The barriers and enablers of older person health assessments in Australian primary care: clinician and patient perspectives

i) Communication

Many patients reported difficulty undertaking HAs due to language barriers. Although patients were aware that an interpreter service could be offered, patients preferred to attend with a family member to overcome the language barrier so they could assist as an interpreter, or felt the need to see a doctor who spoke the same language to undertake a HA:

'Language is a problem.' (Outer metropolitan, patient 2)

'I had no idea what they were actually asking.' (Outer metropolitan, patient 3)

ii) Accessibility

Difficulty attending the clinic in person was cited as a barrier to attending HAs. Patients often had to rely on family to escort them to the clinic. Two of the 15 patients who underwent HAs in this study were accompanied by their daughters to undertake a HA:

'It’s not so easy for them to get to places where they can't drive or they don't drive or, you know, they're away from public transport.' (Outer metropolitan, patient 4)

One patient was also surprised to learn that funding to conduct HAs at home was no longer possible and she noted that her mother had previously undertaken a HA at home:

'That’s ridiculous. She became immobile and ended up needing a wheelchair. She had to be assessed at home.' (Outer metropolitan, patient 5)

iii) Lack of engagement

Some patients found the HA was not relevant to their current level of health and fitness. At least n = 2/15 patients were still in active employment and were offended that the HA questions had the general assumption that people lived at home and didn’t work:

'They assumed that I lived at home and didn't work.' (Inner metropolitan, patient 1)

The manner in which the HA questions were posed were also perceived as patronising to some patients:

'I didn't like the fact that some of the questions were fairly juvenile in terms of what your name was, what your address was, particularly after you've visited the clinic many times. And also, what day of the week it was. I mean, I used to be a manager … I used to be a tax agent. I worked very hard and very long, and … I believe I have a terrific brain. My body’s not so good. But my brain is probably a few years in front of my body. And questions like that just seem to be a little bit silly.' (Inner metropolitan, patient 1)

iv) Lack of patient preparation

Many patients did not understand or receive education regarding the purpose and need to undertake a HA. Some patients felt it was thrust on them by their doctors, whom they had known for many years, and did not understand the medical or personal benefits of HAs for patients:

'It was really put on; it wasn't something I'd chosen to do. I thought it was just part of the system.' (Inner metropolitan, patient 2)

Two patients viewed HAs as a tool that would primarily benefit clinicians by providing them with increased remuneration. One patient assumed that the HA provided the same benefit as a chronic disease management plan and did not provide any further advantage for patients, but saw HAs as an opportunity for increased remuneration for clinicians:

'The medical profession, maybe they try to separate the two to get fees from the government?' (Inner metropolitan, patient 2)

One patient also commented that time was a barrier to HA uptake due to needing to be seen by a nurse followed by a doctor for the completion of a HA, and expressed frustration of the lengthy waiting times that are common in general practice:

'They're [doctors] always late and that’s a disgrace because my time is more valuable than the doctor’s time.' (Inner metropolitan, patient 2)

i) Language, cultural, and educational barriers

The following themes were amalgamated due to an interrelationship between these factors evidenced by the need for an interpreter to overcome language barriers; a preference for alignment of cultural nuances with patients preferring to consult with a doctor of similar cultural background; and perceived feelings of fear or shame among patients due to presumed language insufficiency, cultural differences, or lack of education due to circumstance. Clinicians also perceived language to be a barrier to HAs because of the need to involve an interpreter (professional or family member), which made the assessment even more time-consuming:

'If I'm using an interpreter, it can take triple the amount of time.' (Outer metropolitan, GP1)

Overall, patients preferred to see a GP who spoke the same language and understood the subtle cultural nuances of a doctor–patient relationship. This meant the GPs of a similar cultural background to the patient often undertook the HA entirely themselves, without the assistance of the PN:

'I have a lot of patients [from the same cultural background as myself] who don’t speak any English. So, the health assessment, the whole thing would have to be done by me. So that takes a big chunk out of the session.' (Outer metropolitan, GP1)

Cultural barriers included societal perception of the role of the doctor as the healer and the rescuer, and the difficulty identifying risk factors and practising preventative medicine due to perceived cultural norms:

'My patients don't want to have any assessment. They just want what’s necessary, then they are fine. Also, they don’t want to be put into a nursing home. Well, you know, it’s a cultural thing, I suppose. Yeah. As well as the bit of paranoia that comes with whatever it is.' (Outer metropolitan, GP1)

An experienced primary care registered nurse discussed limited schooling as a HA barrier, which may also contribute to a general disinterest in HAs and fear of undertaking a HA due to associated feelings of fear and shame as it belittled their capacity:

'Admitting that they never attended school … the mathematical questions are too hard.' (Outer metropolitan, PN1)

ii) Time and funding

Experienced clinicians were in agreement that further background could be gleaned by conducting the HA in the patient's home but also discussed some of the associated challenges:

