Journal of Health Services Research & Policy

Older people living with frailty (OPLWF) are often unable to leave hospital even if they no longer need acute care. The aim of this study was to elicit the views of health care professionals in England on the barriers to effective discharge of OPLWF.

We conducted semi-structured interviews with hospital-based doctors and nurses with responsibility for discharging OPLWF from one large urban acute care hospital in England. The data were analysed using the constant comparative method.

We conducted interviews with 17 doctors (12 senior doctors or consultants and 5 doctors in training) and six senior nurses. Some of our findings reflect well-known barriers to hospital discharge including service fragmentation, requiring skilled coordination that was often not available due to high volumes of work, and poor communication between staff from different organizations. Participants’ accounts also referred to less frequently documented factors that affect decision making and the organization of patient discharges. These raised uncomfortable emotions and tensions that were often ignored or avoided. One participant referred to ‘conversations not had’, or failures in communication, because difficult topics about resuscitation, escalation of treatment and end-of-life care for OPLWF were not addressed.

The consequences of not initiating important conversations about decisions relating to the end of life are potentially far reaching not only regarding reduced efficiency due to delayed discharges but also for patients’ quality of life and care. As the population of older people is rising, this becomes a key priority for all practitioners in health and social care. Evidence to support practitioners, OPLWF and their families is needed to ensure that these vital conversations take place so that care at the end of life is humane and compassionate.

A small percentage of patients account for the bulk of population health care utilization and costs in many countries including the United States (US). In the US, 5% of the population has high health care utilization accounting for nearly 50% of health care costs. A subset of this utilization is deemed preventable, and thus potentially cost saving to patients as well as to the health care system. This study sought to identify drivers of preventable utilization from the perspectives of three stakeholder groups in the US: health system leaders; high-need, high-cost (HNHC) patients or their primary caregivers; and physicians.

We performed a qualitative study using interviews of health system leaders and focus groups of HNHC patients, caregivers and physicians. We used a mixed inductive deductive approach to analyse transcripts and identify themes.

We identified three key drivers of preventable high health care utilization: (1) unmet behavioural health needs, (2) socio-economic determinants of health and (3) challenges associated with accessing health care delivery systems.

To be potentially more effective, interventions to reduce preventable high health care utilization should incorporate the perspectives of patients, health system leaders and physicians. Particularly important to stakeholders is increased access to mental-health resources, support for patients with low socio-economic resources and systemic changes that reduce wait times for primary care visits and allow providers more time during patient visits.

To explore the roles of patient navigators in different settings and situations for various patient populations and to understand the rationale for implementing lay and professional models of patient navigation in a Canadian context.

A qualitative descriptive design was applied, using interviews with 10 patient navigators from eight Canadian provinces, and Braun and Clarke’s six phases of thematic analysis to guide the analysis of interview transcripts.

Findings indicate that a patient navigator’s personality and experience (personal and work-related) may be more important than their specific designation (i.e. lay or professional).

Lay and professional navigators in Canada appear to be well suited to provide navigational services across populations. This study has the potential to inform future research, policy, and the delivery of navigation programmes in Canada.

To explore the extent to which national policy in end of life care in England influences and guides local practice, to ensure that care for patients over the age 75 years is of a consistently good quality.

This paper reports on phase one of a larger study and focuses its discussion on the high-level (macro) determinants emerging from the analysis. Fifteen in-depth interviews were conducted with professionals involved in the development of English policy in end of life care.

Factors influencing the quality of end of life care were stratified into three system levels: meso, macro and micro. English national policy was reported to be an important macro-level determinant of effective outcomes, and examples were provided to demonstrate how policy was influencing practice. Yet, the complexity of the area and the range of interacting contributory factors mean the value of policy alone is hard to assess. At the macro-level, concern was voiced around: whether policy was effective in tackling rising inequity; lack of mandatory leverage to exert change relating to end of life outcomes; the impact of ongoing infrastructural change on statutory services; workforce pressures; over-reliance on acute services and continued abdication of responsibility for end of life care to medical professionals supported by the continued dominance of the medical model of care.

