Post-acute rehabilitation care for older people in community hospitals and general hospitals – Philosophies of care and patients' and caregivers' reported experiences: A qualitative study

What affects physical activity in a rehabilitation centre? Voices of patients, nurses, therapists, and activity trackers

PURPOSE

In the context of rehabilitation, research shows a close connection between patients' physical activity, care culture, and the built environment. As these three impact on patients' rehabilitation process, we aim to understand what affects physical activity in a particular rehabilitation centre.

MATERIALS AND METHODS

We combine insights from literature with a qualitative study informed by quantitative data. Semi-structured and walking interviews with 16 patients were informed by output from activity trackers. Two focus-group interviews with respectively four nurses and two therapists provided extra perspectives.

RESULTS

We found that patients interpret physical activity rather narrowly, equating it with therapy. Yet, the data of the activity trackers show that daily activities are often as active as therapy, as confirmed by nurses and therapists. Motivation to be physically active was found in setting clear goals, social interaction, allowing choice and control to achieve a sense of normality, and the built environment. How patients act in and interact with the built environment are closely related to how staff approaches and communicates care.

CONCLUSIONS

The focus on what affects - defines, hampers, or supports - physical activity in a rehabilitation centre allowed developing a better understanding of how care culture and the built environment interrelate.Implications for rehabilitationHow physical activity is perceived by patients reflects the goals they like to achieve through rehabilitation.The built environment is a third factor in the relation between care culture and patients' physical activity.Fully supporting patients to be physically active with respect to their personality and capabilities requires differentiating between patients both in how they are approached (patient- or person-centred) and in how they are spatially facilitated.

Patients' experiences with rehabilitation care: a qualitative study to inform patient-centred outcomes

PURPOSE

To explore patients' experiences with rehabilitation, with a particular focus on outcomes that are perceived to be of value.

MATERIALS AND METHODS

Semi structured interviews were conducted with adults who recently had rehabilitation for a chronic health condition in a hospital or community setting. Banja's definition of rehabilitation (personally fulfilling, socially meaningful and functionally effective) informed the enquiry and interpretation of the findings. Thematic analysis was used to categorise the data into codes and themes.

RESULTS

16 people (40-84 years, 69% male, n = 11) participated in individual telephone-interviews, describing their perspectives on what mattered to them about rehabilitation. The themes generated from the data suggested that participants focused on important social, functional and personal outcomes, but also required two fundamental features in their rehabilitation, namely a personalised and relational experience and a clear understanding of their own progress delivered in a way that is meaningful to them.

CONCLUSIONS

People who undertake rehabilitation express diverse expectations when assessing their outcomes and progress, although common elements could be identified. Participants valued a number of key features about the delivery and evaluation of their rehabilitation. These features revolved around the personalisation of the process and having clarity about progress.Implications for rehabilitationRehabilitation therapists should encourage ongoing personalised discussions about progress to promote clear and shared understanding of what clients and therapists expect, alongside the use of current available measures.Rehabilitation therapists should consider providing opportunities for participants to self-reflect about their experiences and modify their goals based on personal progress and deeper understanding of their circumstances.Rehabilitation therapists should consider assessing the extent to which the individual feels satisfied with and capable of achieving these outcomes before departing from the rehabilitation service.Overall, rehabilitation teams should think about spending more time with the patient to prioritise and understand their individual goals and values.

'Localism and intimacy, and… other rather imponderable reasons of that sort': A qualitative study of patient experience of community hospitals in England

Debates over the value and contribution of community hospitals are hampered by a lack of empirical assessment of the experience of patients using these services. This paper presents findings from a study which included a focus on patient and family-carer experiences of community hospitals in England. We adopted a qualitative design involving nine case study hospitals. Data collection included interviews with patients (n = 60), carers (n = 28) and staff (n = 89). Through patients and carers highlighting the value of community hospitals feeling 'close to home', providing holistic and personalised care and supporting them through difficult transitions, the study confirms the importance of functional and interpersonal aspects of care, while also highlighting the importance of social and psychological aspects. These included having family, friends and the community close, maintaining social connections during periods of hospital treatment, and feeling less anonymous and anxious when attending the hospital due to the high levels of familiarity and connectedness. Although the experiences uncovered in this study were not uniformly positive, patients and carers placed a high overall value on the care provided by community hospitals, often arguing that these were distinctive when compared to their experiences of using other health and care services. The study suggests the need to weigh the full range of these dimensions of patient experience-functional, interpersonal, social and psychological-when assessing the role and contribution of community hospitals.

