Quality and coordination in home care: a national cross-sectional multicenter study – SPOTnat

Homecare services include a wide range of medical treatments and therapies, basic care (e.g., personal hygiene), domestic services (e.g., household support) and social services. However, it has been neglected in most countries compared to hospitals and nursing homes, especially regarding healthcare research. As a result, while many countries see high-quality, sustainable care at home as a high-value goal, there are many knowledge gaps in the homecare setting. For agencies, challenges include an increasing demand combined with a workforce shortage, constant cost pressure, and issues with both care coordination and care quality. Problematically, owing to a long shortage of research, knowledge of these elements is scant. In this sector, large-scale studies that consider macro-, meso-, and micro-level factors and incorporate multiple perspectives and measurements to capture coordination and quality of care are extremely rare. When the SPOTnat study (Spitex Koordination und Qualität - eine nationale Studie (homecare coordination and quality – a national study)) began, no published study had examined how homecare agencies perform regarding care coordination. More importantly, though, none had determined which factors are associated with care coordination in the homecare setting. Moreover, across the entire health sector, no clear, accepted concept was available either of what exactly constitutes coordination, or of what it entails. This dissertation is embedded in the SPOTnat study. Preparing it, the overall goal was to deepen our understanding of the homecare sector regarding care coordination and quality. Therefore, a preliminary goal was to clarify the concept of care coordination. Later goals included describing the various financial and regulatory mechanisms operating in the Swiss homecare setting. That information made it possible to explore how those factors relate to homecare agencies’ structures, processes, and working environments, how system and agency factors are related to care coordination, and ultimately how care coordination is related to quality of care. CHAPTER 1 presents the background, the target research gap and the rationale behind this dissertation. We look closely at the unique challenges of the homecare setting, particularly regarding coordination and care quality. In CHAPTER 2 we establish a theoretical basis for care coordination and explain how the concept of coordination can be understood and measured. Our newly-constructed COORA (care coordination) framework differentiates clearly between coordination as a process—i.e., tasks people perform to coordinate versus coordination as a state, i.e., the desired outcome of the coordination process. Applying this distinction to both measurement and interpretation of results helps avoid misleading conclusions. The COORA theoretical framework is based on the full range of influential coordination literature. Iteratively developed in consultation with healthcare professionals, patients and their relatives, it considers the complex relationships between the many factors influencing coordination (as an outcome), and is applicable not only to homecare but across healthcare settings. However, measurement of both care coordination and quality of care remains a challenge. Further research will be necessary to develop and validate a questionnaire that reliably measures care coordination as an outcome. CHAPTER 3 presents the research protocol for the SPOTnat study, a national multi-center cross-sectional survey in Swiss homecare settings. That study included 88 homecare agencies. Using public records and data from questionnaires sent to those agencies’ 3323 employees (including managers and homecare staff), 1508 clients and 1105 relatives of those clients, the SPOTnat research team gathered data on homecare financing mechanisms, agency characteristics and homecare employees' working environments and coordination activities, as well as staff- and patient-level perceptions of coordination and quality of care. CHAPTER 4 discusses our analyses of how regulatory and financial mechanisms explain differences in agency structures, processes and work environments. Based on the mechanisms acting on the participating agencies, we divided them into four groups. Our analyses showed considerable inter-group differences, especially in the range and volume of services provided, but also regarding their employment conditions and cost structures. The most prominent inter-group differences related to the conditions of their cantonal and municipal service agreements. Alongside such details, financial incentives must harmonize the care goals, i.e., achieving and maintaining accessible, high-quality homecare, with the regulatory goals, i.e., assuring the quality and financial sustainability of that care. CHAPTER 5 includes an analysis of how selected explicit and implicit agency-level coordination (process) mechanisms are linked to successful coordination (as an outcome). The results revealed that several implicit mechanisms, i.e., communication/information exchange, role clarity, mutual respect/trust, accountability/predictability/common perspectives, and knowledge of the health system, all correlate with employee-perceived coordination ratings. We also found that certain coordination mechanisms mediated the effects both of agency characteristics (i.e., staffing/ workload and overtime) and of external factors (i.e., regulations). In CHAPTER 6, the final included study gives insights regarding how both homecare employees’ and clients’ coordination-relevant perceptions relate to one another’s quality-of-care ratings. Our analyses indicate that employee-perceived care coordination ratings correlate positively with their own ratings of their quality of care, while client-perceived care coordination problems correlated inversely with client-reported quality of care. Client-perceived coordination problems also correlated positively with hospitalizations and unscheduled urgent medical visits, but not significantly with emergency department visits. No associations were found between employee-perceived coordination and either healthcare service utilization or client quality-of-care ratings. Alongside these relationships, various coordination deficiencies, for example, poor information flow, also became apparent. To conclude, CHAPTER 7 provides a synthesis of the main findings and discusses the results in relation to practical, political and research implications. While contributing further to the understanding of care coordination via the COORA framework, this dissertation also raises various methodological issues. From a practical perspective, measuring and operationalizing both coordinating processes and quality of care outcomes remain challenging issues. While our qualitative results suggest that improving coordination will lead to higher-quality care, testing and ultimately exploiting any such relationship will require not only improved financial and technical structures, but the abandonment of outmoded siloed attitudes regarding the entire homecare sector

Clarifying the muddy concept of home healthcare coordination: A comprehensive theoretical framework.

