Enhancing health system interfaces: a study of experiences of sub-acute care patients, their carers & providers

Aims

1. Examine experiences and impacts of the Geriatric Evaluation and Management (GEM) service on patients following different care pathways

2. Examine how personal, systemic and local community factors impact and influence GEM patients' journeys across acute, sub-acute and primary care settings

3. Determine optimal approaches to local coordination of individualised primary health care and subacute services for older people with complex care needs

Synopsis

Hospital admissions for emergencies are increasing worldwide and the largest increases are for people over 65 years. Older people present to the emergency department (ED) with multiple, interrelated medical, functional and psychosocial issues and have complex care needs. In the absence of coordinated, comprehensive needs assessment and planning, these patients have an increased risk of deterioration in function, readmissions and imposed institutional care.

The Geriatric Evaluation and Management (GEM) model of care is a national policy direction for multidisciplinary, coordinated care of older patients with multiple conditions and complex health care needs who present at the ED. There is compelling evidence that a GEM model of care is effective in reducing functional decline, mortality and discharge to residential aged care. Due to system fragmentation and the complex needs of older patients following discharge, a GEM service is unlikely to significantly impact on avoidable hospital admissions unless issues at the acute, sub-acute and primary care interfaces are also identified and addressed. Patient care can be compromised during transitions between hospital and community based care because of poor integration between sectors, services and providers, consumers being unaware of, or unable to access services, poor communication and service gaps.

To optimise patient care and achieve real systems benefits from investment in GEM services, systematic documentation of the patient journey across the continuum of care is required, including what contributes to problems at the system interfaces that might result in avoidable hospital presentations. There is research on the interface between acute, sub-acute and primary care in metropolitan settings - However, evidence is required in regional and rural areas where limited services, workforce shortages and distance challenge effective service delivery for older people.

A GEM service commenced in Cairns in 2010, with services delivered in a sub-acute setting focused on optimising functional independence. Each patient is assessed by a multidisciplinary team and individual care plans developed. For continuity of care, each plan involves discussions with the patient, the patient's family and community agencies that are already involved, or could potentially enable discharge to the community.

The project will use a qualitative methodology to examine the journey by older people presenting at ED who are referred to the GEM service and discharged to the community. It will examine service experience, needs and access to services from the perspective of patients, carers and service providers. The study will provide a longitudinal perspective on the patient journey through acute, sub-acute and primary care and empirical evidence of what matters to patients in sub-acute care. It will identify service gaps in addressing health and social care needs across the spectrum of care and specify the critical components of integrated care for older people in the community. It will provide policy makers and health service planners with empirically derived recommendations for improving the quality of sub-acute care and system interfaces and by consequent, contribute to reducing the number of older patients who present unnecessarily at the ED and re-enter from primary care to sub-acute care via the ED.

Partnerships

  • Chief investigator: Dr Edward Strivens, College of Medicine and Dentistry, Division of Tropical Health and Medicine, James Cook University
  • Dr Desley Harvey, Senior Research Fellow, Cairns and Hinterland Hospital and Health Service
  • A/Prof Michele Foster, Social Policy Unit, School of Social Work and Human Services, University of Queensland
  • Rachel Quigley, Queensland Health
  • Dr Michael Wilson, CEO, Far North Queensland Medicare Local

In partnership with the

  • Far North Queensland Medicare Local
  • University of Queensland Australia
  • Queensland Government