Hearing the voices of older adult patients: processes and findings to inform health services research

Interventions to minimise hospital winter pressures related to discharge planning and integrated care: a rapid mapping review of UK evidence

Background

Winter pressures are a familiar phenomenon within the National Health Service and represent the most extreme of many regular demands placed on health and social care service provision. This review focuses on a part of the pathway that is particularly problematic: the discharge process from hospital to social care and the community. Although studies of discharge are plentiful, we identified a need to focus on identifying interventions and initiatives that are a specific response to 'winter pressures'. This mapping review focuses on interventions or initiatives in relation to hospital winter pressures in the United Kingdom with either discharge planning to increase smart discharge (both a reduction in patients waiting to be discharged and patients being discharged to the most appropriate place) and/or integrated care.

Methods

We conducted a mapping review of United Kingdom evidence published 2018-22. Initially, we searched MEDLINE, Health Management Information Consortium, Social Care Online, Social Sciences Citation Index and the King's Fund Library to find relevant interventions in conjunction with winter pressures. From these interventions we created a taxonomy of intervention types and a draft map. A second broader stage of searching was then undertaken for named candidate interventions on Google Scholar (Google Inc., Mountain View, CA, USA). For each taxonomy heading, we produced a table with definitions, findings from research studies, local initiatives and systematic reviews and evidence gaps.

Results

The taxonomy developed was split into structural, changing staff behaviour, changing community provision, integrated care, targeting carers, modelling and workforce planning. The last two categories were excluded from the scope. Within the different taxonomy sections we generated a total of 41 headings. These headings were further organised into the different stages of the patient pathway: hospital avoidance, alternative delivery site, facilitated discharge and cross-cutting. The evidence for each heading was summarised in tables and evidence gaps were identified.

Conclusions

Few initiatives identified were specifically identified as a response to winter pressures. Discharge to assess and hospital at home interventions are heavily used and well supported by the evidence but other responses, while also heavily used, were based on limited evidence. There is a lack of studies considering patient, family and provider needs when developing interventions aimed at improving delayed discharge. Additionally, there is a shortage of studies that measure the longer-term impact of interventions. Hospital avoidance and discharge planning are whole-system approaches. Considering the whole health and social care system is imperative to ensure that implementing an initiative in one setting does not just move the problem to another setting.

Limitations

Time limitations for completing the review constrained the period available for additional searches. This may carry implications for the completeness of the evidence base identified.

Future work

Further research to consider a realist review that views approaches across the different sectors within a whole system evaluation frame.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130588) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 31. See the NIHR Funding and Awards website for further award information.

Reflections from the 'Hold the door open' project: Inviting older adults across the UK to shape dissemination of health research findings

BACKGROUND

This project sought to expand patient and public involvement (PPI) practices to the development of research finding dissemination with people aged 55+ years. The project is innovative due to its UK-wide approach and use of PPI to plan better ways to share findings of health research with older adults, extending PPI beyond research project initiation to support dissemination activities.

OBJECTIVE

The aim of this study is to understand how to develop effective public engagement activities with older adults to disseminate findings of health research. We hope to promote greater inclusivity and advance our understanding of this demographic.

METHODS

This project combined three approaches: (i) an online questionnaire to ask what activities older adults enjoy; (ii) online planning workshops seeking public contributors' input in event planning and (iii) community events to share research findings and raise awareness of PPI. Activities were carried out in Cardiff, Belfast, Glasgow and Tewkesbury.

RESULTS

The planning workshops clarified that in-person activities and offering options for activities were important. Based on feedback from our contributors, all our events focused around a talk and question and answer session. Other short activities included light exercise and a writing activity.

DISCUSSION

Our multiphase approach helped us develop informative activities that reflected the questionnaire results and the feedback from the workshops, as we tailored our events to each location. A phased approach allowed both researchers and contributors to gradually deepen their understanding.

CONCLUSION

Further awareness raising is needed to develop the role older adults currently hold in health research activities. Working closely with existing communities can help broaden diversity.

