Abstract

Background: A comprehensive primary healthcare (PHC) approach requires clear referral and continuity of care pathways. South Africa is a lower-middle income country (LMIC) that lacks data on the role of intermediate care (IC) services in the health system. This study described the model of service provision at one facility in Cape Town, including reason for admission, the mix of services and skills provided and needed, patient satisfaction, patient outcome and articulation with other services across the spectrum of care. Methods: A multi-method design was used. Sixty-eight patients were recruited over one month in mid-2011 in a prospective cohort. Patient data were collected from clinical record review and an interviewer-administered questionnaire, administered shortly after admission to assess primary and secondary diagnosis, referring institution, knowledge of and previous use of home based care (HBC) services, reason for admission and demographics. A telephonic questionnaire at 9-weeks post-discharge recorded their vital status, use of HBC post-discharge and their satisfaction with care received. Staff members completed a self-administered questionnaire to describe demographics and skills. Cox regression was used to identify predictors of survival. Results: Of the 68 participants, 38% and 24% were referred from a secondary and tertiary hospital, respectively. Stroke (35%) was the most common single reason for admission. The three most common reasons reported why care was better at the IC facility were staff attitude, the presence of physiotherapy and the wound care. Even though most patients reported admission to another health facility in the preceding year, only 13 patients (21%) had ever accessed HBC and only 25% (n=15) of discharged patients used HBC post-discharge. Of the 57 patients traced on follow-up, 21(37%) had died. The presence of a Care-plan was significantly associated with a 62% lower risk of death (hazard ratio: 0.38; CI 0.15–0.97). Notably, 46% of staff members reported performing roles that were outside their scope of practice and there was a mismatch between what staff reported doing and their actual tasks. Conclusion: Clients understood this service as a caring environment primarily responsible for rehabilitation services. A Care-plan beyond admission could significantly reduce mortality. There was poor referral to and poor articulation with HBC services. IC services should be recognised as an integral part of the health system and should be accessible.

Highlights

  • In the United States, subacute care (SAC) may be interchangeably described as Postacute Care,[8] accessed in a wide range of settings that include skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs) or the care delivered by home health agencies (HHAs) in patients’ residences.[8]

  • In 2012, the Western Cape (WC) provincial Department of Health (DoH) undertook a review of its SAC policy,[21,22] and a task team report led to the development of an intermediate care (IC) policy framework in September 2012, which revised the organisation of what was delivered as a SAC programme in the health department.[21,22]

  • This study was initiated in response to the strategic opportunity identified by the WC DoH for IC to improve the efficiency of the health system, and to provide data for planning an efficient district health system (DHS) based on a primary healthcare (PHC) approach

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Summary

Introduction

More than 3 decades have passed since the Alma–Ata conference outlined the primary healthcare (PHC) approach as a strategy for equitable and appropriate healthcare.[1,2] Key elements of the PHC approach are: (a) it is not limited to curative services but is inclusive of preventive and rehabilitative care; (b) services should prioritise those most in need; and (c) to provide comprehensive healthcare, it “... should be sustained by integrated, functional and mutually supportive referral systems....”1 Unlike the concept of primary care, with which it is often confused,[1,2,3,4] the broader conception of PHC describes an approach to the organisation of the health system that includes services delivered to individuals (primary care services) and public health-type functions.[3]. While SAC is the term commonly used in the international literature, this study uses the definition of IC used in the policy.[21,22] In this policy IC is described as an intergrated provision of inpatient sub-acute, stepdown, respite, palliative and some chronic services.[21,22] The study describes the model of service provision of a single large IC facility in Cape Town and its role in the continuum of care This was achieved through characterising (i) patient demographics and reason for admission; (ii) patient care needs in relation to the skills of staff who provide IC; (iii) duration of stay in the facility; (iv) patient and staff understanding of IC; (v) patient outcomes; (vi) survival at follow up and the; (vii) availability of family support. This study defines continuum of care as the patient journey within the health system and how services relate to each other; International Journal of Health Policy and Management, 2018, 7(2), 167–179

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