Using a Patient Hotel: Perceptions of the Quality of Care by Patients Undergoing Analysis for Gastrointestinal Motility Disorders in the Netherlands

There is growing demand to improve healthcare services for patients. Patient hotel models can be applied to allow shorter inpatient stays, however, whether this improves patient satisfaction and quality of care is unknown. All consecutive patients referred for analysis of gastrointestinal (GI) motility disorders at Maastricht UMC, the Netherlands, who stayed overnight in the patient hotel (June 2017-July 2018), were asked to complete a questionnaire on patient satisfaction and quality of care. On a 4-point Likert scale, most patients reported they were largely to absolutely satisfied with the quality of care, regarding coordination, information, courtesy of nurses and staff, and privacy. Cost savings between 48,433 and 74,613 euros for 1 year were achieved, amounting to 613-944 euros per patient. Positive patient satisfaction and perception of quality of care with the patient hotel model were achieved. We show that moving overnight stays from inpatient to an outpatient hotel provides substantial financial savings for hospitals, healthcare providers, and insurance companies.

Measuring and optimising the efficiency of community hospital inpatient care for older people: the MoCHA mixed-methods study

Background

Community hospitals are small hospitals providing local inpatient and outpatient services. National surveys report that inpatient rehabilitation for older people is a core function but there are large differences in key performance measures. We have investigated these variations in community hospital ward performance.

Objectives

(1) To measure the relative performance of community hospital wards (studies 1 and 2); (2) to identify characteristics of community hospital wards that optimise performance (studies 1 and 3); (3) to develop a web-based interactive toolkit that supports operational changes to optimise ward performance (study 4); (4) to investigate the impact of community hospital wards on secondary care use (study 5); and (5) to investigate associations between short-term community (intermediate care) services and secondary care utilisation (study 5).

Methods

Study 1 – we used national data to conduct econometric estimations using stochastic frontier analysis in which a cost function was modelled using significant predictors of community hospital ward costs. Study 2 – a national postal survey was developed to collect data from a larger sample of community hospitals. Study 3 – three ethnographic case studies were performed to provide insight into less tangible aspects of community hospital ward care. Study 4 – a web-based interactive toolkit was developed by integrating the econometrics (study 1) and case study (study 3) findings. Study 5 – regression analyses were conducted using data from the Atlas of Variation Map 61 (rate of emergency admissions to hospital for people aged ≥ 75 years with a length of stay of < 24 hours) and the National Audit of Intermediate Care.

Results

Community hospital ward efficiency is comparable with the NHS acute hospital sector (mean cost efficiency 0.83, range 0.72–0.92). The rank order of community hospital ward efficiencies was distinguished to facilitate learning across the sector. On average, if all community hospital wards were operating in line with the highest cost efficiency, savings of 17% (or £47M per year) could be achieved (price year 2013/14) for our sample of 101 wards. Significant economies of scale were found: a 1% rise in output was associated with an average 0.85% increase in costs. We were unable to obtain a larger community hospital sample because of the low response rate to our national survey. The case studies identified how rehabilitation was delivered through collaborative, interdisciplinary working; interprofessional communication; and meaningful patient and family engagement. We also developed insight into patients’ recovery trajectories and care transitions. The web-based interactive toolkit was established [http://mocha.nhsbenchmarking.nhs.uk/ (accessed 9 September 2019)]. The crisis response team type of intermediate care, but not community hospitals, had a statistically significant negative association with emergency admissions.

