Development of a patient-centred care pathway across healthcare providers: a qualitative study

Tove Røsstad, Helge Garåsen, Aslak Steinsbekk, Olav Sletvold, Anders Grimsmo, Tove Røsstad, Helge Garåsen, Aslak Steinsbekk, Olav Sletvold, Anders Grimsmo

Abstract

Background: Different models for care pathways involving both specialist and primary care have been developed to ensure adequate follow-up after discharge. These care pathways have mainly been developed and run by specialist care and have been disease-based. In this study, primary care providers took the initiative to develop a model for integrated care pathways across care levels for older patients in need of home care services after discharge. Initially, the objective was to develop pathways for patients diagnosed with heart failure, COPD and stroke. The aim of this paper is to investigate the process and the experiences of the participants in this developmental work. The participants were drawn from three hospitals, six municipalities and patient organizations in Central Norway.

Methods: This qualitative study used focus group interviews, written material and observations. Representatives from the hospitals, municipalities and patient organizations taking part in the development process were chosen as informants.

Results: The development process was very challenging because of the differing perspectives on care and different organizational structures in specialist care and primary care. In this study, the disease perspective, being dominant in specialist care, was not found to be suitable for use in primary health care because of the need to cover a broader perspective including the patient's functioning, social situation and his or her preferences. Furthermore, managing several different disease-based care pathways was found to be unsuitable in home care services, as well as unsuitable for a population characterized by a substantial degree of comorbidity. The outcome of the development process was a consensus that outlined a single, common patient-centred care pathway for transition from hospital to follow-up in primary care. The pathway was suitable for most common diseases and included functional and social aspects as well as disease follow-up, thus merging the differing perspectives. The disease-based care pathways were kept for use within the hospitals.

Conclusions: Disease-based care pathways for older patients were found to be neither feasible nor sustainable in primary care. A common patient-centred care pathway that could meet the needs of multi- morbid patients was recommended.

Figures

Figure 1
Figure 1
Common care pathway for transition from hospital and follow-up of home care recipients. The boxes represent procedures and checklists and the arrows the flow of information between involved parties. It starts with the patient being reported as ready for discharge and information is exchanged (1 and 2). Home care services are established (3), and within three days a district 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 aide 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).