Effective healthcare coordination is vital when such care is provided as a collaborative effort by many individuals and their task activities are interdependent. Coordination is necessary to ensure that care not only meets the needs of patients, but also avoids negative consequences for them due to omitted, inefficient, unnecessary, or even incorrect treatments. It also helps conserve resources. This has contributed to a rapid increase in articles on this subject. Still, while care coordination topics are gaining the attention of researchers, there are a number of issues experienced, including the delineation of limitations, inconsistent definitions, and problems with measurement. Therefore, the aim of this article is to refine the concept of homecare coordination and provide a comprehensive theoretical framework, illustrated with examples from practice. Focusing on this goal, we have reviewed the extant literature on the subject to develop a theoretical homecare coordination framework. The first intermediary goal was to integrate relevant concepts across multiple theories and frameworks into a unified synthesis. We do so in two parts: (1) analysis of extant coordination frameworks and theories; and (2) the presentation of our newly developed theoretical framework for homecare coordination. The new framework differentiates clearly between coordination as a process—i.e., what people do to coordinate and coordination as an outcome—i.e., the state of coordination. Applying this distinction to both, measurement and interpretation of results helps avoid misleading conclusions. As a research outcome, our framework builds upon the extant coordination literature, considers the complex relationships among the various coordination-related factors and, while focusing on homecare, is applicable to various healthcare settings in general. A nuanced differentiation and explanation of the elements involved enable a more consistent operationalization of the coordination concept. Additionally, as they explicitly address the healthcare system's micro, meso, and macro levels, they can be applied across diverse healthcare settings to investigate homecare coordination

Care coordination in homecare and its relationship with quality of care: A national multicenter cross-sectional study

As health care complexity increases, skilled care coordination is becoming increasingly necessary. This is especially true in homecare settings, where services tend to be highly interprofessional. Poor coordination can result in services being provided twice, at the wrong time, unnecessarily or not at all. In addition to risking harm to the client, such confusion leads to unnecessary costs. From the patient's perspective, then, professional coordination should help both to remove barriers limiting quality of care and to minimize costs. To date, though, studies examining the relationship between care coordination and care quality have faced multiple challenges, leading to mixed results. And in homecare contexts, where the clients are highly vulnerable and diverse care interfaces make coordination especially challenging, such studies are rare.; Therefore, the aim of this study was to explore the relationship, from the perspectives of clients and of homecare professionals, between coordination and quality of care. For both groups, we hypothesized that better coordination would correlate with higher ratings of quality of care. For the clients, we predicted that higher coordination ratings would lead to lower incidence of unplanned health care use, i.e., emergency department (ED) visits, unscheduled urgent medical visits and hospitalizations.; This study is part of a national multi-center cross-sectional study in the Swiss homecare setting. We recruited 88 homecare agencies and collected data between January and September 2021 through written questionnaires for agencies' managers, employees (n = 3223) and clients (n = 1509). To test our hypotheses, we conducted multilevel analyses.; Employee-perceived care coordination ratings correlated positively with employee-rated quality of care (OR = 2.78, p < .001); client-perceived care coordination problems correlated inversely with client-reported quality of care (β = -0.55, p < .001). Client-perceived coordination problems also correlated positively with hospitalizations (IRR = 1.20, p < .05) and unscheduled urgent medical visits (IRR = 1.18, p < .05), but not significantly with ED visits. No associations were discernible between employee-perceived coordination quality and either health care service use or client quality-of-care ratings.; While results indicate relationships between coordination and diverse aspects of care quality, various coordination gaps (e.g., poor information flow) also became apparent. The measurement of both care coordination and quality of care remains a challenge. Further research should focus on developing and validating a coordination questionnaire that measures care coordination

The home care work environment's relationships with work engagement and burnout: A cross-sectional multi-centre study in Switzerland

