Data Collection
Telephone interviews were conducted between March 2016 and October 2016 using semistructured guides developed from the project aims and from related literature in implementation science.20,21 Interview domains included clinic structure, team member roles and responsibilities, current practices for collecting functional status data, and opinions on barriers and facilitators to assessing and recording functional status (Appendix:
). Interviews were recorded and transcribed verbatim.
Data Analysis
Rapid analysis, a team-based qualitative approach was used to engage efficiently and systematically with the data.22,23 This approach allowed results to be analyzed more quickly than in traditional qualitative analysis in order to inform intervention design and develop implementation strategies.23 Rapid analysis typically includes organization of interview data into summary templates, followed by a matrix analysis, which was used to create process maps.24
Summary Templates
Summary templates were developed from the interview guides by shortening each question into a representative code. The project team then read the transcripts and summarized key points in the appropriate section of the template. This process, known as data reduction, is used to organize and highlight material so conclusions can be drawn from the data easily.22 In order to maintain rigor and trustworthiness, one team member conducted the interview, and a different team member created the interview summary. All team members reviewed each summary and met regularly to discuss results.
The summary templates were converted into matrix analyses, a method of displaying data to identify relationships, including commonalities and differences.24 The matrixes were organized by stakeholder group and clinic in order to compare functional status assessment and documentation workflows across clinics.
Process Maps
Finally, the team used the matrix data to create process maps for each clinic of when, where, and by whom functional status information was assessed and documented. These maps were created using Microsoft Visio (Redmond, WA). The maps integrated perspectives from all participants to give an overview of the process for collecting functional status data in each clinic setting. To ensure accuracy, participants at each site received process maps to solicit feedback and validation.
Results
Forty-six participants at 6 medical centers (20 MDs and NPs, 19 RNs and LPNs, and 7 SWs) from 9 primary care clinics provided samples and interviews. The study team identified 3 general approaches to functional status assessment: (1) Routine collection of functional status data via a standardized clinical reminder; (2) Routine collection of functional status data via methods other than a clinical reminder (eg, a previsit telephone screen or electronic note template); and (3) Ad hoc approaches to measuring functional status (ie, no standard or routine approach to assessing or documenting functional status). The study team selected 4 clinics (2 PACTs and 2 GeriPACTs) clinics to serve as examples of the 3 identified approaches.
The processes for functional status assessment in each of 4 clinics are summarized in the following detailed descriptions (Table).
Clinic 1
Clinic 1 is a GeriPACT clinic that routinely assesses and documents functional status for all patients (efigure 1, available at feprac.com). The clinic’s current process includes 4 elements: (1) a patient questionnaire; (2) an annual clinical reminder administered by an RN; (3) a primary care provider (PCP) assessment; and (4) a postvisit SW assessment if referred by the PCP.
All newly referred patients are mailed a paper questionnaire that includes questions about their medical history and functional status. The patient is asked to bring the completed questionnaire to the first appointment. The clinic RN completes this form for returning patients at every visit during patient intake.
Second, the clinic uses an annual functional status clinical reminder for patients aged ≥ 75 years. The reminder includes questions about a patient’s ability to perform ADLs and IADLs with 3 to 4 response options for each question. If the clinical reminder is due at the time of a patient appointment, the RN fills out the reminder using information from the paper questionnaire. The RN also records this functional status in the nursing intake note. The RN may elect to designate the PCP as a cosigner for the nursing intake note especially if there are concerns about or changes in the patient’s functional status.
Third, the RN brings the paper form to the PCP, who often uses the questionnaire to guide the patient history. The PCP then uses the questionnaire and patient history to complete a functional status template within their visit note. The PCP also may use this information to inform patient care (eg, to make referrals to physical or occupational therapy).
Finally, the PCP might refer the patient to SW. The SW may be able to see the patient immediately after the PCP appointment, but if not, the SW follows up with a phone call to complete further functional status assessment and eligibility forms.
In addition to the above assessments by individual team members, the PACT has an interdisciplinary team huddle at the end of each clinic to discuss any issues or concerns about specific patients. The huddles often focus on issues related to functional status.