Health professional perspectives on systems failures in transitional care for patients with dementia and their carers: a qualitative descriptive study

BACKGROUND

Healthcare professionals engage in discharge planning of people with dementia during hospitalisation, however plans for transitioning the person into community services can be patchy and ineffective. The aim of this study was to report acute, community and residential care health professionals' (HP) perspectives on the discharge process and transitional care arrangements for people with dementia and their carers.

METHODS

A qualitative descriptive study design and purposive sampling was used to recruit HPs from four groups: Nurses and allied health practitioners involved in discharge planning in the acute setting, junior medical officers in acute care, general practitioners (GPs) and Residential Aged Care Facility (RACF) staff in a regional area in NSW, Australia. Focus group discussions were conducted using a semi-structured schedule. Content analysis was used to understand the discharge process and transitional care arrangements for people with dementia (PWD) and their carers.

RESULTS

There were 33 participants in four focus groups, who described discharge planning and transitional care as a complex process with multiple contributors and components. Two main themes with belonging sub-themes derived from the analysis were: Barriers to effective discharge planning for PWD and their carers - the acute care perspective: managing PWD in the acute care setting, demand for post discharge services exceeds availability of services, pressure to discharge patients and incomplete discharge documentation. Transitional care process failures and associated outcomes for PWD - the community HP perspective: failures in delivery of services to PWD; inadequate discharge notification and negative patient outcomes; discharge-related adverse events, readmission and carer stress; and issues with medication discharge orders and outcomes for PWD.

CONCLUSIONS

Although acute care HPs do engage in required discharge planning for people with dementia, participants identified critical issues: pressure on acute care health professionals to discharge PWD early, the requirement for JMOs to complete discharge summaries, the demand for post discharge services for PWD exceeding supply, the need to modify post discharge medication prescriptions for PWD, the need for improved coordination with RACF, and the need for routine provision of medication dose decision aids and home medicine reviews post discharge for PWD and their carers.

Research in hospital discharge procedures addresses gaps in care continuity in the community, but leaves gaping holes for people with dementia: a review of the literature

AIM

To examine the literature on the impact of the discharge experience of patients with dementia and their continuity of care.

METHODS

Peer-reviewed and grey literature published in the English language between 1995 and 2014 were systematically searched using Medline, CINAHL, PubMed, PsycINFO and Cochrane library databases, using a combination of the search terms Dementia, Caregivers, Integrated Health Care Systems, Managed Care, Patient Discharge. Also reviewed were Department of Health and Ageing and Alzheimer's Australia research reports between 2000 and 2014.

RESULTS

The review found a wide range of studies that raise concerns in relation to the quality of care provided to people with dementia during hospital discharge and in transitional care.

CONCLUSION

Discharge planning and transitional care for patients with dementia are not adequate and are likely to lead to readmission and other poor health outcomes.

Pragmatic cluster randomised controlled trial of facilitated family case conferencing compared with usual care for improving end of life care and outcomes in nursing home residents with advanced dementia and their families: the IDEAL study protocol

BACKGROUND

Care for people with advanced dementia requires a palliative approach targeted to the illness trajectory and tailored to individual needs. However, care in nursing homes is often compromised by poor communication and limited staff expertise. This paper reports the protocol for the IDEAL Project, which aims to: 1) compare the efficacy of a facilitated approach to family case conferencing with usual care; 2) provide insights into nursing home- and staff-related processes influencing the implementation and sustainability of case conferencing; and 3) evaluate cost-effectiveness.

