Challenges, benefits and weaknesses of intermediate care: results from five UK case study sites

Intermediate care in caring for dementia, the point of view of general practitioners: A key informant survey across Europe

Background

Intermediate care is often defined as healthcare occurring somewhere between traditional primary (community) and secondary (hospital) care settings. High quality intermediate care is important in dementia, may prevent caregiver burnout and also lead to optimal care for people with dementia. However, very little is known about the point of intermediate care for persons with dementia in Europe.

Research questions

What intermediate care services exist and how are they utilized in the care of people with dementia in Europe?

Objective

This study aims at describing the point of view of General Practitioners on intermediate care services for people with dementia across Europe.

Methods

Key informant survey was sent to GPs via a self-developed questionnaire with space for open ended comments. 16 European countries participated to this cross-sectional mixed method study. Given the volunteer nature of the study, no minimum sample size requirements were applied to participation. Convenience sampling technique was used to address variations due to regional variations and regulations within the same country. Descriptive analyses of all intermediate care facilities groups by countries were performed. Qualitative analyses approach was used for the optional-free text to exemplify and/or complete the reasons contained in the closed response categories.

Results

The questionnaire was sent to 16 European countries. 583 questionnaires were analyzed. The responding physicians were 48 (± 11) years old on average and they had been in practice for an average of 18 (+ /11) years. The types of intermediate care considered were integrated at-home services, respite and relief services, day care centers and nursing homes. Their availability was considered very inhomogeneous by the majority of respondents. The main benefits of intermediate care cited were better medical care for the patient (78%), better quality of life for the caregiver (67%), prevention of the caregiver burden (73%) and a break for the caregiver (59%). The reported difficulties were: accessing these facilities due to limited financial support (76%) and cumbersome administrative procedures (67%). Many other facets of our findings were captured in the qualitative themes that emerged.

Conclusion

Intermediate care in Europe is diverse and heterogeneous. Major concerns of GPs are about the cost issues and the cumbersome administrative procedures to access them.

Stakeholder collaboration in long-term care of older people in Lithuania

Demographic situation, changes in the role of women in society and growing demand for long-term care (LTC) of older people have challenged the ability to meet the growing LTC needs in most developed countries. In countries where responsibility for LTC is still largely laid on families, it is, however, even more critical and calls for improvements in formal LTC systems. More intensive stakeholder collaboration in LTC policy development, organising and delivery are of primary importance in improving LTC systems. Such collaboration, however, is not always successful; thus, it is critical to understand what makes it effective and efficient. In this paper, we specifically look into multistakeholder collaboration in LTC in Lithuania, one of the fastest ageing countries in the EU, with the demand for LTC services growing fast and exceeding the supply despite rising business and NGO engagement. To determine facilitators of such collaboration, we build on the data obtained through eight focus group discussions with all key stakeholder representatives (LTC policymakers, organisers and service providers [public, private and NGOs], 54 participants in total). Our findings indicate that in addition to national and organisational level facilitators studied in prior research, there are important individual level factors, such as meaningfulness at work, concern and care for others, possibility for personal growth and development, satisfaction with supervision, a sense of belonging and role clarity. On the other hand, our results show that collaboration is constrained by a shortage of human resources, increased workload caused by growing LTC demand, bureaucratic requirements, legal restrictions, lack of awareness of LTC service availability among elder persons, and prevailing social norms and attitudes to institutionalised care. Interestingly, a lack of financial resources is not perceived as a major constraint.

'Patients come with two garbage bags full of problems and we have to sort them.' A qualitative study of the experiences of healthcare professionals on patients admitted to short-term residential care in the Netherlands

BACKGROUND

Short-term residential care (STRC) facilities were recently implemented in the Netherlands to provide temporary care to older adults with general health problems. The aim of STRC is to allow the individual to return home. However, 40% of patients are discharged to long-term care facilities. In-depth data about characteristics of patients admitted and challenges in providing STRC are missing.

OBJECTIVE

To obtain perspectives of STRC professionals on the patient journey from admission to discharge.

DESIGN

Qualitative study.

SETTING

Eight nursing homes and three hospitals.

SUBJECTS

A total of 28 healthcare professionals.

METHODS

A total of 13 group interviews with in-depth reviews of 39 pseudonymised patient cases from admission to discharge. Interviews were analysed thematically.

RESULTS

Many patients had complex problems that were underestimated at handover, making returning to home nearly impossible. The STRC eligibility criteria that patients have general health problems and can return home do not fit with current practice. This results in a mismatch between patient needs and the STRC that is provided. Therefore, planning care before and after discharge, such as advance care planning, social care and home adaptations, is important.

