Additionally, maps, specific information on distance and timing to clinic, and resources for the disabled might have preempted some access and facility issues.
Ubel and colleagues have described that accurate predictions about the emotional impact of potential outcomes are critical steps in making good health-care decisions.20
Miscalculations, due to lack of knowledge or personal awareness, can result in poor choices. Accordingly, processes that help patients facing such decisions to carefully contemplate the options and anticipate their likely experiences may prove meaningful. For instance, future patients facing similar circumstances might benefit from the knowledge that adjustment and acceptance improves steadily over time. Future research might explore how specific interventions, based on the concerns expressed by our patients, can mitigate the emotional impact of transition and improve patient satisfaction.
Although patients value continuity, empiric data have shown that only a few patients will spend additional time or money to maintain continuity.21
The patients believed to most value continuity include the elderly, the less educated, those with Medicare and Medicaid insurance, the chronically ill, and those with poor self-reported health status.22
The commentaries from our informants highlight the fact that current health status and concerns about future health problems may impede even those patients who would be willing to spend additional time or money in order to maintain continuity.
Several limitations of this study should be considered. This study relied exclusively on self-report. However, this is considered to be the most direct approach for understanding attitudes and beliefs. Secondly, the written format used for this study may have excluded low literacy, non-English speaking patients, and patients with certain cognitive and physical disabilities. Thirdly, this study involved only older patients from a single clinic in a specific geographic area and may not be generalizable to other patients or settings. Fourth, the timing of the inquiry, 8 months after the change, may have introduced some recall bias for patients elaborating on the rationale for their decision to select one site over the other. Fifth, the frequency with which any of the themes was described by informants was less than 50 percent. Qualitative analysis does not allow us to know whether ‘distance’ was a more important theme than ‘relationship with physician’ merely because it was mentioned more frequently. If all subjects were specifically asked about each theme, the number of comments related to each would certainly be higher. However, it is important to note that the responses emerging from the open-ended question about the impact of the closure of the primary clinic were spontaneous and unsolicited. Finally, despite the fact that our sample size was predetermined based on power calculations related to a quantitative arm of inquiry, the authorship team reviewing the narrative writings believes that thematic saturation was reached.
In conclusion, this study describes how older patients dealt with and felt about an unwanted major change in their health care. Individuals in this cohort made decisions based on their beliefs, attitudes, goals, and the resources available to them. Organizations may want to be particularly mindful of and sensitive to patients’ needs when planning changes that will be disruptive or impact upon continuity and prepare them for the complexities of what they are likely to experience.