PATIENT OR PUBLIC CONTRIBUTION

Thirty-three public contributors helped facilitate this project. Two of these also contributed to this article by writing a reflection of their experiences, one of whom also provided feedback for the article.

What are the priorities for research of older people living in their own home, including those living with frailty? A systematic review and content analysis of studies reporting older people's priorities and unmet needs

BACKGROUND

There is limited evidence regarding the needs of older people, including those living with frailty, to inform research priority setting.

OBJECTIVES

This systematic review aimed to identify the range of research priorities of community-dwelling older people living in their own home, including those living with frailty.

METHODS

Included studies were from economically developed countries and designed to identify the priorities for research or unmet needs of community-dwelling older people. Studies were excluded if they described priorities relating to specific health conditions. Medline, Embase, PsycInfo and CINAHL were searched (January 2010-June 2022), alongside grey literature. Study quality was assessed, but studies were not excluded on the basis of quality. A bespoke data extraction form was used and content analysis undertaken to synthesise findings.

RESULTS

Seventy-five reports were included. Seven explicitly aimed to identify the priorities or unmet needs of frail older people; 68 did not specify frailty as a characteristic. Study designs varied, including priority setting exercises, surveys, interviews, focus groups and literature reviews. Identified priorities and unmet needs were organised into themes: prevention and management, improving health and care service provision, improving daily life, meeting carers' needs and planning ahead.

DISCUSSION

Many priority areas were raised by older people, carers and health/care professionals, but few were identified explicitly by/for frail older people. An overarching need was identified for tailored, collaborative provision of care and support.

CONCLUSION

Review findings provide a valuable resource for researchers and health/care staff wishing to focus their research or service provision on areas of importance for older people.

Including the voice of older people in the co-design of perioperative pathways of care

Older people constitute the majority of high-risk surgical patients. Despite this, they are often excluded from patient and public involvement and engagement (PPIE) and research in the perioperative setting. Comprehensive Geriatric Assessment (CGA)-based perioperative services demonstrate clinical and cost effectiveness for older patients but are not delivered at all hospitals. Scaling up such services across the NHS requires PPIE to deliver quality, patient-centred care with fidelity to existing evidence. We describe the process of, and outputs from, PPIE in older patients to inform future implementation and evaluation of CGA-based perioperative services at scale. Results show older patients value CGA-based perioperative care and support widespread implementation to deliver streamlined perioperative care, coordinated specialist input and clear communication between clinicians and with patients. This case study illustrates how to champion the voice of older people to develop pathways of care aligned to needs of service users.

Funded hospital discharges to care homes: a cohort study

BACKGROUND

Optimising timely discharge from hospitals is an international priority. In 2020, the Coronavirus disease 2019 (COVID-19) pandemic resulted in the United Kingdom Government implementing the Discharge to Assess (D2A) model across England. This funded temporary care home placement to allow further recovery and assessment of care needs outside of the hospital.

OBJECTIVES

Determine if older adults discharged from hospital to care homes after implementation of D2A differ in their characteristics or outcomes.

DESIGN AND METHODS

Two cohorts of older adults discharged from hospital to care homes pre- and post-implementation of the D2A model (n = 244), with 6 months of follow-up. Data were extracted from routinely collected healthcare records.

RESULTS

The mean duration of the hospital admission was reduced (29 vs. 23 days (P = 0.02)) but discharges to care homes did not increase with implementation of D2A (n = 161 in both cohorts prior to exclusions). In July-December 2020 (post-implementation), 28% of people were living in a private residence 6 months post-discharge, compared with 18% in the same period in 2019 (P = 0.09). When those who died were excluded, this changed to 40 vs. 28% (P = 0.19). There was no change in 6-month mortality (26 vs. 35% (P = 0.17)), and no increase in readmission rate (0.48 vs. 0.63 (P = 0.21) readmissions-per-patient over 6 months). No differences in key characteristics were found. However, patients were placed in care homes further from admission addresses (17.3 vs. 9.8 km (P = 0.00001)).

