The Information Flow in a Healthcare Organisation with Integrated Units

Motivational interviewing for reducing rehospitalisation and improving patient activation among patients with heart failure or chronic obstructive pulmonary disease: a randomised controlled trial

OBJECTIVES

The aim is to evaluate the effects of a motivational interviewing-based intervention, Supporting Patient Activation in Transition to Home, on rehospitalisation and patient activation among patients with heart failure or chronic obstructive pulmonary disease.

DESIGN

A randomised, controlled, analysis-blinded trial was conducted.

SETTING

Participants were recruited from two hospitals in mid-Sweden and the intervention and interviews were conducted post-discharge.

PARTICIPANTS

207 participants with heart failure or chronic obstructive pulmonary disease were recruited. Participants were randomised to receive five motivational interviewing sessions post-discharge (n=103) or a control group (n=104).

OUTCOME MEASURES

Rehospitalisation within 180 days post-discharge was retrieved, and patient activation was assessed using the Patient Activation Measure at baseline, 30, 90 and 180 days post-discharge. We used a generalised estimating equation to assess the difference in the secondary outcome, patient activation, between the intervention group and the control group during the 180-day follow-up.

RESULTS

No statistically significant differences between the groups were found for rehospitalisation (p=0.33 to 0.41) or patient activation over time (B=-1.67, -0.71 and -0.83 (95% CI -5.45 to 2.10, -4.06 to 2.64 and -4.28 to 2.62), respectively).

CONCLUSION

Post-discharge motivational interviewing to decrease rehospitalisation or support patient activation does not seem beneficial for patients with heart failure or chronic obstructive pulmonary disease. The high disease burden may have limited patient participation in the intervention.

TRIAL REGISTRATION NUMBER

NCT02823795.

Hospital-to-Home Transitions for Lung Cancer Patients-A Qualitative Study of Healthcare Professionals' Experiences

AIMS AND OBJECTIVES

To explore the professional practice of transferring patients with lung cancer from hospitals to their homes through the experiences of healthcare professionals (HCPs) working in hospitals.

BACKGROUND

Hospital-to-home transitions are particularly challenging for vulnerable patients, including lung cancer patients, and could threaten patient safety. There is a need to improve coordination between specialised and community care and to develop knowledge on the practice of transferring patients with lung cancer.

DESIGN

A descriptive qualitative design was used. Consolidated criteria for reporting qualitative research (COREQ) were followed for reporting.

METHODS

Six focus group interviews with nurses and two focus group interviews with physicians at pulmonary medicine units in two hospitals in Norway were conducted. Qualitative content analysis was used to analyse the focus group interviews.

RESULTS

Patients' vulnerability and gratitude motivated HCPs to ensure that patients experienced the best hospital-to-home transition. The following obstacles made it challenging to plan for a good hospital-to-home transition and to transfer the responsibility for the patient to the municipality: lack of time and routines to attend to the patient's individual needs, lack of established standards for patient information, absence of resources and predictability, and inadequate communication tools for collaborating with the primary healthcare services.

CONCLUSION

The healthcare system does not provide hospital units and HCPs with adequate resources to accommodate the individual needs of lung cancer patients in hospital-to-home transitions. HCPs compensate with supplementary initiatives to secure patient safety, but the additional responsibility and tasks leave them overworked.

RELEVANCE TO CLINICAL PRACTICE

The study provides knowledge on lung cancer patients' needs in hospital-to-home transitions and how HCPs try to ensure patient safety by compensating for the healthcare system's deficiencies.

PUBLIC CONTRIBUTION

A reference group comprising one patient representative from the Norwegian Cancer Society and five HCPs with varied relevant backgrounds contributed to the overall design, recruited participants, and provided feedback on the interview guide.

Patient pathways in primary health care - an interview study across various health care personnel in a Canadian and a Norwegian county

BACKGROUND

Due to demographic changes in the Western world governments emphasize the need for viable solutions, e.g. through decentralization of specialist health care services and better coordination within and between health care services. Both Norway and Canada have been through health care reforms and initiatives aiming to improve continuity and coordination of services. Organizational change to primary care in both countries encompasses both team-based service delivery involving allied health professionals, and new blended payment models. The objective of this study was to explore patient pathways in primary healthcare from various health personnel's perspectives, and across various primary care organizations in Norway and Canada.