CONCLUSIONS

STRC is used by patients with complex health problems and pre-existing functional decline. Evidence-based guidelines, appropriate staffing and resources should be provided to STRC facilities. We need to consider the environmental context of the patient and healthcare system to enable older adults to live independently at home for longer.

Panorama da produção científica sobre Cuidados Intermediários e Hospitais Comunitários: uma revisão integrativa

RESUMO Mudanças epidemiológicas decorrentes do envelhecimento populacional motivaram transformações nos sistemas de saúde mundiais. Desde 1990, emergem discussões sobre Cuidados Intermediários (CI), visando diminuir hospitalizações, melhorar a coordenação do cuidado e estimular políticas públicas de cuidados próximos ao território. Este trabalho objetivou apresentar e analisar a literatura científica sobre CI, enfatizando serviços de Hospitais Comunitários. Realizou-se uma revisão integrativa, combinando os descritores “Intermediate Care”, “Community Hospitals”, “Intermediate Care Facilities”, “Long-Term Care”, “Hospitals Chronic Disease” e “Rehabilitation Services”, nos idiomas português, inglês e espanhol, nas bases Portal Regional da Biblioteca Virtual em Saúde, PubMed e Biblioteca Digital Brasileira de Teses e Dissertações. Após processo de busca e elegibilidade, foram incluídos 30 documentos para síntese qualitativa, provenientes de: Reino Unido, Noruega, Espanha, Dinamarca, Austrália e Itália. Resultados apontam para a eficácia, a efetividade e a eficiência dos CI, com boas avaliações por parte de profissionais e usuários. Os CI, como estratégia de fortalecimento da Atenção Primária à Saúde, redução de internações, favorecimento da independência funcional dos pacientes e seu retorno à comunidade, apresentam-se como uma inovação em saúde e aposta promissora. Entretanto, persistem lacunas na literatura que ensejam mais estudos sobre o tema, com vistas a subsidiar a tomada de decisão.

Implementing an integrated acute response service: professional perceptions of intermediate care

Purpose

The purpose of this study is to examine the implementation, care processes and sustainability of an integrated, intermediate Acute Response Team (ART) service. The primary aims of the service are to enhance the level of health and social care integration across a range of organisations, to ensure a timelier and appropriate service for people in the community at risk of admission to hospital.

Design/methodology/approach

A qualitative methodology was employed in order to gain a deep understanding of the experiences of staff members within the ART service and external stakeholders. Twenty-one professionals took part in a focus group or one-to-one interviews. Data were analysed thematically.

Findings

The key to successful implementation was that the service was co-created from the “ground-up” with support from local provider organisations. The inclusion of general practitioners (GPs) as part of the team was instrumental in setting up and maintaining the service and seems to be unique in intermediate care settings. Referrals into the ART service were dependent on awareness of the service at the interface with mainstream services. Transitions out were sometimes delayed due lack of availability of social care packages. To ensure sustainability of the ART and other integrated intermediate care services, continued resources, especially skilled staff members, are necessary.

Originality/value

This study adds to the intermediate care and acute response service literature by offering insights into “what works” from a professional perspective in terms of service implementation, care processes and sustainability, in an integrated care system.

From the service user association's perspective

Purpose

The aim of this study was to identify key components of integrated mental health and social care services that contribute to value for service users in Sweden.

Design/methodology/approach

An explorative research study design was used, based on data from four group interviews conducted in June and August 2017 with service user representatives.

Findings

The analysis resulted in eight subcategories reflecting components that were reported to contribute to value for service users. These subcategories were grouped into three main categories: (1) professionals who see and support the whole person, (2) organizational commitment to holistic care and (3) support for equal opportunities and active participation in society.

Research limitations/implications

The findings are primarily transferable to integrated mental health and social care services, as they emphasize key components that contribute to value for service users in these specific settings.

Practical implications

The complexity of integrated mental health and social care services requires coordination across the individual and organizational levels as well as ongoing dialogue and partnerships between service users, service user associations and health and social care organizations. In this integration, it is important that service users and service user associations not only are invited but also keen to participate in the design of care and support efforts.

Originality/value

Service User Associations (SUAs) can act as a bridge between county and municipal services through their participation in the development of local activities; at the regional and national levels, SUAs can help achieve more equitable integrated services. It is important that SUAs are not only invited but encouraged to actively participate in the design of such care and support efforts.