Limitations

The econometric analyses were based on cross-sectional data and were also limited by missing data. The low response rate to our national survey means that we cannot extrapolate reliably from our community hospital sample.

Conclusions

The results suggest that significant community hospital ward savings may be realised by improving modifiable performance factors that might be augmented further by economies of scale.

Future work

How less efficient hospitals might reduce costs and sustain quality requires further research.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

A systematic literature review of the patient hotel model

BACKGROUND

The patient hotel model was developed in Northern Europe as a response to increased demand for health and wellbeing services. According to current literature the patient hotel model is a concept of care provision which combines non-acute hospital care with hospitality to afford patients/guests increased satisfaction and security whilst benefitting from evidenced based care.

OBJECTIVE(S)

This paper evaluates the concept of the patient hotel model. It presents the findings of a systematic review of existing literature evaluating the benefits such a model can bring to healthcare services and reports on the efficacy in terms of cost to health service providers, and health outcomes to patients/guests. The authors' aimed to complete a meta-analysis of the data, but were unable to, due to the diversity in the descriptions, service provisions, and client group.

DESIGN

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used to conduct and report this systematic review. In order to focus the research question, the PICO (Population; Intervention; Comparison and Outcome) framework was used to develop a strategy in literature searching, to ensure systematic rigor.

DATA SOURCES/REVIEW METHODS

Cochrane Database of Systematic Reviews, OVID MEDLINE, CINAHL, Embase, ScienceDirect, Web of Science, and Scopus databases were used to search for randomized controlled trials, quasi experimental studies, quantitative and qualitative studies conducted between January 1st 2008 and August 9th, 2018, published in a peer reviewed journal in English or which provided an abstract in English. Citation searches and hand searches were also conducted.

RESULTS

8,693 papers were retrieved and from abstract screening 68 full-text articles were assessed for eligibility by applying an inclusion and exclusion criteria. Seven articles were retained for quality assessment. Methodological rigor was appraised using accepted criteria for the evaluation of research. On appraisal, one systematic review, one Randomized Clinical Trial, two qualitative studies, one quantitative survey, one retrospective analysis of services, and one comparative analysis paper were included for data synthesis. The functionality of the patient hotel model differed across the six countries that reported on them in the included studies, from oncology care, medical care, post-acute rehabilitation and perioperative care. The studies included in this review broadly focused on the themes of patient experience and/or cost, with the intention of informing future service provision. Studies relating to cost efficacy looked at the potential financial savings which could be realized through adopting the patient hotel model. The appraised studies found positive benefits of adopting the patient hotel model, both in terms of cost and patient satisfaction. One study explored the role of nurses in a patient hotel.

CONCLUSIONS

The lack of consistent definition, diversity in the descriptions, service provisions, and client groups meant that the results could only be systematically reviewed and not synthesized into a meta-analysis. The inconsistencies in labeling and description also have implications for the review process, as studies adopting more abstract classification of the patient hotel model may not have been included in the review. On balance, the appraised evidence appears to suggest that there are positive benefits to patients, nurses and healthcare providers. However further research of greater rigor is needed to provide a better understanding of these outcome measures. Implications for rehabilitation Patient hotels have particular relevance to the field of rehabilitation as they have a strong ethos of promoting self-care and independence, facilitated through greater freedom and family involvement. The patient hotel model has the potential to impact healthcare provision on the global stage, but there is no universal definition, making evidence evaluation difficult. The patient hotel model combines the concepts of health and hospitality and could potentially provide a cost-effective alternative to healthcare, with positive outcomes for patient experience as well as patient health. There is a need to explore new systems of care delivery which provide increased patient satisfaction, and a seamless continuum of care at the acute and primary care interface. This paper examines the patient hotel model of care, and its merits in terms of care provision, patient satisfaction and service efficiency, contributing to the embryonic literature in this field.

Analysis of the profile, characteristics, patient experience and community value of community hospitals: a multimethod study

Background

Community hospitals have been part of England’s health-care landscape since the mid-nineteenth century. Evidence on them has not kept pace with their development.

