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Substudy 15 Executive Summary

Substudy 15: An Analysis of Blockage to the Effective Transfer of Clients from Acute Care to Home Care

by Caryl Arundel and Sholom Glouberman


Home care is an important component of health care services in Canada. It serves three main functions - to support individuals to stay in their homes and communities, to facilitate in home convalescence and care of postacute patients and to prevent institutionalization and/or hospitalization. This study looks at one component of home care - the substitution function of care in the home for hospital care. Specifically it looks at acute care patient discharge from hospitals to home care and the effectiveness of the discharge process.

Acute care support is an increasing component of home care programs in Canada. While the proportion of acute to nonacute care service varies considerably across the country, it is estimated that approximately one third of all home care is acute care service. As hospitals are pressured by financial pressures, early discharge policies, emergency backlogs and admission waiting lists, quality home care becomes critically important. This has put pressure on the home care system as a whole and in particular on the discharge relationships and processes between the two sectors. Jurisdictions have responded in a number of ways and the literature documents a range of process and program best practices.

This study looks at discharge practice from a broader, systems perspective by investigating how roles, relationships and structural boundaries between the home care and hospital sectors impact on patient discharge. A systems framework developed by Mintzberg and Glouberman was valuable in focussing attention on those boundaries at the hospital and home care levels and at the system level where they interact. The authors argue that the current way of thinking about the elements of the system overlooks this separation and differentiation and ignores the dynamic nature of the system.

Substudy 15 is based on a series of interviews and focus groups with hospital and home care-based practitioners in seven jurisdictions in Canada. These included people who provide care, are responsible for patient cure, represent the community and represent the administration, financial and policy controls on the system. The seven sites demonstrated a range of barriers that impede effective patient discharge. Barriers were identified within each of the interview subgroups, between them and between the two separate organizations. The sites also provided evidence of a number of best practices that served to span the boundaries and move towards greater program integration and coordination. There was limited evidence of system or structural integration.

The study has also been informed by an Expert Panel, representing a range of professions, organizations and interests. Their insights and expertise were valuable in reinforcing the importance of a systems approach to the study of patient discharge and in contributing to the identification and discussion of barriers and best practice issues.

Key Findings

Barriers to Discharge

The study identifies a wide range of barriers to effective patient discharge. They have been summarized into six main types of system barriers:

1. System Barriers to Working Together - includes barriers resulting from definitions of roles and responsibilities as well as the scheduling, availability and assignment of human resources.

2. Family/Caregiver/Patient Barriers - barriers resulting from resistance to discharge, lack of education/awareness of benefits of early discharge and lack of family or caregiver capacity to provide support to discharged patient.

3. Geographic Barriers - includes barriers in rural access to services, supports, equipment and supplies. Interjurisdictional barriers are also evident in "out of region" patient discharge.

4. System Management and Control Barriers - barriers resulting from inflexible governance structures, rigid systems, processes or controls. Financial controls put different pressures on each sector. Organizational focus on incompatible performance measures can similarly inhibit effective discharge relationships. Lack of common access to patient information is a significant barrier to patient discharge in some jurisdictions.

5. Constant system change - this overarching barrier inhibits the development of external formal and informal relationships and the focus and energy available for boundary-spanning initiatives.

6. Resource Barriers - three main types of resource barriers are identified. First, the system does not seem to be resourced appropriately to respond easily to new demands for service or to provide the range and scope of supports necessary to patient discharge. Second, shortages of trained health care professionals can result in barriers to discharge. And finally, limited community supports for discharged patients as well as few alternatives to home care discharge create barriers.

Lack of system resources is a significant barrier to more effective discharge in that it restricts organizational and program capacity to respond and diverts attention from quality service and care to rationing and coping. Cost shifting between acute care and home care sectors complicates the relationship often creating a win-lose climate for the interface. Cost shifting is also occurring between sectors, for example, as resources are shifted from long term care home supports to acute care home care supports. Not only is this anticipated to lead to greater demand on acute and institutional care, but it also leads to competition for resources within the community sector. The community sector in general is not resourced to support increasing postacute patients discharged from hospital. Costs are also shifted to the patient and caregivers as the types and hours of service are reduced and patients must pay much of the cost of medications, equipment and supplies, which would otherwise have been covered in the acute care setting.

