The impact of an Intermediate Care Hospital on the chain of care for hospitalized elderly people
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Better care for elderly people with chronic conditions and comprehensive care needs has become a health policy priority in many countries. Elderly patients are particularly vulnerable to discontinuities in care, and are often those most in need of a health care system that is capable of appropriate collaboration and communication across care levels. Various arrangements have been introduced to improve coordination of health care services for these patients. Intermediate care is one such service. In this thesis an intermediate care service, called an Intermediate Care Hospital (ICH) that provides support after hospital discharge, was evaluated. The aim of the thesis focused on two main aspects; the impact of the ICH on health care utilization, and health professionals’ experiences with the ICH. To answer the aims two quantitative studies and one qualitative study were conducted. The first study was a retrospective comparative cohort study investigating whether a municipality with an ICH had different health care utilization rates and a different risk of readmission for persons aged 60 years and older than a municipality without an ICH. The second study, a controlled observational study, compared persons in the same age group and the same two municipalities as the first study, but included only patients who were suitable for an ICH stay. This study investigated the effectiveness of discharges to a municipality with an ICH compared to discharges to a municipality without an ICH, on readmissions, mortality, activities of daily living, and health care use. The third study used qualitative methods to investigate how health care professionals experienced discharge from the hospital via the ICH compared to direct discharge to primary health care in a municipality without intermediate care. The results from the first quantitative study showed that the length of hospital stay decreased from the time the ICH was introduced (2007) in the municipality and remained lower than the length of stay in the municipality without an ICH throughout the observation period (2008- 2012). During the years after the establishment of the ICH, only small differences were observed between the municipalities in rates of admissions and readmissions, and there were only minor changes in the two municipalities’ utilization of primary health care both in extent and pattern. The main findings in the second study, that compared patients suitable for ICH stays, was that the patients who were discharged to the municipality with an ICH used fewer hospital days while the primary health care utilization between the municipalities was similar. The qualitative study reported that the ICH was experienced as an extension of a hospital and a buffer for primary health care. It improved the discharge process by increasing the capacity to receive patients from the hospital and improving the preparations before discharge to primary health care. However, there was still a need for better communication with the preceding care level, in particular between the ICH professionals and primary health care. Having an ICH in the municipality reduced the number of hospital days and the length of stays for patients aged 60 years and older, but had minor impact on the primary health care utilization. The ICH facilitated early hospital discharge for elderly patients in the municipality while keeping the risk of readmissions, mortality and the post-hospitalization care needs on the same level as the municipality without an ICH. It was found that the frailest patients were selected to discharge to the ICH. Furthermore, the thesis suggests that successful integration of intermediate care in the chain of care depends on the partners’ ability to develop common perspectives, shared goals, clarified roles, and to view their services as a part of a total chain of care.