Implementing a care pathway for elderly patients, a comparative qualitative process evaluation in primary care

Background: In Central Norway a generic care pathway was developed in collaboration between general hospitals and primary care with the intention of implementing it into everyday practice. The care pathway targeted elderly patients who were in need of home care services after discharge from hospital. The aim of the present study was to investigate the implementation process of the care pathway by comparing the experiences of health care professionals and managers in home care services between the participating municipalities. Methods: This was a qualitative comparative process evaluation using data from individual and focus group interviews. The Normalization Process Theory, which provides a framework for understanding how a new intervention becomes part of normal practice, was applied in our analysis. Results: In all of the municipalities there were expectations that the generic care pathway would improve care coordination and quality of follow-up, but a substantial amount of work was needed to make the regular home care staff understand how to use the care pathway. Other factors of importance for successful implementation were involvement of the executive municipal management, strong managerial focus on creating engagement and commitment among all professional groups, practical facilitation of work processes, and a stable organisation without major competing priorities. At the end of the project period, the pathway was integrated in daily practice in two of the six municipalities. In these municipalities the care pathway was found to have the potential of structuring the provision of home care services and collaboration with the GPs, and serving as a management tool to effect change and improve knowledge and skills. Conclusion: The generic care pathway for elderly patients has a potential of improving follow-up in primary care by meeting professional and managerial needs for improved quality of care, as well as more efficient organisation of home care services. However, implementation of this complex intervention in full-time running organisations was demanding and required comprehensive and prolonged efforts in all levels of the organisation. Studies on implementation of such complex interventions should therefore have a long follow-up time to identify whether the intervention becomes integrated into everyday practice

Unwanted incidents during transition of geriatric patients from hospital to home: a prospective observational study

<p>Abstract</p> <p>Background</p> <p>Geriatric patients recently discharged from hospital experience increased chance of unplanned readmissions and admission to nursing homes. Several studies have shown that medication-related discrepancies are common. Few studies report unwanted incidents by other factors than medications. In 2002 an ambulatory team (AT) was established within the Department of Geriatrics, St. Olavs University Hospital HF, Trondheim, Norway. The AT monitored the transition of the patients from hospital to home and four weeks after discharge in order to reveal unwanted incidents.</p> <p>The aim of the present study was to describe unwanted incidents registered by the AT among patients discharged from a geriatric evaluation and management unit (GEMU) by character, frequency and stage in the transitional process. Only unwanted incidents with a severity making contact with the primary health care (PHC) necessary were registered.</p> <p>Methods</p> <p>A prospective observational study with patients treated in the GEMU and followed by the AT was performed. Current practice included comprehensive geriatric assessment and management including discharge planning in the GEMU and collaboration with the primary health care on appointments on assistance to be provided after discharge from hospital. Unwanted incidents severe enough to induce contact with the primary health care were registered during the transitional phase and after discharge.</p> <p>Results</p> <p>118 patients (65% female), with mean age 83.2 ± 6.4 years participated. Median Barthel Index at discharge was 18 (interquartile range 16-19) and median Mini Mental Status Examination 24 (interquartile range 21-26). A total of 146 unwanted incidents were registered in 70 (59%) of the patients. Most frequent were unwanted incidents related to drug prescription regime (32%), exchange of information in and between the GEMU and the primary health care (25%) and service or help provided from the PHC (17%).</p> <p>Conclusions</p> <p>Despite a seemingly well-organised system for transition of patients from the GEMU to their homes, one or more unwanted incidents occurred in most patients during discharge or four weeks post discharge. The study has revealed areas of importance for improving transitional care of geriatric patients.</p

Generic care pathway for elderly patients in need of home care services after hospital discharge: A cluster RCT with nested qualitative studies of development and implementation

