Implementing a care pathway for elderly patients, a comparative qualitative process evaluation in primary care

BMC Health Services Research

Anders Grimsmo²  Line Kristoffersen¹  Erna Håland³  Aslak Steinsbekk⁴  Helge Garåsen¹  Tove Røsstad¹ 

[1] Department of Health and Welfare Services, City of Trondheim, Trondheim, Norway;Norwegian Health Net, Trondheim, Norway;Department of Adult learning and Counselling, Norwegian University of Science and Technology (NTNU), Trondheim, Norway;Department of Public Health and General Practice, Norwegian University of Science and Technology (NTNU), Trondheim, Norway

关键词: Normalization Process Theory;    Health care quality;    Process evaluation;    Complex intervention;    Implementation;    Home care services;    Primary care;    Checklists;    Continuity of patient care;    Care pathway;   

Others  :  1135513
DOI  :  10.1186/s12913-015-0751-1

 received in 2014-05-20, accepted in 2015-02-17,  发布年份 2015

【 摘 要 】

Background

In Central Norway a generic care pathway was developed in collaboration between general hospitals and primary care with the intention of implementing it into everyday practice. The care pathway targeted elderly patients who were in need of home care services after discharge from hospital. The aim of the present study was to investigate the implementation process of the care pathway by comparing the experiences of health care professionals and managers in home care services between the participating municipalities.

Methods

This was a qualitative comparative process evaluation using data from individual and focus group interviews. The Normalization Process Theory, which provides a framework for understanding how a new intervention becomes part of normal practice, was applied in our analysis.

Results

In all of the municipalities there were expectations that the generic care pathway would improve care coordination and quality of follow-up, but a substantial amount of work was needed to make the regular home care staff understand how to use the care pathway. Other factors of importance for successful implementation were involvement of the executive municipal management, strong managerial focus on creating engagement and commitment among all professional groups, practical facilitation of work processes, and a stable organisation without major competing priorities. At the end of the project period, the pathway was integrated in daily practice in two of the six municipalities. In these municipalities the care pathway was found to have the potential of structuring the provision of home care services and collaboration with the GPs, and serving as a management tool to effect change and improve knowledge and skills.

Conclusion

The generic care pathway for elderly patients has a potential of improving follow-up in primary care by meeting professional and managerial needs for improved quality of care, as well as more efficient organisation of home care services. However, implementation of this complex intervention in full-time running organisations was demanding and required comprehensive and prolonged efforts in all levels of the organisation. Studies on implementation of such complex interventions should therefore have a long follow-up time to identify whether the intervention becomes integrated into everyday practice.