This study aimed to investigate the levels of burnout and work engagement among home care workers in Switzerland and to test their association with job demands and job resources. We conducted a multi-centre, cross-sectional survey in the German-speaking part of Switzerland with a convenience sample of seven home care agencies. Data were collected between September 2017 and January 2018. We assessed burnout with the Maslach Burnout Inventory (MBI) and work engagement with the Utrecht Work Engagement Scale (UWES) as well as job demands (overtime, work-family conflicts, experienced aggression and work stressors) and job resources (predictability, staffing, teamwork, leadership, collaboration, social support, sense of community, feedback). To investigate the levels of burnout and work engagement, we applied descriptive statistics. Based on Bakker and colleagues' Job Demands-Resources model, we used a path analysis to test the associations of job demands and job resources with burnout and work engagement. We analysed data from 448 home care workers (response rate 61.8%, mean age 44 years (SD 13.2), 96% female). The frequency of burnout in our sample was low, while that of work engagement was high. Job demands correlated positively with emotional exhaustion (β = .54, p < .001) and negatively with work engagement (β = -.25, p < .001). Job resources correlated negatively with emotional exhaustion (β = -.28, p < .001) and positively with work engagement (β = .41, p < .001). Work-family conflicts and work stressors correlated strongest with emotional exhaustion, whereas social support and feedback were found to correlate strongest with work engagement. Improvements to the home care work environment might enhance work engagement and reduce burnout. Corrective interventions could focus on reducing specific aspects of job demands, such as work-family conflicts and work stressors, as well as on increasing aspects of job resources, especially social support and feedback

How external and agency characteristics are related to coordination in homecare - findings of the national multicenter, cross-sectional SPOTnat study.

BACKGROUND Homecare client services are often distributed across several interdependent healthcare providers, making proper care coordination essential. However, as studies exploring care coordination in the homecare setting are scarce, serious knowledge gaps exist regarding how various factors influence coordination in this care sector. To fill such gaps, this study's central aim was to explore how external factors (i.e., financial and regulatory mechanisms) and homecare agency characteristics (i.e., work environment, workforce, and client characteristics) are related to care coordination in homecare. METHODS This analysis was part of a national multicentre, cross-sectional study in the Swiss homecare setting that included a stratified random sample of 88 Swiss homecare agencies. Data were collected between January and September 2021 through agency and employee questionnaires. Using our newly developed care coordination framework, COORA, we modelled our variables to assess the relevant components of care coordination on the structural, process, and outcome levels. We conducted both descriptive and multilevel regression analyses-with the latter adjusting for dependencies within agencies-to explore which key factors are associated with coordination. RESULTS The final sample size consisted of 1450 employees of 71 homecare agencies. We found that one explicit coordination mechanism ("communication and information exchange" (beta = 0.10, p <.001)) and four implicit coordination mechanisms-"knowledge of the health system" (beta = -0.07, p <.01), "role clarity" (beta = 0.07, p <.001), "mutual respect and trust" (beta = 0.07, p <.001), and "accountability, predictability, common perspective" (beta = 0.19, p <.001)-were significantly positively associated with employee-perceived coordination. We also found that the effects of agency characteristics and external factors were mediated through coordination processes. CONCLUSION Implicit coordination mechanisms, which enable and enhance team communication, require closer examination. While developing strategies to strengthen implicit mechanisms, the involvement of the entire care team is vital to create structures (i.e., explicit mechanisms) that enable communication and information exchange. Appropriate coordination processes seem to mitigate the association between staffing and coordination. This suggests that they support coordination even when workload and overtime are higher

Factors associated with homecare coordination and quality of care: a research protocol for a national multi-center cross-sectional study.

INTRODUCTION The persistent fragmentation of home healthcare reflects inadequate coordination between care providers. Still, while factors at the system (e.g., regulations) and organisational (e.g., work environment) levels crucially influence homecare organisation, coordination and ultimately quality, knowledge of these factors and their relationships in homecare settings remains limited. OBJECTIVES This study has three aims: [1] to explore how system-level regulations lead to disparities between homecare agencies' structures, processes and work environments; [2] to explore how system- and organisation-level factors affect agency-level homecare coordination; and [3] to explore how agency-level care coordination is related to patient-level quality of care. DESIGN AND METHODS This study focuses on a national multi-center cross-sectional survey in Swiss homecare settings. It will target 100 homecare agencies, their employees and clients for recruitment, with data collection period planned from January to June 2021. We will assess regulations and financing mechanisms (via public records), agency characteristics (via agency questionnaire data) and homecare employees' working environments and coordination activities, as well as staff- and patient-level perceptions of coordination and quality of care (via questionnaires for homecare employees, clients and informal caregivers). All collected data will be subjected to descriptive and multi-level analyses. DISCUSSION The first results are expected by December 2021. Knowledge of factors linked to quality of care is essential to plan and implement quality improvement strategies. This study will help to identify modifiable factors at multiple health system levels that might serve as access points to improve coordination and quality of care