Generisk pasientforløp for eldre pasienter med behov for hjemmetjenester etter utskriving fra sykehus – utvikling, implementering og effekt Vestlige land står overfor et økende antall eldre pasienter som bor hjemme med mange sykdommer og redusert funksjonsevne. Sykehusoppholdene blir stadig kortere, og oppfølging og rehabilitering i primærhelsetjenesten må skje på et stadig tidligere stadium i sykdomsforløpet. For å sikre gode pasientforløp kreves god informasjonsoverføring, kompetanseoverføring og koordinering mellom helsetjenestenivåene. Utvikling og bruk av strukturerte pasientforløp er en strategi for å skape sammenhengende og effektive helsetjenester av god kvalitet, men bruken har så langt i hovedsak vært begrenset til sykehus. Denne avhandlingen utforsket et strukturert pasientforløp for eldre pasienter med behov for hjemmetjenester etter et sykehusopphold, utviklet av helsepersonell fra sykehus og primærhelsetjenesten i samarbeid med representanter fra pasientorganisasjoner. Pasientforløpet integrerer utreiseplanlegging og oppfølging ved hjemmetjenesten og fastlegen i de fire første ukene etter utskriving fra sykehus. Hovedformålet med avhandlingen var å bidra med kunnskap om utviklingen av et integrert pasientforløp for eldre pasienter som involverte både spesialist- og kommunehelsetjenesten og videre kunnskap om implementeringen og effekten av dette pasientforløpet. Denne avhandlingen utforsket et strukturert pasientforløp for eldre pasienter med behov for hjemmetjenester etter et sykehusopphold, utviklet av helsepersonell fra sykehus og primærhelsetjenesten i samarbeid med representanter fra pasientorganisasjoner. Pasientforløpet integrerer utreiseplanlegging og oppfølging ved hjemmetjenesten og fastlegen i de fire første ukene etter utskriving fra sykehus. Hovedformålet med avhandlingen var å bidra med kunnskap om utviklingen av et integrert pasientforløp for eldre pasienter som involverte både spesialist- og kommunehelsetjenesten og videre kunnskap om implementeringen og effekten av dette pasientforløpet. Det ble gjennomført tre studier. De to første studiene som hadde et kvalitativt design, undersøkte prosessen med å henholdsvis utvikle og implementere pasientforløpet. Den tredje studien var en kluster randomisert studie som undersøkte effekten på pasientnivå. Den første studien viste at de organisatoriske og kulturelle forskjellene mellom spesialist- og kommunehelsetjenesten gjorde det vanskelig å utvikle et felles strukturert pasientforløp. Ansatte fra sykehusene fant det naturlig å utvikle diagnosebaserte forløp i tråd med vanlig praksis i sykehus. Bruk av slike diagnosebaserte pasientforløp ble imidlertid funnet lite hensiktsmessige i hjemmetjenesten for målgruppen som var eldre og ofte hadde flere sykdommer. Arbeidet med diagnosebaserte forløp ble forlatt til fordel for ett generisk pasientforløp gitt navnet Helhetlig Pasientforløp i eget Hjem (HPH, PaTH på engelsk). For å sikre nødvendige observasjoner og kompetanseoverføring ble det utviklet sjekklister som ble brukt ved definerte milepæler i pasientforløpet, blant annet ved kommunikasjon mellom hjemmetjeneste og sykehus eller fastlege. Den andre studien undersøkte implementeringen av HPH i hjemmetjenesten. Den viste at det var krevende å implementere og integrere en kompleks intervensjon som HPH i en organisasjon i full drift. Sammenlikning av implementeringsprosessen mellom kommuner som fortsatte å bruke HPH etter forsøksperioden og de som ikke gjorde det, viste at tydelig ledelse og et omfattende arbeid over tid med tilrettelegging for bruk i det daglige arbeidet og tilstrekkelig trening av ansatte var nødvendig for å skape tilstrekkelig forståelse, engasjement og forpliktelse for å implementere HPH i daglig bruk. I de kommunene der pasientforløpet ble en del av det daglige arbeidet, opplevde de ansatte at de var bedre forberedt når pasienten kom hjem fra sykehus. Dette gav dem større oversikt over pasientens tilstand, og de ble mer proaktive ved ny oppståtte problemer. Lederne i disse kommunene opplevde HPH som et nyttig lederverktøy for å bedre kvaliteten på tjenestene. Den tredje studien var en kluster randomisert kontrollert studie av effekten av HPH i løpet av 12 måneder. Bruken av de fire sjekklistene som utgjorde kjernen i HPH var mangelfull; tre eller flere sjekklister ble dokumentert brukt for bare 36 % av pasientene i de hjemmetjenestene som innførte HPH, men bruken bedret seg over tid. Pasientene i intervensjonsgruppen hadde signifikant flere konsultasjoner hos fastlegen sammenliknet med kontrollgruppen og det var indikasjoner på flere dager hjemme. Vi fant ingen statistisk signifikant forskjeller mellom gruppene på funksjonsnivå eller reinnleggelse (primære utfallsvariabler), helsetjenesteforbruk i sykehus og kommunale institusjoner, dødelighet eller livskvalitet (sekundære utfallsvariabler). Avhandlingen viste at helsepersonell i kommuner der HPH var blitt en del av daglig virksomhet, opplevde at et slikt integrert, generisk pasientforløp kunne gi bedre koordinering og kvalitet på tjenestene. Implementering av denne komplekse intervensjonen var imidlertid krevende. Utilstrekkelig innkjøringsperiode medførte at HPH ikke ble brukt i tilstrekkelig omfang og med tilstrekkelig kvalitet i perioden hvor effekten ble studert. I denne avhandlingen kan man derfor ikke trekke noen endelig konklusjon om hvorvidt et integrert pasientforløpet som HPH, er effektivt på pasientnivå

Unwanted incidents during transition of geriatric patients from hospital to home: A prospective observational study

