Seamless care transitions for elderly people in need of coordinated care
Ann Svensson (Högskolan Väst)
Vårdvetenskap, hälsovetenskap (institutionen för hälso- och vårdvetenskap, fakulteten för hälso- och livsvetenskap)
More about the project
The ongoing transition to Good quality local health care will lead to a shift from hospital care to more proactive care close to the patient. In the future, with increasing age and life expectancy, we will be faced with challenges in providing safe and secure, good quality care, in primary care, in municipal and inpatient care as well as in prehospital emergency care.
There are shortcomings today in how professionals and care providers interact and coordinate care for the elderly with complex care needs. For elderly patients with complex care needs, the transitions between caregivers tend to be a critical point in patient safety. The WHO defines transitions of care as “when a patient moves to, or returns from, a particular physical location or contacts a healthcare professional for the purposes of receiving healthcare. This includes transitions between community dwelling, hospital, residential care settings and consultations with different healthcare providers in out-patient facilities”. A transition of care thus appears when a patient in need of coordinated care is discharged from hospital and the responsibility of care is conveyed to the primary or community care.
Communication failures can lead to many negative outcomes including medication errors, delays in diagnostic testing, diagnosis and treatment as well as avoidable inpatient care or unplanned re-admissions, greater use of emergency care as well as care injuries and higher mortality overall. Through well-functioning coordination, the gaps may become less prominent as diverse parts of the health care system work together as a whole.
The project aims to explore how integrated care and a cohesive care chain can maintain good quality and safe care for elderly people in need of coordinated care.
Elderly people with complex care needs are vulnerable to fragmented care as they often visit several doctors for both chronic and acute conditions. A fragmented care is associated with incorrect medication prescriptions, higher care costs, greater use of emergency care and higher mortality overall. Inadequately coordinated or integrated care from several different care actors often leads to poorer care results with an increased risk of care injuries, avoidable inpatient care, unplanned re-enrollments and repeated care transitions. The need for coordination is believed to increase due to a growing group of patients with complex needs and that today there are challenges for staff in health and care to work in a coordinated manner. A well-functioning collaboration between inpatient care, primary care, municipal care and care and prehospital emergency care could instead contribute to increased care quality, time savings and optimal utilization of the various levels of care that exist.
However, there are no studies on care transitions that map current working methods from a perspective of integrated, coordinated and person-centered care of the elderly with complex care needs. By seeing care as a coherent process rather than separate stages, there is potential to create conditions for a continuity of care for the elderly with complex care needs where information and knowledge is transferred between different care levels and caregivers as well as professional boundaries and caregiver boundaries with the patient's best interests at heart. In person-centered care, a partnership is sought between staff in health care and patients and relatives, with mutual respect for each other's knowledge and experience and equal collaboration. To enable this, access to the same amount of information is required for both parties, and that there is an opportunity for a co-creation of the activities to be carried out. A partnership also presupposes shared decision-making where the patient has insight into decisions about care and treatment based on co-creation. Only when the patient becomes part of the planning process can the conditions for seamless care transitions be achieved.
There is therefore value in examining collaboration and information transfer between different participants in care transitions, as this is a prerequisite for being able to bridge boundaries. By studying how care staff do to collaborate in the existing systems, good examples of solutions can be identified, which could help to promote integrated care for the elderly with complex care needs.
As the proportion of elderly patients with complex care needs increases, a well-developed collaboration is needed between prehospital emergency care, municipality, region and primary care. Increased collaboration can mean increased quality of care, time savings and optimal utilization of the level of care.
The doctoral project is a subpart of the research project Best practice of integrated care, and in The ReAction group – Resilient healthcare and patient activation research group.