Improving care coordination for community-dwelling older Australians: a longitudinal qualitative study
Desley Harvey A B D , Michele Foster C , Edward Strivens A B and Rachel Quigley A BA Cairns and Hinterland Hospital and Health Service, PO Box 902, Cairns, Qld 4870, Australia. Email: Edward.Strivens@health.qld.gov.au; Rachel.Quigley@health.qld.gov.au
B Division of Tropical Health and Medicine, James Cook University, Townsville, Qld 4811, Australia.
C School of Social Work and Human Services, Menzies Health Institute Queensland, Griffith University, Meadowbrook, Qld 4131, Australia. Email: Michele.foster@griffith.edu.au
D Corresponding author. Email: Desley.harvey@health.qld.gov.au
Australian Health Review 41(2) 144-150 https://doi.org/10.1071/AH16054
Submitted: 24 February 2016 Accepted: 21 April 2016 Published: 23 June 2016
Abstract
Objective The aim of the present study was to describe the care transition experiences of older people who transfer between subacute and primary care, and to identify factors that influence these experiences. A further aim of the study was to identify ways to enhance the Geriatric Evaluation and Management (GEM) model of care and improve local coordination of services for older people.
Methods The present study was an exploratory, longitudinal case study involving repeat interviews with 19 patients and carers, patient chart audits and three focus groups with service providers. Interview transcripts were coded and synthesised to identify recurring themes.
Results Patients and carers experienced care transitions as dislocating and unpredictable within a complex and turbulent service context. The experience was characterised by precarious self-management in the community, floundering with unmet needs and holistic care within the GEM service. Patient and carer attitudes to seeking help, quality and timeliness of communication and information exchange, and system pressure affected care transition experiences.
Conclusion Further policy and practice attention, including embedding early intervention and prevention, strengthening links between levels of care by building on existing programs and educative and self-help initiatives for patients and carers is recommended to improve care transition experiences and optimise the impact of the GEM model of care.
What is known about the topic? Older people with complex care needs experience frequent care transitions because of fluctuating health and fragmentation of aged care services in Australia. The GEM model of care promotes multidisciplinary, coordinated care to improve care transitions and outcomes for older people with complex care needs.
What does this paper add? The present study highlights the crucial role of the GEM service, but found there is a lack of systemised linkages within and across levels of care that disrupts coordinated care and affects care transition experiences. There are underutilised opportunities for early intervention and prevention across the system, including the emergency department and general practice.
What are the implications for practitioners? Comprehensive screening, assessment and intervention in primary and acute care, formalised transition processes and enhanced support for patients and carers to access timely, appropriate care is required to achieve quality, coordinated care transitions for older people.
References
[1] Australian Bureau of Statistics (ABS). Population projections Australia, 2012 to 2101. Catalogue no. 3222.0. Canberra: ABS; 2013.[2] Australian Institute of Health and Welfare (AIHW). Admitted patient care 2013–14: Australian hospital statistics. Health services series no. 60. Catalogue no. HSE 156. Canberra: AIHW; 2015.
[3] Toscan J, Mairs K, Hinton S, Stolee P. Integrated transitional care: patient, informal caregiver and health care provider perspectives on care transitions for older persons with hip fracture. Int J Integr Care 2012; 12 xx–xx.
| Integrated transitional care: patient, informal caregiver and health care provider perspectives on care transitions for older persons with hip fracture.Crossref | GoogleScholarGoogle Scholar |
[4] Cheek J, Ballantyne A, Gillham D, Mussared J, Flett P, Lewin G, Walker M, Roder-Allen G, Quan J, Vandermeulen S. Improving care transitions of older people: challenges for today and tomorrow. Qual Ageing 2006; 7 18–26.
| Improving care transitions of older people: challenges for today and tomorrow.Crossref | GoogleScholarGoogle Scholar |
[5] Mudge AM, Shakhovskoy R, Karrasch A. Quality of transitions in older medical patients with frequent readmissions: opportunities for improvement. Eur J Intern Med 2013; 24 779–83.
