Feasibility and acceptability of facilitated advance care planning in outpatient clinics: A qualitative study of health-care professionals experience.

OBJECTIVE: This study sought to determine the feasibility and acceptability of a facilitated advance care planning (ACP) intervention implemented in outpatient clinics, as perceived by health-care professionals (HCPs). METHODS: Data from seven focus groups (n = 27) and nine semi-structured interviews with HCPs recruited as part of a pragmatic, randomised controlled trial (RCT) were analysed using qualitative descriptive methodology. Components of the intervention included HCP education and training, tools to assist HCPs with patient selection, hardcopy information, and ACP documentation, and specialised nurse-facilitators to support HCPs to complete ACP conversations and documentation with patients and caregivers. RESULTS: Health-care professionals working in tertiary outpatient clinics perceived the facilitated ACP intervention as feasible and acceptable. Health-care professionals reported a high level of satisfaction with key elements of the intervention, including the specialised education and training, screening and assessment procedures and ongoing support from the nurse-facilitators. Health-care professionals reported this training and support increased their confidence and ACP knowledge, leading to more frequent ACP discussions with patients and their families. Health-care professionals noted their ability to conduct ACP screening and assessment in clinic was impeded by large clinical caseloads and patient-related factors (e.g., dementia diagnoses, and emotional distress). Additional barriers to ACP implementation identified by HCPs included poor collaboration, constrained time and clinical space, undefined roles and standardised recording procedures for HCPs. CONCLUSIONS: Facilitated ACP intervention in outpatient clinics is perceived by HCPs as feasible and acceptable. Addressing barriers and tailoring implementation strategies may improve the delivery of ACP as part of tertiary outpatient care.

Design and Development of an eHealth Service for Collaborative Self-Management among Older Adults with Chronic Diseases: A Theory-Driven User-Centered Approach.

The increasing prevalence of chronic conditions and multimorbidity poses great challenges to healthcare systems. As patients' engagement in self-managing their chronic conditions becomes increasingly important, eHealth interventions are a promising resource for the provision of adequate and timely support. However, there is inconclusive evidence about how to design eHealth services to meet the complex needs of patients. This study applied an evidence-based and theory-informed user-centered design approach in three phases to identify the needs of older adults and healthcare professionals in the collaborative management of multimorbidity (phase 1), develop an eHealth service to address these needs (phase 2), and test the feasibility and acceptance of the eHealth service in a clinical setting (phase 3). Twenty-two user needs were identified and a web-based application-ePATH (electronic Patient Activation in Treatment at Home)-with separate user interfaces for patients and healthcare professionals was developed. The feasibility study with two nurses and five patients led to a redesign and highlighted the importance of adequately addressing not only varying user needs but also the complex nature of healthcare organizations when implementing new services and processes in chronic care management.

The Information Flow in a Healthcare Organisation with Integrated Units.

INTRODUCTION: Integrated care is believed to provide support to patients with multiple long-term and complex conditions. Transparency in information delivery is key for shared decision-making, and co-production of care. This study aimed to explore information pathways within an integrated healthcare and social care organisation and describe how information continuity was delivered for an older patient with complex care needs. METHODS: An explorative single-case study conducted in a Swedish healthcare organization where municipality and the county council have integrated their services. One focus group discussion and six individual interviews were conducted. RESULTS: Information flow to partners in care was obstructed, with compensatory double documentation, complementary information channels, and information loss. A heavy burden was on the patient and relatives to keep track of and communicate information between different caregivers. Patients were expected to be active partners in their own care, but were largely excluded from the information flow. DISCUSSION: Even integration of care organisations does not imply that integrated care is delivered at the sharp end of practice. An integrated electronic health record is needed to improve accessibility of care information from within all the organisations, facilitating handovers between professionals and levels of care, and involving patients in the information flow.

I did NOT feel like this at all before the accident: do men and women report different health and life consequences of a road traffic injury?

BACKGROUND: Worldwide, injuries represent one of the leading causes of mortality, and nearly one-quarter of all injuries are road traffic related. In many high-income countries, the burden of road traffic injuries (RTIs) has shifted from premature death to injury and disability with long-term consequences; therefore, it is important to assess the full burden of an RTI on individual lives. OBJECTIVE: To describe how men and women with minor and moderate injuries reported the consequences of an RTI on their health and lives. METHODS: The study was designed as an explorative qualitative study, in which the answers to an open-ended question concerning the life and health consequences following injury were analysed using systematic text condensation. PARTICIPANTS: A total of 692 respondents with a minor or a moderate injury were included. RESULTS: The respondents reported the consequences of the crash on their health and lives according to four categories: physical consequences, psychological consequences, everyday life consequences and financial consequences. The results show that medically classified minor and moderate injuries have detrimental long-term health and life consequences. Although men and women report some similar consequences, there are substantial differences in their reported psychological and everyday life consequences following an injury. Women report travel anxiety and PTSD-like symptoms, being life altering for them compared with men, for whom these types of reports were missing. CONCLUSION: These differences emphasise the importance of considering gender-specific physical and psychological consequences following an RTI.

