Generic care pathway for elderly patients in need of home care services after discharge from hospital: a cluster randomised controlled trial

Abstract

Background: Improved discharge arrangements and targeted post-discharge follow-up can reduce the risk of adverse events after hospital discharge for elderly patients. Although more care is to shift from specialist to primary care, there are few studies on post-discharge interventions run by primary care. A generic care pathway, Patient Trajectory for Home-dwelling elders (PaTH) including discharge arrangements and follow-up by primary care, was developed and introduced in Central Norway Region in 2009, applying checklists at defined stages in the patient trajectory. In a previous paper, we found that PaTH had potential of improving follow-up in primary care. The aim of this study was to establish the effect of PaTH-compared to usual care-for elderly in need of home care services after discharge from hospital.

Methods: We did an unblinded, cluster randomised controlled trial with 12 home care clusters. Outcomes were measured at the patient level during a 12-month follow-up period for the individual patient and analysed applying linear and logistic mixed models. Primary outcomes were readmissions within 30 days and functional level assessed by Nottingham extended ADL scale. Secondary outcomes were number and length of inpatient hospital care and nursing home care, days at home, consultations with the general practitioners (GPs), mortality and health related quality of life (SF-36).

Results: One-hundred and sixty-three patients were included in the PaTH group (six clusters), and 141 patients received care as usual (six clusters). We found no statistically significant differences between the groups for primary and secondary outcomes except for more consultations with the GPs in PaTH group (p = 0.04). Adherence to the intervention was insufficient as only 36% of the patients in the intervention group were assessed by at least three of the four main checklists in PaTH, but this improved over time.

Conclusions: Lack of adherence to PaTH rendered the study inconclusive regarding the elderly's functional level, number of readmissions after hospital discharge, and health care utilisation except for more consultations with the GPs. A targeted exploration of prerequisites for implementation is recommended in the pre-trial phase of complex intervention studies.

Trial registration: Clinical Trials.gov NCT01107119 , retrospectively registered 2010.04.18.

Keywords: Care coordination; Care pathway; Checklists; Complex intervention; Continuity of care; Controlled randomised trial; Elderly; Health service research; Primary health care.

Figures

Fig. 1

Patient trajectory for home-dwelling elders (PaTH) (12). The boxes represent procedures and checklists and the arrows the flow of information between the involved parties. The most important information from all checklists was included in the individual daily care plan which was available to all home care professionals at the point of care

Fig. 2

Organisation of health care services participating in PaTH. HCC = home care cluster GP = general practitioner. All hospitals serve as general hospitals to the participating municipalities. Hospital III also has regional and university functions. Every municipality has one or more home care units with nurses and nursing assistants providing health and social care to inhabitants with reduced functional level. One home care cluster included one to three home care units in the same municipality. GPs usually work in group practices and operate independently of the home care services. Every inhabitant has a right of free choice of a regular GP, which implies that the GP may have patients in common with all home care units in the municipality. Larger municipalities have health care allocation offices with municipal case managers who do a broad assessment of patients in need of municipal health and social care services other than private physiotherapy and GP services. They have a purchaser role deciding on what kind of services to be provided

Fig. 3

Flow of clusters and participants