Beyond satisfaction: using the Dynamics of Care assessment to better understand patients' experiences in care.
BACKGROUND
Patient perceptions of and satisfaction with care have become important indicators of the quality of services and the relationship of services to treatment outcomes. However, assessment of these indicators continues to be plagued by measurement problems, particularly the lack of variance in satisfaction data. In this article, we present a new approach to better capture patient perceptions of experiences in care, the Dynamics of Care (DoC) assessment. It is an in-depth approach to defining and assessing patients' perspectives at different junctures in care, including their decisions about whether and where to seek care, the barriers encountered, and the treatments and services received.


METHODS
The purpose of this article is to describe, validate, and discuss the benefits and limitations of the DoC, which was administered as part of a longitudinal study to evaluate the New York State HIV Special Needs Plan (SNP), a Medicaid managed care model for people living with HIV/AIDS. Data are from 426 study respondents across two time points.


RESULTS
The results demonstrate the validity and value of the DoC. Help seeking decisions and satisfaction with care appear to be situation-specific, rather than person-specific. However, barriers to care appear to be more cross-situational for respondents, and may be associated with clients' living situations or care arrangements. Inventories in this assessment that were designed to identify potential deterrents to help seeking and difficulties encountered in care demonstrated clear principal component structures, and helped to explain satisfaction with care. The problem resolution index was found to be independent from satisfaction with care and the data were more normally distributed. DoC data were also associated with subsequent utilization and change in quality of life.


CONCLUSIONS
The DoC was designed to be a flexible, integrated measure to determine individuals' salient service needs, help seeking and experiences in care. One of the many strengths of the assessment is its focus on specific problems in context, thus providing a more sensitive and informative way to understand processes in care from the patient's perspective. This approach can be used to direct new programs and resources to the patients and situations that require them.
Rapkin
Bruce
B
Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, USA. rapkinb@mskcc.org
Weiss
Elisa
E
Chhabra
Rosy
R
Ryniker
Laura
L
Patel
Shilpa
S
Carness
Jason
J
Adsuar
Roberto
R
Kahalas
Wendy
W
Delemarter
Carol
C
Feldman
Ira
I
Delorenzo
Judy
J
Tanner
Ellen
E
D000328:Adult; D018588:Fee-for-Service Plans; D005260:Female; D015658:HIV Infections / Q000628:therapy*; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006801:Humans; D007407:Interviews as Topic; D008137:Longitudinal Studies; D008297:Male; D008484:Medicaid; D006278:Medicare; D008875:Middle Aged; D009518:New York; D010043:Outcome and Process Assessment, Health Care; D017060:Patient Satisfaction; D012044:Regression Analysis; D012747:Sexual Partners; D013221:State Health Plans; D014481:United States