Improving care coordination for community-dwelling older Australians: a longitudinal qualitative study

Loading...
Thumbnail Image
File version
Accepted Manuscript (AM)
Author(s)
Harvey, Desley
Foster, Michele
Strivens, Edward
Quigley, Rachel
Griffith University Author(s)
Primary Supervisor
Other Supervisors
Editor(s)
Date
2017
Size
File type(s)
Location
License
Abstract

Objective: The aim of the present study was to describe the care transition experiences of older people who transfer between subacute and primary care, and to identify factors that influence these experiences. A further aim of the study was to identify ways to enhance the Geriatric Evaluation and Management (GEM) model of care and improve local coordination of services for older people.

Methods: The present study was an exploratory, longitudinal case study involving repeat interviews with 19 patients and carers, patient chart audits and three focus groups with service providers. Interview transcripts were coded and synthesised to identify recurring themes.

Results: Patients and carers experienced care transitions as dislocating and unpredictable within a complex and turbulent service context. The experience was characterised by precarious self-management in the community, floundering with unmet needs and holistic care within the GEM service. Patient and carer attitudes to seeking help, quality and timeliness of communication and information exchange, and system pressure affected care transition experiences.

Conclusion: Further policy and practice attention, including embedding early intervention and prevention, strengthening links between levels of care by building on existing programs and educative and self-help initiatives for patients and carers is recommended to improve care transition experiences and optimise the impact of the GEM model of care.

What is known about the topic?: Older people with complex care needs experience frequent care transitions because of fluctuating health and fragmentation of aged care services in Australia. The GEM model of care promotes multidisciplinary, coordinated care to improve care transitions and outcomes for older people with complex care needs.

What does this paper add?: The present study highlights the crucial role of the GEM service, but found there is a lack of systemised linkages within and across levels of care that disrupts coordinated care and affects care transition experiences. There are underutilised opportunities for early intervention and prevention across the system, including the emergency department and general practice.

What are the implications for practitioners?: Comprehensive screening, assessment and intervention in primary and acute care, formalised transition processes and enhanced support for patients and carers to access timely, appropriate care is required to achieve quality, coordinated care transitions for older people.

Journal Title
Australian Health Review
Conference Title
Book Title
Edition
Volume
41
Issue
2
Thesis Type
Degree Program
School
Publisher link
Patent number
Funder(s)
Grant identifier(s)
Rights Statement
Rights Statement
© 2017 AHHA. This is the author-manuscript version of this paper. Reproduced in accordance with the copyright policy of the publisher. Please refer to the journal's website for access to the definitive, published version.
Item Access Status
Note
Access the data
Related item(s)
Subject
Counselling, wellbeing and community services
Persistent link to this record
Citation
Collections