Older people's care experience in community and general hospitals: a comparative study

Doctors' experiences of providing care in rural hospitals in Southern New Zealand: a qualitative study

OBJECTIVE

To explore rural hospital doctors' experiences of providing care in New Zealand rural hospitals.

DESIGN

The study had a qualitative design, using qualitative content analysis.

SETTING

The study was conducted in South Island, New Zealand, and included nine different rural hospitals.

RESPONDENTS

Semistructured interviews were conducted with 16 rural hospital doctors.

RESULTS

Three themes were identified: 'Applying a holistic perspective in the care', 'striving to maintain patient safety in sparsely populated areas' and 'cooperating in different teams around the patient'. Rural hospital care more than general hospital care was seen as offering a holistic perspective on patient care based on closeness to their home and family, the generalist perspective of care and personal continuity. The presentation of acute life-threatening low-frequency conditions at rural hospitals were associated with feelings of concern due to limited access to ambulance transportation and lack of experience.Overall, however, patient safety in rural hospitals was considered equal or better than in general hospitals. Doctors emphasised the central role of rural hospitals in the healthcare pathways of rural patients, and the advantages and disadvantages with small non-hierarchical multidisciplinary teams caring for patients. Collaboration with hospital specialists was generally perceived as good, although there was a sense that urban colleagues do not understand the additional medical and practical assessments needed in rural compared with the urban context.

CONCLUSIONS

This study provides an understanding of how rural hospital doctors value the holistic generalist perspective of rural hospital care, and of how they perceive the quality and safety of that care. The long distances to general hospital care for acute cases were considered concerning.

'Localism and intimacy, and… other rather imponderable reasons of that sort': A qualitative study of patient experience of community hospitals in England

Debates over the value and contribution of community hospitals are hampered by a lack of empirical assessment of the experience of patients using these services. This paper presents findings from a study which included a focus on patient and family-carer experiences of community hospitals in England. We adopted a qualitative design involving nine case study hospitals. Data collection included interviews with patients (n = 60), carers (n = 28) and staff (n = 89). Through patients and carers highlighting the value of community hospitals feeling 'close to home', providing holistic and personalised care and supporting them through difficult transitions, the study confirms the importance of functional and interpersonal aspects of care, while also highlighting the importance of social and psychological aspects. These included having family, friends and the community close, maintaining social connections during periods of hospital treatment, and feeling less anonymous and anxious when attending the hospital due to the high levels of familiarity and connectedness. Although the experiences uncovered in this study were not uniformly positive, patients and carers placed a high overall value on the care provided by community hospitals, often arguing that these were distinctive when compared to their experiences of using other health and care services. The study suggests the need to weigh the full range of these dimensions of patient experience-functional, interpersonal, social and psychological-when assessing the role and contribution of community hospitals.

Patient experience and satisfaction with admission to an acute geriatric community hospital in the Netherlands: a mixed method study

Purpose

The acute geriatric community hospital (AGCH) in an intermediate care facility is an alternative to conventional hospitalization. A comprehensive geriatric assessment and rehabilitation are integrated into acute medical care for older patients. This study aims to evaluate patient experience and satisfaction with the AGCH.

Design/methodology/approach

This is a mixed method observational study including a satisfaction questionnaire and qualitative interviews with AGCH patients or informal caregivers.

Findings

A total of 152 participants filled in the questionnaire, and thirteen semi-structured interviews were conducted. Twelve categories and four overarching themes emerged in the analysis. In general, study participants experience the admission to the AGCH as positive and are satisfied with the care they received; there were also suggestions for improvement.

Research limitations/implications

Limitations of this study include possible participation bias. The results show that patients value this type of care indicating that it should be implemented elsewhere. Further research will focus on health outcomes, readmission rates and cost effectiveness of the AGCH.

Originality/value

This is the first study to evaluate care satisfaction with the AGCH. It shows that hospitalized older adults positively value the AGCH as an alternative to hospitalization.

Measuring and optimising the efficiency of community hospital inpatient care for older people: the MoCHA mixed-methods study

Background

Community hospitals are small hospitals providing local inpatient and outpatient services. National surveys report that inpatient rehabilitation for older people is a core function but there are large differences in key performance measures. We have investigated these variations in community hospital ward performance.

