Collaborate across silos: Perceived barriers to integration of care for the elderly from the perspectives of service providers

A health-social service partnership programme for improving the health self-management of community-dwelling older adults: a hybrid effectiveness-implementation pilot study protocol

BACKGROUND

The ageing population requires seamless, integrated health and social care services in the community to promote the health of older adults. However, inadequate financial resources, a lack of clear operational guidelines, and various organisational work cultures may affect the implementation quality and sustainability of these services. As a unique approach, this study seeks to examine the preliminary effects of a health-social partnership programme on the health self-management of community-dwelling older adults in Hong Kong. Additionally, the study seeks to ascertain key insights into the mechanisms and processes required to implement and sustain a self-care management programme in broader practice in community settings.

METHODS

This study will use a hybrid effectiveness-implementation design. During the 3-month programme, subjects in the intervention group will receive four Zoom video conference sessions and four telephone calls conducted by a health-social service team that will include a nurse case manager, community workers, general practitioners, a Chinese medicine practitioner, and social workers. Subjects in the control group will receive a monthly social telephone call from a trained research assistant to rule out the possible social effect of the intervention. The reach, effectiveness, adoption, implementation, and maintenance framework (i.e. RE-AIM framework) will be used to evaluate the implementation and effectiveness outcomes. Of the five dimensions included in the RE-AIM framework, only effectiveness and maintenance outcomes will be collected from both the intervention and control groups. The outcomes of the other three dimensions-reach, adoption, and implementation-will only be collected from subjects in the intervention group. Data will be collected pre-intervention, immediately post-intervention, and 3 months after the intervention is completed to evaluate the maintenance effect of the programme.

DISCUSSION

This programme will aim to enhance health-promoting self-care management behaviours in older adults dwelling in the community. This will be the first study in Hong Kong to use the hybrid effectiveness-implementation design and involve key stakeholders in the evaluation and implementation of a health self-management programme using a health-social service partnership approach. The programme, which will be rooted in the community, may be used as a model, if proven successful, for similar types of services.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04442867. Submitted 19 June 2020.

Contextualizing evidence-based nurse-led interventions for reducing 30-day hospital readmissions using GRADE evidence to decision framework: A Delphi study

BACKGROUND

High 30-day readmission rates increase hospital costs and negatively impact patient outcomes in many healthcare systems, including Hong Kong. Evidence-based and local adaptable nurse-led interventions have not been established for reducing 30-day hospital readmissions among general medical patients in Hong Kong's public healthcare system.

AIMS

The aim of this study was to select and refine evidence-based nurse-led interventions for reducing 30-day hospital readmissions among general medical patients in Hong Kong's public healthcare system using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) framework.

METHODS

Eighteen local healthcare stakeholders were recruited to carry out a two-step process. In step 1, stakeholders were invited to prioritize nurse-led interventions which were supported by existing evidence and suggest important combinations of different interventions. For all interventions prioritized in step 1, step 2 involved stakeholders performing a two-round Delphi questionnaire aiming to generate consensus-based interventions appropriate to the local context. GRADE EtD framework was applied to guide the decision-making process, taking into account certainty of evidence, benefits and harms, resource use, equity, acceptability, and feasibility.

RESULTS

Four out of eight nurse-led interventions reached a positive consensus with percentage agreement ranging from 70.6% to 82.4%. GRADE EtD criteria ratings showed that over 70% of stakeholders agreed these four interventions were probably acceptable and feasible, though the certainty of evidence was low or moderate. Half of stakeholders believed their desirable effects compared to undesirable effects were large. However, the resources required and how these nurse-led interventions might affect health inequities when implemented were uncertain. Preliminary implementation issues included high complexity of delivering multiple nurse-led intervention components, and challenges of coordinating different involved parties in delivering the interventions. Appropriate resource allocation and training should be provided to address these potential problems, as suggested by stakeholders.