Aim

To provide a comprehensive analysis of the profile, characteristics, patient experience and community value of community hospitals.

Design

A multimethod study with three phases. Phase 1 involved national mapping and the construction of a new database of community hospitals through data set reconciliation and verification. Phase 2 involved nine case studies, including interviews and focus groups with patients (n = 60), carers (n = 28), staff (n = 132), volunteers (n = 68), community stakeholders (n = 74) and managers and commissioners (n = 9). Phase 3 involved analysis of Charity Commission data on voluntary support.

Setting

Community hospitals in England.

Results

The study identified 296 community hospitals with beds in England. Typically, the hospitals were small (< 30 beds), in rural communities, led by doctors/general practitioners (GPs) and nurses, without 24/7 on-site medical cover and provided step-down and step-up inpatient care, with an average length of stay of < 30 days and a variable range of intermediate care services. Key to patients’ and carers’ experiences of community hospitals was their closeness to ‘home’ through their physical location, environment and atmosphere and the relationships that they support; their provision of personalised, holistic care; and their role in supporting patients through difficult psychological transitions. Communities engage with and support their hospitals through giving time (average 24 volunteers), raising money (median voluntary income £15,632), providing services (voluntary and community groups) and giving voice (e.g. taking part in communication and consultation). This can contribute to hospital utilisation and sustainability, patient experience, staff morale and volunteer well-being. Engagement varies between and within communities and over time. Community hospitals are important community assets, representing direct and indirect value: instrumental (e.g. health care), economic (e.g. employment), human (e.g. skills development), social (e.g. networks), cultural (e.g. identity and belonging) and symbolic (e.g. vitality and security). Value varies depending on place and time.

Limitations

There were limitations to the secondary data available for mapping community hospitals and tracking charitable funds and to the sample of case study respondents, which concentrated on people with a connection to the hospitals.

Conclusions

Community hospitals are diverse but are united by a set of common characteristics. Patients and carers experience community hospitals as qualitatively different from other settings. Their accounts highlight the importance of considering the functional, interpersonal, social and psychological dimensions of experience. Community hospitals are highly valued by their local communities, as demonstrated through their active involvement as volunteers and donors. Community hospitals enable the provision of local intermediate care services, delivered through an embedded, relational model of care, which generates deep feelings of reassurance. However, current developments may undermine this, including the withdrawal of GPs, shifts towards step-down care for non-local patients and changing configurations of services, providers and ownership.

Future work

Comparative studies of patient experience in different settings; longitudinal studies of community support and value; studies into the implications of changes in community hospital function, GP involvement, provider-mix and ownership; and international comparative studies could all be undertaken.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Shifting care from community hospitals to intensive community support: a mixed method study

Aim To examine how the introduction of intensive community support (ICS) affected admissions to community hospital (CH) and to explore the views of patients, carers and health professionals on this transition.

BACKGROUND

ICS was introduced to provide an alternative to CH provision for patients (mostly very elderly) requiring general rehabilitation.

METHOD

Routine data from both services were analysed to identify the number of admissions and length of stay between September 2012 and September 2014. In total, 10 patients took part in qualitative interviews. Qualitative interviews and focus groups were undertaken with 19 staff members, including managers and clinicians. Findings There were 5653 admissions to CH and 1710 to ICS between September 2012 and September 2014. In the five months before the introduction of ICS, admission rates to CH were on average 217/month; in the final five months of the study, when both services were fully operational, average numbers of patients admitted were: CH 162 (a 25% reduction), ICS 97, total 259 (a 19% increase). Patients and carers rated both ICS and CH favourably compared with acute hospital care. Those who had experienced both services felt each to be appropriate at the time; they appreciated the 24 h availability of staff in CH when they were more dependent, and the convenience of being at home after they had improved. In general, staff welcomed the introduction of ICS and appreciated the advantages of home-based rehabilitation. Managers had a clearer vision of ICS than staff on the ground, some of whom felt underprepared to work in the community. There was a consensus that ICS was managing less complex and dependent patients than had been envisaged.