CONCLUSIONS

Implementation of D2A did not result in poorer outcomes but was associated with a reduced length of hospital stay.

Reducing delayed transfer of care in older people: A qualitative study of barriers and facilitators to shorter hospital stays

INTRODUCTION

Growing numbers of older patients occupy hospital beds despite being 'medically fit' for discharge. These Delayed Transfers of Care amplify inefficiencies in care and can cause harm. Delayed transfer because of family or patient choice is common; yet, research on patient and family perspectives is scarce. To identify barriers to, and facilitators of, shorter hospital stays, we sought to understand older people's and caregivers' thoughts and feelings about the benefits and harms of being in hospital and the decisions made at discharge.

METHODS

A multimethod qualitative study was carried out. Content analysis was carried out of older people's experiences of health or care services submitted to the Care Opinion online website, followed by telephone and video interviews with older people and family members of older people experiencing a hospital stay in the previous 12 months.

RESULTS

Online accounts provide insight into how care was organized for older people in the hospital, including deficiencies in care organization, the discharge process and communication, as well as how care was experienced by older people and family members. Interview-generated themes included shared meanings of hospitalization and discharge experiences and the context of discharge decisions including failure in communication systems, unwarranted variation and lack of confidence in care and lack of preparation for ongoing care.

CONCLUSION

Poor quality and availability of information, and poor communication, inhibit effective transfer of care. Communication is fundamental to patient-centred care and even more important in discharge models characterized by limited assessments and quicker discharge. Interventions at the service level and targeted patient information about what to expect in discharge assessments and after discharge could help to address poor communication and support for improving discharge of older people from hospital.

PATIENT OR PUBLIC CONTRIBUTION

The Frailty Oversight Group, a small group of older people providing oversight of the Community Aging Research 75+ study, provided feedback on the research topic and level of interest, the draft data collection tools and the feasibility of collecting data with older people during the COVID-19 pandemic. The group also reviewed preliminary findings and provided feedback on our interpretation.

Research priority setting related to older adults: a scoping review to inform the Cochrane-Campbell Global Ageing Partnership work programme

OBJECTIVE

To explore and map the findings of prior research priority-setting initiatives related to improving the health and well-being of older adults.

DESIGN

Scoping review.

DATA SOURCES

Searched MEDLINE, EMBASE, AgeLine, CINAHL and PsycINFO databases from January 2014 to 26 April 2021, and the James Lind Alliance top 10 priorities.

ELIGIBILITY CRITERIA

We included primary studies reporting research priorities gathered from stakeholders that focused on ageing or the health of older adults (≥60 years). There were no restrictions by setting, but language was limited to English and French.

DATA EXTRACTION AND SYNTHESIS

We used a modified Reporting Guideline for Priority Setting of Health Research (REPRISE) guideline to assess the transparency of the reported methods. Population-intervention-control-outcome (PICO) priorities were categorised according to their associated International Classification of Health Interventions (ICHI) and International Classification of Functioning (ICF) outcomes. Broad research topics were categorised thematically.

RESULTS

Sixty-four studies met our inclusion criteria. The studies gathered opinions from various stakeholder groups, including clinicians (n=56 studies) and older adults (n=35), and caregivers (n=24), with 75% of the initiatives involving multiple groups. None of the included priority-setting initiatives reported gathering opinions from stakeholders located in low-income or middle-income countries. Of the priorities extracted, 272 were identified as broad research topics, while 217 were identified as PICO priorities. PICO priorities that involved clinical outcomes (n=165 priorities) and interventions concerning health-related behaviours (n=59) were identified most often. Broad research topics on health services and systems were identified most often (n=60). Across all these included studies, the reporting of six REPRISE elements was deemed to be critically low.

CONCLUSION

Future priority setting initiatives should focus on documenting a more detailed methodology with all initiatives eliciting opinions from caregivers and older adults to ensure priorities reflect the opinions of all key stakeholder groups.