LINKING EVIDENCE TO ACTION

Using the GRADE EtD framework, four nurse-led interventions were recommended by healthcare stakeholders as possible strategies for reducing 30-day hospital readmissions among general medical patients in Hong Kong. To address preliminary implementation issues, nurses' role as care coordinators should also be strengthened to ensure smooth delivery of nurse-led intervention components, and to facilitate multidisciplinary collaboration during service delivery.

A comparison of nurses and elderly patients' perceptions of caring behaviors in intensive care units

OBJECTIVE

Differences in patients and nurses' perceptions of caring behaviors arouse patient dissatisfaction. Continuous monitoring and assessment of caring behaviors has revealed its problems, and this in turn would promote care services by planning rational interventions and removing the problems. The present study aimed to compare nurses and elderly patients' perceptions of nurses' caring behaviors in intensive care units in accordance with Watson's transpersonal caring theory.

METHODS

In this descriptive-analytical study, 70 nurses were selected using the census method, and 70 elderly patients over 60 years old were also selected using purposive sampling method from the intensive care units of Lorestan University of Medical Sciences during 2012-2013. Caring Behavior Inventory for Elders (CBI-E) was adopted in this research to detect the nurses and elderly patients' perceptions of caring behaviors. In the data analysis phase, Kruskal-Wallis, Mann-Whitney U, and Pearson correlation tests were used.

RESULTS

The research findings revealed no statistically significant difference between the total scores of nurses' 83.80 (22.93), 95% CI [78.40, 89.20] and elderly patients' 80.09 (26.00), 95% CI [74, 86.20] perception of nurses' caring behaviors (P=0.379). From the viewpoint of the nurses and elderly patients, responding quickly to a patient's call 100.00 (0.00), 95% CI [100.00, 100.00] had the highest mean scores and patient participation in caring process had the lowest mean scores among nurses 22.86 (33.71), 95% CI [15.00, 30.80] and elderly patients 14.29 (28.41), 95% CI [7.63, 20.90].

CONCLUSION

This study indicated the elderlies and nurses' similar perceptions of caring behaviors in intensive care units. This finding would help nurses to recognize and prioritize the elderly patients' care needs, thereby promoting the quality of care services.

Collaboration and coordination of health and care services for older people with dementia by multidisciplinary health and care providers: a scoping review protocol

INTRODUCTION

Collaboration and coordination of health and care services are key to catering for the diverse needs of a growing population of older people with dementia. When multidisciplinary health and care providers work together, they have the possibility to use resources in a fair, accurate and effective way and thereby do the right thing, at the right time, for the right individual. The aim of this scoping review is to map how different care-providing agencies collaborate and coordinate health and care services for older people with dementia.

METHODS AND ANALYSIS

A scoping review will be carried out following the proposed methodology by Joanna Briggs Institute and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension guidelines. Systematic searches will be carried out in scientific databases. Studies published within the last 10 years will be included based on certain eligibility criteria. All included studies will be critically appraised using the Research Pyramid. Data from included studies will be charted and subjected to content analysis.

ETHICS AND DISSEMINATION

Ethics approval is not required for scoping reviews. The dissemination of findings will be conducted through conference presentations and publication in international scientific journals.

Advancing community-engaged research during the COVID-19 pandemic: Insights from a social network analysis of the trans-LINK Network