Best Practices

Effective discharge practice is a relationship between formal systems and structures, relationships and system capacity. Formal systems, processes and procedures are necessary to structure the relationship between the two sectors. They set parameters and define formal roles. Relationships and informal networks are important to bridge gaps between the formal systems and extend the effectiveness of the discharge practice. These relationships develop and endure outside the formal structure and role assignment. The third element, system capacity, is critical to support the two sectors to achieve effective discharge. Adequate budget, resources and program capacity are essential underpinnings of an effectively functioning system.

The study proposes a set of eleven factors important to best discharge practice.

Formal Systems:
1. Legitimization of the relationship between acute care and home care
2. Access to compatible and/or common information systems
3. Flexible use of resources

Relationships and Informal Networks:
4. Formal opportunities for communication and the development of working relationships
5. Continuity and stability of staff assignment
6. Boundary spanning positions

System Capacity:
7. Program resources
8. Access to home care - availability of referral and assessment service
9. Home care supports
10. Community supports
11. Continuum of care

Not surprisingly, no jurisdiction involved in the study demonstrated best practice in all the factors. Some focussed their energies within one of the three areas, formal systems, relationships and system capacity, while others attempted to make progress in all three. In many jurisdictions strong informal relationships between hospitals and home care staff were able to counterbalance barriers associated with formal systems and processes.

The findings also suggest that there are thresholds beyond which little additional progress can be made towards best practice. For example, most jurisdictions realized discharge-related improvements when roles and relationships were better defined between hospitals and home care. Further progress appears stalled because of problems associated with client information. Until patient information is accessible and shared many are uncertain about further improvement in the discharge process.

Interface issues are complex. The study found that old methods of coordination based on standard responses to situations did not work well in the complex health care environment. Networks based on informal relationships were more important as approaches to develop best practices and to improve communication and education. The findings also suggest that there is no one approach to hospital to home care patient transfer that will work. Instead there is a need to recognize the unique characteristics of each jurisdiction and to capitalize on opportunities to strengthen relationships between the sectors and develop a common focus. A number of the jurisdictions are introducing boundary spanning positions or "boundroids" to informally support the development of stronger relationships between the sectors as well as to educate and facilitate the discharge process where necessary. Others are designing discharge positions to work within both the hospital and home care sectors.

The current climate of ongoing financial, policy and structural change also served to complicate the discharge interface. Two of the sites appeared better able to provide an effective discharge process in the current changing environment. Both home care programs were long-standing, well-focussed programs with "strong cultures" and positive reputations built on client focussed care. They had consistent leadership and direction. Both programs had managed, over a period of time, to build a strong set of formal and informal relationships with the hospital and community sector which served to support them when the formal relationships and environment were changed.

Related Issues

It has been estimated that families and informal caregivers provide approximately 80 per cent of all home care supports. Further work needs to be directed at understanding the linkages between families and informal caregivers and the formal discharge systems and programs. Not only do acute care and home care have to work together to effect patient discharge but they also have to work with the prime caregivers, the family.

The study cautions that changes to the relationship between acute care hospitals and home care programs will have impacts on relationships with other sectors. While it is important to achieve effective and efficient acute care discharge processes, attention must be directed to unintended impacts on the community sector and the continuing care sector in particular.

Substudy 15 raises some additional issues that deserve further attention and study. The relationship of home care to emergency departments is an important component of the hospital to home care interface that was outside the scope of this study. The study highlighted the need to build a stronger and more robust community service system to provide a broader range of community supports and to support care in the community. And finally, many involved in the study urged the development of more creative options to care for postacute individuals and individuals requiring higher levels of care than can be supported by current home care programs. At present, there are few alternatives to acute care hospitalization or institutionalization.