References

    1. The coordination reform. Proper treatment - at the right place and right time. Oslo: Norwegian Ministry of health and care services; 2008–2009. vol. Report no 47 to the Storting.
    1. Morris J, Beaumont D, Oliver D. Decent health care for older people. BMJ. 2006;332(7551):1166–1168. doi: 10.1136/bmj.332.7551.1166.
    1. Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004;141(7):533–536.
    1. Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009;7(2):100–103. doi: 10.1370/afm.971.
    1. Conroy S, Ferguson C, Woodard J, Banerjee J. Interface geriatrics: evidence-based care for frail older people with medical crises. Br J Hosp Med (Lond) 2010;71(2):98–101.
    1. Mesteig M, Helbostad JL, Sletvold O, Rosstad T, Saltvedt I. Unwanted incidents during transition of geriatric patients from hospital to home: a prospective observational study. BMC Health Serv Res. 2010;10:1. doi: 10.1186/1472-6963-10-1.
    1. Payne S, Kerr C, Hawker S, Hardey M, Powell J. The communication of information about older people between health and social care practitioners. Age Ageing. 2002;31(2):107–117. doi: 10.1093/ageing/31.2.107.
    1. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646–651. doi: 10.1046/j.1525-1497.2003.20722.x.
    1. Dancy M. Bridging the treatment gap: the secondary care perspective. Heart. 2005;91(2):ii32–34. doi: 10.1136/hrt.2005.062083. Discussion ii43-38.
    1. Vedel I, Monette M, Beland F, Monette J, Bergman H. Ten years of integrated care: backwards and forwards. The case of the province of Quebec, Canada. Int J Integr Care. 2011;11:e004.
    1. Rudkjobing A, Olejaz M, Birk HO, Nielsen AJ, Hernandez-Quevedo C, Krasnik A. Integrated care: a Danish perspective. BMJ. 2012;345:e4451. doi: 10.1136/bmj.e4451.
    1. Shepperd S, Doll H, Angus RM, Clarke MJ, Iliffe S, Kalra L, Ricauda NA, Tibaldi V, Wilson AD. Avoiding hospital admission through provision of hospital care at home: a systematic review and meta-analysis of individual patient data. CMAJ. 2009;180(2):175–182. doi: 10.1503/cmaj.081491.
    1. Shepperd S, Doll H, Broad J, Gladman J, Iliffe S, Langhorne P, Richards S, Martin F, Harris R. Early discharge hospital at home. Cochrane Database Syst Rev. 2009;1 CD000356.
    1. Naylor MD, Sochalski JA. Scaling up: bringing the transitional care model into the mainstream. Issue Brief (Commonw Fund) 2010;103:1–12.
    1. Smith SM, Allwright S, O’Dowd T. Effectiveness of shared care across the interface between primary and specialty care in chronic disease management. Cochrane Database Syst Rev. 2007;3 CD004910.
    1. Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52(5):675–684. doi: 10.1111/j.1532-5415.2004.52202.x.
    1. Fjaertoft H, Indredavik B, Lydersen S. Stroke unit care combined with early supported discharge: long-term follow-up of a randomized controlled trial. Stroke. 2003;34(11):2687–2691. doi: 10.1161/01.STR.0000095189.21659.4F.
    1. Bolibar I, Plaza V, Llauger M, Amado E, Anton PA, Espinosa A, Dominguez L, Fraga M, Freixas M, de la Fuente JA. Assessment of a primary and tertiary care integrated management model for chronic obstructive pulmonary disease. BMC Publ Health. 2009;9:68. doi: 10.1186/1471-2458-9-68.
    1. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281(7):613–620. doi: 10.1001/jama.281.7.613.
    1. Rytter L, Jakobsen HN, Ronholt F, Hammer AV, Andreasen AH, Nissen A, Kjellberg J. Comprehensive discharge follow-up in patients’ homes by GPs and district nurses of elderly patients. A randomized controlled trial. Scand J Prim Health Care. 2010;28(3):146–153. doi: 10.3109/02813431003764466.
    1. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002;288(15):1909–1914. doi: 10.1001/jama.288.15.1909.
    1. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Aff (Millwood) 2009;28(1):75–85. doi: 10.1377/hlthaff.28.1.75.
    1. Patient-centered medical home. [ ]
    1. Hellesø R, Fagermoen MS. Cultural diversity between hospital and community nurses: implications for continuity of care. International Journal of Integrated Care. 2010;10:e036.
    1. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655. doi: 10.1136/bmj.a1655.
    1. Garasen H, Hendriksen C. Health care for the elderly–perspectives in relation to implementation of results from intervention studies in Norway and Denmark. Scand J Public Health. 2009;37(3):223–226. doi: 10.1177/1403494809105025.
    1. The Regular GP Scheme has now been introduced. .
    1. Johnsen JR. In: Health Systems in Transition. Bankauskaite V, editor. Norway: World health Organization; 2006. p. 187.
    1. Patient process redesign. .
    1. What is Lean. [ ]
    1. Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001;358(9280):483–488. doi: 10.1016/S0140-6736(01)05627-6.
    1. Giorgi A. Sketch of a psycological phenomenological method, in Phenomenology and psycological research. Pittsburg, PA: Duquesne University Press; 1985.
    1. Barondess JA. Specialization and the physician workforce: drivers and determinants. JAMA. 2000;284(10):1299–1301. doi: 10.1001/jama.284.10.1299.
    1. Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med. 2009;7(4):293–299. doi: 10.1370/afm.1023.
    1. Romøren TI. [Community nursing - a shift in responsibilities and target groups] Aldring og livsløp. 2007;1:9.
    1. Brevik I. The new home care services - far more than old age welfare services. Oslo: Norwegian Institute for Urban and Regional Research; 2010. 2.
    1. Kalseth B, Midttun L, Paulsen B, Nygård L. [Development in municipal and hospital health care - service development and interaction] Trondheim: Sintef; 2004. p. 145. (Sintef rapport).
    1. [Medical services to recipients of non- institutionalised local authority assistance] Oslo: Norwegian Directorate of Health; 2006.
    1. Valderas JM, Mercer SW, Fortin M. Research on patients with multiple health conditionns: different constructs, different views, one voice. Journal of Comorbidity. 2011;1:1–3.
    1. Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162(20):2269–2276. doi: 10.1001/archinte.162.20.2269.
    1. Robinson JH, Callister LC, Berry JA, Dearing KA. Patient-centered care and adherence: definitions and applications to improve outcomes. J Am Acad Nurse Pract. 2008;20(12):600–607. doi: 10.1111/j.1745-7599.2008.00360.x.
    1. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004;351(27):2870–2874. doi: 10.1056/NEJMsb042458.
    1. Caughey GE, Roughead EE, Shakib S, McDermott RA, Vitry AI, Gilbert AL. Comorbidity of chronic disease and potential treatment conflicts in older people dispensed antidepressants. Age Ageing. 2010;39(4):488–494. doi: 10.1093/ageing/afq055.
    1. Stein KV. The Cause for Action? Decision Making and Priority Setting in Intergrated Care. Vienna: Vienna University of Economics and Business Administration; 2010. (Doctoral Thesis).
    1. Plsek PE, Greenhalgh T. Complexity science: The challenge of complexity in health care. BMJ. 2001;323(7313):625–628. doi: 10.1136/bmj.323.7313.625.

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