Bridging the gap between the home and the hospital: a qualitative study of partnership working across housing, health and social care

Rising demand and financial challenges facing public services have increased the impetus for greater integration across housing, health and social care. To provide insight into the benefits and challenges of partnership, we interviewed 37 housing professionals and held a validation workshop with eight external agencies working within a new, integrated housing service in the United Kingdom. The strength of the initiative rests on the capacity of neighborhood officers to conduct home visits and refer tenants to support agencies. Yet this strength poses problems in partnership building because increased referrals threaten to overwhelm already stretched health services. Despite broadly supporting the initiative, officers expressed concern over losing specialist housing knowledge whilst filling in gaps for services. Tensions over professional role boundaries between officers and social workers, poor communication, lack of capacity in external agencies and difficulties in sharing information were identified as barriers to partnership. Whilst capacity issues were acknowledged, partner agencies welcomed the initiative and called for joint meetings and colocation of services. Lack of capacity of external agencies to respond to referrals threatens integrated housing and health initiatives. Greater interprofessional collaboration and further investment across the system is required to increase capacity and ensure referrals are translated into healthcare outcomes.

Implementing a step down intermediate care service

Purpose

The purpose of this paper is to explore implementation and development of step-down intermediate care (IC) in Glasgow City from the perspective of staff.

Design/methodology/approach

The study used qualitative methods. Nine key members of staff were interviewed and three focus groups were run for social work, rehabilitation and care home staff. Framework analysis was used to identify common themes.

Findings

The proposed benefits of IC were supported anecdotally by staff. Perceived enablers included: having a range of engaged stakeholders, strong leadership and a risk management system in place, good relationships, trust and communication between agencies, a discharge target, training of staff, changing perception of risk and risk aversion, the right infrastructure and staffing, an accommodation-based strategy for patients discharged from IC, the right context of political priorities, funding and ongoing adaptation of the model in discussion with frontline staff. Potential improvements included a common recording system shared across all agencies, improving transition of patients from hospital to IC, development of a tool for identifying suitable candidates for IC, overcoming placement issues on discharge from IC, ensuring appropriate rehabilitation facilities within IC units, attachment of social work staff to IC units and finding solutions to issues related to variation in health and social care systems between sectors and hospitals.

Originality/value

The findings of this study help the ongoing refinement of the IC service. Some of the recommendations have already been implemented and will be of value to similar services being developed elsewhere.

Health-care professionals' experiences of patient participation among older patients in intermediate care-At the intersection between profession, market and bureaucracy

Background

Patient participation is a key concern in health care. Nevertheless, older patients often do not feel involved in their rehabilitation process. Research states that when organizational conditions exert pressure on the work situation, care as a mere technical activity seems to be prioritized by the health‐care staff, at the expense of patient involvement.

Objective

The aim of this article is to explore how health‐care professionals experience patient participation in IC services, and explain how they perform their clinical work balancing between the patient's needs, available resources and regulatory constraints.

Design

Using a framework of professional work and institutional logics, underpinned by critical realism, we conducted semi‐structured interviews with 18 health‐care professionals from three IC institutions.

Results

IC appears as an important service in the patient pathway for older people with a great potential for patient participation. However, health care staff may experience constraints that prohibit them from using professional discretion, which is perceived as a threat to patient participation. Further, they may adopt routines that simplify their interactions with patients. Our results call for more emphasis on an individualized rehabilitation process and a recognition that psychological and social aspects are critical for patient participation in IC.

Conclusion

Patients interact in the face of conflicting institutional priorities or protocols. The study adds important knowledge about the practice of patient participation in IC from a front‐line provider perspective. Underlying mechanisms are identified to understand and recommend how to facilitate patient participation at different levels in narrowing the gap between policy and clinical work in IC.

Measuring the impact of step down intermediate care on delayed discharge: an interrupted time series analysis

BACKGROUND

Intermediate care (IC) acts as a bridging service between hospital and home, for those deemed medically fit for discharge but who are delayed in hospital. The aim of this study was to measure the effect of IC and a 72-hour discharge target on days delayed.

METHODS

Rate of days delayed per 1000 population aged 75 years+ in Glasgow City was compared before and after onset of IC with a 6-month phase-in period, using segmented linear regression. Inverclyde and West Dunbartonshire (IWD) was a control. Autoregressive and moving average terms were included in the model, as well as a Fourier term to adjust for seasonality.

