BACKGROUND: A comprehensive Primary Health Care approach includes clear referral and continuity of care pathways. South Africa lacks data that describe Intermediate Care (IC) services and its role in the health system. This study aimed to describe the model of service provision at an IC facility and the role it plays in the continuity of care in Cape Town. METHODS: Sixty-eight patients (65% Response Rate) were recruited in a prospective cohort design over a one-month period in mid-2011. Patient data were collected from a clinical record review and an interviewer-administered questionnaire, administered at a median interval between admission and interview of 11 days to assess primary and second ary diagnosis, knowledge of and previous use of Home Based Care (HBC) services, reason for admission, demographics and information on referring institution. A telephonic interviewer-administered questionnaire to patients or their family members post-discharge recorded their vital status, use of HBC post-discharge and their level of satisfaction with care received at the IC facility. A Cox regression model was run to identify predictors of survival and the effect of a Care-plan on survival. Seventy staff members (82%) were recruited in a cross-sectional study using a self-administered questionnaire to describe demographics, level of education and skills in relation to what they did for patients and what they thought patients needed. RESULTS: Of the 68 participants, 38 % and 24% were referred from a secondary and tertiary hospital, respectively, and 78% were resident of a higher income community. Stroke (35%) was the most common single reason for admission at acute hospital. The three most common reasons reported by patients why care was better at the IC facility than the referring institution was the caring and friendly staff, the presence of physiotherapy and the wound care. Even though a large proportion of the IC inpatients had been admitted in a health facility on the year preceding the study, only 13 patients (21%) had used a Community Health Worker (CHW) ever before and only 25% (n=15) of the discharged patients had a confirmed CHW visit post-discharge. The presence of a Care-plan was significantly associated with a 62% lower risk of death (Hazard Ratio: 0.380; CI 0.149-0.972). Notably, 46% of staff members reported performing roles that were outside their scope of practice and there was a mismatch between what staff reported doing and their actual tasks. In addition, of the 57 patients that could be traced on follow-up 21(37%) had died. CONCLUSION: Patients and family understood this service as a caring environment that is primarily responsible for rehabilitation services. Furthermore, a Care-plan which extends beyond admission could have a significant impact on reducing mortality. IC services should therefore be recognised as an integral part of the health system and it should be accessed by all who need it.

Background: Increased pressure, rising demand and cost constraints have driven a need for radical service re-design in the NHS. To deliver re-design objectives it is necessary to understand how they are perceived by service users and providers. Aim: To investigate the views of patients and health care professionals (HCP) on aspects of health policy and service re-design affecting primary care. Setting: Patients and HCPs from one geographical area in England. Method: Themes from phase one qualitative interviews were explored quantitatively using a questionnaire in phase two and a discrete choice experiment (DCE) in phase three. Factor analysis was used to explore HCP responses in phase two. In phase three the DCE was administered to explore patients‟ relative priorities of a range of attributes. Results: HCPs had concerns that the Quality Outcomes Framework (QOF) detracted from the patient‟s agenda and did not improve health outcomes. GPs felt continuity of care was important Monday through Friday but were not keen on its provision out of hours. Neither did they feel nurses could run chronic disease management clinics without a GP present. Patients felt continuity could be provided by different HCPs for different conditionsPatients stated continuity of care and consultation duration were the most important attributes in a primary care service. However, in the DCE they prioritised both being seen on the day and by a GP over longer appointments. Patient preference to be seen by a GP may reflect the low uptake of non-medical prescribing in the area. Conclusion: Continuity of care, while remarked as being important to both HCPs and patients, appears less important when weighted against other primary care service attributes. HCPs appear to want longer consultations whereas patients saw time as encompassing both the time to wait for an appointment and consultation length. For patients, the quality of the time with a HCP may be more important than its duration, additionally patients appear to want choice but not necessarily to choose.

Philosophiae Doctor - PhD (School of Public Health) / South Africa has an estimated two million documented and undocumented immigrants. In addition, Statistics South Africa (2014) notes very significant internal migration. This mobile population is affected by chronic communicable and non-communicable diseases such as TB, HIV, and diabetes, although it has a Constitutional right to health and healthcare. Their quality of healthcare and disease control also affects the general population and the burden on the health system can be increased by inadequately managed chronic conditions as well as acute health care needs. Access to healthcare and continuity of care reflect both patient agency and the health system. Community Health Workers (CHWs) play an important role in linking communities and patients to health services and vice versa. The aim of this study was to understand how agricultural migrants in the Cape Winelands District of Western Cape Province of South Africa navigated the healthcare system to access healthcare services including securing continuity of care, and in particular the role of CHWs in this process, in order to inform policy and practice.

