Exploring hospital readmissions from the primary healthcare service: A multiple case study
Introduction: Hospital readmissions have received increased attention in the past years due to the negative impact on quality of care, health services’ resources and finances. The hospital readmission issue is a multifaceted phenomenon involving numerous processes (e.g. discharge, transition, admission), a number of actors (e.g. nurses, patients, physicians) and is effected by both contextual and patient related factors. The primary healthcare services are deeply involved in the hospital readmission process, including their responsibility for caring for the patients post hospital discharge, and the primary care physician’s responsibilities in decision-making concerning hospital readmissions. In contrast to the primary healthcare services’ important role in hospital readmissions, research in this area is limited.
Furthermore, readmission research has mostly taken a quantitative stance, despite the wide complexity of the phenomenon, thus demonstrating a need for more qualitative research on hospital readmissions from the primary healthcare services.
Aim: To explore hospital readmissions from a primary healthcare perspective, aiming to increase knowledge about factors that lead to hospital readmissions from the primary healthcare service. More specifically, the thesis aimed to develop new knowledge about:
- General practitioners (GPs) and nursing home physicians’ decision- making in hospital
- The role of nursing home resources in readmission processes (e.g. staffing, nurse competence, physician coverage) as seen from nursing home staff and
- Hospital physicians view on hospital discharges to, and readmissions from, the primary healthcare
Methods: This thesis was conducted as a multiple case study, and includes three qualitative studies investigating hospital readmissions. The thesis included two cases with multiple sub-units. A case was defined as a municipality with included primary healthcare service and a common hospital. The sub-units consisted of four nursing homes, each of which had nursing home nurses and leaders, primary care physicians (GPs and nursing home physicians) and hospital physicians. The first study included semi-structured interviews with primary care physicians and observational studies in the included nursing homes. The second study included focus group interviews with nurses and semi-structured interviews with nursing home leaders. The third study included semi-structured interviews with hospital physicians (residents and consultants), in addition to extraction of significant elements from the commissioner’s documents for the Regional Health Authorities from 2012 – 2018. All data material was analyzed using Granheim & Lundmans’ approach to content analysis.
Results: Study I showed that the complexity of patients being discharged to the primary healthcare service had increased, consequently increasing complexity and quantity of the primary care physician’s work tasks.
Moreover, patients were perceived to be discharged too early, sometimes with undeclared medical issues, adding to the primary care physicians’ work tasks in terms of, for example, referring patients to other specialist healthcare services. Information exchange, coordination and communication between the primary healthcare service and the hospital was described as poor, particularly when patients were being discharged. These factors, combined with a busy work schedule, were related to decisions to readmit patients to the hospital.
Several other factors affected the primary care physician’s decision in this regard. The patients’ and their families’ wishes were highly relevant, although pressure to readmit patients could also come from this group. The nurses were said to be another important influencer in these decisions, mainly through their knowledge about the patients but also through the presence or absence of adequate nurse competence and staffing.
Study II found that the needs of nursing home patients had become more complex, demanding complex nursing procedures and additional resources, ultimately changing the function of the nursing homes. It was the experience of nurses and nursing home leaders that patients were from time to time discharged too early, not always adequately treated causing an increased likelihood of hospital readmission. Nurse competence and staffing were believed to be of significance for hospital readmissions, making capacity building central in all nursing homes. However, staffing and competence varied in the respective nursing homes, and along with it, the focus for capacity building. Overall, a struggle with too many assistants and unstable staffing on weekends was reported. Physician coverage in the nursing homes, which was observed to be varied, was another factor perceived to affect hospital readmissions, along with physician competence, adequat communication and coordination between healthcare services. Economy was mostly perceived not to influence patient care directly.
In study III, hospital physicians believed that patients, on occasion, were discharged from the hospital too early, sometimes causing hospital readmissions. The criteria for discharging patients had changed, leading to more patients with more complicated needs being discharged to the primary healthcare service. The hospital discharge was perceived as an intricate process involving assessments from different health personnel, requiring several planning steps and being effected by numerous factors (e.g. the patients self-care ability, the patients’ living condition and the place to which the patient was being discharged). However, in some cases, the decision to discharge could be affected by non-medical factors such as ward capacity. As a counterpart, the primary healthcare service sometimes lacked capacity to receive patients who were ready for discharge, causing unnecessarily prolonged hospital stays, and further pressure on the ward’s capacity.
Additionally, there were sometimes disagreements between the hospital physicians, and the Decision Office (in the municipality) in regards to what care level the patient should receive after the hospital stay. Although adequate communication between the healthcare services was perceived as an influencing factor for hospital readmissions by most hospital physicians, the communication was limited and most often consisted of the hospital stay summary.
Conclusion: The results of this thesis identified several factors affecting hospital readmissions from the primary healthcare service such as competence and staffing in the primary healthcare services, poor coordination and information exchange between the healthcare services and capacity of hospitals and the primary care services. The thesis found a high degree of consensus among the investigated healthcare professionals at different healthcare levels in what they believed influenced hospital readmissions.
Many of these influential aspects were linked to organizational conditions. Due to the surge of patients with complications into the primary healthcare services, the nursing homes’ function had changed towards institutions more similar to the hospitals. However, staffing, competence and physician coverage did not seem to have been adjusted accordingly, increasing the probability of unnecessary readmissions. The changed patient group affected the primary care physicians’ work tasks, yet they were still making decisions on hospital readmissions with minimal peer support.