Intermediate care: for better or worse? Process evaluation of an intermediate care model between a university hospital and a residential home

A myriad of factors influencing the implementation of transitional care innovations: a scoping review

Background

Care transitions of older persons between multiple care settings are frequently hampered by various issues such as discontinuous care delivery or poor information transfer among healthcare providers. Therefore, several innovations have been developed to optimize transitional care (TC). This review aims to identify which factors influence the implementation of TC innovations.

Methods

As part of TRANS-SENIOR, an international innovative training and research network focusing on enhancing or avoiding care transitions, a scoping review was conducted. The five stages of the Arksey and O’Malley framework were followed. PubMed/MEDLINE, EMBASE, and CINAHL were searched, and eligible studies published between years 2000 and 2020 were retrieved. Data were extracted from the included studies and mapped to the domains and constructs of the Consolidated Framework for Implementation Research (CFIR) and Care Transitions Framework (CTF).

Results

Of 1537 studies identified, 21 were included. Twenty different TC innovations were covered and aimed at improving or preventing transitions between multiple care settings, the majority focused on transitions from hospital to home. Key components of the innovations encompassed transition nurses, teach-back methods, follow-up home visits, partnerships with community services, and transfer units. Twenty-five prominent implementation factors (seven barriers, seven facilitators, and eleven factors with equivalent hindering/facilitating influence) were shown to affect the implementation of TC innovations. Low organizational readiness for implementation and the overall implementation climate were topmost hindering factors. Similarly, failing to target the right population group was commonly reported as a major barrier. Moreover, the presence of skilled users but with restricted knowledge and mixed attitudes about the innovation impeded its implementation. Among the eminent enabling factors, a high-perceived advantage of the innovation by staff, along with encouraging transition roles, and a continuous monitoring process facilitated the implementation of several innovations. Other important factors were a high degree of organizational networks, engaging activities, and culture; these factors had an almost equivalent hindering/facilitating influence.

Conclusions

Addressing the right target population and instituting transition roles in care settings appear to be specific factors to consider during the implementation of TC innovations. Long-term care settings should simultaneously emphasize their organizational readiness for implementation and change, in order to improve transitional care through innovations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01087-2.

Municipal Acute Units as Part of the Clinical Pathway for Older Patients

Introduction

Since 2016, Norwegian municipalities have been obliged to provide municipal acute 24-hour services representing a service before or instead of hospital treatment. This study explores two municipal acute units (MAUs) as part of the clinical pathway for older patients.

Methods

Patients and healthcare providers from MAUs, purchaser offices, home-based nursing, and physicians were interviewed. Interview transcripts were analysed using systematic text condensation.

Results

The collaboration between the MAU staff and the GPs, the purchaser offices and the home-based services is described as challenging, mostly due to disagreement regarding patients' admission and discharge. The providers' different understanding seems to derive especially from where they are working in a way that suits their own work functions.An exigent collaboration between providers in the MAUs and their collaborative partners hampers the clinical pathway for older patients in the municipal healthcare service.

Conclusion and discussion

When a new healthcare service such as an MAU becomes a part of the clinical pathway in a municipality, it is important to invest a considerable effort in measures designed to strengthen relational and structural collaboration to make the clinical pathway smooth.

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.

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.

Three Different Outcomes in Older Community-dwelling Patients Receiving Intermediate Care in Nursing Home after Acute Hospitalization

OBJECTIVES

To evaluate the recovery and outcome of older communitydwelling patients admitted to intermediate care (IC) in nursing homes after acute hospitalization, and to compare patients who were able and unable to return directly to their own homes.

DESIGN

Prospective, observational, cohort study conducted between June 2011 and 2014.

SETTING

A 19- bed IC unit in a nursing home with increased multidisciplinary staffing.

PARTICIPANTS

A total of 961 community-dwelling patients, ≥70 years of age, considered to have a rehabilitation potential and no major cognitive impairment or delirium, transferred from internal medicine, cardiac, pulmonary and orthopaedic hospital departments.

MEASUREMENTS

Demographic data, clinical information, comprehensive geriatric assessment (CGA), discharge destination and length of stay. Residence status and mortality 1 month, 2 months, 3 months, and 6 months after discharge from the hospital.