Objectives

(1) To measure the relative performance of community hospital wards (studies 1 and 2); (2) to identify characteristics of community hospital wards that optimise performance (studies 1 and 3); (3) to develop a web-based interactive toolkit that supports operational changes to optimise ward performance (study 4); (4) to investigate the impact of community hospital wards on secondary care use (study 5); and (5) to investigate associations between short-term community (intermediate care) services and secondary care utilisation (study 5).

Methods

Study 1 – we used national data to conduct econometric estimations using stochastic frontier analysis in which a cost function was modelled using significant predictors of community hospital ward costs. Study 2 – a national postal survey was developed to collect data from a larger sample of community hospitals. Study 3 – three ethnographic case studies were performed to provide insight into less tangible aspects of community hospital ward care. Study 4 – a web-based interactive toolkit was developed by integrating the econometrics (study 1) and case study (study 3) findings. Study 5 – regression analyses were conducted using data from the Atlas of Variation Map 61 (rate of emergency admissions to hospital for people aged ≥ 75 years with a length of stay of < 24 hours) and the National Audit of Intermediate Care.

Results

Community hospital ward efficiency is comparable with the NHS acute hospital sector (mean cost efficiency 0.83, range 0.72–0.92). The rank order of community hospital ward efficiencies was distinguished to facilitate learning across the sector. On average, if all community hospital wards were operating in line with the highest cost efficiency, savings of 17% (or £47M per year) could be achieved (price year 2013/14) for our sample of 101 wards. Significant economies of scale were found: a 1% rise in output was associated with an average 0.85% increase in costs. We were unable to obtain a larger community hospital sample because of the low response rate to our national survey. The case studies identified how rehabilitation was delivered through collaborative, interdisciplinary working; interprofessional communication; and meaningful patient and family engagement. We also developed insight into patients’ recovery trajectories and care transitions. The web-based interactive toolkit was established [http://mocha.nhsbenchmarking.nhs.uk/ (accessed 9 September 2019)]. The crisis response team type of intermediate care, but not community hospitals, had a statistically significant negative association with emergency admissions.

Limitations

The econometric analyses were based on cross-sectional data and were also limited by missing data. The low response rate to our national survey means that we cannot extrapolate reliably from our community hospital sample.

Conclusions

The results suggest that significant community hospital ward savings may be realised by improving modifiable performance factors that might be augmented further by economies of scale.

Future work

How less efficient hospitals might reduce costs and sustain quality requires further research.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

Analysis of the profile, characteristics, patient experience and community value of community hospitals: a multimethod study

Background

Community hospitals have been part of England’s health-care landscape since the mid-nineteenth century. Evidence on them has not kept pace with their development.

Aim

To provide a comprehensive analysis of the profile, characteristics, patient experience and community value of community hospitals.

Design

A multimethod study with three phases. Phase 1 involved national mapping and the construction of a new database of community hospitals through data set reconciliation and verification. Phase 2 involved nine case studies, including interviews and focus groups with patients (n = 60), carers (n = 28), staff (n = 132), volunteers (n = 68), community stakeholders (n = 74) and managers and commissioners (n = 9). Phase 3 involved analysis of Charity Commission data on voluntary support.

Setting

Community hospitals in England.

Results

The study identified 296 community hospitals with beds in England. Typically, the hospitals were small (< 30 beds), in rural communities, led by doctors/general practitioners (GPs) and nurses, without 24/7 on-site medical cover and provided step-down and step-up inpatient care, with an average length of stay of < 30 days and a variable range of intermediate care services. Key to patients’ and carers’ experiences of community hospitals was their closeness to ‘home’ through their physical location, environment and atmosphere and the relationships that they support; their provision of personalised, holistic care; and their role in supporting patients through difficult psychological transitions. Communities engage with and support their hospitals through giving time (average 24 volunteers), raising money (median voluntary income £15,632), providing services (voluntary and community groups) and giving voice (e.g. taking part in communication and consultation). This can contribute to hospital utilisation and sustainability, patient experience, staff morale and volunteer well-being. Engagement varies between and within communities and over time. Community hospitals are important community assets, representing direct and indirect value: instrumental (e.g. health care), economic (e.g. employment), human (e.g. skills development), social (e.g. networks), cultural (e.g. identity and belonging) and symbolic (e.g. vitality and security). Value varies depending on place and time.

Limitations

There were limitations to the secondary data available for mapping community hospitals and tracking charitable funds and to the sample of case study respondents, which concentrated on people with a connection to the hospitals.