The links between the existence of policy at the macro-level of the system and the effective enactment of good practice remain unclear, although strategies are suggested to help achieve greater national consistency in end of life care outcomes. Policymakers must pay attention to the following: controlling the rise in localism and its contribution to regional inequalities; the impact of continuous infrastructural change together with increasing workforce pressures; encouraging broader professional and public responsibility for recognition and care of those at the end of life.

To conduct a systematic review of the evidence for when a hospital admission for an older person can be avoided in subacute settings. We examined the definition of admission avoidance and the evidence for the factors that are required to avoid admission to hospital in this setting.

Using defined PICOD criteria, we conducted searches in three databases (Medline, Embase and Cinahl) from January 2006 to February 2018. References were screened by title and abstract followed by full paper screening by two reviewers. Additional studies were searched from the grey literature, experts in the field and forward and backward referencing. Data were narratively described, and concept analysis was used to investigate the definition of admission avoidance.

A total of 17 studies were considered eligible for review; eight provided a definition of admission avoidance and 10 described admission avoidance criteria. We identified three factors which play a key role in admission avoidance in the subacute setting: (1) ambulatory care sensitive conditions and common medical scenarios for the older person, which included respiratory infections or pneumonia, urinary tract infections and catheter care, dehydration and associated symptoms, falls and behavioural management, and managing ongoing chronic conditions; (2) criteria/tools, referring to interventions that have used clinical expertise in conjunction with a range of general and geriatric triage tools; in condition-specific interventions, the decision whether to admit or not was based on level of risk determined by defined clinical tools; and (3) personnel and resources, referring to the need for experts to make the initial decision to avoid an admission. Supervision by nurses or physicians was still needed at subacute level, requiring resources such as short-stay beds, intravenous antibiotic treatment or fluids for rehydration and rapid access to laboratory tests.

The review identified a set of criteria for ambulatory care sensitive conditions and common medical scenarios for the older person that can be treated in the subacute setting with appropriate tools and resources. This information can help commissioners and care providers to take on these important elements and deliver them in a locally designed way.

Life story work involves gathering information about a person, their history and interests, and producing a tangible output, usually a book. It is used increasingly in dementia care. However, theory about if, how, and why it affects outcomes is poorly developed, making the choice of evaluation methods and appropriate outcomes difficult. This article uses a systematic review to uncover theories of change and outcomes for life story work in dementia care. We describe the methods and their use in identifying appropriate outcomes for evaluative research, and their potential for improving evaluation of ‘theory poor’ interventions.

A systematic review, carried out using Centre for Reviews and Dissemination guidelines, searched for evidence on underlying theory, good practice, and effectiveness of life story work to inform a feasibility study for the formal evaluation of life story work in dementia care. For the theory element, a ‘landscaping review’ analysed the extracted text, using qualitative techniques and mind maps to uncover both explicit and implicit causal links between life story work and outcomes. We triangulated the review findings with qualitative research, which used focus groups with people with dementia, caregivers, and professionals that explored the outcomes that they would like to see from life story work.

Of the 56 publications reviewed, only 16 were useful for the theory analysis. Six overarching outcomes were identified: the self-worth and empowerment of people with dementia, individual psychological outcomes, improved relationships between care staff and the individual with dementia, better care, more effective engagement of family members/carers within the care setting, and helping carers to cope. Twelve final theories linking these outcomes to life story work via a causal pathway were elicited. There was substantial overlap in the outcomes identified by the review and by carers, people with dementia, and professionals. Together, the results informed our choice of outcome measures for the pilot evaluation.

This approach may enable researchers to identify and develop the theory necessary before evaluation of a complex intervention in other under- or un-theorized areas. It has the potential both to shorten development stages (and thereby costs) in intervention research and improve the intervention itself.