Health equity and wellbeing among older people’s caregivers in New Zealand during COVID-19: Protocol for a qualitative study

Background

Knowledge of the challenges unpaid caregivers faced providing care to older people during the COVID-19 pandemic is limited. Challenges may be especially pronounced for those experiencing inequitable access to health and social care. This participatory action research study, located in New Zealand, has four main objectives, (i) to understand the challenges and rewards associated with caregiving to older care recipients during the COVID-19 pandemic restrictions; (ii) to map and collate resources developed (or mobilised) by organisations during the pandemic; (iii) to co-produce policy recommendations, identify useful caregiver resources and practices, prioritise unmet needs (challenges); and, (iv) to use project results in knowledge translation, in order to improve caregivers access to resources, and raise the profile and recognition of caregivers contribution to society.

Methods and analysis

Māori, Pacific and rural-dwelling caregivers to 30 older care-recipients, and 30 representatives from organisations supporting caregivers in New Zealand will be interviewed. Combining data from the interviews and caregivers letters (from an archive of older people’s pandemic experiences), framework analysis will be used to examine the interrelated systems of the human ecological model and the impact on caregiving experiences during the pandemic. Resources that service providers had created or used for caregivers and older people will be collated and categorised. Through co-production with caregivers and community partners we will produce three short films describing caregivers’ pandemic experiences; identify a suite of resources for caregivers to use in future events requiring self-isolation, and in everyday life; and generate ideas to address unresolved issues.

Understanding the Needs and Priorities of People Living with Persistent Pain and Long-Term Musculoskeletal Conditions during the COVID-19 Pandemic-A Public Involvement Project

BACKGROUND

Critiques of public involvement (PI) are associated with failing to be inclusive of under-represented groups, and this leads to research that fails to include a diversity of perspectives.

AIM

The aim of this PI project was to understand the experiences and priorities of people from three seldom-heard groups whose musculoskeletal pain may have been exacerbated or treatment delayed due to COVID-19. Engaging representatives to report diverse experiences was important, given the goal of developing further research into personalised and integrated care and addressing population health concerns about access and self-management for people with musculoskeletal pain.

METHODS

The project was approved via Sheffield Hallam University Ethics but was exempt from further HRA approval. A literature review was conducted, followed by informal individual and group discussions involving professionals and people with lived experience of (a) fibromyalgia pain, (b) those waiting for elective surgery and (c) experts associated with the care home sector. Findings from the literature review were combined with the insights from the public involvement. Resulting narratives were developed to highlight the challenges associated with persistent pain and informed the creation of consensus statements on the priorities for service improvement and future research. The consensus statements were shared and refined with input from an expert steering group.

RESULTS

The narratives describe pain as a uniformly difficult experience to share with professionals; it is described as exhausting, frustrating and socially limiting. Pain leads to exclusion from routine daily activities and often resigns people to feeling and being unwell. In all cases, there are concerns about accessing and improving services and critical issues associated with optimising physical activity, functional wellbeing and managing polypharmacy. Exercise and/or mobilisation are important and commonly used self-management strategies, but opportunity and advice about safe methods are variable. Services should focus on personalised care, including self-management support and medication management, so that people's views and needs are heard and validated by health professionals.

CONCLUSIONS

More research is needed to explore the most effective pain management strategies, and public involvement is important to shape the most relevant research questions. Health and care systems evaluation is also needed to address the scale of the population health need. The pandemic appears to have highlighted pre-existing shortcomings in holistic pain management.

Does a discharge to assess programme introduced in England meet the quadruple aim of service improvement?

Purpose

This paper intends to examine and evaluate the implementation and delivery of a discharge to assess pathway based on the UK Department of Health and Social Care Hospital Discharge Policy in relation to the quadruple aim of healthcare improvement: improving patient experience, reducing costs, benefiting the wider population and improving the work life of staff.

Design/methodology/approach

Using a place based partnership in the south of England, 18 staff involved the delivery of discharge to assess and four patients who had recently been through the pathway were interviewed and the narratives analysed using a framework method.