| Quality of transitions in older medical patients with frequent readmissions: opportunities for improvement.Crossref | GoogleScholarGoogle Scholar | 24055382PubMed |
[6] Giosa JL, Stolee P, Dupuis SL, Mock SE, Santi SM. An examination of family caregiver experiences during care transitions of older adults. Can J Aging 2014; 33 137–53.
| An examination of family caregiver experiences during care transitions of older adults.Crossref | GoogleScholarGoogle Scholar | 24754978PubMed |
[7] Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc 2003; 51 549–55.
| Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs.Crossref | GoogleScholarGoogle Scholar | 12657078PubMed |
[8] Mansah M, Fernandez R, Griffiths R, Chang E. Effectiveness of strategies to promote safe transition of elderly people across care settings. JBI Library Syst Rev 2009; 7 1036–90.
[9] Manderson B, Mcmurray J, Piraino E, Stolee P. Navigation roles support chronically ill older adults through healthcare transitions: a systematic review of the literature. Health Soc Care Community 2012; 20 113–27.
| Navigation roles support chronically ill older adults through healthcare transitions: a systematic review of the literature.Crossref | GoogleScholarGoogle Scholar | 21995806PubMed |
[10] Productivity Commission. Caring for older Australians: overview, report no. 53, final inquiry report. Canberra: Productivity Commission; 2011.
[11] Ellis G, Whitehead MA, O’Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev 2011; 7 CD006211xxx
[12] Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4 50
| 19664226PubMed |
[13] Stetler CB, Legro MW, Wallace CM, Bowman C, Guihan M, Hagedorn H, Kimmel B, Sharp ND, Smith JL. The role of formative evaluation in implementation research and the QUERI experience. J Gen Intern Med 2006; 21 S1–8.
| The role of formative evaluation in implementation research and the QUERI experience.Crossref | GoogleScholarGoogle Scholar | 16637954PubMed |
[14] Allen J, Hutchinson AM, Brown R, Livingston PM. Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review. BMC Health Serv Res 2014; 14 346
| 25128468PubMed |
[15] Beech R, Henderson C, Ashby S, Dickinson A, Sheaff R, Windle K, Wistow G, Knapp M. Does integrated governance lead to integrated patient care? Findings from the innovation forum. Health Soc Care Community 2013; 21 598–605.
| 23638993PubMed |
[16] Baillie L, Gallini A, Corser R, Elworthy G, Scotcher A, Barrand A. Care transitions for frail, older people from acute hospital wards within an integrated healthcare system in England: a qualitative case study. Int J Integr Care 2014; 14 e009
| 24868193PubMed |
[17] Ritchie J, Spencer L, O’Connor W. Carrying out qualitative analysis. In Ritchie J, Lewis J, editors. Qualitative research practice: a guide for social science students and researchers. Thousand Oaks, CA: Sage; 2011. pp. 219–62.
[18] Nicholson C, Meyer J, Flatley M, Holman C. The experience of living at home with frailty in old age: a psychosocial qualitative study. Int J Nurs Stud 2013; 50 1172–9.
| The experience of living at home with frailty in old age: a psychosocial qualitative study.Crossref | GoogleScholarGoogle Scholar | 22307022PubMed |
[19] Vass M, Avlund K, Parner ET, Hendriksen C. Preventative home visits to older home-dwelling people and different functional decline patterns. Eur J Ageing 2007; 4 107–13.
| Preventative home visits to older home-dwelling people and different functional decline patterns.Crossref | GoogleScholarGoogle Scholar |
[20] Imhof L, Naef R, Wallhagen MI, Schwarz J, Mahrer-Imhof R. Effects of an advanced practice nurse in-home health consultation program for community-dwelling persons aged 80 and older. J Am Geriatr Soc 2012; 60 2223–31.
| Effects of an advanced practice nurse in-home health consultation program for community-dwelling persons aged 80 and older.Crossref | GoogleScholarGoogle Scholar | 23194103PubMed |
[21] Stijnen MMN, Jansen MWJ, Vrijhoef HJM, Duimel-Peeters IGP. Development of a home visitation programme for the early detection of health problems in potentially frail community-dwelling older people by general practices. Eur J Ageing 2013; 10 49–60.
