UC Berkeley

Patient-centered care represents a paradigm shift for healthcare as the field undergoes massive restructuring to align health services delivery systems with the health of the patient as conceptualized by the biopsychosocial model rather than the biomedical model. As paradigm shifts cannot be implemented in a piecemeal manner, members within healthcare organizations are at risk of initiative fatigue. To understand how to facilitate the implementation of patient-centered care, this dissertation consists of three papers addressing factors that impact patient-centered care at macro, meso, and micro levels. The first paper, “Patient-Centered Culture at Physician Practices During Interconnected Changes in Ownership, Size, and Specialty Mix,” was the first large, longitudinal study to simultaneously assess the effects of changes in size, ownership, and specialty mix on practices’ use of strategies to improve responsiveness to patients using difference-in-difference regression. Increases in practice size, rather than changes in ownership or specialty mix, were associated with decreased patient responsiveness. The implication is that modular organization designs may mitigate the risk of decreased patient-centeredness when practices transition ownership from physicians to systems. The second paper, “Primary Care Team Participation and Patients’ Experience of Chronic Illness Care,” uses hierarchical linear regression to examine the relationship between participatory communication among interprofessional primary care team members and patients’ experiences of chronic illness care. Rather than a synergistic relationship as hypothesized, the results indicate that more participatory communication among team members does not translate into better patients’ experiences of chronic illness care. For the third paper, “Patient Activation as a Pathway to Shared Decision-making among Adults with Diabetes or Cardiovascular Disease,” cross lagged panel models are used to estimate asymmetries in the bidirectional relationship of patient activation and patients’ experiences of shared decision-making among adults with diabetes and/or cardiovascular disease. Patient activation has a much stronger impact on patients’ experiences of shared decision-making than the reverse. The implication is that primary care practices should target shared decision-making interventions at activated patients, while prioritizing patient activation among patients with low activation. In conclusion, patient-centered healthcare might be best conceptualized as a complex adaptive system. People must be empowered to make decisions when their local circumstances are too complex for centralized control and information must be shared in the process to ensure efficient adaptation. The primary role of healthcare organizations in such a context is to establish guiding principles and enabling structures. Practice and research implications are discussed within this framework of healthcare as a complex adaptive system.