Interorganizational Collaboration in Transitional Care – A Study of a Post-Discharge Programme for Elderly Patients

Abstract

Introduction and aim:This article reports a study of a post-discharge programme for elderly patients in Norway. It took place in an intermediate ward for transitional care and was based on collaboration between a municipality and a hospital, which was part of a health enterprise. The aim of the study was to analyse the collaboration and its possible effects on the quality of patient care, and the economic efficiency of the project for the organizations involved.Methodology:A mixed-methods approach, consisting of interviews, questionnaires and analyses of official documents and statistics.Results:The collaboration was working well on the top level of the organizations, but was more problematic on the operative level. However, there were clear signs of improvement. The patients who received transitional care were more satisfied with their stay at the ward than their previous stay at the hospital. They were discharged to their homes more often and perceived to have a higher level of functioning than the hospital patients. Average costs per patient were also lower in the ward than in the hospital departments.Conclusion:The collaboration had mainly positive impacts on the quality of patient care and the economic efficiency of elderly care in the municipality. However, the board of the health enterprise decided to close down the intermediate ward.

Understanding transitional care programs for older adults who experience delayed discharge: a scoping review

“…Although we aimed to include evidence involving Indigenous persons, we did not find any applicable research. Forty-nine percent of the studies were conducted in Europe [ 18 , 19 , 29 – 33 , 35 – 39 , 42 , 43 , 45 , 51 , 53 , 55 , 57 ], 27% in the U.S.A. [ 20 – 23 , 25 , 26 , 44 , 52 , 54 , 56 ], 11% in Australia [ 24 , 27 , 28 , 48 ], 8% in Asia [ 40 , 41 , 49 ], and 5% in Canada [ 46 , 50 ]. Different study designs were used, with the most common being retrospective cohort or chart audit designs ( n = 9) [ 20 , 21 , 25 , 27 , 30 , 39 , 46 , 49 , 52 ]; followed by prospective cohort design ( n = 7) [ 18 , 19 , 24 , 26 , 41 , 44 , 45 ]; RCTs ( n = 7) [ 23 , 28 , 33 , 35 , 38 , 53 , 55 ]; non-randomized design ( n = 4) [ 22 , 29 , 40 , 57 ]; case study ( n = 2) [ 31 , 32 ]; pre-test post-test ( n = 2) [ 48 , 50 ]; and other de...…”

“…1. Treatment Continued medical care as initiated in acute care in addition to nursing, PT, SW and nutritional interventions [ 18 , 45 ] Nursing case management [ 28 , 33 , 36 , 37 , 40 , 42 , 46 , 49 , 51 , 53 , 56 ] Acute, episodic medical care [ 21 , 23 , 29 , 33 , 38 , 44 – 46 , 52 , 53 ] Specialized interventions such as respiratory therapy, enteral nutrition, IV therapy, wound care, dialysis, pain control, terminal care [ 20 , 21 , 24 , 30 , 36 , 38 , 40 , 42 , 48 ] Geriatric consultation [ 37 , 42 , 46 , 53 , 55 ] Medication reconciliation [ 21 , 22 , 38 , 55 ] Mobility and rehabilitation training including transfers, stairs, strength and balance exercises and provision of mobility aids [ 24 , 26 – 30 , 32 , 33 , 38 ...…”

Enhancing Care Transitions for Older People through Interprofessional Simulation: A Mixed Method Evaluation

“…Older people often have complex needs and thus require services from health and social care professionals from various organizations and sectors [12], with a resulting risk of duplication of services and inconsistencies in approach [2]. Integrated care could therefore particularly benefit older people with complex needs, especially as they experience regular transitions between services [3456].…”

“…However, care transitions continue to be a problematic area of policy and practice within England [51415] and internationally [1016]. Recently, Orvik et al [2] argued that transitional care has become of central importance in efforts to improve the quality of health services and patient safety globally. Initiatives to improve transitional care should focus on the people involved and how they can effectively collaborate.…”

“…Initiatives to improve transitional care should focus on the people involved and how they can effectively collaborate. There needs to be high quality communication within the interprofessional team and with the family for successful care transitions to home for older people [17] and effective collaborative practice is essential to prevent adverse events related to transitions [2]. …”