Transfer of nursing home residents to emergency departments: organizational differences between nursing homes with high vs. low transfer rates.

AIM: To explore possible factors in the organization of nursing homes that could be related to differences in the rate of transfer of residents from nursing homes to emergency department. DESIGN: Explorative. METHOD: In a single municipality, qualitative and quantitative data were collected from documents and through semi-structured interviews with 11 RNs from five nursing homes identified as having the highest vs. six identified as having the lowest transfer rates to emergency department. Data were analysed by non-parametric tests and basic content analysis. RESULTS: All nursing homes in the highest transfer rate group and one in the lowest transfer rate group were run by private for-profit providers. Compared with the low group, the high group had fewer updated advance care plans and the RNs interviewed had less work experience in care of older people and less training in care of persons with dementia. There was no difference in nursing home size or staff/resident ratio. The RNs described similar possibilities to provide palliative care, medical equipment and perceived medical support from GPs.

General practitioners' experiences as nursing home medical consultants.

OBJECTIVE: To describe general practitioners' experiences of being the principal physician responsible for a nursing home. METHOD: Fifteen general practitioners assigned to a nursing home participated in semi-structured qualitative interviews. Data were analysed using systematic text condensation. RESULT: Medical assessment is the main duty of general practitioners. Advance care planning together with residents and family members facilitates future decisions on medical treatment and end-of-life care. Registered Nurses' continuity and competence are perceived as crucial to the quality of care, but inadequate staffing, lack of medical equipment and less-than-optimal IT systems for electronic healthcare records are impediments to patient safety. CONCLUSION: The study highlights the importance of advance care planning together with residents and family members in facilitating future decisions on medical treatment and end-of-life care. To meet the increasing demands for more complex medical treatment at nursing homes and to provide high-quality palliative care, there would seem to be a need to increase Registered Nurses' staffing and acquire more advanced medical equipment, as well as to create better possibilities for Registered Nurses and general practitioners to access each other's healthcare record systems.

The frequency of and reasons for acute hospital transfers of older nursing home residents.

The purpose of the study was to examine the frequency of and reason for transfer from nursing homes to the emergency department (ED), whether these transfers led to admission to a hospital ward, and whether the transfer rate differs as a function of type of nursing home provider and to identify the frequency of avoidable hospitalizations as defined by the Swedish Association of Local Authorities and Regions (SALAR). The design was retrospective, descriptive. Data were collected in a Swedish municipality where 30,000 inhabitants are 65 years or older. Structured reviews of the electronic healthcare records were performed. Included were residents living in a nursing home age 65+, with healthcare records including documented transfers to the ED during a 9-month period in 2010. The transfer rate to the ED was 594 among a total of 431 residents (M=1.37 each). 63% resulted in hospitalization (M=7.12 days). Nursing home's transfer rate differed between 0.00 and 1.03 transfers/bed and was higher for the private for-profit providers than for public/private non-profit providers. One-fourth of the transfers were caused by falls and/or injuries, including fractures. The frequency of avoidable hospitalizations was 16% among the 375 hospitalizations. The proportion of transfers to the ED ranged widely between nursing homes. The reasons for this finding ought to be explored.

Communication and coordination during transition of older persons between nursing homes and hospital still in need of improvement.

AIM: To investigate registered hospital and nursing home nurses' experiences of coordination and communication within and between care settings when older persons are transferred from nursing homes to hospital and vice versa. BACKGROUND: It has previously been reported that transfers to hospital from nursing homes and discharge of patients from hospital are surrounded by communication difficulties. However, studies focusing on both hospital and nursing home registered nurses' experiences of communication and coordination within and between nursing homes and hospitals are uncommon. DESIGN: A descriptive study design with a qualitative approach was used. METHODS: In 2008, three focus group discussions were conducted with registered nurses from hospitals and nursing homes (n=20). Data were analysed using content analysis. RESULTS: Nursing home registered nurses found it difficult to decide whether the older person should be referred to hospital from the nursing home. Hospital registered nurses reported often trying to stop premature discharges or having to carry out the discharge although it had not been fully prepared. Both hospital and nursing home registered nurses suggested increased collaboration to understand each other's work situation better. CONCLUSION: Communication and coordination among hospital and nursing home registered nurses need to be furthered improved. Registered nurses' coordination and planning in the nursing home are extremely important to future elder care. We recommend that the medical care plan be regularly updated and meticulously followed, the aim being to reduce the risk of inappropriate medical treatment and nursing care and unnecessary transfer and admission to hospital.