Background: Geriatric patients recently discharged from hospital experience increased chance of unplanned readmissions and admission to nursing homes. Several studies have shown that medication-related discrepancies are common. Few studies report unwanted incidents by other factors than medications. In 2002 an ambulatory team (AT) was established within the Department of Geriatrics, St. Olavs University Hospital HF, Trondheim, Norway. The AT monitored the transition of the patients from hospital to home and four weeks after discharge in order to reveal unwanted incidents. The aim of the present study was to describe unwanted incidents registered by the AT among patients discharged from a geriatric evaluation and management unit (GEMU) by character, frequency and stage in the transitional process. Only unwanted incidents with a severity making contact with the primary health care (PHC) necessary were registered. Methods: A prospective observational study with patients treated in the GEMU and followed by the AT was performed. Current practice included comprehensive geriatric assessment and management including discharge planning in the GEMU and collaboration with the primary health care on appointments on assistance to be provided after discharge from hospital. Unwanted incidents severe enough to induce contact with the primary health care were registered during the transitional phase and after discharge. Results: 118 patients (65% female), with mean age 83.2 ± 6.4 years participated. Median Barthel Index at discharge was 18 (interquartile range 16-19) and median Mini Mental Status Examination 24 (interquartile range 21-26). A total of 146 unwanted incidents were registered in 70 (59%) of the patients. Most frequent were unwanted incidents related to drug prescription regime (32%), exchange of information in and between the GEMU and the primary health care (25%) and service or help provided from the PHC (17%). Conclusions: Despite a seemingly well-organised system for transition of patients from the GEMU to their homes, one or more unwanted incidents occurred in most patients during discharge or four weeks post discharge. The study has revealed areas of importance for improving transitional care of geriatric patients

Helhetlige pasientforløp – gjennomføring i primærhelsetjenesten

Et av hovedmålene i samhandlingsreformen har vært at kommuner i samarbeid med sykehus skal kunne tilby helhetlige og integrerte tjenester før og etter sykehusopphold, basert på sammenhengende pasientforløp. Kommuner og foretak er derfor i den nye helse -og omsorgsloven blitt pålagt å inngå forpliktende samarbeidsavtaler om innleggelse og utskrivning av pasienter. Vi har fulgt noen sykehus og kommuner som sammen har forsøkt å utvikle helhetlige pasientforløp for KOLS, hjertesvikt, slag og hoftebrudd som også omfattet oppfølging i kommunen. Vi finner at spesialisering av tjenester og personell i primærhelsetjenesten for oppfølging av spesifikke diagnoser hverken er bærekraftig eller funksjonelt. I tillegg vil det å forlenge diagnosespesifikke forløp fra sykehus ut i kommunen bidra til fragmentering av tjenestene til eldre og kronisk syke. I noen av kommunene ble det utviklet og tatt i bruk generisk diagnoseuavhengige forløp. Det fungerte for disse kommunene og framstår som en mer bærekraftig modell

Implementing a care pathway for elderly patients, a comparative qualitative process evaluation in primary care

Background: In Central Norway a generic care pathway was developed in collaboration between general hospitals and primary care with the intention of implementing it into everyday practice. The care pathway targeted elderly patients who were in need of home care services after discharge from hospital. The aim of the present study was to investigate the implementation process of the care pathway by comparing the experiences of health care professionals and managers in home care services between the participating municipalities. Methods: This was a qualitative comparative process evaluation using data from individual and focus group interviews. The Normalization Process Theory, which provides a framework for understanding how a new intervention becomes part of normal practice, was applied in our analysis. Results: In all of the municipalities there were expectations that the generic care pathway would improve care coordination and quality of follow-up, but a substantial amount of work was needed to make the regular home care staff understand how to use the care pathway. Other factors of importance for successful implementation were involvement of the executive municipal management, strong managerial focus on creating engagement and commitment among all professional groups, practical facilitation of work processes, and a stable organisation without major competing priorities. At the end of the project period, the pathway was integrated in daily practice in two of the six municipalities. In these municipalities the care pathway was found to have the potential of structuring the provision of home care services and collaboration with the GPs, and serving as a management tool to effect change and improve knowledge and skills. Conclusion: The generic care pathway for elderly patients has a potential of improving follow-up in primary care by meeting professional and managerial needs for improved quality of care, as well as more efficient organisation of home care services. However, implementation of this complex intervention in full-time running organisations was demanding and required comprehensive and prolonged efforts in all levels of the organisation. Studies on implementation of such complex interventions should therefore have a long follow-up time to identify whether the intervention becomes integrated into everyday practice

Possibilities and Benefits of Intermediate Care Units in Healthcare Systems from a Logistics Perspective

Part 4: Collaborative NetworksInternational audienceIntermediate care units have been established as a response to the emerging challenges of healthcare systems to maintain high quality and continuous care. While the term is well known in both literature and practice, it lacks a unified definition. There is no common consensus of how intermediate care units can be successfully implemented and properly utilized in healthcare systems. Large variations of services in intermediate care units can be found. This literature review has structured the existing research on intermediate care units, identifying the possibilities and benefits of intermediate care units in healthcare systems from a logistics perspective. The main findings discussed in this study concern the following topics: the effect of intermediate care units on healthcare system performance and patient outcomes, and potential users of and services provided by intermediate care units. This study presents the state-of-the-art research on intermediate care units and suggests topics for further research