Transitions of Care Leaving the hospital: the concerns of
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1 Transitions of Care Leaving the hospital: the concerns of complex chronic disease patients Julia Ho, BA, BHA, RPN 1,2 Kerry Kuluski, MSW, PhD 1 Ashlinder Gill, PhD (c) 1 Bridgepoint Collaboratory for Research and Innovation 1 Ryerson University, School of Health Services Management 2 May 13, 2014
2 Background Chronic Disease Chronic disease makes up 60% of the global disease burden (WHO, 2005) 70% of the population over the age of 45 has two or more chronic conditions in Ontario (MOHLTC, 2007) Chronic disease is estimated to be 55% of total health care costs (MOHLTC, 2007) Complexity Challenges Long-time illness with ongoing care needs Heavy users of health care system Health problems related to multi-morbidities, functional impairments, mental health problems, addictions and social vulnerabilities (Lyons et al., 2012) Slide 2
3 Background Transitions of Care Bridgepoint Hospital, Toronto, ON Bridgepoint Study: mixed-method large scale study, 2011, analysis of in-patient population s characteristics, needs and experiences Transitions are problematic patients need more support during admission and discharge (Lyons et al., 2012) Transitions of care is a vulnerable process for patients (Kuluski et al., 2013) Adverse events, low satisfaction of care, re-admission (Naylor et al, 2008) Interventions: discharge checklists, questionnaires, provider-to-provider handoff tools (Coleman & Chalmers, 2006; Doran et al., 2013; Graumlinch, Novotny & Aldag, 2008; Halasyamani et al., 2006; Weiss & Piacentine, 2006) Slide 3
4 Objective: Determine the key themes about discharge concerns from the perspective of complex chronic disease patients Research Question: What are the issues and concerns complex chronic disease patients have about hospital discharge? Slide 4
5 Methods Setting: Bridgepoint Hospital (Toronto, ON) Purposeful sampling N=116 42% male 13% under 44 years old, 52% between years old, 46% older than 65 years old Mean age=63, Range= % Caucasian Average of 5 health conditions (25% had 7-12 conditions) Average length of stay (at time of interview)=162 days Slide 5
6 Methods Data collection: Self-designed survey, closed and open ended questions (Kuluski et al., 2013) NVivo Node Report Study Design: Secondary Analysis Qualitative Description (Sandelowski, 2000) Slide 6
7 Methods Data Analysis Open Coding Axial Coding Final Themes Examine data Group into categories Manual sorting OSOP (one sheet of paper) (Ziebland & McPherson, 2006) Context and interactions Consensus between 3 reviewers Three Reviewers Slide 7
8 Results Process Consequences Needs Uncertainty in the care plan Loss of comforts and security in the hospital Home care supports Friction in the providerpatient relationship Premature discharge Care burden on family Adverse events at home Uprooting Life Accessible home Management of daily activities Bridgepoint Legal Entity 2014 Slide 8
9 Results Patient Characteristics No apparent demographic trends in any of the themes Different age groups, both sexes, different martial status groups, range of number of health conditions, length of stay, represented across three themes Some patients had multiple concerns represented in two or more themes A small proportion of patients reported no concerns: Tended to be younger, fewer health conditions, shorter lengths of stay (at time of interview), more likely to have a partner Slide 9
10 Theme 1: Process Slide 10
11 Theme 1: Process Example Quotes Uncertainty in the care plan: I m scared of the fact that I don t know what I m anticipating when I come home.scared of the fact that just in general, that I honestly don t know what s going to happen to me after May 16 when this cast comes off. Friction in the patient-provider relationship: in one ear and out the other...what I'm saying is that I am getting a strong kind of a push out of here by the doctor, and down from there. Slide 11
12 Theme 1: Process Example Quote Premature discharge: I: Do you feel ready to go home? R: Not ready but you know, the doctors say you are ready so I am going to go home. But I don t think I m ready. I: Why do you feel that you re not ready to go home? R: I got the impression that they brought me here, and they say, okay, physiotherapy, they will make you walk and you will go home. So no, I think I m going to go that way. I think I m going to go back home with my crutch and come back and take physio Slide 12
13 Theme 2: Consequences Slide 13
14 Theme 2: Consequences Example Quotes Loss of comforts and security of the hospital: In the sense of having people to talk to all the time, yes. Because I talk to a lot of people around here, and I m going to miss that. Of course I prefer to be healthy and have a nice place to live but the atmosphere here is pretty good, and I m going to miss it. Adverse events at home: And the possibility of slipping, and because I live alone, nobody would even know I have fallen. So that is the big issue for me I m afraid of falling, yes. Slide 14
