In a period of demographic change, financial restrictions and emphasis on collaboration between care levels, it essential to establish how to secure good care pathways for older people. This project, conducted at the Health Services Research Centre at Akershus University Hospital, honed in on four key current areas for older patients in order to inform the development of good quality, user centred and effective services.
The team has produced 26 scientific articles and 45 presentation to scientific and professional audiences. Together with ?Kompetansebroen? we have developed popular science material for dissemination to primary and secondary services, the education sector and end user of services. Summary articles, podcasts, films and links to the scientific articles can be found here: https://www.kompetansebroen.no/tema/pathways-pasientforlop?o=ahus
SUMMARY OF WORK PACKAGES
Work package 1: How do municipal acute units function and how can they be improved?
From 1 January 2016, all Norwegian municipalities are obliged to provide beds in Municipal Acute Units (MAU) for patients in need of immediate treatment for an identified condition, and for whom hospital admission is not required. Sub-study 1 investigated the quality of care and collaboration in MAUs, based on 70 interviews with patients, family carers, and health professionals. Results show limited and unclear user involvement, a lack of agreement about which patients to admit, and whether MAUs should relieve pressure on hospitals or home services/nursing homes. Small MAUs were experiences as less robust compared to the inter-municipal ones, but provided more local autonomy. Sub-study 2 analysed patient flows through 10 MAUs to ascertain whether they function as intended. Results show how the implementation of MAUs as a national policy could have been improved at the outset if the authorities had analysed the situation using simple mathematical modelling. Statistical regressions and simulation modelling of predictors for MAU admission and discharge, identify potential gains by merging MAUs to larger units
Work package 2: Mapping problematic medication use and developing a brief intervention
Older people are often prescribed strong medication against pain, sleeplessness or anxiety, the long term use of which might put them at risk. This work packages sought to map the extent of problematic use and negative side effects of such medication and develop and test strategies to reduce risk. We first validated, for the Norwegian context, an instrument for detecting problematic use. We screened 400 older inpatients, of whom 40% were long term users of strong medication, and this was associated with reduced health, quality of life, and cognitive functioning. A qualitative sub-study investigated how communication about medication with patients at risk can be improved. Based results of the two parts we have developed a brief intervention to reduce risks, which is currently being tested in a feasibility trial. Due to the pandemic, this work is still ongoing.
Work package 3: Family caregivers? perspectives on integration and interaction in dementia care
Through a qualitative study of 23 family carers, we found that they seek to protect those living with dementia from different forms of harm: physical, emotional, economic and relational. Family cares cooperate with health professionals at both primary and secondary levels, but sometimes their views differs of what is necessary to do, what should be prioritised, and what represents good quality care. In those situations, family carers use different approached to influence services. One factor that seems to impact their weighing up different approaches to exert influence, seems to be their personal resources (knowledge, communications skills etc). This was investigated further in a survey of 200 family carers, and we identified associations between family carers level of health literacy and experiences stress, quality of life and time spent on providing care.
Work package 4: Care in the last stages of life in a multicultural society
Care in the last stages of life goes beyond medical care. It is about assisting someone to complete a life in the context of their values, priorities and worldview. The proportion of patients from minority backgrounds receiving palliative care in Norway is increasing. We know little about how these service and their opportunities for offering services to a diverse population. On the basis of 84 qualitative interviews with health professionals and family carers, we explored such issues and how services to this group should be organised. Three sub-studies investigate spiritual and existential care in hospital; experiences with multi-disciplinary teams in palliative hospital wards, and; experience of family carers/bereaved from both minority and majority backgrounds.
In an era of rapid demographic change, economic restraint, and an increasing role of Norwegian municipalities in the provision of health services, understanding how we can achieve healthy ageing by designing high quality, cost-effective care systems is essential. Public policy emphasises integration and continuity of care as key components in achieving this.
This proposal includes mixed-method research in four Work Packages that address central current questions of how to develop good pathways for older people. WP1: how Municipal Acute Units function in practice and how their performance may be maximised. WP2: whether early intervention by GPs can reduce medication misuse and medication related harm. WP3: what role family caregiving may play in the delivery and integration of care to dementia patients. WP4: how services can enhance quality of life and provide good palliative services for older people in a multicultural society.
The WPs are designed so that they illuminate the breadth of the challenges that lie ahead in providing integrated care through vertical and horizontal collaborations. Moreover, they facilitate the analysis of themed cross-cutting areas. These are: quality of life, equity, costs, and the perspectives of users and of health professionals on the integration of care for older people.
Our plan for dissemination and knowledge mobilisation includes structured methods for translating finding into the design of improved pathways for older people and into the training of the next generation health professionals.