Obstacles to and opportunities for care collaboration through the utilization of an effective preventive care process for frail older adults: A study protocol for a mixed methods study design.

doi:10.21203/rs.3.rs-2565347/v1

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Study protocol

Obstacles to and opportunities for care collaboration through the utilization of an effective preventive care process for frail older adults: A study protocol for a mixed methods study design.

https://doi.org/10.21203/rs.3.rs-2565347/v1

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Background: The gap between the groups in society experiencing good health and those not is increasing. Frail older adults are among the most vulnerable groups. Malnutrition, poor oral health, pressure ulcers and falls are common problems increasing the risk of hospitalization or admission to residential care facilities. An effective preventive care process is therefore needed to prevent such adverse events. Interprofessional care collaboration between the teams in residential care facilities, home help care, primary care, and hospital care is described as being prerequisite for an effective, safe, and effective preventive care process. However, the way in which thisprocess is carried out across Sweden’s municipalities varies. There is also a need to understand how managers in elderly care, interprofessional teams, and older adults themselves perceive how well the process of care collaboration functions. The protocol outlined here describes the design of a study aimed at exploring factors that constitute obstacles to and opportunities for care collaboration within and between different care providers through the utilization of an effective preventive care process for frail older adults in Sweden, based on the quality register Senior alert.

Method: A convergent mixed methods study design will be used combining quantitative (quality registers and open data) and qualitative data (practice-based semi structural interviews and focus group interviews with key informants at various organisational levels in elderly care). The results will provide the foundation for the creation of a model for an effective preventive care process for frail older adults, including improved care collaboration, which will be tested in a pilot study.

Discussion: Frail older adults face a high risk of negative events and hospitalization, which in turn leads to increased healthcare costs and decreased quality of life. There is a knowledge gap with regard to the obstacles to and opportunities for an effective preventive care process regarding these negative events. To increase patient safety and provide equitable care for frail older adults, good collaboration between care providers and the use of quality registers might be of importance.

Age care

Co-design

Improvement science

Preventive care process

Quality register

From a healthcare perspective, frail older adults probably constitute the largest vulnerable group in society. Due to complex healthcare needs they are dependent on collaboration between various care providers and professions (i.e. nurses, dietitians, occupational therapists, dentists, assistant nurses, physicians, social service workers), regardless of the administrative level of their care (1). However, it is well known that the process of collaboration between different care providers and between different healthcare and social service professionals, within or between organisations, is complex. Moreover, low staff continuity and inadequate access to staff with appropriate skills make the provision of quality elderly care challenging (2, 3). Actions to prevent, for example, pressure ulcers, falls, malnutrition and poor oral health are often overlooked and given low priority compared with the treatment of diseases or injuries (4, 5). Taken together, achieving well-functioning collaboration in the care of older adults is a complex process. In addition, there is limited understanding of how to make the system work effectively in order to provide safe, person-centred care for frail older adults (6). Considering these considerable challenges, we will study care collaboration using the preventive care process (PcP) in the qualitative register Senior alert (SA).

A greater understanding of the mechanisms that contribute to care collaboration within and between organisations in Sweden in the PcP, regardless of level of administration, might increase patient safety (7), counteract adverse events, and promote equality of care for frail older adults (8) throughout the country. There is no generally accepted terminology in Sweden for the concept of “care collaboration” and a plethora of methods and tools to enable better collaboration can be found in the healthcare sector and/or the literature (9–11). In the literature, the attribute that is associated with collaboration often includes concepts such as “sharing”, i.e., sharing of resources and/or decision-making. Other attributes of collaboration are “teamwork” and “respect” with regard to improving patient safety and quality of care (ibid). In medical and nursing sciences the concept of collaboration has been highlighted as valuable and might contribute to building trust in the relationships between patients and relatives and the healthcare professions (12, 13). Positive outcomes of collaboration are quality of care, patient safety, and making it easier for the patient to gain an overview of his/her care process (14, 15). Previous studies indicate that care collaboration in healthcare seems to be considered highly valuable in principle, and that older adults and caregiver’s want to be actively engaged in a dialogue regarding care (16), but that collaboration is difficult to achieve in all situations in everyday care (17). The difficulties seem to refer to the absence of clear goals or clear evaluation criteria, which contributes to a misconception regarding care collaboration (9). In research, the value of care collaboration has been questioned (18, 19). This scepticism is due to the evaluation methods used where most studies seem to be designed to assess how participants experienced and/or perceived care collaboration; further studies are therefore needed (4). The study presented here will add knowledge by applying a convergent mixed methods design based on statistics from SA and open data, which will constitute the basis for the individual and focus group interviews, in order to better understand the obstacles to and opportunities for collaboration.