METHODS

The study had a qualitative design, including interviews with physicians, nurses and managers (n = 19) in primary care, from a county in Norway and a region in Canada. Data were analyzed with a thematic approach, in line with recommendations from Braun & Clarke.

RESULTS

Three themes were identified: 1) Structural challenges, 2) Towards a more specialized primary health care and 3) Dedication could improve continuity. Findings indicate that coordinating health care services was assumed difficult due to different health care levels, funding systems, managements, electronic record systems and organizations. Hospitals were assumed more task oriented, while primary health care services were considered more care oriented, and this challenged the coordination across organizations. Primary care services were perceived to be more and more specialized, also representing a threat for coordination and continuity. Health care personnel in both countries perceived that dedicated personnel for each patient could improve information flow and continuity across services.

CONCLUSIONS

Achieving continuity and coordination of health care services seems challenging. Integration strategies seem essential for reducing silo thinking and fragmentation of health care services.

Successful ability to stay at home - an interview study exploring multiple diagnosed older persons and their relatives' experiences

BACKGROUND

Society places increased demands on regions and municipalities to jointly carry out activities for multi-diagnosed older persons with extensive coordination needs. Interprofessional collaboration is reported as an important success factor for the overall health care of this group of patients. This project focuses on older persons with multiple diagnoses and their relatives' own experiences of what is most important for safety and security in their homes. The aim of the study was: to illuminate the meaning of success for the ability to stay at home as experienced by older persons with multiple diagnoses and their relatives.

METHODS

The project had a descriptive explorative design with a phenomenological hermeneutic approach based on analysis of 14 in-depth interviews with older people and their relatives.

FINDINGS

Own resources were identified such as belief in the future, spiritual belief, social network, having loved ones and pets. Technical aids were seen as helpful resources, working as indoor and outdoor security safeguards. These resources included having good telephone contact with social and professional networks as well as other forms of personal equipment such as a personal alarm. The professional network was a resource, acting as support when the patient's own abilities were not sufficient. Finally, having personnel who had the time and interest to listen was seen as crucial to experience safety.

CONCLUSIONS

The main reason for being able to continue homecare was the person's self-care system, their personal, social, and technical resources. Professional care development should anchor team work to the patient's own system of self and informal care.

Exploring potential drivers of patient engagement with their health data through digital platforms: A scoping review

BACKGROUND

Patient engagement when providing patient access to health data results from an interaction between the available tools and individual capabilities. The recent digital advancements of the healthcare field have altered the manifestation and importance of patient engagement. However, a comprehensive assessment of what factors contribute to patient engagement remain absent. In this review article, we synthesised the most frequently discussed factors that can foster patient engagement with their health data.

METHODS

A scoping review was conducted in MEDLINE, Embase, and Google Scholar. Relevant data were synthesized within 7 layers using a thematic analysis: (1) social and demographic factors, (2) patient ability factors, (3) patient motivation factors, (4) factors related to healthcare professionals' attitudes and skills, (5) health system factors, (6) technological factors, and (7) policy factors.

RESULTS

We identified 5801 academic and 200 Gy literature records, and included 292 (4.83%) in this review. Overall, 44 factors that can affect patient engagement with their health data were extracted. We extracted 6 social and demographic factors, 6 patient ability factors, 12 patient motivation factors, 7 factors related to healthcare professionals' attitudes and skills, 4 health system factors, 6 technological factors, and 3 policy factors.

CONCLUSIONS

Improving patient engagement with their health data enables the development of patient-centered healthcare, though it can also exacerbate existing inequities. While expanding patient access to health data is an important step towards fostering shared decision-making in healthcare and subsequently empowering patients, it is important to ensure that these developments reach all sectors of the community.