Conclusions

Community hospitals are diverse but are united by a set of common characteristics. Patients and carers experience community hospitals as qualitatively different from other settings. Their accounts highlight the importance of considering the functional, interpersonal, social and psychological dimensions of experience. Community hospitals are highly valued by their local communities, as demonstrated through their active involvement as volunteers and donors. Community hospitals enable the provision of local intermediate care services, delivered through an embedded, relational model of care, which generates deep feelings of reassurance. However, current developments may undermine this, including the withdrawal of GPs, shifts towards step-down care for non-local patients and changing configurations of services, providers and ownership.

Future work

Comparative studies of patient experience in different settings; longitudinal studies of community support and value; studies into the implications of changes in community hospital function, GP involvement, provider-mix and ownership; and international comparative studies could all be undertaken.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Shifting care from community hospitals to intensive community support: a mixed method study

Aim To examine how the introduction of intensive community support (ICS) affected admissions to community hospital (CH) and to explore the views of patients, carers and health professionals on this transition.

BACKGROUND

ICS was introduced to provide an alternative to CH provision for patients (mostly very elderly) requiring general rehabilitation.

METHOD

Routine data from both services were analysed to identify the number of admissions and length of stay between September 2012 and September 2014. In total, 10 patients took part in qualitative interviews. Qualitative interviews and focus groups were undertaken with 19 staff members, including managers and clinicians. Findings There were 5653 admissions to CH and 1710 to ICS between September 2012 and September 2014. In the five months before the introduction of ICS, admission rates to CH were on average 217/month; in the final five months of the study, when both services were fully operational, average numbers of patients admitted were: CH 162 (a 25% reduction), ICS 97, total 259 (a 19% increase). Patients and carers rated both ICS and CH favourably compared with acute hospital care. Those who had experienced both services felt each to be appropriate at the time; they appreciated the 24 h availability of staff in CH when they were more dependent, and the convenience of being at home after they had improved. In general, staff welcomed the introduction of ICS and appreciated the advantages of home-based rehabilitation. Managers had a clearer vision of ICS than staff on the ground, some of whom felt underprepared to work in the community. There was a consensus that ICS was managing less complex and dependent patients than had been envisaged.

CONCLUSION

ICS can provide a feasible adjunct to CH that is acceptable to patients. More work is needed to promote the vision of ICS amongst staff in both community and acute sectors.

Community hospitals and their services in the NHS: identifying transferable learning from international developments – scoping review, systematic review, country reports and case studies

Background

The notion of a community hospital in England is evolving from the traditional model of a local hospital staffed by general practitioners and nurses and serving mainly rural populations. Along with the diversification of models, there is a renewed policy interest in community hospitals and their potential to deliver integrated care. However, there is a need to better understand the role of different models of community hospitals within the wider health economy and an opportunity to learn from experiences of other countries to inform this potential.

Objectives

This study sought to (1) define the nature and scope of service provision models that fit under the umbrella term ‘community hospital’ in the UK and other high-income countries, (2) analyse evidence of their effectiveness and efficiency, (3) explore the wider role and impact of community engagement in community hospitals, (4) understand how models in other countries operate and asses their role within the wider health-care system, and (5) identify the potential for community hospitals to perform an integrative role in the delivery of health and social care.

Methods

A multimethod study including a scoping review of community hospital models, a linked systematic review of their effectiveness and efficiency, an analysis of experiences in Australia, Finland, Italy, Norway and Scotland, and case studies of four community hospitals in Finland, Italy and Scotland.

Results

The evidence reviews found that community hospitals provide a diverse range of services, spanning primary, secondary and long-term care in geographical and health system contexts. They can offer an effective and efficient alternative to acute hospitals. Patient experience was frequently reported to be better at community hospitals, and the cost-effectiveness of some models was found to be similar to that of general hospitals, although evidence was limited. Evidence from other countries showed that community hospitals provide a wide spectrum of health services that lie on a continuum between serving a ‘geographic purpose’ and having a specific population focus, mainly older people. Structures continue to evolve as countries embark on major reforms to integrate health and social care. Case studies highlighted that it is important to consider local and national contexts when looking at how to transfer models across settings, how to overcome barriers to integration beyond location and how the community should be best represented.

Limitations

The use of a restricted definition may have excluded some relevant community hospital models, and the small number of countries and case studies included for comparison may limit the transferability of findings for England. Although this research provides detailed insights into community hospitals in five countries, it was not in its scope to include the perspective of patients in any depth.