DESIGN/METHODS

A pragmatic parallel cluster randomised controlled trial design will be used. Twenty Australian nursing homes will be randomised to receive either facilitated family case conferencing or usual care. In the intervention arm, we will train registered nurses at each nursing home to work as Palliative Care Planning Coordinators (PCPCs) 16 h per week over 18 months. The PCPCs' role will be to: 1) use evidence-based 'triggers' to identify optimal time-points for case conferencing; 2) organise, facilitate and document case conferences with optimal involvement from family, multi-disciplinary nursing home staff and community health professionals; 3) develop and oversee implementation of palliative care plans; and 4) train other staff in person-centred palliative care. The primary endpoint will be symptom management, comfort and satisfaction with care at the end of life as rated by bereaved family members on the End of Life in Dementia (EOLD) Scales. Secondary outcomes will include resident quality of life (Quality of Life in Late-stage Dementia [QUALID]), whether a palliative approach is taken (e.g. hospitalisations, non-palliative medical treatments), staff attitudes and knowledge (Palliative Care for Advanced Dementia [qPAD]), and cost effectiveness. Processes and factors influencing implementation, outcomes and sustainability will be explored statistically via analysis of intervention 'dose' and qualitatively via semi-structured interviews. The pragmatic design and complex nature of the intervention will limit blinding and internal validity but support external validity.

DISCUSSION

The IDEAL Project will make an important contribution to the evidence base for dementia-specific case conferencing in nursing homes by considering processes and contextual factors as well as overall efficacy. Its strengths and weaknesses will both lie in its pragmatic design.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12612001164886. Registered 02/11/2012.

Prostate cancer screening in Primary Health Care: the current state of affairs

This study aims to examine the current practice of General practitioners (GPs)/primary care physicians in opportunistic screening for prostate cancer (PC) by digital rectal examination(DRE) and Prostate Specific Antigen(PSA) testing and identify any difference in screening practice. Printed copies and/or electronic versions of a survey was distributed amongst 438 GPs throughout Australia in 2012. Statistical analyses (Wilcoxon rank-sum test, Fisher's exact test or Pearson chi-square test)were performed by outcomes and GP characteristics.There were a total of 149 responses received (34%), with similar gender distribution in rural and metropolitan settings. 74% GPs believed PSA testing was at least 'somewhat effective' in reducing PC mortality with annual PSA screening being conducted by more GPs in the metropolitan setting compared to the rural GPs (35% vs 18.4%), while 25% of rural GPs would not advocate routine PSA screening. When examining the concordance between DRE and PSA testing by gender of GP, the male GPs reported performing PSA testing more frequently than DRE in patients between ages 40 to 69 (p = 0.011). Urology Society guidelines (77.2%) and College of GPs (73.2%) recommendations for PC screening were thought to be at least 'somewhat useful'. Although reference ranges for PSA tests were felt to be useful, the majority (65.8%) found it easier to refer to an urologist due to the disagreements in guidelines. In conclusion, the current guidelines for PSA screening appear to cause more confusion due to their conflicting advice, leaving GPs to formulate their own practice methods, calling for an urgent need for uniform collaborative guidelines.

The telehealth skills, training, and implementation project: an evaluation protocol

Background

Telehealth appears to be an ideal mechanism for assisting rural patients and doctors and medical students/registrars in accessing specialist services. Telehealth is the use of enhanced broadband technology to provide telemedicine and education over distance. It provides accessible support to rural primary care providers and medical educators. A telehealth consultation is where a patient at a general practice, with the assistance of the general practitioner or practice nurse, undertakes a consultation by videoconference with a specialist located elsewhere. Multiple benefits of telehealth consulting have been reported, particularly those relevant to rural patients and health care providers. However there is a paucity of research on the benefits of telehealth to medical education and learning.

Objective

This protocol explains in depth the process that will be undertaken by a collaborative group of universities and training providers in this unique project.

Methods

Training sessions in telehealth consulting will be provided for participating practices and students. The trial will then use telehealth consulting as a real-patient learning experience for students, general practitioner trainees, general practitioner preceptors, and trainees.

Results

Results will be available when the trial has been completed in 2015.

Conclusions

The protocol has been written to reflect the overarching premise that, by building virtual communities of practice with users of telehealth in medical education, a more sustainable and rigorous model can be developed. The Telehealth Skills Training and Implementation Project will implement and evaluate a theoretically driven model of Internet-facilitated medical education for vertically integrated, community-based learning environments

GPs, medications and older people: A qualitative study of general practitioners' approaches to potentially inappropriate medications in older people

AIM

To explore the prescribing, and the rationale for this prescribing, of potentially inappropriate medications (PIMs) in older persons by Australian general practitioners (GPs).