RESULTS

Prior to IC, rate of days delayed increased in both Glasgow City and the rest of Scotland. There was a large reduction in rate of days delayed in Glasgow during the phase-in period, greater than the rest of Scotland but comparable with that observed in IWD, with subsequent increases thereafter. Adjusting for changes in IWD, the impact of IC and the discharge target in Glasgow City was a level change of -15.20 (95% CI -17.52 to -12.88) and a trend change of -0.29 (95% CI -0.55 to -0.02). This is equivalent to a predicted reduction due to IC of -16.04 days delayed per 1000 population per month, in June 2016, and a relative reduction of 35%.

CONCLUSION

IC and the 72-hour discharge target were associated with a reduction in days delayed. Rate of days delayed continued to increase over time, although at a slower rate than if IC had not been implemented.

A critical evaluation of integrated care: a case study of the supported discharge service

Purpose

The purpose of this paper is to evaluate the Supported Discharge Service as a case study of integrated care. The paper will critically evaluate integrated care with regard to patient outcomes, patient satisfaction and cost and productivity.

Design/methodology/approach

A retrospective mixed methods case study design was adopted utilising patient satisfaction questionnaires, therapy outcome measure and a performance dashboard to measure improvements in patient satisfaction, patient outcomes and cost and productivity.

Findings

Measured improvements were observed in the integrated discharge process and analysis of the findings demonstrated a statistically significant improvement in patient outcomes, high levels of patient satisfaction and improved productivity subsequently leading to financial savings.

Research limitations/implications

Due to convenience sampling, the small sample size and a short time frame when analysing patient outcomes, the generalisability of results is limited. Despite this, with integrated care being polymorphous the findings can be utilised to develop theoretical principles to make assertions about integration (Wikfeldt, 1993).

Originality/value

This paper draws on the importance of integration as the principal driver of reform within the healthcare system. Even though on a small scale, the case study provides evidence to support the use of integration to improve patient outcomes, patient satisfaction and financial savings.

User participation in a Municipal Acute Ward in Norway: dilemmas in the interface between policy ideals and work conditions

User participation has become an increasingly important principle in health care over the last few decades. Healthcare professionals are expected to involve patients in treatment decisions. Clear guidance as to what this should entail for professionals in clinical work is not accounted for in legislation. In this study, we explore how healthcare professionals in a Municipal Acute Ward perceived, experienced and performed user participation. The ward represents a new short-time service model for emergency assistance in Norway. We focused on the challenges the professionals faced in clinical work and how they dealt with these. Data were drawn from qualitative interviews with 11 healthcare professionals and from 10 observations in relation to previsits and physician's rounds in the ward. Transcripts of interviews and observations were analysed using a method for systematic text condensation. In the analysis, we applied Lipsky's perspective on dilemmas of street-level bureaucrats. The results show that that the professionals perceived user participation as an important and natural part of their work. They experienced difficulties related to collaboration with patients, caregivers, and professionals in other services, and with framework conditions that caused conflicting expectations, responsibility, and priorities. The professionals seemed to take a pragmatic approach to user participation, managing it within narrow perspectives. Our study indicates that the participants dealt with the dilemmas at the cost of user participation. The results demonstrate that there is a gap between the outlined health policy and the professionals' opportunities to fulfil this policy in clinical work regarding user participation. The policy decision-makers should recognise the balancing work required of healthcare professionals to deal with difficulties in clinical work. The knowledge that professionals possess as performers of services and the need for valuing in policy processes should be acknowledged.

Providing effective and preferred care closer to home: a realist review of intermediate care

Intermediate care is one of the number of service delivery models intended to integrate care and provide enhanced health and social care services closer to home, especially to reduce reliance on acute care hospital beds. In order for health and social care practitioners, service managers and commissioners to make informed decisions, it is vital to understand how to implement the admission avoidance and early supported discharge components of intermediate care within the context of local care systems. This paper reports the findings of a theory-driven (realist) review conducted in 2011-2012. A broad range of evidence contained in 193 sources was used to construct a conceptual framework for intermediate care. This framework forms the basis for exploring factors at service user, professional and organisational levels that should be considered when designing and delivering intermediate care services within a particular local context. Our synthesis found that involving service users and their carers in collaborative decision-making about the objectives of care and the place of care is central to achieving the aims of intermediate care. This pivotal involvement of the service user relies on practitioners, service managers and commissioners being aware of the impact that organisational structures at the local level can have on enabling or inhibiting collaborative decision-making and care co-ordination. Through all interactions with service users and their care networks, health and social care professionals should establish the meaning which alternative care environments have for different service users. Doing so means decisions about the best place of care will be better informed and gives service users choice. This in turn is likely to support psychological and social stability, and the attainment of functional goals. At an organisational level, integrated working can facilitate the delivery of intermediate care, but there is not a straightforward relationship between integrated organisational processes and integrated professional practice.

