WORK PACKAGE 1 examined the users perspectives on quality when elderly patients are transferred between the specialist and primary health care services. Totally 21 scientific articles are published and three PhD thesis completed. The empirical material shows insufficient patient participation and working conditions that does not enable person-centered health services. Better cooperation between the various levels in the health service and a more user-friendly information are requested. Regarding quality in health services, three areas of tension emerge. I) Tension between person-centered services versus standardized services. II) Tension between biomedical approach versus biopsychosocial approach. III) Tension between professional practice based on action competency versus relational competency. The three areas of tensions highlight the importance of a systems perspective on health services for the elderly. There is a call for more focus on a person-centered culture with a focus on users preferences, working conditions for health professionals and supportive leadership. Based on work package 1, a short film is developed based on real-life scenarios that puts the spotlight on how user participation can be implemented in clinical work. The purpose of the short film is to increase the knowledge of health professionals to implement user participation in practice. WORK PACKAGE 2 examined 1) hospital admissions, readmissions and average length of stay for elderly patients, 2) the effect of care service reforms on the use of hospitals, 3) and collaboration between hospitals and municipalities. Register data showed a 38% probability of death or re-admission within three years among older patients who had not received hospital services two years prior to an acute admission. Two care service reforms were investigated. I:Prevention of hip fractures and II: Preventive home visits. In addition, a cost-effectiveness analysis was made of home nursing visits to patients who have been admitted for heart failure. The intervention of hip fracture prevention had no effect, but home nursing visits reduced hospital use and were cost-effective. Surveys showed correlations between the type and extent of contact between nurses in hospitals and the municipalities and the efficiency and quality of the transition. E-mail was most common used. A majority of the hospital nurses said that e-mail contributed to an efficient and safe discharge. Many municipal nurses did not receive enough information from hospitals, i.e. 50% (in hospitals and municipalities) wanted to supplement e-mail with telephone contact. There was a strong correlation between whether the nurses had telephone contact and efficient information exchange as well as quality of the transition. AREBDISPAKKE 3 studied interaction between different units at the municipal level. Based on register data, findings showed that the course of the transfer between services were different, long courses with few transitions are most common, but a small group of older people have short and intensive courses. It is the use of short-term stay that generates displacements between services. The results from a questionnaire to nurses showed that mainly information about medicines and medical conditions are registered in the patient records. Information about psychosocial needs is poorly documented, this shows a limited focus on patients' holistic needs. The survey also showed that information is important for good interaction. Municipality size matters and small municipalities state that information is better available than larger municipalities. In general, the results show that coordination is better, where interaction often occurs. Observation in the wards of short-term stays show extensive information work related to the transfer of the elderly. The work is related to collecting, supplementing, screening and translating necessary information. The framework for this work is provided by formal structures, but informal structures, such as notes and conversations, are an important support in the daily work. Employee competence and independence are important keys with respect to good quality of transfer for elderly patients. WORK PACKAGE 4 is based on empirical findings across the three work packages. The results indicate that successful service flow models for older users of municipal services must contain the following components: 1. Person-centered planned hospital discharge 2. Development of a person-centered care plan with emphasis on self-management of chronic diseases 3. Proper follow-up at home, especially when it comes to medication, proactive monitoring of symptoms, 4. A competent interdisciplinary and holistic team approach that includes the elderly patient and their family in the team, 5. Continuity in health care, 6. Proper communication between all parties involved (hospital doctors and GPs), 7. Appropriate digital support for communication and information flow
Virkninger og effekter basert på prosjektets resultater mht prosjektets hovedmålet var å produsere forskningsbasert kunnskap om overganger mellom spesialist- og kommunale helsetjenester for eldre pasienter. Hovedmålet er oppnådd basert på blant annet produksjon av 3 PhD avhandlinger, 41 vitenskapelige artikler, 4 vitenskapelig bøker/ antologier, samt kapitler i to vitenskapelige bøker. Det er registrert 34 allmennrettede formidlingstiltak, 23 oppslag i massemedia og 95 brukerrettede formidlingstiltak basert på resultatene i prosjektet. Forskerne har økt sin metodologiske og teoretiske kompetanse og formidlet forskningsbasert kunnskap til media,klinikere i praksisfeltet,policy-utformer,ansatte i forvaltning,ansatte på høyskoler og universiteter samt studenter på bachelor,master og PhD nivå. Kunnskapsbasert utdanning og profesjonell praksis er styrket basert på forskerne bidrag med forelesninger på bachelor,master og ph.d. nivå
National health and care reforms during recent years have increased municipalities' responsibility for developing integrated health and care services in collaboration with hospitals as well as individual users. One of the main concerns, a few years after the implementation of the Coordination Reform, is the impact of changed discharge practices for older patients' transition from specialized hospital care to municipal care services, and the potential increased fragmentation of health and care services for this particularly vulnerable group. So far, research on transitional care from hospital to municipal care settings continues to highlight individual patient factors, and fails to include a focus on macro- and meso levels. A study aimed at increased understanding of the role of cross-sectoral factors that constitute barriers for high quality care transitions for older people from hospital to municipal care is thus warranted. We propose an integrated three-way approach in developing a cross-sectoral model on 30-days transitional care in geriatric patients, by assessing (1) user perspectives on quality of transitional care; (2) vertical coordination between hospital and municipal health and care services ; and (3) horizontal coordination in transitional care- within and between municipalities. The empirical analyses will build upon a combination of data sources including register data (NPR, KOSTRA and IPLOS), a survey among nurses and coordinators at hospitals and municipalities, and qualitative interviews with patients, health professionals and municipal managers. Users contribute directly to the project by their involvement in the data collection and sampling of informants, and are represented through a user reference group that gives feedback on the milestones of the project. The project and its consortium will strengthen the foundation for knowledge-based education and professional practice by conducting practice-based and practice-oriented services research.