Development of a patient-centred care pathway across healthcare providers: a qualitative study

BACKGROUND: Different models for care pathways involving both specialist and primary care have been developed to ensure adequate follow-up after discharge. These care pathways have mainly been developed and run by specialist care and have been disease-based. In this study, primary care providers took the initiative to develop a model for integrated care pathways across care levels for older patients in need of home care services after discharge. Initially, the objective was to develop pathways for patients diagnosed with heart failure, COPD and stroke. The aim of this paper is to investigate the process and the experiences of the participants in this developmental work. The participants were drawn from three hospitals, six municipalities and patient organizations in Central Norway. METHODS: This qualitative study used focus group interviews, written material and observations. Representatives from the hospitals, municipalities and patient organizations taking part in the development process were chosen as informants. RESULTS: The development process was very challenging because of the differing perspectives on care and different organizational structures in specialist care and primary care. In this study, the disease perspective, being dominant in specialist care, was not found to be suitable for use in primary health care because of the need to cover a broader perspective including the patient’s functioning, social situation and his or her preferences. Furthermore, managing several different disease-based care pathways was found to be unsuitable in home care services, as well as unsuitable for a population characterized by a substantial degree of comorbidity. The outcome of the development process was a consensus that outlined a single, common patient-centred care pathway for transition from hospital to follow-up in primary care. The pathway was suitable for most common diseases and included functional and social aspects as well as disease follow-up, thus merging the differing perspectives. The disease-based care pathways were kept for use within the hospitals. CONCLUSIONS: Disease-based care pathways for older patients were found to be neither feasible nor sustainable in primary care. A common patient-centred care pathway that could meet the needs of multi- morbid patients was recommended

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

Norsk sammendrag: 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

Additional file 1: of Generic care pathway for elderly patients in need of home care services after discharge from hospital: a cluster randomised controlled trial

Main PaTH checklists and individual daily care plan. (DOCX 23 kb

Geriatric assessment with management for older patients with cancer receiving radiotherapy. Protocol of a Norwegian cluster-randomised controlled pilot study

About 50% of patients with cancer are expected to need radiotherapy (RT), and the majority of these are older. To improve outcomes for older patients with cancer, geriatric assessment (GA) with management (GAM) is highly recommended. Evidence for its benefits is still scarce, in particular for patients receiving RT. We report the protocol of a cluster-randomised pilot study designed to test the effect, feasibility and health economic impact of a GAM intervention for patients ≥65 years, referred for palliative or curative RT. The randomising units are municipalities and city districts. The intervention is municipality-based and carried out in collaboration between hospital and municipal health services from the start of RT to eight weeks after the end of RT. Its main constituents are an initial GA followed by measures adapted to individual patients' impairments and needs, systematic symptom assessments and regular follow-up by municipal cancer nurses, appointed to coordinate the patient's care. Follow-up includes at least one weekly phone call, and a house call four weeks after the end of RT. All patients receive an individually adapted physical exercise program and nutritional counselling. Detailed guidelines for management of patients' impairments are provided. Patients allocated to the intervention group will be compared to controls receiving standard care. The primary outcome is physical function assessed by the European Organisation of Research and Treatment of Cancer Quality of Life Questionnaire C-30. Secondary outcomes are global quality of life, objectively tested physical performance and use of health care services. Economic evaluation will be based on a comparison of costs and effects (measured by the main outcome measures). Feasibility will be assessed with mixed methodology, based on log notes and questionnaires filled in by the municipal nurses and interviews with patients and nurses. The study is carried out at two Norwegian RT centres. It was opened in May 2019. Follow-up will proceed until June 2022. Statistical analyses will start by the end of 2021. We expect the trial to provide important new knowledge about the effect, feasibility and costs of a GAM intervention for older patients receiving RT.publishedVersio

Vascular risk factor control and adherence to secondary preventive medication after ischemic stroke