Findings

All four dimensions of the quadruple aim were felt to be positively impacted by the discharge to assess pathway in varying degrees. Staff described improvements to working lives; patients described a positive experience. There was no evidence of reduced costs and wider benefit through reduced length of stay was suggested rather than demonstrated. The study showed a need to ensure both information flows and discharge process are smooth, that there is sufficient community capacity and capability, a need for strong relationships and shared goals, for clarity of pathway and empowered staff, and for an avoidance of the over prescription of care.

Originality/value

The revised discharge to assess pathway in England has been in place since 2020 and no other assessments of the pathway were found that related the changes to the quadruple aim framework.

Meeting ethical challenges with authenticity when engaging patients and families in end-of-life and palliative care research: a qualitative study

BACKGROUND

Delivering high quality, patient- and family-centered care depends upon high quality end-of-life and palliative care (EOLPC) research. Engaging patients and families as advisors, partners, or co-investigators throughout the research lifecycle is widely regarded as critical to ensuring high quality research. Engagement is not only an ethical obligation, it also raises ethical challenges of its own. We conducted a qualitative study to understand ethical challenges and potential solutions when engaging patients and families in EOLPC research.

METHODS

We recruited and interviewed 20 clinical investigators and 22 patients or family caregivers through the Palliative Care Research Cooperative Group (PCRC). Interview transcripts were analyzed using constructivist grounded theory methodology. Analysis sought to identify ethical challenges and potential solutions, as well as to synthesize findings into practical recommendations tailored to engaging patients and families in EOLPC research.

RESULTS

Our study identified 8 ethical challenges considered unique to the EOLPC research context and 11 potential solutions to these challenges. The most frequently described ethical challenges included the need to minimize burdens of engagement for patients and caregivers, challenges of dealing with death and illness, and paternalism or "gatekeeping" (i.e., withholding the opportunity to participate from patients or caregivers). Investigators and patients or family caregivers conceptualized ethics challenges differently; several issues appeared to fall outside a traditional research ethics paradigm and more into the ethics of relationships. We synthesized these findings into 4 practical recommendations hypothesized to support authentic engagement.

CONCLUSIONS

Engaging patients and families in EOLPC research can raise unique ethical challenges. These challenges can be overcome to empower participation, minimize the unique burdens of EOLPC, and promote diversity. Whereas traditional research ethics tend to emphasize protecting research participants who may be vulnerable, an ethics approach based on authentic engagement that explores what it means for investigators and patients or family caregivers to be in a relationship may be needed. Future research is needed to explore this approach and test these recommendations in practice.

Ethical considerations for engaging frail and seriously ill patients as partners in research: sub-analysis of a systematic review

BACKGROUND

The commitment to engage patients as partners in research has been described as a political, moral and ethical imperative. Researchers feel ill-equipped to deal with potential ethical implications of engaging patients as partners. The aim of this study is to identify the ethical considerations related to engaging frail and seriously ill (FSI) patients as partners in research.

METHODS

We conducted a sub-analysis of a prior systematic review of 30 studies that engaged FSI patients as partners in research. Studies were included if they reported ethical considerations associated with partnering. We performed deductive content analysis, data were categorized according to Beauchamp and Childress' Principles of Biomedical Ethics (2019): autonomy, non-maleficence, beneficence, and justice.

RESULTS

Twenty-five studies were included. Common ethical considerations reported in relation to the principles were: autonomy - promoting desired level of involvement, addressing relational and intellectual power, facilitating knowledge and understanding of research; non-maleficence - protection from financial burden, physical and emotional suffering; beneficence - putting things right for others, showing value-added, and supporting patient-partners; and, justice - achieving appropriate representation, mutual respect for contributions, and distributing risks and benefits.

CONCLUSIONS

When partnering with FSI patients, research teams need to establish shared values and ensure processes are in place to identify and address ethical issues. Researchers and patients should work together to clarify the intent and outcomes of the partnership, actively address power differentials, recognize and minimize the potential for unintended harm, and strive to maximize the benefits of partnership.