RESULTS

The trajectory of recovery was divided into 3 groups: 1) Rapid recovery, able to return home after median 14 days in IC (n=785, 82%); 2) Slow recovery, requiring additional transfer to other nursing home after IC, but still able to return home within 2 months (n=106, 11%). 3) Poor recovery, requiring transfer to other nursing home after IC and still in a nursing home or dead at 2 months (n=66, 7%). Significant different clinical characteristics were demonstrated between the patients in the 3 groups. After 6 months, the recovery of patients with rapid or slow recovery was similar, 87% were living at home, compared to only 20% of the patients with poor recovery. In multiple logistic regression analysis, slow or poor recovery was significantly associated with low scores on the Barthel index and orthopaedic admission diagnosis.

CONCLUSIONS

Although the majority of patients selected for treatment in the IC unit were able to recover and return home, a group of patients needed extra time, up to 2 months, to recover and another group had a poor chance of recovering and returning home. Different caring pathways for different patient groups may be considered in the PAC setting.

Being back home after intermediate care: the experience of older people

Older people may face many challenges and experience insecurity after discharge from hospital to home. To bridge the potential gap between general hospital and home, the concept of intermediate care (IC) was developed in the year 2000. IC aims to safeguard older people from being discharged to their home before they have sufficiently recovered. However, knowledge within this area is sparse, and the experience of older people in particular is yet to be explored. The aim of this study was to explore older people's experiences of being back home after a stay in an IC unit. Data were drawn from 12 interviews. Transcripts were analysed using a phenomenological approach. The essential meaning of being back home after a stay in an IC unit was characterised by uncertainty. Four constituents emerged: experiencing a state of shock about coming home, dependence on informal helpers, feeling a sense of isolation, and fearing loss of functional ability permanently.

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.

The influence of an intermediate care hospital on health care utilization among elderly patients--a retrospective comparative cohort study

BACKGROUND

An intermediate care hospital (ICH) was established in a municipality in Central Norway in 2007 to improve the coordination of services and follow-up among elderly and chronically ill patients after hospital discharge. The aim of this study was to compare health care utilization by elderly patients in a municipality with an ICH to that of elderly patients in a municipality without an ICH.

METHODS

This study was a retrospective comparative cohort study of all hospitalized patients aged 60 years or older in two municipalities. The data were collected from the national register of hospital use from 2005 to 2012, and from the local general hospital and two primary health care service providers from 2008 to 2012 (approx. 1,250 patients per follow-up year). The data were analyzed using descriptive statistics and analysis of covariance (ANCOVA).

RESULTS

The length of hospital stay decreased from the time the ICH was introduced and remained between 10% and 22% lower than the length of hospital stay in the comparative municipality for the next five years. No differences in the number of readmissions or admissions during one year follow-up after the index stay at the local general hospital or changes in primary health care utilization were observed. In the year after hospital discharge, the municipality with an ICH offered more hour-based care to elderly patients living at home (estimated mean = 234 [95% CI 215-252] versus 175 [95% CI 154-196] hours per person and year), while the comparative municipality had a higher utilization of long-term stays in nursing homes (estimated mean = 33.3 [95% CI 29.0-37.7] versus 21.9 [95% CI 18.0-25.7] days per person and year).

CONCLUSIONS

This study indicates that the introduction of an ICH rapidly reduces the length of hospital stay without exposing patients to an increased health risk. The ICH appears to operate as an extension of the general hospital, with only a minor impact on the pattern of primary health care utilization.

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.

Residential and nursing homes: how can they meet the challenge of an aging population?

A rapidly aging society presents important challenges to care homes. Faced with increasingly elderly residents and progressively more complex clinical and social care needs, nursing and residential homes will have to address a number of issues. These include: how to maintain residents’ quality of life as well as quality of care; how to integrate health and social care provision; how best to manage their interface with hospitals in order to prevent avoidable hospitalizations and facilitate early discharges; and how to utilize new technology in a cost-effective manner. This review examines evidence from across the world on how care home placements can evolve to meet these challenges, with discussion largely adopting a UK perspective. The evidence on innovative ways of working to achieve such aims is growing, although slowly. The potential for new technologies to maintain quality and contain costs is significantly under-developed. More research is now needed.

Hospital discharge planning and continuity of care for aged people in an Italian local health unit: does the care-home model reduce hospital readmission and mortality rates?

