Professional care at home: Patient‐centredness, interprofessionality and effectivity? A scoping review

Abstract

The aim of this scoping review was to describe the state of knowledge on professional care at home with regard to different perspectives on patient-centredness, content of care, interprofessional collaboration, competence framework and effectivity. A scoping review, n = 35 papers, from four databases (EBSCO, CINAHL, Medline, Swemed) were reviewed between May and August 2018 using the terms:hospital-at-home, hospital-in-the-home, advanced home healthcare, hospital-based home care or patient-centered medical home. Criteria for inclusion in this review included full text papers, published between 2001 and 2018, in English, Swedish or Finnish. A descriptive content analysis was conducted. Patient-centredness appears to be one aim of professional care at home, but clarity is lacking regarding patient recruitment and the planning and evaluation of care. Content depends, to a certain degree, on the type of care at home and how it is organised: the more non-acute care needs, the more nurse-coordinated care and family involvement and the less interprofessionality. The competence framework presupposed for care at home was extensive yet not explicit, varying from maturity, clinical experience, collaboration skills, ongoing clinical assessment education to Master's studies or degree. The effectivity of care at home services was discussed in terms of experiential, clinical and economic aspects. Patients and their family caregivers were satisfied with care at home, but there was no consensus on clinical or economic outcomes compared with inpatient care. In the context of professional care at home, there is still a lot to do regarding patient-centredness, patient recruitment, patient and care staff education, the organisation of interprofessional collaboration and the analysis of effectivity. K E Y W O R D S advanced home care, competence, effectivity, home care, hospital at home, hospital in the home, interprofessionality, Patient-centred care | e271 VAARTIO-RAJALIN ANd FAGERSTRÖM

Balancing between extremes—Work in hospital‐at‐home

“…HAH can be offered as form of primary, specialized or private care or as a combination of these. In one scoping review (Vaartio‐Rajalin & Fagerström, , N = 35), researchers found that before a planned hospital stay or in conjunction with hospital discharge, a physician or a rapid response team should conduct a holistic assessment of a patient's physical and psychological health, acute and chronic symptoms, symptom distress, functional status, disease stage, comorbidities and motivation. This assessment could be performed at the hospital, during a proactive or acute, unscheduled home visit or by telephone call.…”

“…HAH is realized in interprofessional teams (comprised of a physician/geriatrician and a nurse; possibly even social workers, pharmacists, nutrition therapists or physiotherapists) together with patient's near‐ones. In regard to the nursing being provided, HAH activities are realized by either registered nurses (RNs), district nurses (DNs) or advanced practitioner nurses (APNs) (Vaartio‐Rajalin & Fagerström, . ).…”

“…There are some profession‐specific competency requirements for HAH staff. In a scoping review, researchers found that the competence framework for rapid response team members was comprised of 2–30 years clinical experience in a specialty, the undertaking of a physical assessment, the completion of a clinical reasoning course at degree or Master's level, the completion of non‐medical prescribing studies, having a clinical supervisor and engaging in self‐reflection through the use of a competency workbook (Vaartio‐Rajalin & Fagerström, ). Other researchers have seen that the competence framework for those engaged in rapid response team work but not nursing per se included employment in senior roles in acute hospital settings , specialization or experience in acute care, oncology or gerontology, having or working towards a Master's level degree in advanced practice and/or having completed modules in advanced physical assessment skills and having completed a non‐medical prescribers course (Öhlen, Forsberg, & Broberg, ).…”

“…Advanced practitioner nurses are often responsible for clinical history taking, drawing up care plans and coordinating care teams (Fagerström, ). In the home care context, APNs are known to shoulder great responsibility for the advanced health and nursing care being received and researchers have demonstrated that APN‐led care results in equivalent or better outcomes than physician‐led services in regard to the reduction in s ymptom burden, self‐management and behavioural outcomes, disease‐specific indicators, patient's satisfaction and perception of quality of life and health service use (Chan et al, ; Pouliot, Weiss, Pratt, & DiSorbo, ; Vaartio‐Rajalin & Fagerström, ). The ICN Nurse Practitioner/ Advanced Practice Nursing Network (https://international.aanp.org/Practice/APNRoles) defines an APN as, “a registered nurse who has acquired the expert knowledge base, complex decision‐making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country where s/he is credentialed to practise.” Compared with specialist nurses, APNs generally have a 2‐year Masters level degree and more advanced skills in advanced nursing and medical care and, usually, the extended authority to prescribe medication.…”

“…Person‐centred care has also been defined as respect for the personal narratives that reflect a person's sense of self, lived experiences and relationships and the recognition of this respect through the safeguarding of a partnership in shared decision‐making and in meaningful activities in a personalized environment (Ekman et al, ; Kitwood, ; McCormack & McCance, ). In a scoping review with an HAH context (Vaartio‐Rajalin & Fagerström, ), researchers found that patient‐centredness was perceived as respect for a patient's autonomy, self‐determination capacity and social relationships and made concrete through a continuous, trustful relationship established during the planning and evaluation of care by nurses together with the patient and his/her near‐ones. Patient‐centredness was thus based on the patient's needs while still being financially viable, with care taking place in the patient's home (seen as the patient's “own”) environment.…”