Improving care coordination for community-dwelling older Australians: a longitudinal qualitative study

被引:18
作者
Harvey, Desley [1 ,2 ]
Foster, Michele [3 ]
Strivens, Edward [1 ,2 ]
Quigley, Rachel [1 ,2 ]
机构
[1] Cairns & Hinterland Hosp & Hlth Serv, POB 902, Cairns, Qld 4870, Australia
[2] James Cook Univ, Div Trop Hlth & Med, Townsville, Qld 4811, Australia
[3] Griffith Univ, Menzies Hlth Inst Queensland, Sch Social Work & Human Serv, Meadowbrook, Qld 4131, Australia
关键词
TRANSITIONAL CARE; HEALTH-SERVICES; PEOPLE; HOME; CAREGIVER; PATIENT; IMPLEMENTATION; OPPORTUNITIES; EXPERIENCES; CHALLENGES;
D O I
10.1071/AH16054
中图分类号
R19 [保健组织与事业(卫生事业管理)];
学科分类号
摘要
Objective The aim of the present study was to describe the care transition experiences of older people who transfer between subacute and primary care, and to identify factors that influence these experiences. A further aim of the study was to identify ways to enhance the Geriatric Evaluation and Management (GEM) model of care and improve local coordination of services for older people. Methods The present study was an exploratory, longitudinal case study involving repeat interviews with 19 patients and carers, patient chart audits and three focus groups with service providers. Interview transcripts were coded and synthesised to identify recurring themes. Results Patients and carers experienced care transitions as dislocating and unpredictable within a complex and turbulent service context. The experience was characterised by precarious self-management in the community, floundering with unmet needs and holistic care within the GEM service. Patient and carer attitudes to seeking help, quality and timeliness of communication and information exchange, and system pressure affected care transition experiences. Conclusion Further policy and practice attention, including embedding early intervention and prevention, strengthening links between levels of care by building on existing programs and educative and self-help initiatives for patients and carers is recommended to improve care transition experiences and optimise the impact of the GEM model of care. What is known about the topic? Older people with complex care needs experience frequent care transitions because of fluctuating health and fragmentation of aged care services in Australia. The GEM model of care promotes multidisciplinary, coordinated care to improve care transitions and outcomes for older people with complex care needs. What does this paper add? The present study highlights the crucial role of the GEM service, but found there is a lack of systemised linkages within and across levels of care that disrupts coordinated care and affects care transition experiences. There are underutilised opportunities for early intervention and prevention across the system, including the emergency department and general practice. What are the implications for practitioners? Comprehensive screening, assessment and intervention in primary and acute care, formalised transition processes and enhanced support for patients and carers to access timely, appropriate care is required to achieve quality, coordinated care transitions for older people.
引用
收藏
页码:144 / 150
页数:7
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