Professionals’ roles in the hospital discharge of older adults in 3 Nordic cities: a vignette study

Background

The hospital discharge process of older adults in need of both medical and social care post hospitalisation requires extensive care coordination. Cooperation and continuity between involved care providers are essential, however, existing care systems including the Nordic care systems, are poorly designed to provide health and social care to patients with complex health and social care needs which increases the risk of certain groups not receiving optimal care.

Aim and methods

This study aims to examine and compare what roles, responsibility and actions nurses take in the hospital discharge process of older adults with complex care needs in three Nordic cities: Copenhagen (Denmark), Stockholm (Sweden) and Tampere (Finland). A vignette study consisting of three fictive cases was conducted face-to-face with nurses in Copenhagen (n = 11), Stockholm (n = 16) and Tampere (n = 8). Participants were identified through the researchers’ networks and snowball sampling. The vignettes represent older patients with age-related medical conditions of which one also has cognitive loss and one looks after their partner with dementia. The cases further include differences in the home help received by their children, physical obstacles in their homes and unwillingness of becoming a burden to the system. A thematic approach is used for the data analysis.

Results and conclusions

Preliminary results suggest that the informants’ roles and engagement in the coordination and collaboration may differ both within and between the systems studied, and that they take responsibility beyond their job roles particularly if the patient has no close relatives. The study is of public health importance as it identifies gaps in how the care is organised in the three welfare states targeted. It also sheds light on the complexities of providing universal care in ageing societies where a growing proportion of older adults have both medical and social care needs.

Key messages

The influence of sociodemographic factors and close relatives at hospital discharge and post hospital care of older people with complex care needs: nurses’ perceptions on health inequity in three Nordic cities

Hospital discharge of older people in need of both medical and social care following their hospital stay requires extensive coordination. This study aims to examine and compare the views of nurses in three Nordic cities on the influence of sociodemographic factors and having close relatives, for the hospital discharge and post hospital care of older people with complex health and social care needs. Thirty-five semi-structured interviews (Copenhagen n = 11, Tampere n = 8, Stockholm n = 16) with nurses were conducted. The nurses were identified through the researchers’ networks, invitation and snowball sampling, and recruited from hospitals, primary care practices, home care units, home nursing units, and geriatric departments. The interviews were transcribed and analysed using thematic analysis. Interpretations were discussed and agreed within the team. Four main themes and 13 sub-themes were identified. Across the cities, informants reported that the patient’s health status, rather than their gender or ethnicity, steered the discharge date and further care. Care costs, commonly reported in Tampere but also in Copenhagen and Stockholm including costs for medications and home help, were considered barriers for disadvantaged older people. Home situation, local arrangements and differences in collaboration between healthcare professionals at different sites also influenced the hospital discharge. Generally, the patient’s health status steered the hospital discharge and post-hospital care. Close relatives were regarded important and a potential advantage. Some informants tried to compensate for the absence of close relatives, highlighting the importance of care systems that can compensate for this to minimise avoidable inequity.

Integrated transitional care for older patients discharged from hospital and ED

Background

Care integration through high level care continuation for older patients discharged from the hospital may secure positive health outcomes and reduce subsequent emergency visits. Integrated transitional care is, however, challenged by fragmented care delivery systems. We explored integrated transitional care from the delivery system perspective in three Nordic cities (Copenhagen, Stockholm and Tampere) to compare levels of integration of social and health service delivery systems and care paths for older patients discharged from hospital.

Methods

Information on organizational structure and care integration was obtained from administrative documents, legislation and statistics, webpages of the cities, and empirical studies. Based on the material we outlined the degree of integration at different levels and mapped the possible care paths for older patients discharged from the hospital for each city.

Results

All three cities are characterized by fragmented care systems for older patients based on financially and organizationally independent institutions. Sweden and Denmark, however, have introduced legislation to steer the integration of services between the local and regional level actors. However, older patients still have complex care paths after discharge from hospital care.

Conclusions

The fragmented care systems for older patients consisting of independent institutions across local and regional levels may impede integrated transitional care. Alternative care settings for older people with different needs could be an asset, but they can also form a hurdle for care continuation if the responsibilities and liaison between these sites are not clear.

Key messages

The fragmented organisation of care systems for older patients may impede integrated transitional care. The care facilities for older patients after discharge is targeted to accommodate the complex and varying needs, but pose challenges for continuity of care.