Academic journal article Australian Health Review

Improving Care Coordination for Community-Dwelling Older Australians: A Longitudinal Qualitative Study

Academic journal article Australian Health Review

Improving Care Coordination for Community-Dwelling Older Australians: A Longitudinal Qualitative Study

Article excerpt


Older people represent the fastest growing age group of Australia's population,1 and their hospital admission rates are increasing rapidly.2 Because of complex and fluctuating health needs, their pathway through the hospital system,3 and across the health system as a whole,4 often includes multiple care transitions, creating uncertainty and bringing them into contact with numerous healthcare professionals.5 Care transitions ('periods of time when an individual either moves to a new care setting or changes levels of care within a setting' 6) typically comprise a complex set of activities.7 As such, transitions involve risks that can compromise service safety and quality, as well as patient outcomes.7-9 In Australia, the aged care system is difficult to navigate, with services poorly coordinated across different levels and locations of care.10

Since 2010, the Australian Government has invested substantially in subacute care and implementation of Geriatric Evaluation and Management (GEM) services. This geriatricianled service model promotes a multidisciplinary, coordinated solution to improve care transition experiences and outcomes for older people.11 Delivered in a dedicated ward area, the GEM model is effective in reducing functional decline, mortality and discharge to residential aged care.11 The objective of the GEM model is to plan and provide medical, psychosocial and rehabilitative care tailored to a patient's specific needs and to ensure coordinated discharge planning.11 However, implementation of complex service delivery innovations, such as the GEM model, can be difficult to achieve in specific contexts.12 The response of patients and healthcare professionals, as well as factors within the local context, can have a bearing on how implementation progresses.13 In this case, the fragmentation of aged care services and the complex needs of older people following discharge pose particular challenges.14 Therefore, formative evaluations based on diverse data sources can be beneficial in revealing factors in the local context that inform successful implementation.13

The aim of the present formative evaluation was to: (1) describe care transition experiences from multiple perspectives and identify personal, systemic and local factors affecting these experiences; and (2) identify applied solutions that could be used to enhance implementation and capacity of the GEM model.


Design and setting

An exploratory, longitudinal case study design was used to address the aim of the study. This involved repeat interviews with patients and carers, patient chart audits and focus groups with service providers. Case study research is suited to in-depth investigation of patient journeys over time and across the continuum of care.3,15 Study rigor was derived by triangulation of multiple data sources, data collection methods and researcher perspectives during analysis, prolonged engagement between researchers and participants, and an audit trail of decisions and procedures.16

The location of the study was a regional Queensland hospital. At the time of the study, two specialised Older Persons Evaluation, Rehabilitation and Assessment (OPERA) units were progressively replaced by a 32-bed purpose-built OPERA ward. The model of care, based on principles of GEM, was consistent across all settings. Ethics approval for the study was obtained from the Far North Queensland Human Research Ethics Committee (HREC/12/QCH/76-802) and James Cook University Human Research Ethics Committee (H5460).

Participants and recruitment procedure

A criterion sampling approach was used to recruit patients of the GEM service with a Mini-Mental State Examination (MMSE) score >20 and a nominated carer (excluding privately paid carers). As data were collected and reviewed, purposive sampling was adopted so that the sample reflected variation in pre-admission history, carer circumstances, length of stay, post-acute service eligibility, demographic characteristics and relevance to the emerging analysis. …

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