BACKGROUND

Hospital discharge planning is aimed to decrease length of stay in hospitals as well as to ensure continuity of health care after being discharged. Hospitalized patients in Turin, Italy, who are in need of medical, social and rehabilitative care are proposed as candidates to either discharge planning relying on a care-home model (DPCH) for a period of about 30 days, or routine discharge care. The aim of this study was to evaluate whether a hospital DPCH that was compared with routine care, improved patients' outcomes in terms of reduced hospital readmission and mortality rates in patients aged 64 years and older.

METHODS

In a retrospective observational cohort study a sample of 380 subjects aged 64 years and over was examined. Participants were discharged from the hospital S. Giovanni Bosco in Turin, Italy from March 1st, 2005 to February 28th, 2006. Of these subjects, 107 received routine discharge care while 273 patients were referred to care-home (among them, 99 received a long-term care intervention (LTCI) afterwards while 174 did not). Data was gathered from various administrative and electronic databases. Cox regression models were used to evaluate factors associated with mortality and hospital readmission.

RESULTS

When socio-demographic factors, underlying disease and disability were taken into account, DPCH decreased mortality rates only if it was followed by a LTCI: compared to routine care, the Hazard Ratio (HR) of death was 0.36 (95% Confidence Interval (CI): 0.20 - 0.66) and 1.15 (95%CI: 0.77 - 1.74) for DPCH followed by LTCI and DPCH not followed by LTCI, respectively. On the other hand, readmission rates did not significantly differ among DPCH and routine care, irrespective of the implementation of a LTCI: HRs of hospital readmission were 1.01 (95%CI: 0.48 - 2.24) and 1.18 (95%CI: 0.71 - 1.96), respectively.

CONCLUSION

The use of DPCH after hospital discharge reduced mortality rates, but only when it was followed by a long-term health care plan, thus ensuring continuity of care for elderly participants.

Hospital discharge planning and continuity of care for aged people in an Italian local health unit: does the care-home model reduce hospital readmission and mortality rates?

Background

Hospital discharge planning is aimed to decrease length of stay in hospitals as well as to ensure continuity of health care after being discharged. Hospitalized patients in Turin, Italy, who are in need of medical, social and rehabilitative care are proposed as candidates to either discharge planning relying on a care-home model (DPCH) for a period of about 30 days, or routine discharge care. The aim of this study was to evaluate whether a hospital DPCH that was compared with routine care, improved patients' outcomes in terms of reduced hospital readmission and mortality rates in patients aged 64 years and older.

Methods

In a retrospective observational cohort study a sample of 380 subjects aged 64 years and over was examined. Participants were discharged from the hospital S.Giovanni Bosco in Turin, Italy from March 1^st, 2005 to February 28^th, 2006. Of these subjects, 107 received routine discharge care while 273 patients were referred to care-home (among them, 99 received a long-term care intervention (LTCI) afterwards while 174 did not). Data was gathered from various administrative and electronic databases. Cox regression models were used to evaluate factors associated with mortality and hospital readmission.

Results

When socio-demographic factors, underlying disease and disability were taken into account, DPCH decreased mortality rates only if it was followed by a LTCI: compared to routine care, the Hazard Ratio (HR) of death was 0.36 (95% Confidence Interval (CI): 0.20 – 0.66) and 1.15 (95%CI: 0.77 – 1.74) for DPCH followed by LTCI and DPCH not followed by LTCI, respectively. On the other hand, readmission rates did not significantly differ among DPCH and routine care, irrespective of the implementation of a LTCI: HRs of hospital readmission were 1.01 (95%CI: 0.48 – 2.24) and 1.18 (95%CI: 0.71 – 1.96), respectively.

Conclusion

The use of DPCH after hospital discharge reduced mortality rates, but only when it was followed by a long-term health care plan, thus ensuring continuity of care for elderly participants.

In-reach specialist nursing teams for residential care homes: uptake of services, impact on care provision and cost-effectiveness

BACKGROUND

A joint NHS-Local Authority initiative in England designed to provide a dedicated nursing and physiotherapy in-reach team (IRT) to four residential care homes has been evaluated. The IRT supported 131 residents and maintained 15 'virtual' beds for specialist nursing in these care homes.

METHODS

Data captured prospectively (July 2005 to June 2007) included: numbers of referrals; reason for referral; outcome (e.g. admission to IRT bed, short-term IRT support); length of stay in IRT; prevented hospital admissions; early hospital discharges; avoided nursing home transfers; and detection of unrecognised illnesses. An economic analysis was undertaken.