Background Studies regarding adequacy of secondary stroke prevention are limited. We report medication adherence, risk factor control and factors influencing vascular risk profile following ischaemic stroke. Methods A total of 664 home‐dwelling participants in the Norwegian Cognitive Impairment After Stroke study, a multicenter observational study, were evaluated 3 and 18 months poststroke. We assessed medication adherence by self‐reporting (4‐item Morisky Medication Adherence Scale) and medication persistence (defined as continuation of medication(s) prescribed at discharge), achievement of guideline‐defined targets of blood pressure (BP) (<140/90 mmHg), low‐density lipoprotein cholesterol (LDL‐C) (<2.0 mmol L−1) and haemoglobin A1c (HbA1c) (≤53 mmol mol−1) and determinants of risk factor control. Results At discharge, 97% were prescribed antithrombotics, 88% lipid‐lowering drugs, 68% antihypertensives and 12% antidiabetic drugs. Persistence of users declined to 99%, 88%, 93% and 95%, respectively, at 18 months. After 3 and 18 months, 80% and 73% reported high adherence. After 3 and 18 months, 40.7% and 47.0% gained BP control, 48.4% and 44.6% achieved LDL‐C control, and 69.2% and 69.5% of diabetic patients achieved HbA1c control. Advanced age was associated with increased LDL‐C control (OR 1.03, 95% CI 1.01 to 1.06) and reduced BP control (OR 0.98, 0.96 to 0.99). Women had poorer LDL‐C control (OR 0.60, 0.37 to 0.98). Polypharmacy was associated with increased LDL‐C control (OR 1.29, 1.18 to 1.41) and reduced HbA1c control (OR 0.76, 0.60 to 0.98). Conclusion Risk factor control is suboptimal despite high medication persistence and adherence. Improved understanding of this complex clinical setting is needed for optimization of secondary preventive strategies

Geriatric assessment with management for older patients with cancer receiving radiotherapy. Protocol of a Norwegian cluster-randomised controlled pilot study

About 50% of patients with cancer are expected to need radiotherapy (RT), and the majority of these are older. To improve outcomes for older patients with cancer, geriatric assessment (GA) with management (GAM) is highly recommended. Evidence for its benefits is still scarce, in particular for patients receiving RT. We report the protocol of a cluster-randomised pilot study designed to test the effect, feasibility and health economic impact of a GAM intervention for patients ≥65 years, referred for palliative or curative RT. The randomising units are municipalities and city districts. The intervention is municipality-based and carried out in collaboration between hospital and municipal health services from the start of RT to eight weeks after the end of RT. Its main constituents are an initial GA followed by measures adapted to individual patients' impairments and needs, systematic symptom assessments and regular follow-up by municipal cancer nurses, appointed to coordinate the patient's care. Follow-up includes at least one weekly phone call, and a house call four weeks after the end of RT. All patients receive an individually adapted physical exercise program and nutritional counselling. Detailed guidelines for management of patients' impairments are provided. Patients allocated to the intervention group will be compared to controls receiving standard care. The primary outcome is physical function assessed by the European Organisation of Research and Treatment of Cancer Quality of Life Questionnaire C-30. Secondary outcomes are global quality of life, objectively tested physical performance and use of health care services. Economic evaluation will be based on a comparison of costs and effects (measured by the main outcome measures). Feasibility will be assessed with mixed methodology, based on log notes and questionnaires filled in by the municipal nurses and interviews with patients and nurses. The study is carried out at two Norwegian RT centres. It was opened in May 2019. Follow-up will proceed until June 2022. Statistical analyses will start by the end of 2021. We expect the trial to provide important new knowledge about the effect, feasibility and costs of a GAM intervention for older patients receiving RT

Geriatric assessment with management for older patients with cancer receiving radiotherapy. Protocol of a Norwegian cluster-randomised controlled pilot study

About 50% of patients with cancer are expected to need radiotherapy (RT), and the majority of these are older. To improve outcomes for older patients with cancer, geriatric assessment (GA) with management (GAM) is highly recommended. Evidence for its benefits is still scarce, in particular for patients receiving RT. We report the protocol of a cluster-randomised pilot study designed to test the effect, feasibility and health economic impact of a GAM intervention for patients ≥65 years, referred for palliative or curative RT. The randomising units are municipalities and city districts. The intervention is municipality-based and carried out in collaboration between hospital and municipal health services from the start of RT to eight weeks after the end of RT. Its main constituents are an initial GA followed by measures adapted to individual patients' impairments and needs, systematic symptom assessments and regular follow-up by municipal cancer nurses, appointed to coordinate the patient's care. Follow-up includes at least one weekly phone call, and a house call four weeks after the end of RT. All patients receive an individually adapted physical exercise program and nutritional counselling. Detailed guidelines for management of patients' impairments are provided. Patients allocated to the intervention group will be compared to controls receiving standard care. The primary outcome is physical function assessed by the European Organisation of Research and Treatment of Cancer Quality of Life Questionnaire C-30. Secondary outcomes are global quality of life, objectively tested physical performance and use of health care services. Economic evaluation will be based on a comparison of costs and effects (measured by the main outcome measures). Feasibility will be assessed with mixed methodology, based on log notes and questionnaires filled in by the municipal nurses and interviews with patients and nurses. The study is carried out at two Norwegian RT centres. It was opened in May 2019. Follow-up will proceed until June 2022. Statistical analyses will start by the end of 2021. We expect the trial to provide important new knowledge about the effect, feasibility and costs of a GAM intervention for older patients receiving RT. Trial registration: ClinTrials.gov, ID NCT03881137, initial release 13th of March 2019