Conclusions

At a time when emphasis is being placed on integrated and community-based care, community hospitals have the potential to assume a more strategic role in health-care delivery locally, providing care closer to people’s homes. There is a need for more research into the effectiveness and cost-effectiveness of community hospitals, the role of the community and optimal staff profile(s).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Epilepsy monitoring - The patients' views: A qualitative study based on Kolcaba's Comfort Theory

PURPOSE

The aim of this qualitative study was to determine which perception of personal comfort patients name in the context of their hospitalization in an Austrian Epilepsy Monitoring Unit (EMU).

METHODS

Problem-centred interviews with twelve inpatients were conducted. Data analyses were done according to Mayring's qualitative content analyses following the technique of structuring-deductive category assignment.

RESULTS

Patients experienced different kinds of comfort along with their hospitalization in the EMU. Comfort-decreasing factors were bed rest, boredom, and waiting for possible seizures. As comfort-increasing factors, hope for enhanced seizure control, support by family and staff, and intelligible information about the necessity of restrictive conditions were identified.

CONCLUSIONS

The study results should assist health care professionals, enabling them to design comfort enhancing interventions for patients undergoing video-electroencephalography (EEG) investigations in an EMU. Some of these seem to be simple and obtainable without high financial or technical effort. Others are more complex and have to be further assessed for their feasibility.

Community Hospitals in Selected High Income Countries: A Scoping Review of Approaches and Models

BACKGROUND

There is no single definition of a community hospital in the UK, despite its long history. We sought to understand the nature and scope of service provision in community hospitals, within the UK and other high-income countries.

METHODS

We undertook a scoping review of literature on community hospitals published from 2005 to 2014. Data were extracted on features of the hospital model and the services provided, with results presented as a narrative synthesis.

RESULTS

75 studies were included from ten countries. Community hospitals provide a wide range of services, with wide diversity of provision appearing to reflect local needs. Community hospitals are staffed by a mixture of general practitioners (GPs), nurses, allied health professionals and healthcare assistants. We found many examples of collaborative working arrangements between community hospitals and other health care organisations, including colocation of services, shared workforce with primary care and close collaboration with acute specialists.

CONCLUSIONS

Community hospitals are able to provide a diverse range of services, responding to geographical and health system contexts. Their collaborative nature may be particularly important in the design of future models of care delivery, where emphasis is placed on integration of care with a key focus on patient-centred care.

A qualitative study of patient experiences of decentralized acute healthcare services

OBJECTIVE

Municipality acute wards (MAWs) have recently been launched in Norway as an alternative to hospitalizations, and are aimed at providing treatment for patients who otherwise would have been hospitalized. The objective of this study was to explore how patients normally admitted to hospitals perceived the quality and safety of treatment in MAWs.

DESIGN

The study had a qualitative design. Thematic analysis was used to analyze the data.

SETTING

The study was conducted in a county in south-eastern Norway and included five different MAWs.

PATIENTS

Semi-structured interviews were conducted with 27 participants who had required acute health care and who had been discharged from the five MAWs.

RESULTS

Three subthemes were identified that related to the overarching theme of hospital-like standards ("almost a hospital, but…"), namely (a) treatment and competence, (b) location and physical environment, and (c) adequate time for care. Participants reported the treatment to be comparable to hospital care, but they also experienced limitations. Participants spoke positively about MAW personnel and the advantages of having a single patient room, a calm environment, and proximity to home.

CONCLUSIONS

Participants felt safe when treated at MAWs, even though they realized that the diagnostic services were not similar to that in hospitals. Geographical proximity, treatment facilities and time for care positively distinguished MAWs from hospitals, while the lack of diagnostic resources was stressed as a limitation. Key points   Municipality acute wards (MAWs) have been implemented across Norway. Research on patient perspectives on the decentralization of acute healthcare in MAWs is lacking.   • Patients perceive decentralized acute healthcare and treatment as being comparable to the quality they would have expected in hospitals.   • Geographical proximity, a home-like atmosphere and time for care were aspects stressed as positive features of the decentralized services.   • Lack of diagnostic resources was seen as a limitation.