'I want to ski and race, not just ski': a qualitative study on athletes' and stakeholders' perspectives on return-to-sport in high-performance Snowsports

This study explored stakeholders' perspectives on current practices, challenges and opportunities related to the return-to-sport (RTS) process in high-performance Snowsports. We conducted fourteen semi-structured interviews with athletes, coaches and health professionals from multiple countries using online video platforms. The data were transcribed verbatim and analysed based on constant comparative analysis employing the principles of Grounded Theory. Codes were grouped into categories and main concepts and a conceptual model were derived. According to the participants, RTS should be considered a continuous process to bring the athlete back to competition as fast and safely as possible, whereas speed is often prioritised over safety. Participants described the need for a structured and criteria-based process. Despite the multiple phases and the diversity of involved professionals, the process is individualised and unique, highlighting the value of having the athlete at the centre of the RTS process. It was considered essential to provide a safe environment and build trustworthy relationships. Additionally, access to resources, communication and cooperation among all experts was perceived as critical to successful RTS. Our participants described the value of continuity and an athlete-centred approach to the RTS process. The challenges, such as interprofessional communication, the lack of objective sport-specific criteria, and the diversity of resources and network structures, were perceived as practical issues that influenced the process, which should be tailored for each athlete accordingly to reach a successful RTS.

"Being the main character but not always involved in one's own care transition" - a qualitative descriptive study of older adults' experiences of being discharged from in-patient care to home

BACKGROUND

The growing number of older adults with chronic diseases challenges already strained healthcare systems. Fragmented systems make transitions between healthcare settings demanding, posing risks during transitions from in-patient care to home. Despite efforts to make healthcare person-centered during care transitions, previous research indicates that these ambitions are not yet achieved. Therefore, there is a need to examine whether recent initiatives have positively influenced older adults' experiences of transitions from in-patient care to home. This study aimed to describe older adults' experiences of being discharged from in-patient care to home.

METHODS

This study had a qualitative descriptive design. Individual interviews were conducted in January-June 2022 with 17 older Swedish adults with chronic diseases and needing coordinated care transitions from in-patient care to home. Data were analyzed using inductive qualitative content analysis.

RESULTS

The findings indicate that despite being the supposed main character, the older adult is not always involved in the planning and decision-making of their own care transition, often having poor insight and involvement in, and impact on, these aspects. This leads to an experience of mismatch between actual needs and the expectations of planned support after discharge.

CONCLUSIONS

The study reveals a notable disparity between the assumed central role of older adults in care transitions and their insight and involvement in planning and decision-making.

Delineating and clarifying the concept of self-care monitoring: a concept analysis

AIM

To delineate and clarify the meaning of the concept of self-care monitoring from a patient perspective.

METHODS

A systematic search was performed in the databases ASSIA, CINAHL, PsycInfo, and PubMed (January 2016-September 2021). A selection of 46 peer-reviewed articles was included in the study and analysed using Rodgers' Evolutionary Method for Concept Analysis.

RESULTS

The following four attributes were identified: Tracking symptoms, signs, and actions, Paying attention, Being confident, and Needing routines, creating a descriptive definition: "Self-care monitoring is an activity that means a person has to pay attention and be confident and needs routines for tracking symptoms, signs, and action." The antecedents of the concept were shown to be Increased knowledge, Wish for independence, and Commitment. The concepts' consequences were identified as Increased interaction, Perceived burden, and Enhanced well-being.

CONCLUSIONS

This concept analysis provides extensive understanding of self-care monitoring from a patient perspective. It was shown that the concept occurs when a person practices self-care monitoring at home either with or without devices. A descriptive definition was constructed and presented with exemplars to encourage practice of the concept in various healthcare settings and could be of relevance to people with chronic illnesses or other long-term conditions.

Cooperation between Public Primary Health Care and Occupational Health Care Professionals in Work Ability-Related Health Issues

Work disability creates significant expenses for nations and causes human suffering by limiting patients' lives. International studies show that to enhance recognition of and support for work disability, cooperation, mutual trust, and information exchange between public primary health care and occupational health care must be strengthened. However, little is known of how health care professionals experience this cooperation. The aim of this study was to understand how professionals experience the cooperation between public primary health care and occupational health services regarding patients' work ability. Semi-structured interviews were conducted with 29 health care professionals working in five small cities (<10,000 inhabitants) in Finland. Interviews were audio and video recorded, transcribed verbatim, and analyzed through inductive thematic analysis. Three key themes were identified from the interviews: attitudes toward the other health care sector, the exchange of information, and resources for cooperation. Professionals seem to have poor knowledge about the services available and how care is given in the other sector, appearing to lead to weak mutual trust. The public primary health care professionals especially emphasized the benefits of cooperation, but several issues were mentioned as barriers to cooperation. These results can be used when planning effective patient paths and service provisioning models.

