Hospital at home and integrated care. The perspectives of relatives and municipality workers.

An increasing proportion of elderly people in the population and a higher prevalence of chronic diseases represent considerable challenges for healthcare policy and close family in Western societies. Review studies conclude that hospital organized home treatment programs contribute to better health care and lower costs. This project takes as its starting point an ambulatory service model for pulmonary patients. The overall aim of the project is to contribute in better health- and long-term care services for patients with chronic diseases. We combine different methods for studying the family caregivers` role and the social interaction with the healthcare services. In times of a pronounced policy of mobilizing informal care resources, an awareness of the complexity of relationships connected to informal caregiving is crucial to the development of appropriate support for informal carers. A survey was carried out during 2009-2010 among close family of COPD-ill patients who had been admitted to a national hospital run by the Norwegian Heart and Lung Patient Organization for clinical examination, treatment, and rehabilitation of patients with lung diseases. The results are published in an article describing who the informal caregivers of COPD-patients are, what kind of help they provide, and how they experience providing help to the patient (Gautun, Lurås & Werner 2012). The qualitative study is based on observations of ambulatory nurses home visits to COPD-patients and interviews with caregivers and the nurses. The first article deals with how spouses manage challenges connected to the combination of their role as informal caregivers and their role as spouses (Aasbø, Kristvik, Solbrække & Werner 2016). Striving for normality makes it more complicated to receive help, making the disease and loss of function visible, thus threatening their experiences of themselves as individuals and as a couple. Both receiving and rejecting professional help can support or undermine their experiences of being a biographical we. The second article explores how spouses negotiate their role as caregivers with patients and health care professionals during acute exacerbation and the question of hospital admission (Aasbø, Rugkåsa, Solbrække & Werner 2017). The third article deals with the way ambulatory lung nurses work in home visits and the delicate work of supporting both the patient and the caregiving spouse in the visits (in review).

The project is based on a randomised controlled study (RCT), carried out at Akershus University Hospital (AHUS) and Aker University Hospital, aiming to compare hospital at home with in-hospital treatment for COPD in patients with exacerbations that lead t o hospital admission. The RCT are mainly based on quantitative methods, and the focuses are patient experiences, treatment quality, and the use of resources for the hospital and the regional health enterprise. With the current study we enlarge the focus i n the RCT and explore the role of relatives and municipality workers, and also the hospital health care providers carring out the hospital at home program. The overall questions is whether assistance from relatives is crucial when organising hospital at h ome programs, and whether the municipalities are prepared and have the necessary competence to carry through such organisational changes. The current study consists of three sub-projects based on a mixed methods design, combining questionnaire survey, in- depth interviews and focus group interviews, aiming at exploring the hospital at home organisation from different angles. To develop knowledge on preconditions for a successfully integration of a hospital at home program we apply theoretical concepts from social science and gender theory. In accordance we enlarge the health economic analysis in the RCT to include unpaid household (caring) work. Drawing on the different perspectives from the ongoing RCT and the current study, we aim at contribute in develo ping knowledge in the core of health services research; the service delivery, the patient, and the relative.