Perceived quality of an alternative to acute hospitalization: an analytical study at a community hospital in Hallingdal, Norway

There is growing international interest in the geography of health care provision, with health care providers searching for alternatives to acute hospitalization. In Norway, the government has recently legislated for municipal authorities to develop local health services for a selected group of patients, with a quality equal to or better than that provided by hospitals for emergency admissions. General practitioners in Hallingdal, a rural district in southern Norway, have for several years referred acutely somatically ill patients to a community hospital, Hallingdal sjukestugu (HSS). This article analyzes patients' perceived quality of HSS to demonstrate factors applicable nationally and internationally to aid in the development of local alternatives to general hospitals. We used a mixed-methods approach with questionnaires, individual interviews and a focus group interview. Sixty patients who were taking part in a randomized, controlled study of acute admissions at HSS answered the questionnaire. Selected patients were interviewed about their experiences and a focus group interview was conducted with representatives of local authorities, administrative personnel and health professionals. Patients admitted to HSS reported statistically significant greater satisfaction with several care aspects than those admitted to the general hospital. Factors highlighted by the patients were the quiet and homelike atmosphere; a small facility which allowed them a good overall view of the unit; close ties to the local community and continuity in the patient-staff relationship. The focus group members identified some overarching factors: an interdisciplinary and holistic approach, local ownership, proximity to local general practices and close cooperation with the specialist health services at the hospital. Most of these factors can be viewed as general elements relevant to the development of local alternatives to acute hospitalization both nationally and internationally. This study indicates that perceived quality should be one of the main motivations for developing alternatives to general hospital admissions.

The role of an intermediate unit in a clinical pathway

INTRODUCTION

Different care models have been established to achieve more coordinated clinical pathways for older patients in the transition between hospital and home. This study explores an intermediate unit's role in a clinical pathway for older patients with somatic diseases.

THEORY AND METHODS

Qualitative data were collected via interviews, observations, and a questionnaire. Participants included patients and healthcare providers within both specialist and primary healthcare. Transcripts of interviews and field notes were analyzed using a method of systematic text condensation.

RESULTS

Healthcare providers in the hospital, the intermediate unit, and the municipalities have different opinions about who is a 'suitable' patient for the unit and what is the proper time for hospital discharge. This results in time-consuming negotiations between the hospital and the unit. Incompatible computer systems increase the healthcare provider's workload. Several informants are doubtful as to whether a stay in the unit is useful to the patients, while the patients are mostly pleased with their stay and the transferral.

CONCLUSION AND DISCUSSION

This study describes challenges that may occur when a new unit is established in an existing healthcare system in order to achieve an appropriate clinical pathway from hospital to home.

Identifying modifiable factors to improve quality for older adults in hospital: a scoping review

BACKGROUND

Traditional ways of viewing hospitalisation do not always recognise how elements within the hospital environment contribute to disability. Four theoretical dimensions of older adult-hospital environment fit have been proposed in previous research on elder-friendly hospitals: social climate, physical design, care systems and processes, policies and procedures; however, modifiable factors for each dimension are not yet identified.

DESIGN

Exploratory iterative design guided by Arksey and O'Malley (2005, International Journal of Social Research Methodology 8, 19) scoping review methodology.

METHOD

We undertook a scoping review of primary research related to hospitalised community-dwelling older adults. Keys search terms and criteria were used to identify relevant articles with modifiable factors extracted from articles meeting study criteria.

RESULTS

A total of 66 studies were included and evaluated for modifiable factor mapping. We were able to map all 66 studies to the four dimensions. The majority of included studies described care systems and processes, with little relating to social climate, physical design and policies and procedures. Thirty-nine potentially modifiable factors were identified and mapped to the theoretical dimensions according to four overarching themes: models of care; assessment of potential geriatric issues; targeting care to a specific clinical issue and supporting transitions home themes.

CONCLUSION

The dimensions of older adult-hospital fit help us to organise key features of an elder-friendly hospital and identify potentially modifiable factors. Although it makes intuitive sense to cluster and organise according to the dimensions to help with understanding, this tells us little about the synergy of interactions and hierarchical relationships. Our results highlight the importance of competent gerontological nursing in care for hospitalised older adults and the need for further understanding of the older adult and family as a unit of care.

IMPLICATIONS FOR PRACTICE

Registered nurses have a leadership role to ensure safe quality care for older people in hospital. This leadership role can be framed in interventions that focus on fixing the fit between what older people need and what the hospital environment provides. Modifiable factors for improvement are within the scope and competency of the registered nurse.