Effectiveness of an intermediate care hospital on readmissions, mortality, activities of daily living and use of health care services among hospitalized adults aged 60 years and older--a controlled observational study

BACKGROUND

Intermediate care is a health care model developed to optimize the coordination of health care services and functional independence. In Central Norway, an intermediate care hospital (ICH) was established in a municipality to improve hospital discharge and follow-up among elderly patients with chronic conditions and comprehensive care needs. The aim of this study was to investigate the effectiveness of hospital discharges to a municipality with an ICH compared to discharges to a municipality without an ICH.

METHODS

This was a non-randomized controlled observational study of hospitalized patients aged 60 years and older from two municipalities. Patients (n = 328) admitted to a general hospital from February 2010 through September 2011 were included in the study and followed for 12 months. The data were analyzed using descriptive statistics, analysis of covariance (ANCOVA) and Cox proportional hazard regression.

RESULTS

Each patient discharged from the general hospital to the municipality with an ICH had a shorter length of stay and used on average 4.2 (p = 0.046) fewer hospital days during 1 year compared to patients from the municipality without an ICH. Otherwise, no statistical significant differences were found between the municipalities in terms of hospital readmissions, admissions, mortality, activities of daily living, primary health care utilization or total care days. A post hoc analysis of patients discharged to the ICH compared to the municipality without an ICH, showed that the ICH patients were older and frailer, but the outcome was similar to the main analysis.

CONCLUSIONS

Having an ICH in the municipality facilitated shorter length of hospital stay and kept the risk of readmissions, mortality and post-hospitalization care needs at the same level as without an ICH.

Establishing and implementing best practice to reduce unplanned admissions in those aged 85 years and over through system change [Establishing System Change for Admissions of People 85+ (ESCAPE 85+)]: a mixed-methods case study approach

Background

In England, between 2007/8 and 2009/10, the rate of unplanned hospital admissions of people aged 85 years and above rose from 48 to 52 per 100. There was substantial variation, with some areas showing a much faster rate of increase and others showing a decline.

Objectives

To identify system characteristics associated with higher and lower increases in unplanned admission rates in those aged 85 years and over; to develop recommendations to inform providers and commissioners; and to investigate the challenges of starting to implement these recommendations.

Design

Mixed-methods study using routinely collected data, in-depth interviews and focus groups. Data were analysed using the framework approach, with themes following McKinsey’s 7S model. Recommendations derived from our findings were refined and prioritised through respondent validation and consultation with the project steering group. The process of beginning to implement these recommendations was examined in one ‘implementation site’.

Participants

Six study sites were selected based on admission data for patients aged 85 years and above from primary care trusts: three where rates of increase were among the most rapid and three where they had slowed down or declined. Each ‘improving’ or ‘deteriorating’ site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services, and adult social care. At each site, representatives from these organisations at strategic and operational levels, as well as representatives of patient groups, were interviewed to understand how policies had been developed and implemented. A total of 142 respondents were interviewed.

Results

Between 2007/8 and 2009/10, average admission rates for people aged 85 years and over rose by 5.5% annually in deteriorating sites and fell by 1% annually in improving sites. During the period under examination, the population aged 85 years and over in deteriorating sites increased by 3.4%, compared with 1.3% in improving sites. In deteriorating sites, there were problems with general practitioner access, pressures on emergency departments and a lack of community-based alternatives to admission. However, the most striking difference between improving and deteriorating sites was not the presence or absence of specific services, but the extent to which integration within and between types of service had been achieved. There were also overwhelming differences in leadership, culture and strategic development at the system level. The final list of recommendations emphasises the importance of issues such as maximising integration of services, strategic leadership and adopting a system-wide approach to reconfiguration.

Conclusions

Rising admission rates for older people were seen in places where several parts of the system were under strain. Places which had stemmed the rising tide of admissions had done so through strong, stable leadership, a shared vision and strategy, and common values across the system.

Future work

Research on individual components of care for older people needs to take account of their impact on the system as a whole. Areas where more evidence is needed include the impact of improving access and continuity in primary care, the optimal capacity for intermediate care and how the frail elderly can best be managed in emergency departments.

Study registration

UK Clinical Reasearch Network 12960.

Funding details

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

"It's very complicated": a qualitative study of medicines management in intermediate care facilities in Northern Ireland

Background

Intermediate care (IC) describes a range of services targeted at older people, aimed at preventing unnecessary hospitalisation, promoting faster recovery from illness and maximising independence. Older people are at increased risk of medication-related adverse events, but little is known about the provision of medicines management services in IC facilities. This study aimed to describe the current provision of medicines management services in IC facilities in Northern Ireland (NI) and to explore healthcare workers’ (HCWs) and patients’ views of, and attitudes towards these services and the IC concept.

