Care transitions for frail, older people from acute hospital wards within an integrated healthcare system in England: a qualitative case study

Baillie, Lesley; Gallini, Andrew; Corser, Rachael; Elworthy, Gina; Scotcher, Ann; Barrand, Annabelle

doi:10.5334/ijic.1175

Cited by 63 publications

(144 citation statements)

References 44 publications

(87 reference statements)

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“…Previous studies have shown the importance of better continuity of care and of collaboration between health care providers to avoid gaps in the quality of taking care of the patients [1,3,4,29]. These results supports our results in that the new approach in the Executive inter-professional teamwork could change patients' everyday living situation in a positive direction.…”

Section: Discussionsupporting

confidence: 90%

“…In this case the freedom led to further steps being taken way beyond the original project limitations, offering an integration of professional knowledge between team members. Interprofessional communication has been shown to increase the quality of care for frail older people [29]. This result is underpinned by Schaik et al [30] who, from a study with inter professional teams, draw the conclusion that organizational change often is chosen from the top but ideally should be chosen by the team to be respected and empowered.…”

Section: Discussionmentioning

confidence: 99%

“…Differences exist among different regulations, disciplines, explanatory models and forms of organization. Extended interaction requires respect for each model in order to deal with and take advantage of these differences [1,29]. By having a composite inter-professional team in the emergency department with time to listen and to reveal the patient's underlying problems can create a broader decision base for assessment which might result in offering patients access to the right health care provider and also provide cost effective care.…”

Section: Discussionmentioning

confidence: 99%

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A New Model for Dealing with Patients Who Frequently Arrive Spontaneously at Hospital Emergency Departments Requiring Health Care: A Pilot Study

Persson¹

2014

Int J Nurs Clin Pract

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Background: Patients who repeatedly seek care directly at hospital based somatic emergency departments take up a large proportion of health care resources, at the same time they appear to experience low satisfaction with the care they receive. The purposes of this pilot study were to describe: I) the development of a team model for taking care of frequent visitors to a somatic hospital based ED; II) Eventual changes, over six months, in costs and patients' health care utilization related to pilot testing the model and III), the team's experiences of implementing the model. Methods: A mixed method convergent parallel design was used. Results:The development of the model began as a top-down process and later on into a bottom-up approach once the inter-professional team became involved. The new model functioned as a support for all 12 patients included in the study and collectively their visits decreased by a total of 73 visits (55%). Conclusion:The inference quality description is that a management induced project may be accepted and actively applied when those involved experience freedom to structure the project. Increased communication between different professionals within the hospital and between different caregivers such as ED, primary health care and community social-and health-care, increases the possibility for the patients to be cared for in a sustainable and non-fragmented way.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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A New Model for Dealing with Patients Who Frequently Arrive Spontaneously at Hospital Emergency Departments Requiring Health Care: A Pilot Study

Persson¹

2014

Int J Nurs Clin Pract

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“…Involvement of the patient and informal caregiver can improve continuity of care, quality of care and positive experiences with care [9][10][11]. Therefore, it is important to use different perspectives (patient/professional/informal caregiver) in the evaluation of processes and outcomes on the level of health service delivery (i.e.…”

Section: Introductionmentioning

confidence: 99%

“…alignment with patients' care needs; care coordination; team cooperation; and quality of care) [12]. However, few studies have evaluated multiple perspectives involved with changes in health service delivery [9,10,13].…”

Section: Introductionmentioning

confidence: 99%

Changes in geriatric rehabilitation: a national programme to improve quality of care. The Synergy and Innovation in Geriatric Rehabilitation study

Holstege¹,

Caljouw²,

Zekveld³

et al. 2015

Int J Integr Care

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Objective: To describe changes in the health service delivery process experienced by professionals, patients and informal caregivers during implementation of a national programme to improve quality of care of geriatric rehabilitation by improving integration of health service delivery processes. This article is published in a peer reviewed section of the International Journal of Integrated Care 1 Study setting: Sixteen skilled nursing facilities. Research and TheoryStudy design: Prospective study, comparing three consecutive cohorts.Data collection: Professionals (elderly care physicians, physiotherapists and nursing staff) rated four domains of health service delivery at admission and at discharge of 1075 patients. In addition, these patients [median age 79 (Interquartile range 71-85) years, 63% females] and their informal caregivers rated their experiences on these domains 4 weeks after discharge.Principal findings: During the three consecutive cohorts, professionals reported improvement on the domain team cooperation, including assessment for intensive treatment and information transfer among professionals. Fewer improvements were reported within the domains alignment with patients' needs, care coordination and care quality. Between the cohorts, according to patients (n = 521) and informal caregivers (n = 319) there were no changes in the four domains of health service delivery.Conclusion: This national programme resulted in small improvements in team cooperation as reported by the professionals. No effects were found on patients' and informal caregivers' perceptions of health service delivery.

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Defining the characteristics of intermediate care models including transitional care: an international Delphi study

et al. 2020

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Background Although there is growing utilisation of intermediate care to improve the health and well-being of older adults with complex care needs, there is no international agreement on how it is defined, limiting comparability between studies and reducing the ability to scale effective interventions. Aim To identify and define the characteristics of intermediate care models. Methods A scoping review, a modified two-round electronic Delphi study involving 27 multi-professional experts from 13 countries, and a virtual consensus meeting were conducted. Results Sixty-six records were included in the scoping review, which identified four main themes: transitions, components, benefits and interchangeability. These formed the basis of the first round of the Delphi survey. After Round 2, 16 statements were agreed, refined and collapsed further. Consensus was established for 10 statements addressing the definitions, purpose, target populations, approach to care and organisation of intermediate care models. Discussion There was agreement that intermediate care represents time-limited services which ensure continuity and quality of care, promote recovery, restore independence and confidence at the interface between home and acute services, with transitional care representing a subset of intermediate care. Models are best delivered by an interdisciplinary team within an integrated health and social care system where a single contact point optimises service access, communication and coordination. Conclusions This study identified key defining features of intermediate care to improve understanding and to support comparisons between models and studies evaluating them. More research is required to develop operational definitions for use in different healthcare systems.

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Care transitions for frail, older people from acute hospital wards within an integrated healthcare system in England: a qualitative case study

Cited by 63 publications

References 44 publications

A New Model for Dealing with Patients Who Frequently Arrive Spontaneously at Hospital Emergency Departments Requiring Health Care: A Pilot Study

A New Model for Dealing with Patients Who Frequently Arrive Spontaneously at Hospital Emergency Departments Requiring Health Care: A Pilot Study

Changes in geriatric rehabilitation: a national programme to improve quality of care. The Synergy and Innovation in Geriatric Rehabilitation study

Defining the characteristics of intermediate care models including transitional care: an international Delphi study

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