Actions taken to safeguard the intended health care chain of older people with multiple diagnoses - a critical incident study

Background

Older people with multiple diagnoses often have problems coping with their daily lives at home because of lack of coordination between various parts of the healthcare chain during the transit from hospital care to the home. To provide good care to those persons who have the most complex needs, regions and municipalities must work together. It is of importance to develop further empirical knowledge in relation to older persons with multiple diagnoses to illuminate possible obstacles to person-centred care during the transition between healthcare institutions and the persons livelihood. The aim of the present study was to describe nurses’ experienced critical incidents in different parts of the intended healthcare chain of older people with multiple diagnoses.

Methods

The sample consisted of 18 RNs in different parts of the healthcare system involved in the care of older people with multiple diagnoses. Data were collected by semi structured interviews and analysed according to Critical Incident Technique (CIT). A total of 169 critical incidents were identified describing experiences in recently experienced situations.

Results

The result showed that organizational restrictions in providing care and limitations in collaboration were the main areas of experienced critical incidents. Actions took place due to the lack of preventive actions for care, difficulties in upholding patients’ legal rights to participation in care, deficiencies in cooperation between organizations as well as ambiguous responsibilities and roles. The RNs experienced critical incidents that required moral actions to ensure continued person-centred nursing and provide evidence-based care. Both types of critical incidents required sole responsibility from the nurse. The RNs acted due to ethics, ‘walking the extra mile’, searching for person-centred information, and finding out own knowledge barriers.

Conclusions

In conclusion and based on this critical incident study, home-based healthcare of older people with multiple diagnoses requires a nurse that is prepared to take personal and moral responsibility to ensure person-centred home-based healthcare. Furthermore, the development of in-between adjustments of organizations to secure cooperation, and transference of person-centred knowledge is needed.

Information flow as reproductive governance. Patient journey analysis of information barriers and facilitators to abortion care in the republic of Ireland

Background

Information flow - information communication and transmission pathways and practices within healthcare systems - impacts patient journeys. Historically, regulating information flow was a key technology of reproductive governance in the Republic of Ireland. Pre-2018, law and the State sustained informational barriers to and through abortion care in Ireland. An expanded abortion service was implemented in January 2019.

Method

Patient Journey Analysis (PJA) interrogates informational facilitators and barriers to/through post-2019 abortion care in Ireland. We focus on information flow at the interfaces between the 'public' sphere and 'point of entry', 'point of entry' and primary care, and primary and secondary care.

Materials

The paper uses data from a mixed-method study. A tool for assessing online abortion service information (ASIAT), desktop research, and qualitative data from 108 in-depth interviews with providers, policy-makers, advocacy groups, and service users informed the analysis.

Results

Abortion patient journeys vary. Information flow issues, e.g. communication of how to access services, referral systems, and information handover, act as barriers and facilitators. Barriers increase where movement from primary to secondary is needed.

Applications

The article identifies good practice in information flow strategy, as well as areas for development. It illustrates the significance of information flow in accomplishing reproductive governance.

What is needed for continuity of care and how can we achieve it? - Perceptions among multiprofessionals on the chronic care trajectory

BACKGROUND

Continuity of care (CoC) implies delivery of services in a coherent, logical and timely fashion. Continuity is conceptualized as multidimensional, encompassing three specific domains - relational, management and informational continuity - with emphasis placed on their interrelations, i.e., how they affect and are affected by each other. This study sought to investigate professionals' perceptions of the prerequisites of CoC within and between organizations and how CoC can be realized for people with complex care needs.

METHODS

This study had a qualitative design using individual, paired and focus group interviews with a purposeful sample of professionals involved in the chain of care for patients with chronic conditions across healthcare and social care services from three different geographical areas in Sweden, covering both urban and rural areas. Transcripts from interviews with 34 informants were analysed using conventional content analysis.

