An observational study of older patients' experiences of involvement in discharge planning

"Being the main character but not always involved in one's own care transition" - a qualitative descriptive study of older adults' experiences of being discharged from in-patient care to home

BACKGROUND

The growing number of older adults with chronic diseases challenges already strained healthcare systems. Fragmented systems make transitions between healthcare settings demanding, posing risks during transitions from in-patient care to home. Despite efforts to make healthcare person-centered during care transitions, previous research indicates that these ambitions are not yet achieved. Therefore, there is a need to examine whether recent initiatives have positively influenced older adults' experiences of transitions from in-patient care to home. This study aimed to describe older adults' experiences of being discharged from in-patient care to home.

METHODS

This study had a qualitative descriptive design. Individual interviews were conducted in January-June 2022 with 17 older Swedish adults with chronic diseases and needing coordinated care transitions from in-patient care to home. Data were analyzed using inductive qualitative content analysis.

RESULTS

The findings indicate that despite being the supposed main character, the older adult is not always involved in the planning and decision-making of their own care transition, often having poor insight and involvement in, and impact on, these aspects. This leads to an experience of mismatch between actual needs and the expectations of planned support after discharge.

CONCLUSIONS

The study reveals a notable disparity between the assumed central role of older adults in care transitions and their insight and involvement in planning and decision-making.

Place of care in the last three years of life for Medicare beneficiaries

BACKGROUND

Most older adults prefer aging in place; however, patients with advanced illness often need institutional care. Understanding place of care trajectory patterns may inform patient-centered care planning and health policy decisions. The purpose of this study was to characterize place of care trajectories during the last three years of life.

METHODS

Linked administrative, claims, and assessment data were analyzed for a 10% random sample cohort of US Medicare beneficiaries who died in 2018, aged fifty or older, and continuously enrolled in Medicare during their last five years of life. A group-based trajectory modeling approach was used to classify beneficiaries based on the proportion of days of institutional care (hospital inpatient or skilled nursing facility) and skilled home care (home health care and home hospice) used in each quarter of the last three years of life. Associations between group membership and sociodemographic and clinical predictors were evaluated.

RESULTS

The analytic cohort included 199,828 Medicare beneficiaries. Nine place of care trajectory groups were identified, which were categorized into three clusters: home, skilled home care, and institutional care. Over half (59%) of the beneficiaries were in the home cluster, spending their last three years mostly at home, with skilled home care and institutional care use concentrated in the final quarter of life. One-quarter (27%) of beneficiaries were in the skilled home care cluster, with heavy use of skilled home health care and home hospice; the remaining 14% were in the institutional cluster, with heavy use of nursing home and inpatient care. Factors associated with both the skilled home care and institutional care clusters were female sex, Black race, a diagnosis of dementia, and Medicaid insurance. Extended use of skilled home care was more prevalent in southern states, and extended institutional care was more prevalent in midwestern states.

CONCLUSIONS

This study identified distinct patterns of place of care trajectories that varied in the timing and duration of institutional and skilled home care use during the last three years of life. Clinical, socioregional, and health policy factors influenced where patients received care. Our findings can help to inform personal and societal care planning.

Ward round communication with older patients

OBJECTIVES

Ward round communication is essential to patient care. While communication in general with older patients is well described, little is known about how communication with older patients and their relatives at ward rounds can be optimised. Hence, this scoping review aims to provide an overview of ward round communication with older patients. Furthermore, the review investigates barriers to the optimal communication. Such an overview would provide a point of departure for developing future health care professionals' education in ward round communication training.

METHOD

A scoping review was performed by searching CINAHL, Embase, MEDLINE, and PubMed databases. The search strategy included terms synonymous with "ward rounds" and "older patients." We included studies regarding communication with patients above 65 years during ward rounds. Thematic analysis was applied.

RESULTS

Seven of the 2322 identified papers were included in the present review. Thematic analysis revealed three overall themes: Communication strategy, frailty and patient participation, and organisational and age norm challenges. Barriers included frailty-related patient characteristics and imbalance of power between physicians and patients. Papers focused mainly on what the optimal ward round communication should include rather than how it should be performed.

CONCLUSION

Characteristics of frail older patients and organisational barriers challenge effective and safe ward round communication. Little is known about how ward round communication with frail older patients and their relatives can be optimised.

Understanding data collection strategies for the ethical inclusion of older adults with disabilities in transitional care research: A scoping review protocol

INTRODUCTION

A growing body of evidence suggests that older adults are particularly vulnerable to poor care as they transition across care environments. Thus, they require transitional care services as they transition across healthcare settings. To help make intervention research meaningful to the older adults the intervention aims to serve, many researchers aim to study their experiences, by actively involving them in research processes. However, collecting data from older adults with various forms of disability often assumes that the research methods selected are appropriate for them. This scoping review will map the evidence on research methods to collect data from older adults with disabilities within the transitional care literature.