Methods

Semi-structured interviews were conducted, recorded, transcribed verbatim and analysed using a constant comparative approach with HCWs and patients from IC facilities in NI.

Results

Interviews were conducted with 25 HCWs and 18 patients from 12 IC facilities in NI. Three themes were identified: ‘concept and reality’, ‘setting and supply’ and ‘responsibility and review’. A mismatch between the concept of IC and the reality was evident. The IC facility setting dictated prescribing responsibilities and the supply of medicines, presenting challenges for HCWs. A lack of a standardised approach to responsibility for the provision of medicines management services including clinical review was identified. Whilst pharmacists were not considered part of the multidisciplinary team, most HCWs recognised a need for their input. Medicines management was not a concern for the majority of IC patients.

Conclusions

Medicines management services are not integral to IC and medicine-related challenges are frequently encountered. Integration of pharmacists into the multidisciplinary team could potentially improve medicines management in IC.

How older people cope with frailty within the context of transition care in Australia: implications for improving service delivery

Transition care is increasingly common for older people, yet little is known about the subjective experience of the transition care 'journey' from the perspective of clients themselves. This study examines how older people cope with frailty within the context of a dedicated transition care programme and discusses implications for improving service delivery. Qualitative in-depth interviews were carried out during 2011 in the homes of 20 older people who had recently been discharged from a transition care programme operating in Adelaide, South Australia (average age 80 years, 65% female). Thematic analysis identified three key themes: 'a new definition of recovery', 'complexities of control' and 'the disempowering system'. Despite describing many positive aspects of the programme, including meeting personal milestones and a renewed sense of independence, participants recognised that they were unlikely to regain their previous level of functioning. For some, this was exacerbated by lacking control over the transition care process while adapting to their new level of frailty. Overall, this research highlighted that benefits associated with transition care can be undermined by fragmentation in service delivery, loss of control and uncertainties around future support.

Secondary analysis and literature review of community rehabilitation and intermediate care: an information resource

Background and design

This research was based on a reanalysis of a merged data set from two intermediate care (IC) projects in order to identify patient characteristics associated with outcomes [Nancarrow SA, Enderby PM, Moran AM, Dixon S, Parker SG, Bradburn MJ,et al.The Relationship Between Workforce Flexibility and the Costs and Outcomes of Older Peoples’ Services (COOP). Southampton: National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO); 2010 and Nancarrow SA, Enderby PM, Ariss SM, Smith T, Booth A, Campbell MJ,et al.The Impact of Enhancing the Effectiveness of Interdisciplinary Working (EEICC). Southampton: NIHR SDO; 2012]. Additionally, the impact of different team and staffing structures on patient outcomes and service costs was examined, when possible given the data sets, to enable identification of the most cost-effective service configurations and change over time with service provision. This secondary analysis was placed within updated literature reviews focused on the separate questions.

Research objectives

(1) To identify those patients most likely to benefit from IC and those who would be best placed to receive care elsewhere; (2) to examine the effectiveness of different models of IC; (3) to explore the differences between IC service configurations and how they have changed over time; and (4) to use the findings above to develop accessible evidence to guide service commissioning and monitoring.

Setting

Community-based services for older people are described in many different ways, among which are IC services and community rehabilitation. For the purposes of this report we call the services IC services and include all community-based provision for supporting older people who would otherwise be admitted to hospital or who would require increased length of stay in hospital (e.g. hospital at home schemes, post-acute care, step-up and step-down services).

Participants

The combined data set contained data on 8070 patient admissions from 32 IC teams across England and included details of the service context, costs, staffing/skill mix (800 staff), patient health status and outcomes.

Interventions

The interventions associated with the study cover the range of services and therapies available in IC settings. These are provided by a wide range of professionals and care staff, including nursing, allied health and social care.

Outcome measures

(1) Service data – each team provided information relating to the size, nature, staffing and resourcing of the services. Data were collected on a service pro forma. (2) Team data – all staff members of the teams participating in both studies provided individual information using the Workforce Dynamics Questionnaire. (3) Patient data – patient data were collected on admission and discharge using a client record pack. The client record pack recorded a range of data utilising a number of validated tools, such as demographic data, level of care (LoC) data, therapy outcome measure (TOM) scale, European Quality of Life-5 Dimensions (EQ-5D) questionnaire and patient satisfaction survey.