Objective: This study sought to answer the question “What feasible changes can be made to care processes and clinical information systems to improve Continuity of Care for end of life patients?” Methods: This study adapted Genre Theory and Soft Systems Methodology into a new systems approach, the Circle of Care Modeling Approach. Thirty-four healthcare providers and health IT professionals were interviewed in two communities in British Columbia, Canada. The interviews sought to discover the nature of care provided for end of life patients and how clinical information systems supported care. Interviews were centered on two simulated end of life patients. The patient centric healthcare system, or Circle of Care, was described for each of these patients in each community. Rich Pictures and Conceptual Models were developed based on interview findings. These diagrams were used with participants to discuss gaps in continuity and to seek improvements during a series of structured discussion groups. Results and Discussion: The Circle of Care for end of life patients was found to be large and complex in both communities. Potentially dozens of providers would have been involved in each patient’s care over their last year of life. No provider knew all members of the Circle of Care. All communication activities that were described by participants could be described within the Circle of Care with ten Abstracted Genres. Patient information was housed in many disparate repositories (both paper and electronic) and access to these repositories was limited. The participants described several aspects of Continuity of Care. A new model to describe Continuity of Care was developed based on the findings and taking into account the systems orientation of this study. Six suggested improvements were generated with the study participants to better support Continuity of Care within the communities in this study. These are described in the dissertation. The suggested improvements were compared to existing functionality of clinical information systems. This novel approach to exploring and visualizing the healthcare system from a patient-centric lens, the Circle of Care Modeling Approach, provided a new way of describing and reasoning about the complexities associated with Continuity of Care.

The current context of offender health in England and Wales indicates that offenders re-enter their communities with limited pre-release preparation for the continuity of access to healthcare and an increased risk of release with a health condition and very little support to cope in the community. This study was aimed at mapping the ex-offender health pathway towards identifying ‘touch points’ in the community for the delivery of a nurse led intervention. The study was a qualitative case study underpinned by ‘The Silences Framework’ which enabled it to gain theoretically by situating power with offenders, thus, aiding their ‘Silences’ to be heard, explored and brought to light. Participants meeting the study inclusion criteria were quantitatively ranked on the basis of poor health with those scoring the lowest and confirming their ranking through a confirmation of a health condition selected as cases and interviewed over the course of six months. These interview narratives were confirmed by interviewing individuals in the professional networks of offenders. The study identified the site of post-release supervision as the ‘touch point’ where a nurse led intervention could be delivered. With regards to the delivery of the health intervention, the study indicated that the nurse led intervention be provided as an advisory and signposting service structured on a drop-in and appointment basis. Furthermore, the study indicated that pre-release, offenders were not prepared in prison for the continuity in access to healthcare in the community on release. On-release, offenders’ on-release preparation did not enquire as a matter of procedure on whether offenders were registered with a GP or had the agency to register self with a GP practice in the community. Post release, the study uncovered a disparity between services which address the physical health needs of offenders and those which address their mental and substance misuse health needs.

