title: Primary care providers' experiences caring for complex patients in primary care: a qualitative study.
abstract: BACKGROUND
  Complex patients are increasingly common in primary care and often have poor clinical outcomes. Healthcare system barriers to effective care for complex patients have been previously described, but less is known about the potential impact and meaning of caring for complex patients on a daily basis for primary care providers (PCPs). Our objective was to describe PCPs' experiences providing care for complex patients, including their experiences of health system barriers and facilitators and their strategies to enhance provision of effective care.
  
  
  METHODS
  Using a general inductive approach, our qualitative research study was guided by an interpretive epistemology, or way of knowing. Our method for understanding included semi-structured in-depth interviews with internal medicine PCPs from two university-based and three community health clinics. We developed an interview guide, which included questions on PCPs' experiences, perceived system barriers and facilitators, and strategies to improve their ability to effectively treat complex patients. To focus interviews on real cases, providers were asked to bring de-identified clinical notes from patients they considered complex to the interview. Interview transcripts were coded and analyzed to develop categories from the raw data, which were then conceptualized into broad themes after team-based discussion.
  
  
  RESULTS
  PCPs (N = 15) described complex patients with multidimensional needs, such as socio-economic, medical, and mental health. A vision of optimal care emerged from the data, which included coordinating care, preventing hospitalizations, and developing patient trust. PCPs relied on professional values and individual care strategies to overcome local and system barriers. Team based approaches were endorsed to improve the management of complex patients.
  
  
  CONCLUSIONS
  Given the barriers to effective care described by PCPs, individual PCP efforts alone are unlikely to meet the needs of complex patients. To fulfill PCP's expressed concepts of optimal care, implementation of effective systemic approaches should be considered.
authors.affiliation: Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA. danielle.loeb@ucdenver.edu.
authors.forename: Danielle F
authors.identifier: http://orcid.org/0000-0003-1688-8799
authors.initials: DF
authors.lastname: Loeb
authors.affiliation: Kaiser Colorado, Kaiser Permanente Institute for Health Research, Denver, USA.|Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bayliss
authors.affiliation: Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA.
authors.forename: Carey
authors.initials: C
authors.lastname: Candrian
authors.affiliation: Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.
authors.forename: Frank V
authors.initials: FV
authors.lastname: deGruy
authors.affiliation: Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, 80045, USA.|Kaiser Colorado, Kaiser Permanente Institute for Health Research, Denver, USA.
authors.forename: Ingrid A
authors.initials: IA
authors.lastname: Binswanger
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002908:Chronic Disease; D003120:Colorado; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D018802:Patient-Centered Care / Q000458:organization & administration; D010817:Physician-Patient Relations; D011320:Primary Health Care / Q000458:organization & administration*; D036301:Qualitative Research; D011787:Quality of Health Care
keywords: Chronic disease; Doctor-patient relationship; Medical comorbidity; Medical home/patient-centered medical home; Primary care; Work related stress