METHODS

This was a qualitative study employing semistructured interviews and thematic analysis. GPs who had patients taking at least one PIM were invited to participate. PIMs were defined by the Beers criteria.

RESULTS

Twenty-two GPs from four regions in three Australian states participated. While none were aware of the Beers criteria, participant GPs displayed good knowledge of the potential adverse effects of these medications. They were comfortable with the continued prescription of the medications. This was based on often quite complex harm-benefit considerations of the biopsychosocial contexts of individual patients.

CONCLUSIONS

The concept of 'appropriate' versus 'inappropriate' medications implicit in classification systems such as the Beers criteria is at odds with complex considerations informing decision-making prescribing PIMs in older persons.

Medical students' experiences learning intimate physical examination skills: a qualitative study

BACKGROUND

Intimate physical examination skills are essential skills for any medical graduate to have mastered to an appropriate level for the safety of his or her future patients. Medical schools are entrusted with the complex task of teaching and assessing these skills for their students. The objectives of this study were to explore a range of medical students' experiences of learning intimate physical examination skills and to explore their perceptions of factors which impede or promote the learning of these skills.

METHODS

Individual semi-structured interviews (N = 16) were conducted with medical students in years two to five from the University of Newcastle, as part of a larger research project investigating how medical students develop their attitudes to gender and health. This was a self-selected sample of the entire cohort who were all invited to participate. A thematic analysis of the transcribed data was performed.

RESULTS

Students reported differing levels of discomfort with their learning experiences in the area of intimate physical examination and differing beliefs about the helpfulness of these experiences. The factors associated with levels of discomfort and the helpfulness of the experience for learning were: satisfaction with teaching techniques, dealing with an uncomfortable situation and perceived individual characteristics in both the patients and the students. The examination causing the greatest reported discomfort was the female pelvic examination by male students.

CONCLUSIONS

Student discomfort with the experience of learning intimate physical examination skills may be common and has ongoing repercussions for students and patients. Recommendations are made of ways to modify teaching technique to more closely match students' perceived needs.

Older people with mild cognitive impairment -- their views about assessing driving safety

BACKGROUND

Driving is important for older people to maintain agency, independence and social connectedness. Little research has been conducted into the views of older people with mild cognitive impairment about who decides if they are safe to drive.

AIM

This qualitative study investigates the views of older people with mild cognitive impairment about decision making on driving cessation.

DISCUSSION

Participants value their agency; they wanted to decide when they should stop driving themselves. However, they were also prepared to accept their general practitioner's advice when they became unfit to drive. In the interim, they self regulated the timing and distance of their driving to reduce accident risk.

Dementia - an update on management

BACKGROUND

Dementia is an increasingly common condition in the community. On average, every general practitioner in Australia will see three new cases each year. There are strong reasons for making an early diagnosis of dementia, as this may enable families to plan ahead and to institute management that could reduce cognitive impairment and slow disease progression.

OBJECTIVE

This article discusses the GP's role in the identification and management of dementia in general practice and provides an update on management of this disease.

DISCUSSION

Several new strategies for the management of dementia have emerged recently and GPs should be aware that optimal management of cardiovascular risk factors will improve cognition and may delay onset. Management of exercise, socialisation and cognitive training may improve cognitive function in early-diagnosed cases. The GP's role in initiating service delivery is an important one, and the practice nurse may play an important role in coordinating services for patients in the early stages of dementia.

Influence of rurality on diagnosing dementia in Australian general practice

This article reviews the literature concerning barriers in making a diagnosis of dementia in general practice and examines these from a rural perspective. It is proposed that the increasing prevalence of dementia in coming years in Australia will be felt most keenly in rural communities where there are already shortages of GPs and dementia-specific services to manage growing demand. Evidence suggests that dementia is often not specifically diagnosed by GPs and that this is a global issue. There are many barriers to the diagnosis of dementia in general practice, including time constraints, diagnostic uncertainty, denial of symptoms by patients and families, and stigma. This review examines these barriers and their impact on making a dementia diagnosis from a rural general practice perspective. Identification of these practice issues and their influence on service delivery is essential to inform relevant policy decisions and to improve dementia management in rural general practice.