| Development of a home visitation programme for the early detection of health problems in potentially frail community-dwelling older people by general practices.Crossref | GoogleScholarGoogle Scholar |
[22] Yardley L, Donovan-Hall M, Francis K, Todd C. Older people’s views about falls prevention: a qualitative study. Health Educ Res 2006; 21 508–17.
| Older people’s views about falls prevention: a qualitative study.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD28vlt1Okug%3D%3D&md5=0b22f5d0156ad6297a43d09511986df7CAS | 16467173PubMed |
[23] Grant A, Mackenzie L, Clemson L. How do general practitioners engage with allied health practitioners to prevent falls in older people? An exploratory qualitative study. Australas J Ageing 2015; 34 149–54.
| How do general practitioners engage with allied health practitioners to prevent falls in older people? An exploratory qualitative study.Crossref | GoogleScholarGoogle Scholar | 24889661PubMed |
[24] Arendts G, Fitzhardinge S, Pronk K, Hutton M. Outcomes in older patients requiring comprehensive allied health care prior to discharge from the emergency department. Emerg Med Australas 2013; 25 127–31.
| Outcomes in older patients requiring comprehensive allied health care prior to discharge from the emergency department.Crossref | GoogleScholarGoogle Scholar | 23560962PubMed |
[25] Dossa A, Bokhour B, Hoenig H. Care transitions from the hospital to home for patients with mobility impairments: patient and family caregiver experiences. Rehabil Nurs 2012; 37 277–85.
| Care transitions from the hospital to home for patients with mobility impairments: patient and family caregiver experiences.Crossref | GoogleScholarGoogle Scholar | 23212952PubMed |
[26] Fuji KT, Abbott AA, Norris JF. Exploring care transitions from patient, caregiver, and health-care provider perspectives. Clin Nurs Res 2013; 22 258–74.
| Exploring care transitions from patient, caregiver, and health-care provider perspectives.Crossref | GoogleScholarGoogle Scholar | 23113935PubMed |
[27] Walker R, Johns J, Halliday D. How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery. Health Soc Care Community 2015; 23 216–24.
| How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery.Crossref | GoogleScholarGoogle Scholar | 25427647PubMed |
[28] Dahl U, Steinsbekk A, Jenssen S, Johsen R. Hospital discharge of elderly patients to primary health care, with and without an intermediate care hospital: a qualitative study of health professionals’ experiences. Int J Integr Care 2014; 14 e011
| 24868194PubMed |
[29] Uhrenfeldt L. A qualitative meta-synthesis of patients’ experiences of intra- and inter-hospital transitions. J Adv Nurs 2013; 69 1678–90.
| A qualitative meta-synthesis of patients’ experiences of intra- and inter-hospital transitions.Crossref | GoogleScholarGoogle Scholar | 23509965PubMed |
[30] National Health and Hospitals Reform Commission. A healthier future for all Australians. Final report of the National Health and Hospital Reform Commission. Canberra: National Health and Hospitals Reform Commission; 2009.
[31] Gray LC, Peel NM, Crotty M, Kurrle S, Giles LC, Cameron ID. How effective are programs at managing transition from hospital to home? A case study of the Australian transition care program. BMC Geriatr 2012; 12 6
| How effective are programs at managing transition from hospital to home? A case study of the Australian transition care program.Crossref | GoogleScholarGoogle Scholar | 22416921PubMed |
[32] Giles LC, Halbert JA, Gray LC, Cameron ID, Crotty M. The distribution of health services for older people in Australia: where does transition care fit? Aust Health Rev 2009; 33 572–82.
| The distribution of health services for older people in Australia: where does transition care fit?Crossref | GoogleScholarGoogle Scholar | 20166906PubMed |
[33] Davis S, Byers S, Walsh F. Measuring person-centred care in a subacute health care setting. Aust Health Rev 2008; 32 496–504.
| Measuring person-centred care in a subacute health care setting.Crossref | GoogleScholarGoogle Scholar | 18666878PubMed |