CONCLUSION

ICS can provide a feasible adjunct to CH that is acceptable to patients. More work is needed to promote the vision of ICS amongst staff in both community and acute sectors.

Community hospitals and their services in the NHS: identifying transferable learning from international developments – scoping review, systematic review, country reports and case studies

Background

The notion of a community hospital in England is evolving from the traditional model of a local hospital staffed by general practitioners and nurses and serving mainly rural populations. Along with the diversification of models, there is a renewed policy interest in community hospitals and their potential to deliver integrated care. However, there is a need to better understand the role of different models of community hospitals within the wider health economy and an opportunity to learn from experiences of other countries to inform this potential.

Objectives

This study sought to (1) define the nature and scope of service provision models that fit under the umbrella term ‘community hospital’ in the UK and other high-income countries, (2) analyse evidence of their effectiveness and efficiency, (3) explore the wider role and impact of community engagement in community hospitals, (4) understand how models in other countries operate and asses their role within the wider health-care system, and (5) identify the potential for community hospitals to perform an integrative role in the delivery of health and social care.

Methods

A multimethod study including a scoping review of community hospital models, a linked systematic review of their effectiveness and efficiency, an analysis of experiences in Australia, Finland, Italy, Norway and Scotland, and case studies of four community hospitals in Finland, Italy and Scotland.

Results

The evidence reviews found that community hospitals provide a diverse range of services, spanning primary, secondary and long-term care in geographical and health system contexts. They can offer an effective and efficient alternative to acute hospitals. Patient experience was frequently reported to be better at community hospitals, and the cost-effectiveness of some models was found to be similar to that of general hospitals, although evidence was limited. Evidence from other countries showed that community hospitals provide a wide spectrum of health services that lie on a continuum between serving a ‘geographic purpose’ and having a specific population focus, mainly older people. Structures continue to evolve as countries embark on major reforms to integrate health and social care. Case studies highlighted that it is important to consider local and national contexts when looking at how to transfer models across settings, how to overcome barriers to integration beyond location and how the community should be best represented.

Limitations

The use of a restricted definition may have excluded some relevant community hospital models, and the small number of countries and case studies included for comparison may limit the transferability of findings for England. Although this research provides detailed insights into community hospitals in five countries, it was not in its scope to include the perspective of patients in any depth.

Conclusions

At a time when emphasis is being placed on integrated and community-based care, community hospitals have the potential to assume a more strategic role in health-care delivery locally, providing care closer to people’s homes. There is a need for more research into the effectiveness and cost-effectiveness of community hospitals, the role of the community and optimal staff profile(s).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A qualitative study of patient experiences of decentralized acute healthcare services

OBJECTIVE

Municipality acute wards (MAWs) have recently been launched in Norway as an alternative to hospitalizations, and are aimed at providing treatment for patients who otherwise would have been hospitalized. The objective of this study was to explore how patients normally admitted to hospitals perceived the quality and safety of treatment in MAWs.

DESIGN

The study had a qualitative design. Thematic analysis was used to analyze the data.

SETTING

The study was conducted in a county in south-eastern Norway and included five different MAWs.

PATIENTS

Semi-structured interviews were conducted with 27 participants who had required acute health care and who had been discharged from the five MAWs.

RESULTS

Three subthemes were identified that related to the overarching theme of hospital-like standards ("almost a hospital, but…"), namely (a) treatment and competence, (b) location and physical environment, and (c) adequate time for care. Participants reported the treatment to be comparable to hospital care, but they also experienced limitations. Participants spoke positively about MAW personnel and the advantages of having a single patient room, a calm environment, and proximity to home.

CONCLUSIONS

Participants felt safe when treated at MAWs, even though they realized that the diagnostic services were not similar to that in hospitals. Geographical proximity, treatment facilities and time for care positively distinguished MAWs from hospitals, while the lack of diagnostic resources was stressed as a limitation. Key points   Municipality acute wards (MAWs) have been implemented across Norway. Research on patient perspectives on the decentralization of acute healthcare in MAWs is lacking.   • Patients perceive decentralized acute healthcare and treatment as being comparable to the quality they would have expected in hospitals.   • Geographical proximity, a home-like atmosphere and time for care were aspects stressed as positive features of the decentralized services.   • Lack of diagnostic resources was seen as a limitation.

