Patient narratives: Experiences of older people across the interface between primary and secondary care

Transcription

1 Patient narratives: Experiences of older people across the interface between primary and secondary care Sue Ashby (Keele University) Roger Beech (Keele University) Angela Dickinson (University of Hertfordshire) Catherine Henderson (London School of Economics) Jenny Cove (University of Hertfordshire) PI: Martin Knapp (PSSRU, LSE) Funded by the SDO 1

2 Project aim to compare and critically analyse the impact of different governance models to reduce the utilisation of unplanned inpatient bed days by older people aged 75 and over. Project reference: 08/1618/136 2

3 Context Policy Concerted efforts to reduce unplanned or unnecessary inpatient bed use by older people Numerous policy statements, national targets, local agreements etc (NHS Improvement Plan, Audit Commission, National Beds Inquiry, Older People s NSF, Public Service Agreements, Our Health, Our Care, Our Say ) Research Innovation Forum for older people 9 local authorities and their NHS partners working to find ways to reduce IP bed use by older people 3

4 Methods Phase 1: Exploratory Case Study All 9 IFOP sites (LA s, PCTs, NHSTs etc) Documentary Analysis Structured Questionnaires Phase 2: Explanatory Case Study 3 IFOP sites Patient journeys (Falls, COPD, Stroke) Semi-structured interviews with front-line staff Non-participant observation Senior Manager Interviews Phase 3: Framework Development National Scope Workshops 4

5 Five components of case study Five components (Yin 2009) Study s question(s) Propositions, if any Units of analysis design (Yin 2009) Specific to PhD study How does IC provide person centred care, from the experience and perspective of service users/carers? To identify the circumstance that contribute to a positive service user experience and successful organisational delivery of IC within the context of the wider health economy Crisis event = primary unit of analysis Target service users 75 years + COPD, Falls Stroke Specific geographical area Time At crisis, on discharge, 6-8 weeks post discharge (Clear identification of time boundaries to define beginning and end of the case Copyright Keele University 5

6 Five components of case study design (Yin 2009) Five components (Yin 2009) Specific to PhD study Logic linking data to the propositions Multi case holistic design Replication logic The criteria for interpreting the findings Iterative approach Grounded theory Copyright Keele University 6

7 Convergence of evidence (Adapted from Yin 1993:100) Documents Archival records Observations FACT Patient Interviews Staff Interviews Manager Interviews Copyright Keele University 7

8 Data Collection ID patient with tracker condition [COPD, Fall, CVA] Patient Interview 3 Carer Interview 3 Staff Interview (x2) Initial approach by staff Avoidable/preventable /delayed discharge. Patient Interview 2 Carer Interview 2 Staff Interview (x2) Recruited/Consent Patient Interview 1 Carer Interview 1 Staff Interview (x2) 8

9 DATA 6 Patients n = 14 2 Carers n = 4 19 Staff n= 19 Total Interviews n = 43 Observation of meetings Medical and nursing records Local policies/guidelines Copyright Keele University 9

10 Characteristics of patients Patient Age Presenting condition Avoidable and prevented hospital admission Avoidable and NOT prevented hospital admission 1 87 COPD Delayed hospital discharge Early discharge/ Reduced hospital length of stay 2 86 Fall with fracture 3 94 Fall with fracture 4 85 Fall with fracture 5 87 COPD *repeated admissions 6 93 Fall with fracture 10

11 Patient journeys Transition from chronic disease to end stage disease management [P1;P5] (Avoidable but NOT prevented acute hospital adm) A+E, home arranging intermediate care provision [P2;P6] (Avoidable and prevented acute hospital adm) A+E, acute ward, rehabilitation ward, home [P3;P4] (Reduced acute hospital length of stay) s11

12 Diagram summarising physical movement and transitions of patients through the health and social care system. Community Rehabilitation Personal care support: Formal/informal Transition to home Adjusting Discharge Admission Acutehospital Context Rehabilitation Context: Institutional Pre-hospital Context: Home Homebased IC Transition A&E Department Stabilising Transition to Residential Rehabilitation Adjustingdifferent philosophy of care Discharge Transition Returning home Action: 999 A&E GP Treatment Regaining Function/ Confidence Adjusting Care Home: Context 12