METHODS

The proposed scoping review follows the framework originally described by the Joanna Briggs Institute (JBI) Manual: (1) developing a search strategy, (2) evidence screening and selection, (3) data extraction; and (4) analysis. We will include studies identified through a comprehensive search of peer-reviewed and empirical literature reporting on research methods used to elicit the experiences of older adults with disabilities in transitional care interventions. In addition, we will search the reference lists of included studies. The findings of this review will be narratively synthesized. The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews will guide the reporting of the methods and results.

DISCUSSION

The overarching goal of this study is to develop strategies to assist the research community in increasing the inclusion of older adults with disabilities in transitional care research. The findings of this review will highlight recommendations for research to inform data collection within future intervention research for older adults with disabilities. Study findings will be disseminated via a publication and presentations.

Older Adults' Experiences With Participation and eHealth in Care Coordination: Qualitative Interview Study in a Primary Care Setting

BACKGROUND

Owing to the demographic changes in the elderly population worldwide, delivering coordinated care at home to multimorbid older adults is of great importance. Older adults living with multiple chronic conditions need information to manage and coordinate their care. eHealth can be effective for gaining sufficient information, communicating, and self-managing chronic conditions. However, incorporating older adults' health preferences and ensuring active involvement remain challenging. More knowledge is needed to ensure successful participation and eHealth use in care coordination.

OBJECTIVE

This study aimed to explore multimorbid older adults' experiences with participation and eHealth in care coordination with general practitioners (GPs) and district nurses (DNs).

METHODS

The study had a qualitative explorative approach. Data collection included semistructured interviews with 20 older adults with multimorbidity receiving primary care services from their GPs and DNs. The participants were included by their GPs or nurses at a local intermunicipal acute inpatient care unit. The data analysis was guided by systematic text condensation.

RESULTS

We identified 2 categories: (1) older adults in charge of and using eHealth in care coordination, and (2) older adults with a loss of control in care coordination. The first category describes how communication with GPs and DNs can facilitate participation, the importance of managing own medication, and how eHealth can support older adults' information needs. The second category focuses on older adults who depend on guidance and help from their GPs and DNs to manage their health, describing how a lack of capacity and system support to be involved makes these adults lose control of their care coordination.

CONCLUSIONS

Being in charge of care coordination is important for older multimorbid adults. The results show that older adults are willing to use eHealth to be informed and to seek information, which ensures high levels of participation in care coordination. Future research should investigate how older adults can be involved in electronic information sharing with health care providers.

Measures used to assess interventions for increasing patient involvement in Danish healthcare setting: a rapid review

OBJECTIVE

To identify measures used within Denmark evaluating any type of intervention designed to facilitate patient involvement in healthcare.

DESIGN

Environmental scan employing rapid review methods.

DATA SOURCES

MEDLINE, PsycInfo and CINAHL were searched from 6-9 April 2021 from database inception up to the date of the search.

ELIGIBILITY CRITERIA

Quantitative, observational and mixed methods studies with empirical data on outcomes used to assess any type of intervention aiming to increase patient involvement with their healthcare. Language limitations were Danish and English.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data from 10% of the included studies and, due to their agreement, the data from the rest were extracted by first author. Data were analysed with reference to existing categories of measuring person-centred care; findings were synthesised using narrative summaries. Adapted Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines were used to guide reporting.

RESULTS

Among 3767 records, 43 studies met the inclusion criteria, including 74 different measures used to evaluate interventions aimed at increasing patient involvement within healthcare in Danish hospital and community settings. Generic measures assessed: patient engagement (n=3); supporting self-management (n=8); supporting shared decision-making (n=9); patient satisfaction and experiences of care (n=11); health-related patient-reported outcome (n=20).

CONCLUSIONS

Across Denmark, complex interventions designed to improve patient involvement with healthcare vary in their goals and content. Some targeting healthcare professionals, some patient health literacy and some service infrastructure. A plethora of measures assess the impact of these interventions on patient, professional and service delivery outcomes. Few measures assessed patient involvement directly, and it is unclear which proxy measures capture indicators of perceived involvement. Lack of conceptual clarity between intervention goals, the components of change and measures makes it difficult to see what types of intervention can best support change in services to ensure patients are more effectively involved in their healthcare.

Impact of involvement of relatives in early home visits by a hospital-led geriatric team

OBJECTIVES

To evaluate whether the involvement of relatives in home visits by a geriatric team post-discharge is associated with unplanned readmissions in severely frail patients living alone.

METHODS

A quality improvement project evaluating outcomes from routine care of patients who were severely frail, 65+ years, living alone, and visited at home by a geriatric team after discharge from acute hospital admission. We compared patients who did and did not have relatives attending the visit. Data were analyzed by logistic regression.

RESULTS

Of 437 patients with a mean age of 85.0 (±7.8) years 73% had severe comorbidity, 68% had a low functional ability, and 100 patients (23%) had relatives attending. Attendance of relatives was associated with a lower unplanned 30-day readmission rate (10% vs. 18%, adjusted odds ratio: 0.48 (0.23-1.00) p=0.05).

CONCLUSION

Results highlights the importance of involvement of relatives in care planning in the severely frail older patients living alone.