Transitional care of the elderly from a resilience perspective

Abstract

Major initiatives have been undertaken to understand and improve care transitions, since they increase the likelihood of errors and make patients more vulnerable. The elderly are particularly vulnerable during care transitions owing to the complexity of their treatment. Despite this, relatively little attention has been paid to safety issues affecting the elderly. This thesis focuses on transitional care and more specifically on the hospital discharge of elderly patients to follow-up care in municipal services. The thesis examines and describes this specific care transition using a resilience perspective. Resilience is an emerging approach for analysing complex systems, such as those associated with transitional care. It highlights the value of studying everyday performance to increase understanding of a system's vulnerabilities and its underlying complexities. The concept of resilience is recognized in healthcare through the term 'resilient healthcare' (RHC). By applying the resilience perspective, this thesis brings a new perspective to bear on the study of transitional care of the elderly. Five research questions are addressed: (a) What risks are identified in the literature related to transitional care of the elderly? (b) What interventions are identified in the literature to address these risks? (c) What methodological approaches are suitable for providing an increased understanding of transitional care of the elderly? (d) What characterizes hospital discharge of the elderly to follow-up care in municipal services, and why does discharge performance vary? (e) How does the hospital discharge system adapt to its contextual environment, and what are the implications of those adjustments? Each research question is examined and the results presented in five separate papers (Papers I-V). The overall study design applied in the thesis consisted of two main phases. Phase I was a review of the literature and methodological orientation, covering research questions a-c. Phase 2 consisted of a qualitative case study, using observation as the primary research method, supplemented by individual interviews. This empirical phase covered research questions d-e. The empirical study drew in part upon the Functional Resonance Analysis Method (FRAM), developed within the resilience perspective to analyse performance in complex systems. The thesis consists of two parts. Part I provides an overview and description of the study background, aims, research questions, and theoretical and methodological orientation applied in the thesis. It also includes a discussion of the study findings and concluding remarks on implications and recommendations. Part 2 consists of the five papers examining the research questions. Paper I reveals that adverse events occur during transitional care and indicates that the elderly are a particularly vulnerable patient group. The type of adverse events reported in the literature are drug-related, procedure-related, diagnostic test follow-up errors, nosocomial infections, and falls. The severity of those adverse events varies from laboratory errors to permanent disability and death. The major contributing risk factors for adverse events cited in the literature are ineffective care processes and poor communication. Paper I concludes that multidisciplinary collaboration and effective communication of information are vital components during transitional care of elderly patients. It also highlights the need for further research. Paper II identifies a set of potential intervention types designed to address the risks related to transitional care of elderly patients. The intervention types include the following: profession-oriented interventions (e.g., education and training), organisational interventions (e.g., transfer nurse, discharge protocol, discharge planning, medication reconciliation, a standardized discharge letter, and electronic tools), and interventions oriented to the patient and their next of kin (e.g., patient awareness and empowerment, discharge support). The review in Paper II did not find evidence for the validity of one intervention over any other. However, the findings suggested that effects are more apparent in interventions that involve multi-component approaches. Paper III explains that existing studies on transitional care have primarily employed methods such as individual interviews or focus groups, which examine the experiences of professional groups or stakeholders in isolation. Most studies have looked at the information dynamics and communication processes. Paper III emphasizes the importance of regarding transitional care and hospital discharge as an integrated whole. It explains the need for methodological approaches that contribute to contextual knowledge and increased understanding. Ethnographic research and observational studies appear to be underrepresented in the literature on care transitions. Paper III emphasizes the uniqueness of the design and methodological approaches applied in this thesis, which involved real-time observations with multiple stakeholder perspectives (patients, next of kin, and healthcare providers). Paper IV shows the practical application of FRAM to analyse and model the essential characteristics or functions in hospital discharge of the elderly. It demonstrates that hospital discharge is a complex multi- agency care process with multiple activities and numerous goals. Paper IV provides insight into I0 common functions performed during hospital discharge and highlights the function "review of hospital inpatients to determine whether a patient is medically fit for discharge" as one of the most critical. This activates the overall discharge process and affects all subsequent functions by determining when they are initiated. Paper IV thus illustrates the strong degree of interrelatedness that exists between the I0 discharge functions, highlighting variability and vulnerabilities arising out of functional dependencies. The paper also recognizes and examines the ways the I0 functions vary in timing, duration and precision in performance, and provides insights into several performance-shaping factors that can be attributed to a range of contextual features. These performance-shaping factors include temporal conditions (degree of time pressure), individual and team characteristics, patient factors, organizational factors (unit, specialization, leadership, institutionalized routines), work environment factors (bed availability, availability of municipal services, quality of discharge planning, familiarity with the patient, pressure from next of kin) and regulatory influences (financial incentives). The paper shows that hospital discharge performance is highly sensitive to multiple interacting variables and variation in context. Using the example of the Norwegian Coordination Reform (20I2), Paper V illustrates how a system reform can affect hospital discharge performance. It shows how clinical environments adjust their functioning to new demands and how the outcomes of those adjustments are experienced by patients, next of kin, and hospital and primary care personnel. It also underscores the pertinent characteristics of everyday clinical work, particularly the trade-offs and inherent tensions in hospital discharge of the elderly. The paper shows how the outcome of hospital discharge varies from different perspectives. From a hospital perspective, outcomes of the adjustments imposed by the reform were mainly perceived as successful. Hospital personnel reported improved discharge planning, closer dialogue with primary care, increase in time efficiency on the day of discharge, decrease in delayed discharges and better bed availability. From a primary care perspective, the picture was more nuanced and outcomes were perceived as variable and sometimes problematic. Healthcare providers in primary care described an unpredictable post-discharge period and increased complexity of care patterns following the adjustments of the reform (e.g., increase in number of transitions and increased need for coordination between care sites). From the perspective of patients and their next of kin, the adjustments often had negative effects. The elderly were poorly involved in the discharge planning process and the increase in the number of transitions post-discharge posed mental and physical challenges. Paper V stresses the need for clarification of acceptable successful outcomes and system definitions in relation to hospital discharge. One of the main strengths of this thesis lies in the application of FRAM to facilitate comprehensive, detailed accounts of the hospital discharge process for the elderly. This extends the usual methodological approaches, which tend to focus on single dimensions. The use of FRAM identified a number of less well-recognized issues that might explain variation in discharge performances and outcomes. It revealed, for example, the strong degree of interrelatedness between discharge functions, highlighting how performance variability may arise from functional interdependencies. These findings imply that the concepts of complex interactions and dependencies should be applied as analytical dimensions when studying transitional care. In the context of transitional care, we should extend the analysis beyond narrowly-defined clinical microsystems in and across care levels, and include patients and their next of kin in a multi-agency stakeholder perspective. To incorporate these additional perspectives, the concept of work as experienced by patients and next of kin should be introduced to the FRAM terminology. The results of this thesis also show that observational research approaches are powerful ways to understand and describe discharge characteristics and performance variability and should therefore be seen as integral to the FRAM approach. Last, the thesis adds a documented overview of risks involved and available interventions for transitional care of the elderly.