Governance Of The Care Of Older Adults In Sweden

Sweden as a welfare state provides care and a social security system for every individual in the country throughout the entire course of their life. The healthcare system is governed by the democratically elected parliament. The country’s regions and municipalities are responsible for the provision of health and social care services; these are financed by taxes. However, the regions and municipalities have independent powers of taxation, meaning that they tax separately. This can create a financial obstacle to well-functioning care collaboration. Further, the health and social care of older adults is provided by the regions and the municipalities and is governed by two laws: the Social Services Act (SoL) and Health Care Act (HSL). The regions are governed by the HSL and the municipalities by the SoL and HSL. SoL is a civil rights law giving the individual specified rights and HSL is a law of obligation addressing the obligations of Swedish care providers. The care of older adults in Sweden is, therefore, complex since it is governed by two legal spaces with different perspectives and different sources of financing; this entails challenges for care collaboration across organizational boundaries (Fig. 1). In total, 21 regional councils are responsible for the provision of hospital, primary, psychiatric, and dental care for the population. The regional councils are responsible for dental care for persons needing special support or dental care as part of disease treatment and/or surgery. In addition to the HSL, the care provider’s obligations are described in the Dental Care Act (TvL), the Patient Act (PL), the Patient Data Act (PDL), and the staff's obligations are described in the Patient Safety Act (PSL). At local level, there are 290 municipalities governing residential care facilities and home help care services in accordance with the SoL. Healthcare in residential care facilities and home help care is governed by the HSL. Approximately 80,000 older adults in Sweden live in municipal residential care facilities (20) and are permanently in need of care from different care providers (21, 22).

The complexity of elderly care governance and the increased risk of hospitalisation and admission of older adults to residential care facilities create challenges for care collaboration between different care providers. There is, therefore, a need to identify the obstacles to and opportunities for fully utilizing the potential for the collaborative care of frail older adults in the prevention of negative events. Based on the WHO definition of prevention (23), the importance of preventive measures to reduce, for example, hospital readmissions among frail persons was demonstrated as early as 2001 (24, 25) and still poses challenges(26). Moreover, a deeper understanding of how the interplay within and between interprofessional teams is perceived within and between different care providers is crucial in order to contribute to patient safety and to strengthen the quality of care, regardless of geography, socioeconomics, place of birth, disability, age, gender or ethnic background (27).

Senior Alert

Senior alert (SA) is the largest quality register in Sweden aimed at frail older adults in need of healthcare and long-term care; it is used by 288 of Sweden’s 290 municipalities (28). A quality register contains individualised data concerning medical interventions, procedures, and outcomes within healthcare production. Registers are monitored annually and approved for financial support by an National Executive Committee. SA promotes quality improvement through the preventive care process (PcP) (Fig. 2) in which staff screen for the risks for falls, bladder dysfunction, pressure ulcers, malnutrition, and poor oral health. After risk assessment, underlying causes, actions, and follow-up are implemented and registered, allowing for comprehensive monitoring and evaluation at individual, care unit, and societal levels. SA can also be used to achieve various aims, such as providing an integrated and active means of enabling continuous staff learning and for quality improvement in care, as well as for research.

