Author: Stacey Masters
Masters, Stacey, 2017 Post-hospital transitions for older adults and their carers, Flinders University, School of Medicine
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Older adults with an unplanned hospital admission can be at risk of premature admission to residential aged care (RAC). The process by which this occurs frequently results in a sense of disempowerment. A range of policy initiatives including Transition Care (TC) have been implemented to reduce this potential risk. However, minimal research has examined patient experiences of TC. The present thesis addresses this gap in the literature.
The program comprised three lines of enquiry. The first focused on TC, with two related studies examining the perceptions of service providers, older adults and proxies regarding the extent to which TC is goal oriented, patient-centred and restorative, and provides a seamless transition from hospital to home or RAC. The second line of enquiry examined decision making about entry to RAC from the perspectives of older adults, carers, social workers and community members. The level of community support for a cash entitlement at the point of entry to RAC was also assessed. The third line of enquiry described a randomised controlled trial of a health literacy and coaching intervention in residential TC.
More specifically, the first study examined the level of congruence between the ‘key requirements’ of a TC program, as set out in the Guidelines, and actual performance as self-reported by TC services. Low levels of General Practitioner and Geriatrician involvement in TC were reported as well as challenges in meeting the requirement for pharmacist-led reconciliation of medicines and securing adequate services for clients at discharge from TC, compared with the Guidelines. Having identified these mismatches between guidelines and practice, the second study reported the development of a measure of older adults’ experiences of TC to enable the consumer’s view to be documented. Initial testing was undertaken as part of a national telephone survey of TC recipients three months after discharge from TC. Overall, sound reliability and validity of the measure was demonstrated.
As the perceptions of relocation of the three key actors in the decision to move from hospital to RAC (the patient, family and social worker) have rarely been explored, the third study examined pathways to hospitalisation and consequent RAC entry. Older adults expressed a desire to participate in decisions about their future care, regardless of outcome. Spouses generally provided substantial care prior to relinquishing this role. While social workers indicated that families should plan ahead for RAC, adult children reported resistance to anticipatory conversations with ageing parents about their future living arrangements. TC was thought to provide a better environment for older adults, both generally and for those waiting for a RAC bed. However, medical imperatives sometimes made this option unsuitable.
The views of ‘ordinary Australians’ about the proposal for an aged care entitlement that would provide older adults with a real choice about where they receive care have also not been canvassed previously. The fourth study therefore reported the findings of a series of questions on this topic posed to a representative sample via a Health Omnibus Survey. A preference for a cash entitlement was indicated, although this declined with advancing age. The final study reported is a randomised controlled trial to assess the efficacy of a health literacy and coaching intervention in a residential TC setting. The study aimed to support patients to take a more active role in their health care and equip carers for the role of health advocates for older persons. Older adults and carers in the intervention group reported higher scores on a measure of the quality of care transitions compared with a ‘usual care’ group.
These five novel empirical studies provide valuable information for clinicians developing targeted intervention programs designed to enhance patient and carer participation in planning for future care. Such interventions have the potential to improve the transition experience and reduce adverse outcomes commonly associated with care transitions.
Keywords: care transitions, older adults, post-hospital, decision-making, entry to residential aged care
Subject: Medicine thesis
Thesis type: Doctor of Philosophy
Completed: 2017
School: School of Medicine
Supervisor: A/Prof Malcolm Bond