Organisation de la sortie d’hospitalisation et impact sur la santé des patients. Nous avons réalisé une revue systématique afin d’explorer l’association potentielle entre des éléments factuels des processus de sortie d’hospitalisation et de continuité des soins en aval et la survenue d’événements de santé en post-hospitalisation. Les résultats indiquent une absence d’association entre la survenue d’un dysfonctionnement ou d’une action d’amélioration au cours du processus de sortie et la mortalité. Concernant les réhospitalisations ou les passages aux urgences, l’analyse de la littérature apporte une réponse plus nuancée. Parallèlement, l’hétérogénéité constatée entre les études empêche la réalisation d’une synthèse quantitative et entrave une évaluation robuste de l’impact d’éléments factuels des processus de sortie et de continuité des soins sur la santé des patients.Point de vue des patients sur l’organisation de leur sortie d’hospitalisation. Nous avons comparé le point de vue des patients sur le processus de sortie selon deux modes de recueil, auto-questionnaire complété sur un site internet dédié versus entretien téléphonique, en tirant profit de l’infrastructure de l’étude SENTIPAT. Même si le taux de réponse des patients du groupe internet était inférieur à celui des patients du groupe téléphone, les informations rapportées par les patients via Internet ne différaient pas significativement de celles recueillies par téléphone. Nos résultats suggèrent le déploiement d’un système d’information pérenne permettant à des patients volontaires de transmettre leur point de vue sur la sortie d’hospitalisation et incitent à développer le concept de patient sentinelle. / Organization of hospital discharge and impact on patient health outcomes. We made a systematic review of the literature with the aim of exploring associations between components of the hospital-discharge process–including continuity of care thereafter–and patients’ health outcomes in the post-discharge period. Results indicate that none of the studies reported a statistically significant association between the presence of a component or an intervention likely improving the quality of hospital-discharge process and mortality. As regards rehospitalizations or emergency department visits, the analysis of the literature provides a more balanced response. At the same time, the wide heterogeneity observed across the studies prevents from performing a meaningful meta-analysis and no consistent statistical association between components of the hospital-discharge process including continuity of care thereafter and patient health outcomes could be identified.Patients’ opinions on the hospital discharge process. Taking advantage of the SENTIPAT trial, we undertook an ancillary study that compared two methods for collecting patients’ opinions on the discharge process: questionnaire self-completion on a dedicated internet website versus a telephone interview. Although the internet patients’ response rate was lower than that of the telephone patients, estimates of patient satisfaction on the discharge process issued from both modes of administration of the questionnaire were similar. Results advocate for establishing a permanent information system that would enable volunteering patients to express their opinions on hospital discharge and for developing the concept of sentinel patient.

Bakgrund: Barnmorskor upplever att rotationsarbete och kontinuitet i arbetet leder till en god vård, bredare kunskap samt att det uppskattas av patienter. Barnmorskorna känner sig mer välmående i sin arbetssituation. Det leder även till en dubbel kompetens hos barnmorskorna. Syfte: Syftet med studien var att beskriva barnmorskors upplevelse av att arbeta roterande mellan mödrahälsovård och förlossningsvård. Metod: En kvalitativ intervjustudie där semistrukturerade intervjuer med åtta deltagande barnmorskor arbetande i mellansverige utfördes. En kvalitativ innehållsanalys utfördes vilken resulterade i fyra kategorier samt nio subkategorier. Resultat: Barnmorskornas upplevelser av att arbeta roterande beskrevs som ett omväxlande och givande arbete som gav glädje och tillfredsställelse, trots att det var arbetsamt. Samtidigt var det en utmanande uppgift då de behövde hålla sig uppdaterade på två arbetsplatser, få ihop tidboken på barnmorskemottagningen och bibehålla kompetensen på förlossningsavdelningen. Arbetsplatserna skiljde sig åt vilket var med fördelar och nackdelar. En viktig grundsten i arbetet var kollegialt stöd, och att ha en hemarbetsplats istället för två upplevdes positivt. Rotationsarbete ur patientsynvinkel ansåg barnmorskorna vara uteslutande positivt då de kunde ge ett utökat stöd till de födande vilket var en vinst för både barnmorskan och patienten. Slutsats: Trots att det kräver extra arbete från barnmorskorna är upplevelserna av att arbeta roterande övervägande positiva både ur barnmorskans eget perspektiv samt deras beskrivning av respons från patienterna. Det finns relevans för att genomföra ytterligare forskning inom området genom att intervjua en större grupp med barnmorskor. / Background: Midwives experience that working rotationally and with continuity leads to a quality of good care, bigger knowledge and the care is valued by patients. This also leads to a double competency for the midwives. Aim: The aim of the study was to describe midwives’ experience of working rotation between antenatal care and perinatal care. Method: A qualitative interview study with semi structured interviews were conducted, with eight participating midwives working in the central Sweden. An analysis was conducted, resulting in four categories and nine subcategories. Result: The midwives’ experiences of working rotationally were described as a varied and rewarding job that brought joy and satisfaction, even though the work was trying. The work was a challenging task, they needed to be updated at two workplaces, make sure the patients were being cared for at the maternity clinic and maintain the expertise at the maternity ward. The workplaces differed, which was advantageous and disadvantageous. An important cornerstone for the work was collegiate support and having one instead of two working places. From the patients’ point of view the rotationally work by the midwives was positive as they could provide increased support for childbearing women, which was beneficial for the midwives and the patient. Conclusion: Although it requires extra work from the midwives, the experience of working with rotation is mostly positive both from the midwife’s own perspective as well as their description of the patient’s response. There is relevance for conducting further research in the field by interviewing a larger group of midwives.