13 Voluntary sector Diagram summarising the networks accessed by patients in their journeys through the health and social care system Social care Community Rehab Homebased IC Home A&E Acute hospital Rehabilitation: Institutional Care Home Health or Social care Action: 999 A&E GP NHS Direct Rapid Response 13

14 Patient Journey Participant Code: S1P1 To A&E Carer Daily Mon-Fri GP GP EXAC COPD Age 87 SON I Social Care Son Carer Carer 2 visits daily Laundry, Shopping, Cleaning RIP 13 days post hospital discharge A&E Acute Hospital Bed (40 days) District Nurse Son Pressure area care ACUTE TIME ONGOING

15 Patient Journey Participant Code: S1P2 PMH CVA, Parkinsons, Carer 4 visits daily Key safe and life line in situ Family & Neighbour support Fall IC 86 years IC Case management To A&E Home 1 day Rapid Response Social Care Carer 4 visits daily A&E A + E Overnight ACUTE TIME Rapid Response REHABILITATION Community Hospital IC Community Hospital Bed 13 weeks Family Support Neighbours Help with Laundry, Cleaning ONGOING Nephew NoK Shopping 15

16 Phases Crisis Acute Rehabilitation Within areas MDT s worked well Transitional stages highlighted hotspots in patients journeys 16

17 Crisis phase Service delivery Lack of knowledge alternative health services and how to access them. Timeliness of response Out of hours History of ill health? monitoring Quality of care Role of family and friends - Expectations and carers Role of formal services Patient choice 17

18 And I mentioned in hospital I was astonished when the young man, the young doctor, said I think you can go home tomorrow, and I said I don t feel fit, and he argued with me about it and I said well what about me going to [rehabilitation unit] for a bit and he said oh no, no, you d be much better at home, get back to normal. And so against my will really I finally, I suppose they would say agreed, but there didn t seem any option but to go home and it was then I found I wasn t able to cope. [P5] 18

19 Acute Phase Service delivery Rehab in acute hospital Rehabilitation convalescence Capacity of and timely access to community bedded rehabilitation Home visits Information provision and decision making Patients hoped for and actual function Trepidations around early discharge and new services Delays in discharges Quality of care Isolation /Loneliness Distress -Attitudes - Continuity of care -Internal hospital transfers Locus of decision making around discharge plans Positive acknowledgement of ward staff 19

20 So I was a bit upset really because I thought I don t know anything about (name of rehab unit) and people had said (name of community hospital) was very nice.my son rang and I said to him, I feel a bit upset, I don t know anything about (name of rehab unit)..he got onto the website or internet or something and got all the details and I said, Oh it sounds great, you know I am quite happy about going there. And I was when I came in. But they don t really give you any choice do they? [P4] 20

21 Sometimes, it s waiting for the rehab beds to become available, sometimes there s lots and sometimes you re waiting a length of time for the rehab bed and we are stretched but we try to see patients as much as we can possible but obviously our priorities do lie with patients that are being discharged home, say for example if they live alone they are our priorities, whereas patients whoarelistedfor rehab,asmuchasi dliketoget round and see all of them, sometimes it s just not feasible, because of staffing we can t physically see every patient, it s just not [P4F1T1] 21

22 Rehabilitation Service delivery Accessing services in a timely way Matching needs to resources Case managers Environments (clinical/homely] Quality of care Person centred Rapport with staff Confidence building Planning for discharge Continuity (outreach) Conflicting philosophies of care 22

23 I don t know what would have happened if I hadn t gone to(name of rehab centre), I mean there d have been no way I could have coped, nearly three weeks I was there, wasn t it? But what they d do without those sort of places, I don t know. P4T3... Everything seemed to fall in place for me alright, you know, I didn t have any grumbles about anything. Because you get some people that grumble about everything, don t you?... I thought it was quite good and all the staff were good and very considerate so it s the staff really in order to make it, isn t it? P2T3 23

24 For discussion Levels of involvement Decision making / Choice Uncertainty Vulnerability Isolation Presence of a carer Copyright Keele University 24

25 What next? Dissemination of information to: Individual sites (locally informing intermediate care strategy) Publication of main research report (final editorial stages) Peer reviewed journal publications Draft chapters PhD thesis 25