Results

(1) The provision of IC across England is highly variable with different referral routes, team structures, skill mix and cost-effectiveness; (2) in more recent years, patients referred to IC have more complex needs associated with more severe impairments; (3) patients most likely to improve were those requiring rehabilitation as determined by levels 3, 4 and 5 on the LoC (> 40% for impairment, activity and participation, and > 30% for well-being as determined on the TOM scale); (4) half of all patients with outcome data improved on at least one of the domains of the TOM scale; (5) for every 10-year increase in age there was a 6% decrease in the odds of returning home. The chance of remaining or returning home was greater for females than males; (6) a high percentage of patients referred to IC do not require the service; and (7) teams including clinical support staff and domiciliary staff were associated with a small relative improvement in TOM impairment scores when compared with other teams.

Conclusions

This study provides additional evidence that interdisciplinary teamworking in IC may be associated with better outcomes for patients, but care should be taken with overinterpretation. The measures that were used within the studies were found to be reliable, valid and practical and could be used for benchmarking. This study highlights the need for funding high-quality studies that attempt to examine what specific team-level factors are associated with better outcomes for patients. It is therefore important that studies in the future attempt empirically to examine what process-level team variables are associated with these outcomes.

Funding

The NIHR Health Services and Delivery Research programme.

Experiences of older adults in transition from hospital to community

This study examined how patients experience transitions to community from hospitals, inclusive of daily living problems and medical concerns. Analysing qualitative data from interviews with 36 individuals including 17 high-risk older adults with multiple chronic health conditions recently discharged from hospital, and 19 family members who provided the patients with ongoing care, we asked (1) What are the challenges that patients experience in transitioning home from the hospital, and (2) What are the system and policy solutions that can address the challenges these patients experience? Our findings reveal both short- and long-term challenges associated with transitions back home. Short-term challenges include preparing the dwelling for the patient and understanding the organization of care at home. Long-term challenges are associated with practical and emotional concerns. Reflecting on our findings, we suggest that patients' social needs may be equally important to their medical needs during post-discharge recovery, and we discuss implications for policy.

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.

Factors that promote and hinder joint and integrated working between health and social care services: a review of research literature

This article reports the results of a review of the research evidence related to joint working in the field of adult health and social care services in the UK. It explores whether recent reforms to joint working have met the objectives set by policy-makers. The review followed an established methodology: electronic databases were searched using predetermined terms, abstracts were screened against inclusion criteria, studies that met the criteria were read in full and assessed for inclusion and data were extracted systematically. The findings of the review suggest that there is some indication that recent developments, in particular the drive to greater integration of services, may have positive benefits for organisations as well as for users and carers of services. However, the evidence consistently reports a lack of understanding about the aims and objectives of integration, suggesting that more work needs to be done if the full potential of the renewed policy agenda on integration is to be realised. Additionally, while the review acknowledges that greater emphasis has been placed on evaluating the outcome of joint working, studies largely report small-scale evaluations of local initiatives and few are comparative in design and therefore differences between 'usual care' and integrated care are not assessed. This makes it difficult to draw firm conclusions about the effectiveness of UK-based integrated health and social care services.

Hospital discharge of elderly patients to primary health care, with and without an intermediate care hospital - a qualitative study of health professionals' experiences

Introduction

Intermediate care is an organisational approach to improve the coordination of health care services between health care levels. In Central Norway an intermediate care hospital was established in a municipality to improve discharge from a general hospital to primary health care. The aim of this study was to investigate how health professionals experienced hospital discharge of elderly patients to primary health care with and without an intermediate care hospital.

Methods

A qualitative study with data collected through semi-structured focus groups and individual interviews.

Results

Discharge via the intermediate care hospital was contrasted favourably compared to discharge directly from hospital to primary health care. Although increased capacity to receive patients from hospital and prepare them for discharge to primary health care was viewed as a benefit, professionals still requested better communication with the preceding care level concerning further treatment and care for the elderly patients.

Conclusions

The intermediate care hospital reduced the coordination challenges during discharge of elderly patients from hospital to primary health care. Nevertheless, the intermediate care was experienced more like an extension of hospital than an included part of primary health care and did not meet the need for communication across care levels.

The role of an intermediate unit in a clinical pathway

INTRODUCTION

Different care models have been established to achieve more coordinated clinical pathways for older patients in the transition between hospital and home. This study explores an intermediate unit's role in a clinical pathway for older patients with somatic diseases.