15 Theme 2: Consequences Example Quote Burden on family: And I'm not sure my partner can cope with the strain of looking after me. My father, he can't 100% do this for me. He's way too old and he's too weak. He can't bend down or anything. My mother has cognitive issues. So sometimes she's there and sometimes she isn't. Slide 15
16 Theme 2: Consequences Example Quote Uprooting Life: R: I was upset. I didn t want to go to an old aged home. I mean who would? I don t feel like I belong there. I don t feel that s the place I belong. I: Remind me how old you are. R: 56 Slide 16
17 Theme 3: Needs Slide 17
18 Theme 3: Needs Example Quotes Home care supports: Well, I ve had a tremendous amount of stress attempting to get one home service that s coming to bath me once a week. Accessible home: So there are a lot of stairs. So that was my main worry going home, is like can I do the stairs? Slide 18
19 Theme 3: Needs Example Quote Management of daily activities: And now they are sending me home at the end of the month and I m completely alone. And I don t know, the daytime I am not afraid but at night, how am I going to the bathroom? I am unable to stand, unable to walk. Slide 19
20 Conclusions Patients did not feel like active participants in the care planning process Anxiety about being pushed out of hospital Lack of clarity in communication from care providers Patients anticipated major life changes after discharge Relocation (i.e. long-term care placement) Loss of independence, relying on others for daily support Patients felt secure in the hospital and leaving was a uneasy prospect Particularly for people without a support network (live alone) Concerned about managing daily activities at home Slide 20
21 Future Research How can this framework (process, consequences, needs) be applied to discharge planning? Patient-centred care plans(perkins et al., 2012) Increasing home and community supports New models of care to address complex chronic disease population System Navigator (TCM (Naylor et al., 2013), TDM (Forchuk et al, 2007)) Integrated Care (GRACE model (Aliotta et al., 2008)) Slide 21
22 Acknowledgements Bridgepoint Study, 2011 Research Team and Participants Ryerson School of Health Management Practicum Program James Tiessen, PhD Pria Nippak, PhD Ms. Carrie Weibe Slide 22
23 References Aliotta, S. L., Grieve, K., Giddens, J. F., Dunbar, L., Groves, C Boult, C. (2008). Guided Care: a new frontier for adults with chronic conditions. Professional Care Management, 13(3), Canadian Institute for Health Information. (2011). Seniors and the Health Care system: What is the impact of multiple chronic conditions? In Analysis Brief, Ottawa, Ontario: Canadian Institute of Health Information. Coleman, E. A. (2003). Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51(4), Doran, D., Hirdes, J. P., Blais, R., Baker, G. R., Poss, J. W., Li, X.,... McIssac, C. (2013). Adverse events associated with hospitalization or detected through the RAI-HC assessment among Canadian home care clients. Health Policy, 9(1), Forchuk, C., Reynolds, W., Sharkey, S., Martin, M., Jensen, E. (2007). Transitional discharge: based on therapeutic relationships: State of the art. Archives of Psychiatric Nursing, 21(2), Graumlich, J.F., Novotny, N. L., & Alday, J.C. (2008). Brief scale measuring patient preparedness for hospital discharge home: Psychometric propertieis. Journal Hospital Medicine. 3(6), Halasyamani, L., Kripalani, S., Coleman, E., Schnipper, J., van Walraven, C., Nagamine, J.,... Manning, D. (2006). Transition of care for hospitalized elderly patients Development of a discharge checklist for hospitalists. Journal of Hospital Medicine, 1(6), Kuluski, K., Hoang, S. N., Schaink A.K., Alvaro, C., Lyons, R. F., Tobias, R., & Bensimon, C. M. (2013). The care delivery experience of hospitalized patients with complex chronic disease. Health Expectations, Lyons, R. F., Kuluski, K., Alvaro, C., Schaink A.K., & Bernstein, B. (2012). The Face of Complex Chronic Disease: Understanding the patient population at Bridgepoint Health. Toronto: Bridgepoint Collaboratory for Research and Innovation. Slide 23
24 References Ministry of Health and Long-Term Care. (2007). Preventing and Managing Chronic disease: Ontario's framework..ottawa: Author. Naylor, M. D., Bowles, K. H., McCauley, K. M., Maccoy, M. C., Maislin, G., Pauly, M. V., & Krakauer, R. (2013). Highvalue transitional care: Translation of research into practice. Journal of Evaluation in Clinical Practice, 19(5), Perkins, S., Schwartz, M., Anderson, K., Key, C. (2012). SMART Discharge Protocol: A pilot study to standardize the discharge process in an acute care hospital. Retrieved from: Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing and Health, 23(4), Weiss, M.E., Piacentine, L.B., Lokken, L., Ancona, J., Archer, J Vega-Stromberg, T. (2007). Perceived readiness for hospital discharge in adult medical-surgical patients. Clinical Nurse Specialist, 21(1), World Health Organization. (2011). Global status report on noncommunicable diseases 2010: Description of the global burden of NCDs, their risk factors and determinant. Ziebland, S., & McPherson, A. (2006). Making sense of qualitative data: Analysis: An introduction with illustrations from DIPEx (personal experiences of health and illness). Medical Education, 40, Slide 24
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