Development of a patient-centred care pathway across healthcare providers: a qualitative study

Abstract

Background: Different models for care pathways involving both specialist and primary care have been developed to ensure adequate follow-up after discharge. These care pathways have mainly been developed and run by specialist care and have been disease-based. In this study, primary care providers took the initiative to develop a model for integrated care pathways across care levels for older patients in need of home care services after discharge. Initially, the objective was to develop pathways for patients diagnosed with heart failure, COPD and stroke. The aim of this paper is to investigate the process and the experiences of the participants in this developmental work. The participants were drawn from three hospitals, six municipalities and patient organizations in Central Norway.

Methods: This qualitative study used focus group interviews, written material and observations. Representatives from the hospitals, municipalities and patient organizations taking part in the development process were chosen as informants.

Results: The development process was very challenging because of the differing perspectives on care and different organizational structures in specialist care and primary care. In this study, the disease perspective, being dominant in specialist care, was not found to be suitable for use in primary health care because of the need to cover a broader perspective including the patient's functioning, social situation and his or her preferences. Furthermore, managing several different disease-based care pathways was found to be unsuitable in home care services, as well as unsuitable for a population characterized by a substantial degree of comorbidity. The outcome of the development process was a consensus that outlined a single, common patient-centred care pathway for transition from hospital to follow-up in primary care. The pathway was suitable for most common diseases and included functional and social aspects as well as disease follow-up, thus merging the differing perspectives. The disease-based care pathways were kept for use within the hospitals.

Conclusions: Disease-based care pathways for older patients were found to be neither feasible nor sustainable in primary care. A common patient-centred care pathway that could meet the needs of multi- morbid patients was recommended.

Figure 1

Common care pathway for transition from hospital and follow-up of home care recipients. The boxes represent procedures and checklists and the arrows the flow of information between involved parties. It starts with the patient being reported as ready for discharge and information is exchanged (1 and 2). Home care services are established (3), and within three days a district nurse performs a thorough and structured assessment (4). The patient has a consultation with the GP 14 days after discharge (5), and a nurse or aide performs an extended assessment during the first four weeks (6). A daily care plan is continuously updated (7), and if the patient’s condition gets worse, the home care service has a routine for what to observe, whom to contact, and which information to pass on (8).