RESULTS

733 referrals were made during the 2 years (range 0.5 to 13.0 per resident per annum) resulting in a total of 6,528 visits. Two thirds of referrals aimed at maintaining the resident's independence in the care home. According to expert panel assessment, 197 hospital admissions were averted over the period; 20 early discharges facilitated; and 28 resident transfers to a nursing home prevented. Detection of previously unrecognised illnesses accounted for a high number of visits. Investment in IRT equalled 44.38 pounds per resident per week. Savings through reduced hospital admissions, early discharges, delayed transfers to nursing homes, and identification of previously unrecognised illnesses are conservatively estimated to produce a final reduction in care cost of 6.33 pounds per resident per week. A sensitivity analysis indicates this figure might range from a weekly overall saving of 36.90 pounds per resident to a 'worst case' estimate of 2.70 pounds extra expenditure per resident per week.Evaluation early in implementation may underestimate some cost-saving activities and greater savings may emerge over a longer time period. Similarly, IRT costs may reduce over time due to the potential for refinement of team without major loss in effectiveness.

CONCLUSION

Introduction of a specialist nursing in-reach team for residential homes is at least cost neutral and, in all probability, cost saving. Further benefits include development of new skills in the care home workforce and enhanced quality of care. Residents are enabled to stay in familiar surroundings rather than unnecessarily spending time in hospital or being transferred to a higher dependency nursing home setting.

Utilization of health care by patients with multiple sclerosis is based on professional and patient-defined health needs

OBJECTIVE

This cross-sectional study investigates healthcare utilization, and determines which predisposing, enabling, and health factors are associated with healthcare utilization among 121 patients with multiple sclerosis (MS).

METHODS

Data on patient-related predisposing, enabling, and health factors were collected by means of written questionnaires and a home visit from a well-trained physiotherapist.

RESULTS

Of the 121 patients with MS (mean age 43 years, mean score on the Expanded Disability Status Scale 3.5, disease duration 6 years), 16% were hospitalized in the previous year; 62% consulted their general practitioner, and 69% consulted their neurologist in the previous 6 months. Other medical specialists were consulted in the 6-month period by 50% of the study population. In a 4-week period preceding the home visit, 41% of the patients were treated by an allied healthcare professional. Multivariate logistic regression analyses showed that consulting the general practitioner, the neurologist, other medical specialists, and allied healthcare professionals, and the use of equipment/aids by MS patients is primarily related to their health, either as perceived by the patients themselves or defined by the professional.

CONCLUSIONS

MS patients in the Netherlands make appropriate use of healthcare facilities, because their utilization can predominantly be explained by health-related factors, and not by predisposing or enabling factors.

The impact of intermediate care services on job satisfaction, skills and career development opportunities

AIM

The purpose of this study was to examine, in depth, the impact of intermediate care services on staff job satisfaction, skills development and career development opportunities.

BACKGROUND

Recruitment and retention difficulties present a major barrier to the effective delivery of intermediate care services in the UK. The limited existing literature is contradictory, but points to the possibility of staff deskilling and suggests that intermediate care is poorly understood and may be seen by other practitioners as being of lower status than hospital work. These factors have the potential to reduce staff morale and limit the possibilities of recruiting staff.

DESIGN

The research is based on interviews with 26 staff from case studies of two intermediate care services in South Yorkshire.

RESULTS

Participants reported high levels of job satisfaction, which was because of the enabling philosophy of care, increased autonomy, the setting of care and the actual teams within which the workers were employed. For most disciplines, intermediate care facilitated the application of existing skills in a different way; enhancing some skills, while restricting the use of others. Barriers to career development opportunities were attributed to the relative recency of intermediate care services, small size of the services and lack of clear career structures.

CONCLUSIONS

Career development opportunities in intermediate care could be improved through staff rotations through acute, community and intermediate care to increase their awareness of the roles of intermediate care staff. The non-hierarchical management structures limits management career development opportunities, instead, there is a need to enhance professional growth opportunities through the use of consultant posts and specialization within intermediate care.

RELEVANCE TO CLINICAL PRACTICE

This study provides insight into the impact of an increasingly popular model of care on the roles and job satisfaction of workers and highlights the importance of this learning for recruitment and retention of staff.