In 2008, the register focused on three areas: malnutrition, pressure ulcers, and falls among people ≥ 65 years of age. In 2011, the assessment of oral health was included and in 2014 the assessment of bladder dysfunction was added. In the forthcoming study, the assessment of bladder dysfunction will be excluded since the number of registrations is incomplete; four focus areas will therefore be included.

These four risk areas are interrelated; for example a fall could imply a risk for malnutrition and poor oral health, and poor oral health could exacerbate difficulties eating(29). Frail older adults in need of care should therefore undergo risk assessments to ensure that preventive actions are taken and follow-up is performed to avoid adverse events. Common risks among older people are assessed using validated evidence-based instruments (Downton Fall Risk Index (30), DFRI; Modified Norton scale (31); Mini Nutritional Assessment (MNA)(32) and Revised Oral Assessment Guide – J (ROAG-J)(33).

The PcP in SA is based on four steps: 1) Screening for risk assessment: aimed at identifying possible risks within the focus areas; 2) Team-based investigation of the underlying causes: to allow proper measures to be taken; 3) Actions to perform interventions/events: within the focus areas; 4) Follow up: to monitor the effect of the intervention. Based on the outcome of the intervention, decisions may be made regarding the need for new interventions. Complete registration means registration in all four focus areas and in all steps of the process, if a risk has been identified. Complete registration is a prerequisite for the PcP to work effectively and when there is a need for dialogue and/or practical actions within and/or between care providers.

Almost 90,000 risk assessments were performed in residential care facilities in 2020. Risks were identified in at least one of the four focus areas in 92% of cases in residential care facilities and home help care (34). However, not all identified risks led to an intervention, which is in line with previous research concluding that frail persons do not receive planned and performed interventions to the required degree, and SA is therefore not used to its full potential (35). A mismatch between identified risks and planned interventions has also been found suggesting that there are flaws in how the PcP is implemented.

Rationale

On 2 March 2017, the Swedish Government decided to appoint an inquiry chair with the remit of supporting county councils/regions, relevant government agencies and organisations in the coordinated development of modern, equitable, accessible and effective health care. The Inquiry chose the name “Coordinated development for good quality, local health care” in Swedish “Nära Vård”. In the transition to “Nära Vård”, the importance of how collaborative care and a more coherent healthcare system can be organised is central to the success factors that need to be described and/or developed (27). We intend to study care collaboration with regard to the preventive care process in Senior alert (SA), within and between different healthcare organizations, including dental care, and within and between interprofessional teams. When properly used, SA is expected to provide a foundation for the systematic improvement of collaborative care that successfully prevents adverse events and leads to important knowledge within all four risk areas. There is also a need to identify the obstacles to and opportunities for fully utilizing SA to achieve a more effective PcP. Moreover, a deeper understanding of these obstacles and opportunities is needed in order to develop a model for an effective PcP for frail older adults in Sweden. This model can then be tested and upscaled.

Aim

To explore factors that constitute obstacles to and opportunities for care collaboration within and between different care providers in the utilization of an effective preventive care process for frail older adults.

The research questions are:

Are there differences between the quality of registration in the municipalities (QR) (high or low proportion of complete registrations in SA) that can be explained by factors such as demographics, socio-demographics, economy, organization of elderly care, and political majority?
What obstacles to and what support for good collaboration exist within and between different care providers regarding the completion of an effective preventive care process in SA?
How can a model for care collaboration in the preventive care process be improved?

The study design

A convergent mixed methods design(36, 37) divided into three phases will be used (Table 1). The timeline is 4 years from 1 November 2021 to 31 December 2025. The focus in this paper will be on phases 1 and 2. The first phase is quantitative and will compare municipalities in Sweden with regard to data from official statistics. The second phase is qualitative and will be partly based on the results from phase 1; interviews will be conducted to further explore experiences, preferences, and concerns. The third phase involves combining findings from phases 1 and 2. An improved PcP model will be designed and tested in a pilot study (Table 1, Fig. 3).

