Understanding the psychosocial, behavioural and environmental factors behind frequent hospital admissions

Abstract

Introduction: Increasing numbers of hospital admissions is a complex issue of significant concern to health systems around the world, as a significant cost driver of healthcare is inpatient cost[i]. In Singapore, patients who are frequently admitted to hospitals, although comprising a small number, account for a disproportionately high use of scarce healthcare resources. While national efforts are currently underway to provide care planning and coordination to such patients, evidence shows that there is a need for case-finding of at-risk patients before they deteriorate[ii]. To date, most predictive models for frequent admissions are derived using administrative and clinical data, and little is known about the psychosocial, behavioural and environmental factors which contribute to frequent admissions in the local context[iii]. Aims: This study aims to Understand how psychosocial, behavioural and environmental factors contribute to frequent admissions, and identify the gaps in current services to address these factors; and Understand how frequent admitters and their caregivers cope with physical, mental and financial stress. Methods: A qualitative approach was used, where in-depth, semi-structured interviews (n=42) and focus group discussions (n=2) were conducted with 41 health and community care providers, and 13 frequent admitters (defined as patients with three or more admissions in a year) and/or caregivers recruited from both the National University Hospital and community care sectors through purposive sampling. Data analysis was done using a deductive approach[iv]. Results and Key Findings: Key psychosocial factors contributing to frequent admissions included social isolation, the lack of caregiver support or capability, anxious caregivers, caregiver stress and perceptionsthat hospital care was superior to community care. Behavioural factors included lack of motivation for self-care while environmental factors included poor communication during care transition between healthcare settings, and financial subsidy schemes which favour hospital rather than community care. Neighbours and friends were found to be an importance source of social support in preventing readmissions, while religion was found to have mixed impact on how patients or caregivers coped with illness. Discussion and Lessons Learnt: This study highlights the importance ofaddressing social isolation, and that informal networks such as neighbours and friends are an often overlooked source of psychosocial support for patients and their caregivers. Secondly, caregiver training, education and provision of respite services should also be in place to support caregivers in the community. Thirdly, a concerted effort is needed to address patients’ socio-cultural beliefs and perceptions about healthcare, while concurrently improving care integration between healthcare settings. Limitations: Comparatively more healthcare professionals than patients and caregivers were interviewed in this study, as many patients were too ill to be interviewed. Suggestions for Future Research: The findings of this study could be used to develop asurvey to understand the prevalence of factors identified in this study among frequent admitters. A screening tool could then be developed to screen individuals at-risk for frequent admissions so that pre-emptive interventions could be instituted.