Understanding lifestyle and behavior change
Understanding lifestyle and behavior change
Qualitative studies help you plan interventions
The bottom line is that you can’t plan effective interventions for your patients if you don’t understand them. The days of the one-size-fits-all, "I-know-what’s-best-for-you" approach to health care delivery are dead.
Case managers deal with clients who have complex needs across the continuum. To achieve good outcomes, they must understand all the factors that affect the lives of those patients. The key to doing that will not be found in outcomes data but in the richness of qualitative research, says Gerri Lamb, PhD, RN, FAAN, senior corporate director for community programs at Carondelet Health Care in Tucson, AZ.
A new book, Changing Health Care: Creating Tomorrow’s Winning Health Enterprise Today, predicts that health plans and providers that don’t recognize the diverse needs of health care consumers and develop products that recognize diversity are doomed to failure. Some health care professionals and managed care plans already are working to learn more about the populations they serve. And the tool they’re using to gain more insight is qualitative research.
Here’s just one real-world example:
A professional group wanted to open a hospice for AIDS patients in the Minneapolis/St. Paul area. Instead of gathering a multidisciplinary group of providers to develop the hospice model, they asked AIDS patients what they wanted. The patients asked for small-scale, home-based care by people sensitive to the terminal nature of their illness. The hospice was developed with that intimate concept in mind, and it is flourishing.
The AIDS hospice project shows qualitative research in action, says Dan Detzner, PhD, a professor in family social science and associate dean of the College of Human Ecology at the University of Minnesota in St. Paul. "Listening to what people say they want instead of what professionals outside that community think they should want is the strength of qualitative research," he says. And from that type of understanding come effective case management interventions, say case managers and researchers who conduct qualitative research.
"If I don’t understand what is meaningful to you, how can I impact such behaviors as your willingness to take medications or keep appointments? I need to understand what is likely to motivate you," Lamb explains. Qualitative research can provide data and raise questions that quantitative methods can’t generate, because it allows for the discovery of the unexpected.
"The real value of qualitative research is to help you open up whole new areas of which very little is known. For example, case managers are involved in very complex decision making, many software companies are trying to develop tools to help facilitate that decision making, but to develop those tools right now is a little premature because we have very little understanding of the case management decision-making process," she says.
Lamb recalled a master’s thesis in which the degree candidate studied patients who make decisions contrary to the recom- mendations of health care professionals. "The patients’ stories about why they make these decisions were so different from our initial assumptions that it made us step back," she says. "Once we understood how patients made their decisions, it totally changed our strategies for working with those clients."
Qualitative research can help unlock the mystery of problematic or troublesome situations for which you have no clear solution, such as the question of why some clients resist change, Lamb says. "It can give you the tools to be more effective at your job."
In fact, every time you interview a client or provider to assess client needs or determine treatment or rehabilitation goals, you are conducting your own qualitative research. The key is to listen to the needs and goals of the client rather than project your own goals on to the client, Detzner says. (For more information on how to be an effective listener, see Case Management Advisor, February 1997, pp. 29-31.)
Qualitative research often seeks to "discover" rather than "verify," say Lamb and Detzner, and that makes it an excellent compliment or precursor to quantitative studies. Detzner explains that qualitative research methods include:
• spoken words;
• written words in journals, letters, and books;
• recorded field notes of observers or participants in meetings, rituals, and family life;
• life histories in written or oral form;
• visual observations, either live or videotaped.
(To learn more about qualitative research methods, see resource box, at right.)
There are case managers in the field already using qualitative research methods to solve difficult issues. When asked to develop a social work care coordination project for a Medicare risk plan, Gayle Whitcomb, MSW, MSG, a senior consultant with ElderMed America in Woodland Hills, CA, conducted in-depth interviews with providers and administrators to help identify the perceived needs of elderly patients, barriers to effective care, and care coordination opportunities. (For more on Whitcomb’s care coordination project, see story, p. 68.)
"If I had relied on the utilization numbers alone, I would have missed many of the issues we ended up addressing with our care coordination model," she says. "The numbers told us that seniors were making inappropriate use of medical services. We were able to use the numbers to make some assumptions about why patients were using services inappropriately, but we couldn’t get the whole picture," she says. "For example, numbers couldn’t tell us how all the providers and services fit together. Numbers couldn’t tell us how providers communicated with each other. We needed the interviews to design a care coordination model that would address the core issues and not just create another layer of case management."
United HealthCare in Minnetonka, MN, struggled to understand the health care needs of a Southeast Asian refugee population until it conducted qualitative research into the health and medical practices of that population, says Detzner, who helped the company conduct in-depth interviews with Southeast Asian elders.
"The first thing we discovered was that Southeast Asians do not separate mind, body, and spirit. Mental and physical health are one and the same for them. If they are depressed, it is not a separate issue from physiological illness. That’s extremely important to know." (For information about the mind/body connection, see story, p. 73.)
Other questions United HealthCare asked the Southeast Asians included:
• Who would you go to see if you felt sick?
• How do you communicate with a Western doctor?
"The idea is to ask the people themselves, not make assumptions based on your own perceptions. We learned, for example, that a Southeast Asian woman would never undress in front of a male doctor for an examination. Again, that’s important information for providers and payers to understand," Detzner says.
After the initial taped interviews were transcribed and translated, researchers looked for common themes. Researchers then returned to the elders interviewed earlier and asked whether they agreed with the findings.
"We asked them, How does this sound to you?’ We asked follow-up questions and probed even further. The problem with data drawn from random samples, as many quantitative studies are, is that we get objective data, but we don’t know what it means. Qualitative research attempts to get at that meaning," Detzner explains.
In addition, using written surveys to reach certain populations such as illiterate or non-English-speaking ones is difficult if not futile, he says.
Lamb agrees. "In Arizona we serve a very large Hispanic population," she says. "Rather than make assumptions about their health care needs, we are going out and talking to members of the Hispanic community."
Tools to open the black box’
"When you look at the case management literature, one of the first things you notice is the lack of clearly defined interventions. The tools of qualitative research could help open up that black box of case management and help us understand and talk more clearly about the important things case managers do, such as assessment, intervention, and planning," Lamb says.
"Case managers have placed a lot of energy into demonstrating outcomes. Qualitative research does help explain the meaning behind the outcomes data, but it can also be a useful tool to help case managers select their outcomes measures. Case managers need to select measurement instruments that are sensitive to the outcomes they affect. It’s your stories, your experience, your qualitative research that tell you, Yes, this tool measures what I do,’" Lamb explains.
[Editor’s note: For more information about Changing Health Care: Creating Tomorrow’s Winning Health Enterprise Today by Arthur Andersen consultants Kurt Miller and Sharyn Materna, contact Knowledge Exchange at (310) 394-5995.]
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