Data collection and Participants

Phase 1: Data of interest will be derived from SA where municipal residential care facilities in all registering municipalities between 2019 and 2021 will be included. Private municipal residential care facilities and home help care services will be excluded. For each risk assessment, we will check whether the underlying cause, action plan and follow-up have been registered within the four focus areas: pressure ulcers, weight loss, poor oral health, and falls. All municipalities will receive a compliance index based on their results (Table 2). We will select municipalities with a high proportion of complete registrations and low proportion of complete registrations.

Each risk assessment receives a Compliance Index Value (Table 2), which constitutes the municipality’s compliance index (compliance indices range from 1 = complete registration to 0 = totally incomplete registration). For each municipality we will then calculate the average of these values, which will represent the ”Compliance” indicator for each municipality. Subsequently, the 286 municipalities will be sorted according to this indicator. Municipalities with fewer than 1000 risk assessments will be omitted. Among the remaining, the 10 with the highest values of compliance and the 10 with the lowest values of compliance will be studied further. The calculation will be based on the total number of completed registrations and expressed as a percentage in each of the PcP focus areas. Open data from ‘Statistics Sweden’ will be used to examine if differences between the municipalities can be explained by factors such as population, socio-demographics, economy, organisation of elderly care, and political majority. These data are based on information submitted in various surveys from government agencies, enterprises, and private persons.

Phase 2

The basis for this phase consists of interviews in five residential care units within the high compliance index group and five units within the low compliance index group, selected from the identified municipalities in phase 1. In each unit, one focus group interview (~ 4–7 participants) will be performed with interprofessional teams and one focus group interview with older persons and/or next of kin (~ 4–7 participants). Further, 30 semi-structured individual interviews will be held with residential care managers at group and organisation level, for example medically responsible nurses, unit managers, doctors and nurses in primary care, and local politicians. In total, between 110 and 170 key informants will be included. The high compliance index and low compliance index groups, respectively, will be contacted through the head of the administration responsible for elderly care in each municipality and asked to participate in the study. Information about the project will also be sent to the primary care manager, the nurse who is specially trained to assume an expanded role in providing medical care under the supervision of a physician, and to the manager for the Swedish Public Dental Care. When the head of the administration responsible for elderly care in the included municipalities has given consent for participation in the study, project information will be sent to the unit managers of the residential care facilities. Focus group interviews, one per unit, will be conducted with interprofessional teams. In addition, five focus group interviews with older persons and/or next of kin will be performed to explore their experiences of how the collaboration works and the quality of the PcP. The qualitative part of the study will also involve 30 semi-structured individual interviews with managers at group and organisation level.

The interviews will be based on the importance of leadership for effective care collaboration across organisational boundaries, with a focus on identifying factors that represent obstacles to or opportunities for carrying out the PcP.

Results obtained in phase 1 will partly form the basis for the semi-structured individual interviews and the focus group interviews. The focus group questions will, in general, focus on the obstacles to and opportunities for utilizing SA to achieve a more effective PcP and on care collaboration in and/or between teams and different care providers. All interviews will include questions addressing the three attributes defined as important for care collaboration (sharing, teamwork and respect). All respondents will give informed consent and all interviews will include some basic information about the respondents, such as age, sex, and years in service.

Phase 3:

Based on the findings in phases 1 and 2, a model for an effective PcP and improved care collaboration for frail older persons will be developed and implemented in one of the residential care facilities identified in phase 2 of the study. The collection of process data to be used to evaluate the pilot project will be based on the new Medical Research Council guidance (38). We will involve the interprofessional teams, older people and/or next of kin, and care managers to develop a model for an effective PcP and care collaboration for frail older persons.