Collaboration across sectors is critical to address complex health problems, particularly during the current COVID-19 pandemic. We examined the ability to collaborate during the pandemic as part of a baseline evaluation of an intersectoral network of healthcare and community organizations established to improve the collective response to transgender (trans) persons who have been sexually assaulted (the trans-LINK Network). A validated social network analysis survey was sent to 119 member organizations in Ontario, Canada. Survey respondents were asked, ‘Has COVID-19 negatively affected your organization’s ability to collaborate with other organizations on the support of trans survivors of sexual assault?’ and ‘How has COVID-19 negatively affected your organization’s ability to collaborate within the trans-LINK Network?’. Data were analyzed using descriptive statistics. Seventy-eight member organizations participated in the survey (response rate = 66%). Most organizations (79%) indicated that the pandemic had affected their ability to collaborate with others in the network, citing most commonly, increased workload (77%), increased demand for services (57%), and technical and digital challenges (50%). Survey findings were shared in a stakeholder consultation with 22 representatives of 21 network member organizations. Stakeholders provided suggestions to prevent and address the challenges, barriers, and disruptions in serving trans survivors experienced during the pandemic, which were organized into themes. Seven themes were generated and used as a scaffold for the development of recommendations to advance the network, including: increase communication and knowledge exchange among member organizations through the establishment of a network discussion forum and capacity building group workshops; enhance awareness of network organizations by developing a member-facing directory of member services, their contributions, and ability to provide specific supports; strengthen capacity to provide virtual and in-person services and programs through enhanced IT support and increased opportunities for knowledge sharing and skill development; and adopt a network wide syndemic approach that addresses co-occurring epidemics (COVID-19 + racism, housing insecurity, transphobia, xenophobia) that impact trans survivors of sexual assault.

Patient-centeredness in the multimorbid elderly: a focus group study

Background

 Patient-centeredness (PC) aims to adapt health care to the individual needs and preferences of patients. An existing integrative model of PC comprises several dimensions of PC which have not yet been investigated from the patients’ perspective. Older patients with multimorbidity represent a target group for patient-centered care, as their care needs are particularly complex and should be addressed individually. We aimed to assess the perspective that older patients with multimorbidity have of patient-centered care and to examine the transferability of the integrative model of PC to this specific population.

Method

We performed 4 guided focus group interviews with a total of 20 older individuals with multimorbidity. The focus group interviews were audio-recorded and transcribed verbatim. Patients’ statements were content-analyzed applying an a priori designed system of categories that included the dimensions of PC from the integrative model and the additional category ‘prognosis and life expectancy’, which had emerged from an initial literature search on aspects of PC specific to the multimorbid elderly.

Results

The new category ‘prognosis and life expectancy’ was confirmed and expanded to ‘individual care needs related to aging and chronic disesase’. All dimensions of our integrative PC model were confirmed for older patients with multimorbidity. Among these, we found that eight dimensions (individual care needs related to aging and chronic disease, biopsychosocial perspective, clinician-patient communication, essential characteristics of the clinician, clinician-patient-relationship, involvement of family and friends, coordination and continuity of care, access to care) were complemented by aspects specific to this target population.

Conclusions

The integrative PC model is applicable to the population of older patients with multimorbidity. For a population-specific adaptation, it might be complemented by the dimension ‘individual care needs in aging and chronic disease’, in conjunction with age-specific aspects within existing dimensions. Together with corresponding results from a Delphi survey, our adapted PC model will serve as the basis for a subsequent systematic review of instruments measuring PC in older patients with multimorbidity.

Trial registration

PROSPERO (https://www.crd.york.ac.uk/prospero; CRD42018084057; 2018/02/01), German Clinical Trials Register (www.drks.de; DRKS00013309; 2018/01/23).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02448-8.

Improving Detection of Client Complexity in the Community (Impact): A Study Protocol of a Pragmatic Randomized Controlled Trial

Background: Community-dwelling older clients are becoming increasingly complex. Detecting this complexity in clinical practice is limited, with greater reliance on community nurses’ clinical judgment and skills. The lack of a consistent approach to complexity impacts the level of care and support for older clients to remain in their homes for longer. Objective: To examine the effectiveness of the Patient Complexity Instrument (PCI) in addition to nurses’ clinical judgment to enhance detection of complexity, and subsequent older clients’ resource allocation compared to usual nursing assessment. Design: A pragmatic randomized controlled trial will be conducted within a community nursing service in regional Victoria, Australia. Clients 65 years and over referred to the service who are eligible for Commonwealth Home Support Programme (CHSP) funding will be randomized into Control group: usual nursing assessment or Intervention group: usual nursing assessment plus the PCI. Nurse participants are Registered Nurses currently employed in the community nursing service. Results: This study will explore whether introducing the PCI in a community nursing service enhances detection of complexity and client care resource allocation compared to nurses’ clinical judgment based on usual nursing assessment. Conclusion: This protocol outlines the study to enhance the detection of complexity by nurses delivering care for community-dwelling older people in the regional Australian context. The findings will inform the use of a standardized tool to detect complexity among community-dwelling older Australians.

