Implementation of integrated care at a German geriatric hospital: a case study

Abstract

Introduction: The growing prevalence of chronic diseases and rising number of older and often multi-morbid patients have led to an increasing demand for complex, long-term care. During the past decades, integrated care has been endorsed as a means to approach these challenges. This is expected to contribute to better outcomes, increased efficiency and improved access to care. The aim of our study was the investigation of a best practice case of integrated care implementation at a geriatric care hospital in Germany. Specifically, we studied the type of integrated care intervention that was implemented, the barriers and facilitators to its implementation, as well as the outcomes achieved.Background: At the case site, geriatric patients receive care according to the criteria of the national framework of geriatric early rehabilitative complex treatments. These include the provision of care to a geriatric patient population (i.e. multimorbid, older than 60 years) by a multidisciplinary team conducting weekly team meetings and performing a comprehensive geriatric assessments. The length of stay is usually between 15 and 21 days, after which patients are discharged or transferred to a different institution.Methods: A qualitative case study was conducted at a geriatric hospital in Germany. Fifteen semi-structured interviews were conducted with medical doctors, occupational therapists, neuropsychologists, physical therapists and nurses. Relationships between mechanisms (as defined by the Chronic Care Model), context factors (as categorised by the Implementation Model) and outcomes (operationalised as aspects of quality of care) were studied.Results: Integrated care at the geriatric hospital involved components related to the health system, delivery system design and decision support. Self-management support was practiced by individual health professionals but not implemented in a structured way. The staff used a documentation system but because of its age and limitations it could not be considered an information system. Community involvement was not found. Barriers included IT problems, resistance to change by health professionals, problematic leadership, unclear division of tasks, problematic patient transfers to and from the geriatric hospital and cost pressure. Facilitators included the involvement of family members in care process and discharge management, a cooperation attitude among the team members, and flat hierarchical structures. Negative outcomes included frustration among staff members, less time available for the patients and, in some cases, a lower quality of care for the patients. Positive outcomes included successful discharges of complex patients to their homes and a high level of staff satisfaction.Discussion: The analysis of the interplay between the mechanisms, context factors and outcomes is still ongoing. However, the preliminary findings show that evaluations of complex interventions require complex methods of analysis. Instead of simply focusing on input and output, it is necessary to investigate the specific type of integrated care intervention that was implemented, the barriers and facilitators by which its execution was met, as well as the different outcomes that were achieved. During the conference we will specifically focus on these issues and discuss implications for future integrated care practice and research.