SYSTEMATIC REVIEW REGISTRATION

The protocol for the original systematic review has been registered with the International Prospective Register of Systematic Reviews PROSPERO (CRD42019127994).

Conceptualising and constructing 'diversity' through experiences of public and patient involvement in health research

BACKGROUND

Increasing the accessibility of public and patient involvement (PPI) in health research for people from diverse backgrounds is important for ensuring all voices are heard and represented. Critiques of PPI being dominated by 'the usual suspects' reflect concerns over the barriers to involvement in PPI faced by people from minority groups or non-professional backgrounds. Yet, what has received less attention is how undertaking PPI work might produce diverse experiences, potentially shaping the motivation and capacity of people from different backgrounds to continue in PPI.

METHODS

We conducted qualitative research to explore experiences of the health research PPI field in the UK and to understand how these might shape the accessibility of PPI for people of diverse backgrounds. We conducted in-depth and follow-up interviews with five PPI contributors with experience of multiple health research projects, and a focus group with nine people in professional roles relating to PPI. Interview data were analysed using a narrative approach, and then combined with the focus group data for thematic analysis.

RESULTS

The structure, organisation and relationships of health research in the UK all shape PPI experiences in ways that can intersect the different backgrounds and identities of contributors, and can pose barriers to involvement and motivation for some. Navigating processes for claiming expenses can be frustrating particularly for people from lower-income backgrounds or with additional needs, and short-term research can undermine relationships of trust between contributors and professionals. Pressure on PPI coordinators to find 'more diverse' contributors can also undermine ongoing relationships with contributors, and how their inputs are valued.

CONCLUSIONS

To increase diversity within PPI, and to ensure that people of different backgrounds are supported and motivated to continue in PPI, changes are needed in the wider health research infrastructure in the UK. More resources are required to support relationships of trust over time between contributors and professionals, and to ensure the unique circumstances of each contributor are accommodated within and across PPI roles. Finally, critical reflection on the pressure in PPI to seek 'more diverse' contributors is needed, to understand the impacts of this on those already involved.

Partnering with frail or seriously ill patients in research: a systematic review

BACKGROUND

The expectation to include patients as partners in research has steadily gained momentum. The vulnerability of frail and/or seriously ill patients provides additional complexity and may deter researchers from welcoming individuals from this patient population onto their teams. The aim was to synthesize the evidence on the engagement of frail and/or seriously ill patients as research partners across the research cycle.

METHODS

A systematic review was conducted using PRISMA guidelines. A search strategy included MEDLINE®, EMBASE®, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO from database inception to April, 2019. Eligible studies were peer-reviewed qualitative, quantitative, and mixed methods research reporting on the engagement of frail and/or seriously ill patients as partners on research teams. The Mixed Methods Appraisal Tool was used to appraise study quality. Narrative analysis was conducted.

RESULTS

Of 8763 citations, 30 were included. Most studies included individuals with cancer on the research team (60%). Barriers included: lack of time and resources (50%), discontinuity in contribution (37%), and concerns for well-being (33%). Facilitators included: trust and mutual respect (60%), structural accessibility (57%), flexibility in timing and methods of engagement (43%), and attention to care and comfort, (33%). Perceived impacts for patients included: renewed personal sense of agency (37%) and emotional/peer support (37%). Impacts for researchers included sensitization to the lived experience of disease (57%) and an increased appreciation of the benefits of patient engagement (23%). Research design, execution, and outcomes, developed with patients, were deemed more suitable, relevant and reflective of patients' priorities.

CONCLUSIONS

There is emerging evidence to suggest that research partnerships with frail and/or seriously ill patients can be achieved successfully. Patients mostly report benefit from partnering with research teams. Frailty and/or serious illness do present legitimate concerns for their well-being but appear to be successfully mitigated when researchers ensure that the purpose of engagement is well-defined, the timing and methods of engagement are flexible, and the practical and emotional needs of patient partners are addressed throughout the process.

SYSTEMATIC REVIEW REGISTRATION

The systematic review protocol was registered with the International Prospective Register of Systematic Reviews PROSPERO (CRD42019127994).