Outcomes as experienced by older patients after hospitalisation:Satisfaction, acceptance, frustration and hope - a grounded theory study

Background: outcomes of hospitalisation are often described in quantitative terms. It is unknown how older frail patients describe their own outcomes. Objective: to discover how older frail persons describe their own hospitalisation outcomes and the meaning of these outcomes for their daily lives. Design: Constructivist Grounded Theory approach. Participants: frail older people discharged from hospital. Methods: Open interviews in the participant's home. Transcripts were coded inductively according to the Constructivist Grounded Theory approach. Results: Twenty-four interviews were conducted involving 20 unique participants. Although for some participants hospitalisation was just a ripple, for others, it was a turning point. It could have positive or negative impacts on outcomes, including remaining alive, disease, fatigue/condition, complaints, daily functioning, social activities and intimate relationships, hobbies, living situation and mental well-being. Few participants were completely satisfied, but for many, a discrepancy between expectation and reality existed. Some participants could accept this, others remained hopeful and some were frustrated. Factors associated with these categories were research and treatment options, (un)clarity about the situation, setting the bar too high or pushing boundaries, confidence in physicians, character traits and social factors. Conclusions: of the persons whose outcomes did not meet their expectations, some were frustrated, others hopeful and others accepted the situation. The following interventions can help patients to accept: clear communication about options and expectations before, during and after hospitalisation; giving room for emotions; help finding social support, encouragement to engage in pleasant activities and find meaning in small things. For some patients, psychological treatment may be needed

Reliability and validity of the Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP)

Background: The Patient Benefit Assessment Scale for Hospitalised Older Patients (P-BAS HOP) is a tool which is capable of both identifying the priorities of the individual patient and measuring the outcomes relevant to him/her, resulting in a Patient Benefit Index (PBI) with range 0–3, indicating how much benefit the patient had experienced from the admission. The aim of this study was to evaluate the reliability, validity, responsiveness and interpretability of the P-BAS HOP. Methods: A longitudinal study among hospitalised older patients with a baseline interview during hospitalisation and a follow-up by telephone 3 months after discharge. Test-retest reliability of the baseline and follow-up questionnaire were tested. Percentage of agreement, Cohen’s kappa with quadratic weighting and maximum attainable kappa were calculated per item. The PBI was calculated for both test and retest of baseline and follow-up and compared with Intraclass Correlation Coefficient (ICC). Construct validity was tested by evaluating pre-defined hypotheses comparing the priority of goals with experienced symptoms or limitations at admission and the achievement of goals with progression or deterioration of other constructs. Responsiveness was evaluated by correlating the PBI with the anchor question ‘How much did you benefit from the admission?’. This question was also used to evaluate the interpretability of the PBI with the visual anchor-based minimal important change distribution method. Results: Reliability was tested with 53 participants at baseline and 72 at follow-up. Mean weighted kappa of the baseline items was 0.38. ICC between PBI of the test and retest was 0.77. Mean weighted kappa of the follow-up items was 0.51. ICC between PBI of the test and retest was 0.62. For the construct validity, tested in 451 participants, all baseline hypotheses were confirmed. From the follow-up hypotheses, tested in 344 participants, five of seven were confirmed. The Spearman’s correlation coefficient between the PBI and the anchor question was 0.51. The optimal cut-off point was 0.7 for ‘no important benefit’ and 1.4 points for ‘important benefit’ on the PBI. Conclusions: Although the concept seems promising, the reliability and validity of the P-BAS HOP appeared to be not yet satisfactory. We therefore recommend adapting the P-BAS HOP. Keywords: Older adults, Hospitalisation, Patient perspective, Goal setting, Patient-reported outcomes, Validity, Reliability, Responsiveness, Minimal important change (MIC), Value-based health car

Interplaying mechanisms in the implementation of Dementia Care Mapping for delivering Person-centered Care to older adults in nursing home settings.

ABSTRACTPurpose:This research lays out a study that explores the interplay among the elderly care context, the content of Dementia Care Mapping, and the Process of Implementation. The research aims to identify the most influential constraining and supporting mechanisms in realizing Dementia Care Mapping’s central aimof monitoring the individual needs and well-being of older adults suffering from dementia in the Netherlands.Methods:To present our approach, we describe a qualitative cross-case analysis of five nursing homes using Dementia Care Mapping. Qualitative data includes observations and semi structured interviews. Actors included were: directors of facilities (N=2), project leaders (N=2), nurses and head nurses (N=4),licensed ‘mappers’ of the Dementia Care Mapping process (N=4) and family members/informal caregivers of persons with dementia (N=2). The Consolidated Framework of Implementation Research provided theoretical grounding for the conceptual framework that guided this study.Results:With the use of the Consolidated Framework of Implementation Research and our conceptual framework, data collection is guided, data coded and analyzed and findings are presented in a structured comprehensive manner. Results of the cross-case analyses are presented in a matrix, thereby identifyingthe interplaying mechanisms of Dementia Care Mapping implementation.Implications and Limitations: The most important contribution of this research is its novel understanding of factors interplaying when Dementia Care Mapping is implemented for the delivery of Person-centered Care. Furthermore, theinterplaying mechanisms identified in this study help to: 1) understand implementation of such tools in the health care context, 2) explore Dementia Care Mapping’s complexity regarding heterogeneous results in literature and 3) understand Dementia Care Mapping’s contribution to the four constructs ofPerson-centered Care.Practical implications:This study’s findings provide a better understanding for management of the interplaying mechanisms constraining and supporting the realization of Person-centered Care through Dementia Care Mapping.The identification of these mechanisms provides a guide in developing action plans for implementation in the elderly care context.Originality:This research is the first study to identify interplaying mechanisms constraining and supporting Dementia Care Mapping implementation, thereby answering recent calls in literature to fill this gap

Goals of older hospitalised patients:a qualitative descriptive study

Objectives Since the population continues ageing and the number of patients with multiple chronic diseases is rising in Western countries, a shift is recommended from disease oriented towards goal-oriented healthcare. As little is known about individual goals and preferences of older hospitalised patients, the aim of this study is to elucidate the goals of a diverse group of older hospitalised patients. Design Qualitative descriptive method with open interviews analysed with inductive content analysis. Setting A university teaching hospital and a regional teaching hospital. Participants Twenty-eight hospitalised patients aged 70 years and older. Results Some older hospitalised patients initially had difficulties describing concrete goals, but after probing all were able to state more concrete goals. A great diversity of goals were categorised into wanting to know what the matter is, controlling disease, staying alive, improving condition, alleviating complaints, improving daily functioning, improving/maintaining social functioning, resuming work/hobbies and regaining/maintaining autonomy. Conclusions Older hospitalised patients have a diversity of goals in different domains. Discussing goals with older patients is not a common practice yet. Timely discussions about goals should be encouraged because individual goals are not self-evident and this discussion can guide decision making, especially in patients with multimorbidity and frailty. Aids can be helpful to facilitate the discussion about goals and evaluate the outcomes of hospitalisation