A qualitative study into the use of formal services for dementia by carers from culturally and linguistically diverse (CALD) communities

Background

People with dementia and their family carers need to be able to access formal services in the community to help maintain their wellbeing and independence. While knowing about and navigating one’s way through service systems is difficult for most people, it is particularly difficult for people from culturally and linguistically diverse (CALD) communities. This study addresses a lack of literature on the use of formal services for dementia by people from CALD backgrounds by examining the experiences and perceptions of dementia caregiving within four CALD communities – Italian, Chinese, Spanish and Arabic-speaking – in south western Sydney, Australia.

Methods

The study used a qualitative design and the methods included focus groups with family carers and one-to-one interviews with bilingual/bicultural community workers, bilingual general practitioners and geriatricians. A total of 121 family carers participated in 15 focus groups and interviews were held with 60 health professionals. All fieldwork was audiotaped, transcribed and subjected to thematic analysis.

Results

People from CALD communities are often unfamiliar with the concept of formal services and there may be strong cultural norms about maintaining care within the family, rather than relying on external services. CALD communities often have limited knowledge of services. There is a preference for services that will allow families to keep their relative at home, for safety as well as cultural reasons, and they are particularly reluctant to use residential care. While there is a preference for ethno-specific or multicultural services, mainstream services also need to ensure they are more flexible in providing culturally appropriate care. Positive outcomes occur when ethno-specific services work in partnership with mainstream programs. Dementia service providers need to develop a trusting relationship with their local CALD communities and promote their services in a way that is understandable and culturally acceptable to members of these communities.

Conclusions

While members of CALD communities may have difficulties accessing formal services, they will use them if they are culturally and linguistically appropriate and can meet their needs. There are a number of ways to improve service provision to CALD communities and the responsibility for this needs to be shared by a range of stakeholders.

The experiences of nurses with mental health problems: colleagues' perspectives

A 3-stage qualitative study conducted in 2008 aimed to explore the issues to inform a mental health education program to deliver to nurses. This article presents the findings of Stage 1. Data were collected from semistructured interviews conducted with 14 Australian nurses. The interviews explored nurses' knowledge and understanding of mental health problems and their workplace experiences of working with nurses with mental health problems. The interviews were audiotaped, transcribed, and analyzed for the main themes: textbook knowledge, day-to-day support, and workplace considerations. These nurses' narratives guided the implementation of a mental health education workshop targeting nurses (Stage 2).

Dementia information for culturally and linguistically diverse communities: sources, access and considerations for effective practice

Providing information about dementia has been shown to produce immense benefits for people living with dementia and their carers. The dementia information needs of culturally and linguistically diverse (CALD) families have not been comprehensively investigated. Addressing this research gap, the current study examines the perspectives of a range of stakeholders – CALD family caregivers (Arabic, Chinese, Italian and Spanish speaking), bilingual and bicultural workers, bilingual general practitioners and geriatricians – about dementia-related information. The study focussed on sources of information, issues of access and considerations for improving information provision. The main findings that are relevant for improving policy and practice are: the need for a more strategic and coordinated approach to dissemination structures and processes, a greater emphasis on supporting and enhancing the interpersonal aspects of information provision, the need for a greater range of information for CALD communities and the need to ensure information resources and processes reflect the circumstances and needs of these communities.

The role of the bilingual/bicultural worker in dementia education, support and care

Members of minority populations often have difficulty knowing about and accessing dementia services. One of the strategies used to promote access is the employment of bilingual/bicultural workers (sometimes referred to as multicultural, link or outreach workers). This study involved interviews with 24 bilingual/bicultural workers in south western Sydney, Australia to gain a better understanding of their role within the dementia field. Seven themes emerged: importance of working with family; process of building trust when moving between two cultures; importance of understanding the culture; self-care and culture; flexibility of their role; linking community members; and linking communities to mainstream services. Bilingual/bicultural workers play a significant and complex role in supporting individuals and families within their community who are affected by dementia. The significance of their role needs to be more clearly acknowledged in the development of policy, further research and service provision within the dementia field.