Methodological and theoretical considerations

A strength of this study is the mixed methods design, which will offer the possibility for the examination of the preventive care process (PcP) from different perspectives. It will also provide opportunities to gain a deeper understanding of, and important insights into, the complexity of the health and social care of older adults. In addition, the ambition is to add knowledge about how an implementation strategy for an effective PcP can be developed in elderly care in Sweden. The project will apply the theory of organisational learning(39) in order to understand how experiences, beliefs, and attitudes contribute to the routines and (40, 41) practice of organisations, taking into consideration the institutional complexity of public organisations (42) and the collaboration between public organisations (43). A systematic review of articles describing the implementation of person-centred care for older persons in out-of-hospital settings (44) showed that interprofessional collaboration, with a focus on preventive measures, is crucial for optimal care practice both for, and in collaboration with, older persons and their relatives, within their own unique circumstances.

The co-design method, used in phase 3, was originally developed as a healthcare quality improvement tool (45), will be used by including a user-centered design and learning perspective (46, 47). This method has proven to be effective by ensuring that working models are relevant and user-friendly, and partly by ensuring engagement in the implementation process (48, 49). The co-design will be supplemented by a person-centred approach, which means that all care providers are seen as skilled partners collaborating with the older person (11, 50). Combining the co-design with a person-centred approach and organisational learning theory will increase the understanding of the complexity that the care of frail older people often involves (39) in order to develop an effective PcP and care collaboration for frail older adults in Swedish elderly care, irrespective of care provider.

Data analysis

Phase 1

Data processing and analysis of risk assessments/interventions will be performed regarding the quantitative data. Descriptive and analytical statistics will be used for the analysis.

Phase 2

Data from various contexts and key informants will be collected. Qualitative content analysis will be employed, which is a systematic and commonly used method to analyse qualitative data.

Phase 3

In line with the framework for process evaluation in the Medical Research Council guidance, data on fidelity to the intervention, contextual factors and how those interacted with the intervention, and mechanisms of impact will be collected through observations and interviews with the participants. Data will be analysed using manifest and latent content analysis (52).

This convergent mixed methods study (51) is based on three phases exploring factors that constitute obstacles to and opportunities for well-functioning care collaboration within and between different care providers. The focus for collaboration is the PcP, based on the quality register Senior alert (SA). Knowledge about how care collaboration works in the context of preventive measures for frail older adults in Sweden is currently limited (38, 52). The Swedish Association of Local Authorities and Regions (SALAR) has launched several initiatives aimed at obtaining such knowledge. The quality registers constitute an important part of the ambition for the sustainable development of future healthcare where person-centred, locally available and equitable care is applied (53). Additionally, they enable structured care information as a basis for follow-up, benchmarking of the quality of care between municipalities and decision making. Another initiative is the National System for Knowledge-based Management within Swedish Healthcare, the National Program Groups (NPO) (2), a joint system to deliver more knowledge-based, equitable, and resource-effective care of high-quality, including prevention, treatment, and rehabilitation measures. In total, 26 national program areas have been covered, where the care of older adults constitutes one area. Furthermore, the 21 Regions in Sweden are all in agreement that collaboration is the key to building sustainable and successful healthcare through the vision “Success must be counted in lives and equality of health”^[6]. All these initiatives are dependent on care collaboration within and between different care providers. The rationale for this study is to increase knowledge about the factors constituting obstacles to and opportunities for well-functioning care collaboration within and between different care providers. The convergent mixed methods design will use an explanatory sequential design, where quantitative data constitutes a basis for the first research question. The second research question will capture the voices of key informants through individual and focus group interviews to gather their views and experiences of being seen and understood in the context. Quantitative and qualitative research designs have their advantages and disadvantages. When a complex phenomenon is studied, both designs might be needed to reach a more complete understanding of the research problem (54). We have chosen an explanatory sequential design since the quantitative data in phase 1 could partly contribute a starting point for the questions asked in the interviews in phase 2. Data from these two phases will then form the basis for the development of an effective PcP model that will be tested in a pilot study in one of the residential care facilities identified in the second phase. If the implementation of the model is successful, we aim to proceed with a research proposal for a full-scale study including residential care facilities in various municipalities with different demographics, socio-demographics, economy, organization of elderly care, and political majority.