【 授权许可】

   
2015 Røsstad et al.; licensee BioMed Central.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B: Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012, 380(9836):37-43.
• [2]Rosstad T, Garasen H, Steinsbekk A, Sletvold O, Grimsmo A: Development of a patient-centred care pathway across healthcare providers: a qualitative study. BMC Health Serv Res 2013, 13:121. BioMed Central Full Text
• [3]Stange KC: The problem of fragmentation and the need for integrative solutions. Ann Fam Med 2009, 7(2):100-3.
• [4]Mistiaen P, Francke AL, Poot E: Interventions aimed at reducing problems in adult patients discharged from hospital to home: a systematic meta-review. BMC Health Serv Res 2007, 7:47. BioMed Central Full Text
• [5]Jolly K, Bradley F, Sharp S, Smith H, Mant D: Follow-up care in general practice of patients with myocardial infarction or angina pectoris: initial results of the SHIP trial. Southampton Heart Integrated Care Project. Fam Pract 1998, 15(6):548-55.
• [6]Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T: Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ 2012, 345:e5205.
• [7]Garåsen H, Windspoll R, Johnsen R: Intermediate care at a community hospital as an alternative to prolonged general hospital care for elderly patients: a randomized controlled trial. BMC Public Health 2007, 7:68. BioMed Central Full Text
• [8]Van Houdt S, Heyrman J, Vanhaecht K, Sermeus W, De Lepeleire J: Care pathways across the primary-hospital care continuum: using the multi-level framework in explaining care coordination. BMC Health Serv Res 2013, 13:296. BioMed Central Full Text
• [9]Bernabei R, Landi F, Gambassi G, Sgadari A, Zuccala G, Mor V, et al.: Randomised trial of impact of model of integrated care and case management for older people living in the community. BMJ 1998, 316(7141):1348-51.
• [10]Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M: Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008, 337:a1655.
• [11]Romoren TI, Torjesen DO, Landmark B: Promoting coordination in Norwegian health care. Int J Integr Care 2011, 11(Spec 10th Anniversary Ed):e127.
• [12]Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC: Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009, 4:50. BioMed Central Full Text
• [13]Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O: Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 2004, 82(4):581-629.
• [14]May CR, Mair F, Finch T, MacFarlane A, Dowrick C, Treweek S, et al.: Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci 2009, 4:29. BioMed Central Full Text
• [15]Ferlie EB, Shortell SM: Improving the quality of health care in the United Kingdom and the United States: a framework for change. Milbank Q 2001, 79(2):281-315.
• [16]Grol R, Wensing M: What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust 2004, 180(6 Suppl):S57-60.
• [17]May C, Finch T: Implementing, Embedding, and Integration Practices: An Outline of Normalization Process Theory. Sociology 2009, 43(3):535-54.
• [18]Normalization Process Theory On-line Users’ Manual and Toolkit [http://www.normalizationprocess.org/]
• [19]McEvoy R, Ballini L, Maltoni S, O’Donnell CA, Mair FS, Macfarlane A: A qualitative systematic review of studies using the normalization process theory to research implementation processes. Implement Sci 2014, 9:2. BioMed Central Full Text
• [20]May C, Finch T, Mair F, Ballini L, Dowrick C, Eccles M, et al.: Understanding the implementation of complex interventions in health care: the normalization process model. BMC Health Serv Res 2007, 7:148. BioMed Central Full Text
• [21]Malterud K: Systematic text condensation: a strategy for qualitative analysis. Scand J Public Health 2012, 40(8):795-805.
• [22]Bamford C, Heaven B, May C, Moynihan P: Implementing nutrition guidelines for older people in residential care homes: a qualitative study using Normalization Process Theory. Implement Sci 2012, 7:106. BioMed Central Full Text
• [23]Lloyd A, Joseph-Williams N, Edwards A, Rix A, Elwyn G: Patchy ‘coherence’: using normalization process theory to evaluate a multi-faceted shared decision making implementation program (MAGIC). Implement Sci 2013, 8(1):102. BioMed Central Full Text
• [24]Gask L, Bower P, Lovell K, Escott D, Archer J, Gilbody S, et al.: What work has to be done to implement collaborative care for depression? Process evaluation of a trial utilizing the Normalization Process Model. Implement Sci 2010, 5:15. BioMed Central Full Text
• [25]Murray E, Burns J, May C, Finch T, O’Donnell C, Wallace P, et al.: Why is it difficult to implement e-health initiatives? A qualitative study. Implement Sci 2011, 6:6. BioMed Central Full Text
• [26]de Stampa M, Vedel I, Mauriat C, Bagaragaza E, Routelous C, Bergman H, et al.: Diagnostic study, design and implementation of an integrated model of care in France: a bottom-up process with continuous leadership. Int J Integr Care 2010, 10:e034.
• [27]Duner A, Blomberg S, Hasson H: Implementing a continuum of care model for older people-results from a Swedish case study. Int J Integr Care 2011, 11:e136.
• [28]Rycroft-Malone J, Seers K, Crichton N, Chandler J, Hawkes CA, Allen C, et al.: A pragmatic cluster randomised trial evaluating three implementation interventions. Implement Sci 2012, 7:80. BioMed Central Full Text
• [29]Kotter J: Leading change. Harvard Business Review Press, Boston; 2012.
• [30]Murray E, Treweek S, Pope C, MacFarlane A, Ballini L, Dowrick C, et al.: Normalisation process theory: a framework for developing, evaluating and implementing complex interventions. BMC Med 2010, 8:63. BioMed Central Full Text
• [31]Whittle C, Hewison A: Integrated care pathways: pathways to change in health care? J Health Organ Manag 2007, 21(3):297-306.
• [32]Lewin S, Glenton C, Oxman AD: Use of qualitative methods alongside randomised controlled trials of complex healthcare interventions: methodological study. BMJ 2009, 339:b3496.