RESULTS

CoC was found to be dependent on professional and cross-disciplinary cooperation at the micro, meso and macro system levels. Continuity is dependent on long-term and person-centred relationships (micro level), dynamic stability in organizational structures (meso level) and joint responsibility for cohesive care and enabling of uniform solutions for knowledge and information exchange (macro level).

CONCLUSIONS

Achieving CoC that creates coherent and long-term person-centred care requires knowledge- and information-sharing that transcends disciplinary and organizational boundaries. Collaborative accountability is needed both horizontally and vertically across micro, meso and macro system levels, rather than a focus on personal responsibility and relationships at the micro level.

Design and Development of an eHealth Service for Collaborative Self-Management among Older Adults with Chronic Diseases: A Theory-Driven User-Centered Approach

The increasing prevalence of chronic conditions and multimorbidity poses great challenges to healthcare systems. As patients' engagement in self-managing their chronic conditions becomes increasingly important, eHealth interventions are a promising resource for the provision of adequate and timely support. However, there is inconclusive evidence about how to design eHealth services to meet the complex needs of patients. This study applied an evidence-based and theory-informed user-centered design approach in three phases to identify the needs of older adults and healthcare professionals in the collaborative management of multimorbidity (phase 1), develop an eHealth service to address these needs (phase 2), and test the feasibility and acceptance of the eHealth service in a clinical setting (phase 3). Twenty-two user needs were identified and a web-based application-ePATH (electronic Patient Activation in Treatment at Home)-with separate user interfaces for patients and healthcare professionals was developed. The feasibility study with two nurses and five patients led to a redesign and highlighted the importance of adequately addressing not only varying user needs but also the complex nature of healthcare organizations when implementing new services and processes in chronic care management.

What matters in care continuity on the chronic care trajectory for patients and family carers?-A conceptual model

AIMS AND OBJECTIVES

To describe essential aspects of care continuity from the perspectives of persons with complex care needs and their family carers.

BACKGROUND

Continuity of care is an important aspect of quality, safety and efficiency. For people with multiple chronic diseases and complex care needs, care must be experienced as connected and coherent, and consistent with medical and individual needs. The more complex the need for care, the greater the need for continuity across different competencies, services and roles.

DESIGN

A constructivist grounded theory approach was applied.

METHODS

Sixteen patients with one or more chronic diseases needing both health care and social care, living in their private homes, and twelve family carers, were recruited. Semi-structured interviews were conducted and analysed with constructivist grounded theory. The COREQ checklist was followed.

RESULTS

A conceptual model of care continuity was constructed, consisting of five categories that were interconnected through the core category: time and space. Patients' and family carers' experiences of care continuity were closely related to timely personalised care delivery, where access to tailored information, regardless of who was performing a care task, was essential for mutual understanding. This required clarity in responsibilities and roles, interprofessional collaboration and achieving a trusting relationship between each link in the chain of care, over time and space. To achieve care continuity, all the identified categories were important, as they worked in synergy, not in isolation.

CONCLUSION

Care continuity for people with complex care needs and family carers is experienced as multidimensional, with several essential aspects that work in synergy, but varies over time and depends on each person's own resources and situational and contextual circumstances.

RELEVANCE TO CLINICAL PRACTICE

The findings promote understanding of patients' and family carers' experiences of care continuity and may guide the delivery of care to people with complex care needs.

[Does the integration of health services management improve clinical coordination? Experience in Catalonia]

OBJECTIVE

To analyze the experience and perception of clinical coordination across care levels and doctor's organizational and interactional related factors, according to the type of management integration of the healthcare services of the area, in Catalonia.

METHOD

Cross-sectional study based on an online survey by self-administration of the questionnaire COORDENA-CAT.

DATA COLLECTION

October-December 2017.

STUDY POPULATION

primary and secondary care (acute and long-term care) doctors of the public Catalan health system.

SAMPLE

3308 doctors.

OUTCOME VARIABLES

experience and perception of clinical coordination, knowledge and use of coordination mechanisms and organizational and interactional factors; explanatory variables: area according to type of management (integrated, semi-integrated, non-integrated), socio-demographic, employment characteristics and attitude toward work. Descriptive analysis by type of area and multivariate analysis by robust Poisson regression.