THEORY AND METHODS

Qualitative data were collected via interviews, observations, and a questionnaire. Participants included patients and healthcare providers within both specialist and primary healthcare. Transcripts of interviews and field notes were analyzed using a method of systematic text condensation.

RESULTS

Healthcare providers in the hospital, the intermediate unit, and the municipalities have different opinions about who is a 'suitable' patient for the unit and what is the proper time for hospital discharge. This results in time-consuming negotiations between the hospital and the unit. Incompatible computer systems increase the healthcare provider's workload. Several informants are doubtful as to whether a stay in the unit is useful to the patients, while the patients are mostly pleased with their stay and the transferral.

CONCLUSION AND DISCUSSION

This study describes challenges that may occur when a new unit is established in an existing healthcare system in order to achieve an appropriate clinical pathway from hospital to home.

Organisation and delivery of home care re-ablement: what makes a difference?

Home-care re-ablement or 'restorative' services are a cornerstone of preventive service initiatives in many countries. Many English local authorities are transforming their former in-house home-care services to provide intensive, short-term re-ablement instead. The focus of this paper is on the organisation and content of re-ablement services and the features of their organisation and delivery that have the potential to enhance or detract from their effectiveness. Qualitative data were collected from five sites with well-established re-ablement services. Data included semi-structured interviews with senior service managers in each site; observation of 26 re-ablement visits to service users across the five sites (four to six in each site) and a focus group discussion with front-line staff in each site (in total involving 37 front-line staff). The data generated from all three sources were analysed using the framework approach. All five services had developed from selective pilot projects to inclusive 'intake' service, accepting almost all referrals for home-care services. A number of features were identified as contributing to the effectiveness of re-ablement services. These included: service user characteristics and expectations; staff commitment, attitudes and skills; flexibility and prompt intervention; thorough and consistent recording systems; and rapid access to equipment and specialist skills in the team. Factors external to the re-ablement services themselves also had implications for their effectiveness; these included: a clear, widely understood vision of the service; access to a wide range of specialist skills; and capacity within long-term home-care services. The paper argues that re-ablement can be empowering for all service users in terms of raising their confidence. However, the move to a more inclusive 'intake' service suggests that outcomes are likely to be considerably lower for service users who have more limited potential to be independent. The paper discusses the implications for practice.

Bringing genetics into primary care: Findings from a national evaluation of pilots in England

Objectives:

Developments in genetic knowledge and clinical applications are seen as rendering traditional modes of organizing genetics provision increasingly inappropriate. In common with a number of developed world countries the UK has sought to increase the role of primary care in delivering such services. However, efforts to reconfigure service delivery face multiple challenges associated with divergent policy objectives, organizational boundaries and professional cultures. This paper presents findings from an evaluation of an English initiative to integrate genetics into ‘mainstream’ clinical provision in the National Health Service.

Methods:

Qualitative research in 11 case-study sites focusing on attempts by pilots funded by the initiative to embed knowledge and provision within primary care illustrating barriers faced and the ways in which these were surmounted.

Results:

Lack of intrinsic interest in clinical genetics among primary care staff was compounded by national targets that focused their attention elsewhere and by service structures that rendered genetics a peripheral concern demanding minimal engagement. Established divisions between the commissioning of mainstream and specialist services, along with the pressures of shorter-term targets, impeded ongoing funding.

Conclusions:

More wide-ranging policy and organizational support is required if the aim of entrenching genetics knowledge and practice across the Health Service is to be realized.

Costs and health outcomes of intermediate care: results from five UK case study sites

The objectives of this study were to explore the costs and outcomes associated with different types of intermediate care (IC) services, and also to examine the characteristics of patients receiving such services. Five UK case studies of 'whole systems' of IC were used, with data collected on a sample of consecutive IC episodes between January 2003 and January 2004. Statistical differences in costs and outcomes associated with different IC services and patient groups were explored. Factors associated with variation in IC episode outcomes (EuroQol EQ-5D and Barthel Index) were explored using an econometric framework. Data were available for 2253 episodes of IC. In terms of Department of Health criteria, a large proportion of patients (up to 47% of those for whom data were available) in this study were inappropriately admitted to IC services. As regards service function, compared to supported discharge, admission avoidance services were associated with both lower costs and greater health and functional gains. These gains appear to be driven, in part, by illness severity (more dependent patients tended to gain most benefit). In addition, these gains appear to be larger where the admission was appropriate. Our work suggests a need for the development and application of robust and reliable clinical criteria for admission to IC, and close co-operation between hospital and community service providers over selection of patients and targeting of IC and acute care services to meet defined clinical need.