Approaches to Addressing Nonmedical Services and Care Coordination Needs for Older Adults

OBJECTIVE

Non-medical services care coordination for daily activities of living is crucial in improving older adults' health and enabling them to age in place, but little is known about specific practices and barriers in this space.

METHODS

Semi-structured interviews were conducted with 41 professionals serving older adults in greater Chicago, Illinois-which consists of diverse urban, suburban, and semi-rural communities-to contextualize non-medical services needs and care coordination processes.

RESULTS

In-home care, home-delivered meals, non-emergency transportation, and housing support were cited as the most commonly needed services, all requiring complex coordination support. Respondents noted a reliance on inefficient phone/fax usage for referral-making and cited major challenges in inter-professional communication, service funding/reimbursement, and HIPAA.

CONCLUSIONS

Non-medical services delivery for older adults is severely impacted by general siloing throughout the care continuum. Interventions are needed to enhance communication pathways and improve the salience and interdisciplinarity of non-medical services coordination for this population.

Integration of health services for the elderly in Asia: A scoping review of Hong Kong, Singapore, Malaysia, Indonesia

Against the backdrop of rapid ageing populations, there is an increasing recognition of the need to integrate various health services for the elderly, not only to provide more coordinated care, but also to contain the rapid cost inflation driven primarily by the curative sector. Funded by the Asia-Pacific Observatory on Health Systems and Policies, this scoping review seeks to synthesize the received knowledge on care integration for the elderly in four Asian societies representing varying socioeconomic and health-system characteristics: Singapore, Hong Kong, Malaysia, and Indonesia. The search for English-language literature published between 2009 and 2019 yielded 67 publications in the final sample. The review finds that both research and practice regarding health service integration are at a preliminary stage of development. It notes a marked trend in seeking to integrate long-term elderly care with curative and preventive care, especially in community settings. Many distinctive models proliferated. Integration is demonstrated not only horizontally but also vertically, transcending public-private boundaries. The central role of primary care is highly prominent in almost all the integration models. However, these models are associated with a variety of drawbacks in relation to capacity, perception, and operation that necessitate further scholarly and policy scrutiny, indicating the robustness and persistence of siloed healthcare practices.

Assessing the Accessibility of Home-Based Healthcare Services for the Elderly: A Case from Shaanxi Province, China

With the rapid increase of the elderly population in China, healthcare services for the elderly have gradually become an important welfare resource. However, the healthcare service for the elderly still has problems such as mismatched supply and demand and unbalanced resources. In order to effectively eliminate the path barriers to match supply and demand, and improve the accessibility of healthcare services, this paper introduces the sustainability of the healthcare service based on the accessibility theory, and constructs an index system from the three dimensions of potential accessibility, realized accessibility, and sustainable accessibility of healthcare services for the elderly. Then, the paper makes a practice application of the index system based on survey data of healthcare services from Shaanxi province, China. Finally, the paper finds that the total accessibility and sustainable accessibility of healthcare services for the elderly in Shaanxi Province are at an average level. The score of potential accessibility is high, indicating that elderly people have greater opportunities to use healthcare services. The realized accessibility score is low, which indicates that the actual use of healthcare services for the elderly presents low satisfaction.