Perceived quality of an alternative to acute hospitalization: an analytical study at a community hospital in Hallingdal, Norway

There is growing international interest in the geography of health care provision, with health care providers searching for alternatives to acute hospitalization. In Norway, the government has recently legislated for municipal authorities to develop local health services for a selected group of patients, with a quality equal to or better than that provided by hospitals for emergency admissions. General practitioners in Hallingdal, a rural district in southern Norway, have for several years referred acutely somatically ill patients to a community hospital, Hallingdal sjukestugu (HSS). This article analyzes patients' perceived quality of HSS to demonstrate factors applicable nationally and internationally to aid in the development of local alternatives to general hospitals. We used a mixed-methods approach with questionnaires, individual interviews and a focus group interview. Sixty patients who were taking part in a randomized, controlled study of acute admissions at HSS answered the questionnaire. Selected patients were interviewed about their experiences and a focus group interview was conducted with representatives of local authorities, administrative personnel and health professionals. Patients admitted to HSS reported statistically significant greater satisfaction with several care aspects than those admitted to the general hospital. Factors highlighted by the patients were the quiet and homelike atmosphere; a small facility which allowed them a good overall view of the unit; close ties to the local community and continuity in the patient-staff relationship. The focus group members identified some overarching factors: an interdisciplinary and holistic approach, local ownership, proximity to local general practices and close cooperation with the specialist health services at the hospital. Most of these factors can be viewed as general elements relevant to the development of local alternatives to acute hospitalization both nationally and internationally. This study indicates that perceived quality should be one of the main motivations for developing alternatives to general hospital admissions.

Institutional contexts contribute to the low priority given to developing self-care independence in a rehabilitation ward: a qualitative study

OBJECTIVES

To examine the institutional contexts that contribute to the low priority given to the development of self-care independence in a rehabilitation ward.

DESIGN

Research was guided by ethnographic principles of Martyn Hammersley and Paul Atkinson (2007). Individual in-depth interviews were completed. Participant observation was done daily during the rehabilitation stay of the patients.

PATIENTS

Six men and three women with neurological impairments and their caregivers.

RESULTS

Patients' daily routines on a rehabilitation ward in Taiwan are described. Four prominent themes emerged from the data: (1) the attitudes of patients, caregivers, and staff facilitated extended rehabilitation stays within the first year after disability, (2) attending therapy sessions was the most important activity, (3) pragmatic considerations, such as 'faster and easier', outweighed the value of developing self-care independence, and (4) strategic organization of daily routines to keep therapy the priority was critical for daily activity.

CONCLUSION

Multiple institutional factors jeopardize the development of self-care independence in a rehabilitation ward. The factors include the primacy of biomedical-oriented rehabilitation ideology, insurance reimbursement policies, and cultural values associated with family caregiving. They legitimize the low priority given to developing self-care independence. Therapists need to include a critical review of daily routines (what and how activities are carried out inside and outside of therapy clinics) as part of therapy regime to identify opportunities and institutional constraints to the development of self-care independence.

Education in geriatric medicine for community hospital staff

Community hospitals provide many services for older people. They are mainly managed by nursing staff, with some specialist input. Little is known about education provided in these facilities. Most education in geriatric medicine is provided in hospitals, despite most elderly care being provided in the community. The authors surveyed senior nursing staff in Irish community hospitals to examine this area in more detail. Staff in all 18hospitals in the Health Service Executive (South) area were invited to participate. The response rate was 100%. Sixteen of the 18 respondents (89%) felt staff did not have enough education in geriatric medicine. Just over half of hospitals had regular staff education sessions in the area, with a minority of sessions led by a geriatrician, and none by GPs. Geriatrician visits were valued, but were requested only every 1-3 months. Staff identified challenging behaviour and dementia care as the areas that posed most difficulty.