The ageing population of Sweden is expected to increase throughout the future decades. Changing life-style trends and smaller families in the modern society has decreased the population’s access to informal care. This is expected to entail an increase in the services provided by specialized home care. This thesis studies the work performed by nurses within the department of specialized home care (ASIH) in Stockholm County. The nurses represent the majority of all professions active at ASIH in Stockholm County, which puts their work in particular interest for this thesis. The thesis focuses on the ways the nurses’ work procedures may influence continuity of care and patient safety. Continuity of care is an essential component in qualitative care and is characterized by well-executed coordination and minimization of broken patient appointments. A high level of continuity of care consequently entails a high level of patient safety. Descriptions of continuity of care at ASIH in Stockholm County can therefore provide indications on current care quality and areas of improvement. The thesis consists of two parts – a literature review containing international research on continuity within home care and an empirical study containing a retrospective analysis based on the Functional Resonance Analysis Method (FRAM). The empirical study creates an overview of work tasks related to nursing performed at three units of ASIH in Stockholm County. The interdependencies between work tasks are identified and important chain reactions are analyzed. The findings from this thesis indicate that extended training programs for nurses in the initial phase of employment is likely to decrease the number of disruptions in the nurses’ work. Furthermore, well-developed routines could facilitate work task procedures which would decrease the number of delays and disruptions in the nurses’ work. It was found that these findings together with information continuity between all parties involved represent significant factors for attaining continuity of care and patient safety at ASIH in Stockholm County. / Den äldre befolkningen i Sverige förväntas öka under de kommande årtiondena. Det moderna samhället har dessutom medfört förändrade livsstilar och allt mindre familjekonstellationer, vilket har resulterat i en minskad tillgång till anhörigvård. Detta förväntas medföra en ökad efterfrågan av tjänster som tillhandahålls av specialiserad hemsjukvård. Den specialiserade hemsjukvården ansvaras av Avancerad Sjukvård I Hemmet (ASIH) i Stockholms län. Sjuksköterskor utgör den största andelen anställda av de yrken som är verksamma vid ASIH. Denna rapport undersöker sjuksköterskornas arbetsflöden vid tre ASIH-enheter i Stockholms län. Rapporten fokuserar på att undersöka på vilka sätt sjuksköterskornas arbetsprocesser kan påverka vårdens kontinuitet och patientsäkerhet. Vårdkontinuitet är ett centralt begrepp i kvalitativ hemsjukvård och kännetecknas av välkoordinerad vård och lågt antal otillfredsställande patientbesök. God vårdkontinuitet förväntas medföra hög patientsäkerhet. Återgivningar av den nuvarande vårdkontinuiteten på ASIH i Stockholms län tros därför kunna skapa en uppfattning om den nuvarande vårdkvaliteten samt eventuella förbättringsområden. Denna rapport utgörs av två delar – en litteraturstudie som innehåller internationell forskning om vårdkontinuitet i hemsjukvård samt en empirisk studie som innehåller en retrospektiv analys baserad på Functional Resonance Analysis Method (FRAM). Den empiriska studien skapar en översikt över sjuksköterskors huvudsakliga arbetsuppgifter vid de tre undersökta ASIH-enheterna belägna i Stockholms län. Arbetsuppgifternas korrelationer samt ömsesidiga påverkan kartläggs och signifikanta kedjereaktioner analyseras. Resultaten i denna rapport påvisar att utökad undervisning för sjuksköterskor i anställningens inledande skede kan troligen minska antalet störningar i sjuksköterskornas dagliga arbete. Dessutom påvisar resultaten att fler tydliga rutiner skulle kunna underlätta sjuksköterskornas arbetsprocesser, vilket skulle kunna minska antal förseningar och störningar i deras dagliga arbete ytterligare. Dessa fynd i kombination med välfungerande kommunikationer mellan alla berörda parter utgör de huvudsakliga åtgärderna för att erhålla vårdkontinuitet och patientsäkerhet hos ASIH i Stockholms län.

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