Nurses' perceptions of a mental health education programme for Australian nurses

In the present study, we present qualitative findings of study of nurses' perceptions of a mental health education programme for Australian nurses. Many nurses avoid disclosing their mental health problem/illness because of the stigmatization by health workers. Mental health education is a successful means to address workplace stigma; thus, it can be anticipated that such education can address workplace difficulties experienced by nurses with mental health problems. During 2008, a qualitative study was conducted to obtain nurses' perceptions of a short mental health education programme for nurses. The workshop purpose was to improve mental health literacy in order to improve support to colleagues with mental health problems. Semistructured, audio-taped interviews were conducted with 13 nurses and then transcribed. A framework analysis approach guided interpretation of the data. The education programme had limited effect on the participants' attitudes towards colleagues with mental health problems. This was likely due to their high level of mental health literacy and experiences prior to the workshop. Participants felt that a more focused nurse-specific programme might have been more efficacious. Implementing a nurse-specific education session is potentially an effective means to improve support to nurses who experience mental health problems.

A new era in mental health care in vanuatu

Inequity in health-care delivery for those with mental illness is widespread throughout low- and middle-income countries. In the Pacific Island countries there are many barriers to addressing the growing mental health burden. In an effort to address this problem, the WHO is coordinating the Pacific Islands Mental Health Network involving 18 countries in the Pacific region with the financial support of New Zealand Aid (NZAid). JB and DP have developed and presented mental health training to health professionals, community leaders, and social service personnel in an environment in Vanuatu that is very different from that of their usual Australian-based general practices. They discuss evidence for their work, an outline of the programme, some difficulties working across different cultures, and the enthusiasm with which the training has been greeted. Vanuatu is now well on its way to addressing the inequity of access to mental health care with a culturally appropriate and self-sustaining mental health workforce.

'Perfect skin', the media and patients with skin disease: a qualitative study of patients with acne, psoriasis and atopic eczema

The relationship of skin disease with societal ideals of beauty, and the role of the media in this relationship, has not previously been researched. The overall objective of this study was to explore the psychological effects of skin disease. The theme of the ideal of perfect skin and the role of the media in generating this ideal arose via an inductive study methodology and was explored in the context of respondents’ psychological morbidity. A qualitative study, 62 semi-structured interviews were conducted with respondents with acne, eczema or psoriasis recruited from both general practice and specialist dermatology practice in an Australian regional city. Interviews were audiotaped, transcribed and subjected to thematic analysis employing a process of constant comparison in which data collection and analysis were cumulative and concurrent. The themes of perfect skin, societal ideals and media influence emerged from this iterative process. Respondents identified a societal ideal of flawless skin, largely mediated by media portrayals of perfection. Failure to meet this ideal precipitated psychological morbidity in female, but not male, respondents. An appreciation of the pervasive pressures of society and media upon females with skin disease may inform management strategies, particularly psychological management strategies, in patients with skin disease.

Patient attitudes - training students in general practice

BACKGROUND

While evidence from Australian studies is lacking, evidence from overseas suggests that patients are generally willing to have a medical student present during general practitioner consultations. This willingness, however, may be contingent upon factors related to the patient, student or consultation.

METHOD

Focus groups and two cross sectional surveys of 296 patients attending 16 general practices in New South Wales.

RESULTS

Patients are willing to have students present, but not for all consultations. Patients find it problematic to have students present during consultations that involve worrying test results, emotional upset, internal examinations, and sexual problems. Younger patients are less willing to have a student present. For all patients the presence of a student may alter the dynamics and content of the consultation; patients are less willing to see a student without the GP also being present.

DISCUSSION

Supervising GPs should be aware of circumstances where patients are less likely to want a student present and of ways in which the presence of a student may alter the consultation.