'Look, there’s no doubt in my belief, it’s ... it would be much more beneficial to do it in their own [home] probably to some extent, like doing house calls … I think, I think when you see people in the clinic room, you don't really get a true understanding of how the domestic situation is. So, you know, how they are negotiating rooms, getting access from beds, to toilets, getting out of chairs, the condition of how they're living. I mean, all these sorts of things you can't get from the verbal interview. So, I would certainly prefer to do it in a face-to-face setting in the home.' (Outer metropolitan, GP2)

'But from a practical point of view, that’s not always possible because of the time constraints. And also, the other problem is that, you know, for some of these elderly [older] patients, they require either a carer or a family member to be present. And there’s the difficulty of coordinating times.' (Outer metropolitan, GP2)

iii) Impact on the doctor–patient relationship

Some patients felt that doctors had a hidden agenda behind asking the patient to undertake the HA, and feared losing their independence. Many clinicians also felt that patients in general did not enjoy the experience of sharing their personal experience in the HA and that it negatively impacted the doctor–patient relationship:

'They feel like you've exposed them to somebody who’s asked them these really harsh questions.' (Outer metropolitan, GP3)

iv) Patient cognition

Patient cognition was identified as a barrier to HAs as it was found to affect the level of patient engagement and interest, as they did not want to be confronted with evidence of physical or mental deterioration in capacity:

'People don't want to know they're getting older, and they're not able to function as they used to be, you know, either mentally or physically.' (Outer metropolitan, GP3)

'If you do have a patient that’s not wanting to come in, [it’s] because they realise they are needing help.' (Outer metropolitan, GP3)

A summary of the major patient and clinician barriers of heath assessments identified can be reviewed in Supplementary Table S1.

i) Raises confidence in current health

Overall, patients unanimously agreed that HAs raised confidence in their current health status as it included detailed questioning of broad aspects of their physical and mental well-being and their supports:

'If anything didn't seem quite right. I would get told about it.' (Inner metropolitan, patient 2)

Patients also viewed HAs as an opportunity to discuss any of their own concerns in a safe and respected environment:

'It just takes a bit of pressure off yourself … that you're not going nutty?' (Outer metropolitan, patient 4)

ii) Opportunity to cover health concerns that do not always arise in shorter consults

The broad nature of the HA coverage allowed the patients opportunity to discuss issues that they would not normally require a medical consultation for, such as home support:

'It was smaller, more relaxed, and I could talk about little things. And that was great. Because I tend to hold a lot of things back a bit … by talking to somebody professional it’s released, gives you [some] life.' (Outer metropolitan, patient 4)

iii) Ensures that everyone is on the same page

Establishing common goals was a key patient enabler of HAs. Patients found it empowering to witness having their personal information, strengths, and limitations documented on file:

'I've got everything on record, I suppose.' (Inner metropolitan, patient 2)

iv) The comprehensive nature of the HA

Patients valued the comprehensive nature of the HA as it allowed the patient to have a good baseline summary of their health documented on record. Patients understood that this could be used as a baseline screening tool to monitor any subtle deteriorations in their capacity or well-being:

'It covers such a broad range of things. You talk about things that you might not otherwise talk about, you know, with a doctor in a short consultation.' (Inner metropolitan, patient 3)

'Everything done in one hit.' (Inner metropolitan, patient 4)

i) Comprehensive coverage of the HA

Clinicians also appreciated that HAs allowed a comprehensive assessment of the biopsychosocial needs of the patient. It allowed the identification of risk factors, such as risk of falls, and ensured that care was up-to-date:

'You feel like you've genuinely understood the patient.' (Outer metropolitan, GP4)

'It would give a comprehensive assessment of their whole life, I suppose and whether they've missed anything, for example, immunisations.' (Outer metropolitan, GP4)

ii) Opportunity to discuss difficult topics

The time pressures and day-to-day demands of general practice limit the opportunity to discuss important topics that may seem out of context to the patient, and HAs are an ideal opportunity to raise these issues in a formalised manner. These include difficult topics such as end-of-life care and appointing a power of attorney:

'I think HAs are great because we go into areas that normally don't come up, they're not always on the patient’s agenda.' (Outer metropolitan, GP4)

iii) Enabled the practice of preventive medicine

As patient files were routinely updated during the HAs, it was also noted to be a good opportunity to practice prevention of deterioration and disease.

'We identify their needs, and then we can guide them for necessary available services.' (Inner metropolitan, GP1)

'Because it’s so comprehensive, you end up reviewing things like, hearing, how they function, and safety, you know, falls risk so and can prevent things from happening. So, you know, you'd rather see the patient and talk about things that they can do to reduce falls than see them after a fall.' (Outer metropolitan, GP4)

'Well, I feel like you know, at least once a year, I get a good idea of how my patients are truly coping, it’s identifying problems that might arise before [they arise], it’s prevention medicine at its best, basically.' (Outer metropolitan, GP4)

iv) Opportunity for increased remuneration for GPs

Clinicians (n = 2/15) reported that the financial rebate associated with the annual HA was a good incentive and motivator for GPs to undertake annual HA to better understand their patients:

'If I was completely 100% honest, what I would say is that health assessments are these little financial rewards that Medicare allows us to claim in order to do what we should be doing regularly anyway.' (Inner metropolitan, GP2)