Implementing a care pathway for elderly patients, a comparative qualitative process evaluation in primary care

Abstract

Background: In Central Norway a generic care pathway was developed in collaboration between general hospitals and primary care with the intention of implementing it into everyday practice. The care pathway targeted elderly patients who were in need of home care services after discharge from hospital. The aim of the present study was to investigate the implementation process of the care pathway by comparing the experiences of health care professionals and managers in home care services between the participating municipalities.

Methods: This was a qualitative comparative process evaluation using data from individual and focus group interviews. The Normalization Process Theory, which provides a framework for understanding how a new intervention becomes part of normal practice, was applied in our analysis.

Results: In all of the municipalities there were expectations that the generic care pathway would improve care coordination and quality of follow-up, but a substantial amount of work was needed to make the regular home care staff understand how to use the care pathway. Other factors of importance for successful implementation were involvement of the executive municipal management, strong managerial focus on creating engagement and commitment among all professional groups, practical facilitation of work processes, and a stable organisation without major competing priorities. At the end of the project period, the pathway was integrated in daily practice in two of the six municipalities. In these municipalities the care pathway was found to have the potential of structuring the provision of home care services and collaboration with the GPs, and serving as a management tool to effect change and improve knowledge and skills.

Conclusion: The generic care pathway for elderly patients has a potential of improving follow-up in primary care by meeting professional and managerial needs for improved quality of care, as well as more efficient organisation of home care services. However, implementation of this complex intervention in full-time running organisations was demanding and required comprehensive and prolonged efforts in all levels of the organisation. Studies on implementation of such complex interventions should therefore have a long follow-up time to identify whether the intervention becomes integrated into everyday practice.

Figures

Figure 1

Generic care pathway (PaTH), for transition from hospital and follow-up of home care recipients[2]. The boxes represent procedures and checklists and the arrows the flow of information between involved parties. It starts with the patient being reported ready for discharge and information is exchanged (1, 2 and 3). Within three days a home care nurse performs a thorough and structured assessment (4). The patient has a consultation with the GP 14 days after discharge (5), and a nurse or nursing assistant performs an extended assessment during the first four weeks (6). A daily care plan is continuously updated (7), and if the patient’s condition gets worse, the home care service has a routine for what to observe, whom to contact and which information to pass on (8). The checklists included practical issues (e.g. whether assistive devices had been ordered and when they would be installed), health issues (e.g. review of medication), social conditions (e.g. if the present accommodation was appropriate for the patients’ level of functioning) and physical and cognitive functioning (e.g. ability to climb stairs, reduced memory). Some checklists were to be used by nurses only (3 and 4), while others were also to be used by nursing assistants (6 and 8). All of the issues on the lists were not necessarily relevant for all patients and the nurses and nursing assistants had to use their professional insight to decide what to assess and how to follow-up.