Examining the Gaps and Issues of End-of-Life Care among Older Population through the Lens of Socioecological Model-A Multi-Method Qualitative Study of Hong Kong

End-of-life (EOL) care for terminal illness and life-limiting conditions is a sector in the health service spectrum that is drawing increased attention. Despite having the world's longest life expectancy and an ever-escalating demand for long-term care, Hong Kong's EOL care was underdeveloped. The current study aims to provide a holistic picture of gaps and issues to EOL care in Hong Kong. Data collection was conducted using a multi-method qualitative approach that included focus groups and in-depth interviews with key informants and stakeholders, and longitudinal case studies with patients and families. Deductive thematic analysis was used to examine service gaps in current EOL care through the lens of a socioecological model where gaps and issues in various nested, hierarchical levels of care as well as the relationships between these levels were studied in detail. Using the model, we identified gaps and issues of EOL care among older populations in Hong Kong at the policy, legal, community, institutional, as well as intrapersonal and interpersonal levels. These include but are not limited to a lack of overarching EOL care policy framework, ambiguity in the legal basis for mental incapacity, legislative barriers for advance directives, inadequate capacity, resources, and support in the community to administer EOL care, inadequate knowledge, training, and resources for EOL care in health and social care sectors, inadequate medical-social interface, general reluctance and fear of death and dying, as well as the cultural interpretation of filial piety that may lengthen the suffering of the dying patients. Findings highlight the multi-level gaps and issues of EOL care in a place where western and eastern culture meet, and shed light on how best to design more effective and comprehensive policy interventions that will likely have a more sustainable and instrumental impact on facilitating person-centered EOL care during the end of life.

"We have two different agendas": the views of general practitioners, social workers and hospital staff on interprofessional coordination for patients with chronic widespread pain

Patients with chronic widespread pain (CWP) are often unfit for work and go through lengthy treatment. In Denmark, this includes contacts with the job center in their municipality, their general practitioner (GP) and one or more hospital units. Little is known about how coordination around patients with CWP functions and is perceived by professionals. Therefore, our aim is to explore how GPs, social workers from municipality job centers and hospital staff experience interprofessional coordination for patients with CWP. Interviews with 7 GPs, 12 social workers, and 10 hospital staff were analyzed using interpretative phenomenological analysis. The participants experienced challenges with coordination, primarily in the relations between social workers and GPs. There was an over-reliance on written communication in situations where the actors had divergent agendas, opposing professional roles and conflicting approaches to time. GPs tended to lengthen the time spans for treating patients, while social workers tried to shorten them so that patients could get back to work. Applying the theory of relational coordination (RC), the findings correspond to a low level of RC, indicating a need for shared accountability, and strengthened interpersonal communication between professionals.Abbreviations: CWP: Chronic widespread pain; GPs: General practitioners; RC: Relational coordination; IPA: Interpretative phenomenological analysis.

Collaboration for drug prevention: Is it possible in a "siloed" governmental structure?

PURPOSE

Norwegian municipalities report that drug misuse is the most important public health challenge. The municipalities play a unique role in drug prevention aimed at youth, since young people rely on several services in their daily lives that are organized by different municipal departments. However, the municipal structure is described as siloed, and the policy areas as differentiated. This situation has led to a need for integration between different policy sectors to prevent drug use and promote health. The following study explores how policymakers describe the structures for integration within local government in practice with regard to drug prevention aimed at youth, contributing to the ongoing debate on collaboration and integration in response to public health challenges.

METHODS

A single case study design was used to investigate the accounts of policymakers from different municipal departments in a Norwegian municipality following Axelsson and Axelsson's conceptual scheme of integration.

FINDINGS

Collaboration between departments was viewed as important to successfully address drug prevention; however, the policymakers recognized problems with integration. The participants described confusion regarding ownership between the departments and a perceived lack of a mandate for collaboration.

CONCLUSIONS

The findings and discussion illustrate that integration of drug prevention in a siloed structure relies on departments appreciating their respective roles in drug prevention and advisers experiencing a mandate to manage the siloes that exist in the organization. By gaining a better understanding of the siloed structures, we can provide valuable information needed to navigate them.