Abstract
BackgroundDifferent models for care pathways involving both specialist and primary care have been developed to ensure adequate follow-up after discharge. These care pathways have mainly been developed and run by specialist care and have been disease-based. In this study, primary care providers took the initiative to develop a model for integrated care pathways across care levels for older patients in need of home care services after discharge. Initially, the objective was to develop pathways for patients diagnosed with heart failure, COPD and stroke. The aim of this paper is to investigate the process and the experiences of the participants in this developmental work. The participants were drawn from three hospitals, six municipalities and patient organizations in Central Norway.MethodsThis qualitative study used focus group interviews, written material and observations. Representatives from the hospitals, municipalities and patient organizations taking part in the development process were chosen as informants.ResultsThe development process was very challenging because of the differing perspectives on care and different organizational structures in specialist care and primary care. In this study, the disease perspective, being dominant in specialist care, was not found to be suitable for use in primary health care because of the need to cover a broader perspective including the patient’s functioning, social situation and his or her preferences. Furthermore, managing several different disease-based care pathways was found to be unsuitable in home care services, as well as unsuitable for a population characterized by a substantial degree of comorbidity. The outcome of the development process was a consensus that outlined a single, common patient-centred care pathway for transition from hospital to follow-up in primary care. The pathway was suitable for most common diseases and included functional and social aspects as well as disease follow-up, thus merging the differing perspectives. The disease-based care pathways were kept for use within the hospitals.ConclusionsDisease-based care pathways for older patients were found to be neither feasible nor sustainable in primary care. A common patient-centred care pathway that could meet the needs of multi- morbid patients was recommended.
Highlights
Different models for care pathways involving both specialist and primary care have been developed to ensure adequate follow-up after discharge
Most studies in the field evaluate models that have been initiated by specialist care services and are based on treatment of single diseases like stroke, heart failure and Chronic obstructive pulmonary disease (COPD) [16,17,18]
In Denmark an intervention was developed within primary care by General practitioner (GP) and home care services that reduced the risk of readmissions and improved medication control for newly discharged elderly patients [20]
Summary
Different models for care pathways involving both specialist and primary care have been developed to ensure adequate follow-up after discharge. Primary care providers took the initiative to develop a model for integrated care pathways across care levels for older patients in need of home care services after discharge. Other models describe care pathways that aim to ensure adequate follow-up after discharge, involving both specialist and primary care services [14,15]. Most studies in the field evaluate models that have been initiated by specialist care services and are based on treatment of single diseases like stroke, heart failure and COPD [16,17,18]. In Denmark an intervention was developed within primary care by GPs and home care services that reduced the risk of readmissions and improved medication control for newly discharged elderly patients [20]
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