RESULTS

Better clinical coordination was observed in integrated areas compared to those semi-integrated, mainly in relation to information transfer, adequate follow-up and perception of coordination in the area. No differences were found between integrated and non-integrated areas in the clinical coordination experience, although there were differences in perception and some related factors. There are common problems across areas, such as accessibility to secondary care.

CONCLUSIONS

Few differences were found between integrated and non-integrated areas, revealing that management integration may facilitate clinical coordination but is not enough. Differences with semi-integrated areas indicate the need to promote cooperation formulas between all the providers of the territory, with common objectives and coordination mechanisms, in order to avoid inequalities in quality of care.

Towards an Integrated Care Organisation from a CEO Perspective

Many experimental projects towards Person-Centred Care (PCC) are successful in the early stages, but founder when the attempt is made to scale them up to encompass the whole organisation. This case study therefore focusses on one manager's attempts to extend the successes of a preliminary project 'Etxean Ondo' that aimed to provide adequate support for the elderly living at home or in nursing homes, as well as for their families and care professionals. Through in-depth interviews with stakeholders, this qualitative study, based on Grounded Theory, sets out to analyse which behaviours, attitudes and values on the part of management appeared to favour full-integration of PCC in this wider context. Analysis of the data gathered allowed the researcher to generate an experimental case model which suggests how the extrinsic, intrinsic and transcendent motivation of stakeholders can be aligned with the goals of upper management to promote full-integration of PCC in such a way as to generate trust, increase participant engagement and create a win-win situation for all. Whilst this is clearly an experimental project, it is hoped that the model provided may prove helpful to other researchers and managers interested in pioneering this type of comprehensive organisational strategic change towards integration.

The Over 75 Service: Continuity of Integrated Care for Older People in a United Kingdom Primary Care Setting

Continuity of care is concerned with quality of care over a period of time. It describes a process by which service users and their families are co-operatively involved with health and social care professionals in managing their care needs. Continuity of care can be divided into informational, managerial and relational and has been associated with improved user- and service-related outcomes. To date, there have been few studies which examine how continuity of care is developed and maintained in integrated primary care systems. This paper explores continuity of care in an integrated Over 75 Service for people living at home with complex health and social care needs. Using a case study approach, qualitative data was collected from multiple sources including interviews with managers and professionals, users and carers, care plans, steering group minutes and field notes. Data was analysed thematically. A number of factors are identified which characterise continuity of care, namely: information sharing through direct communication between providers and the development of trusted relationships within the team; identified care co-ordinators who acted as a conduit for information and communication; the development of ongoing relationships with users and carers requiring dedicated time and accessible and flexible services delivered in the users’ own home.

Elderly patients with complex health problems in the care trajectory: a qualitative case study

BACKGROUND

Elderly patients with multiple health problems often experience disease complications and functional failure, resulting in a need for health care across different health care systems during care trajectory. The patients' perspective of the care trajectory has been insufficiently described, and thus there is a need for new insights and understanding. The study aims to explore how elderly patients with complex health problems engage in and interact with their care trajectory across different health care systems where several health care personnel are involved.

METHODS

The study had an explorative design with a qualitative multi-case approach. Eleven patients (n = 11) aged 65-91 years participated. Patients were recruited from two hospitals in Norway. Observations and repeated interviews were conducted during patients' hospital stays, discharge and after they returned to their homes. A thematic analysis method was undertaken.

RESULTS

Patients engaged and positioned themselves in the care trajectory according to three identified themes: 1) the patients constantly considered opportunities and alternatives for handling the different challenges and situations they faced; 2) patients searched for appropriate alliance partners to support them and 3) patients sometimes circumvented the health care initiation of planned steps and took different directions in their care trajectory.

CONCLUSIONS

The patients' considerations of their health care needs and adjustments to living arrangements are constant throughout care trajectories. These considerations are often long term, and the patient engagement in and management of their care trajectory is not associated with particular times or situations. Achieving consistency between the health care system and the patient's pace in the decision-making process may lead to a more appropriate level of health care in line with the patient's preferences and goals.