Older adults are among the most vulnerable groups in the population and constitute the majority of patients using the healthcare system. An effective preventive care process, including well-functioning care collaboration, is a prerequisite for the prevention of adverse events with regard to malnutrition, poor oral health, pressure ulcers and falls. The knowledge gained from this study may increase understanding of how preventive care for older adults can be improved.

Project Organisation

The members of the research group have considerable experience in both quantitative and qualitative research, including improvement and implementation studies, as well as in clinical practice within health and social care and register research using national quality registers. Furthermore, their backgrounds within healthcare are multi-professional (including occupational therapist, dietitian, nurses, dentist, Public Health Scientist), all with a gerontological focus. Together, the group’s combined scientific experience includes gerontology, geriatrics, rehabilitation, medicine, social science, nutrition, and nursing. Moreover, the research group has long experience of collaboration with various care providers in both municipal care and regional healthcare. Members of the research group also have extensive experience of collaboration with government ministries and other authorities at government level. This extensive range of professional competences forms the basis for elucidating various aspects of the research problems.

A steering group and a reference group will also be recruited. The steering group is intended to have an overarching perspective and contribute to the project’s focus and implementation. The reference group, on the other hand, is intended to act as a critical partner in dialogue with the researchers during the project. Meetings with the steering group and the reference group will be held at least twice a year, when an update and follow-up of the sub-studies and their results will be reported and the planning for the coming year agreed. If necessary, further meetings will be arranged with the steering and reference groups, whose feedback and ideas will be extremely valuable for the project’s development. As well as scientific publication, dissemination of the results to those responsible for the care of older adults within the municipalities and regions is an important part of the project.

Ethics approval and consent to participate:

Ethical approval was received from the Ethics review authority in Uppsala, Sweden, 20220427, (2022-01520-01). All methods will be carried out in accordance with relevant guidelines and regulations. Informed consent will be obtained from all participants once the study starts.

Consent for publication (not applicable)

Availability of data and materials (not applicable)

Competing interests (none)

Funding: The study has received financing from FORTE (no 2021-01807), the Swedish Research Council for Health, Working life and Welfare, to the amount of 5 952 157 SEK and will be in progress from 1 November 2021 to 31 December 2025. The project is a collaboration between Kristianstad University; the University of Gothenburg; Linköping University; the Academic Center for Geriatric Dentistry, Stockholm; and Qulturum, Region Jönköping County. The funding will be managed by Kristianstad University.

Authors' contributions: All authors contributed to the study design. The manuscript was prepared by MB and ER and discussed and elaborated by all authors. M.B prepared Figures 1-3 and Tables 1-2. All authors reviewed the manuscript.

Acknowledgement: (not applicable)

Authors' information: Elisabet Rothenberg, Associate Professor and Registered Dietitian, is the principle investigator and has the main responsibility for the project; she will lead phase 1. Martina Boström, PhD, Development Manager and Public Health Scientist is operational project manager and will lead phase 2. Anette Erichsen Andersson, Associate Professor, Nurse and implementation researcher, will be the leader for phase 3. Helle Wijk, Professor in Nursing and Registered Nurse; Pia Skott, PhD, Dentist, Research and Development Manager for Swedish Public Dental Care, Stockholm and Deputy Director of the Academic Center for Geriatric Dentistry; and Åsa Larsson Ranada, PhD, Occupational Therapist, will participate by contributing their expertise in all phases and ensuring the interdisciplinary perspective.

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Tables 1-2 is available in the Supplementary Files section.

No competing interests reported.

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Obstacles to and opportunities for care collaboration through the utilization of an effective preventive care process for frail older adults: A study protocol for a mixed methods study design.

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Abstract

Figures

Background

Governance Of The Care Of Older Adults In Sweden

Senior Alert

Rationale

Aim

Methods

The study design

Data collection and Participants

Phase 3:

Methodological and theoretical considerations

Data analysis

Discussion

Conclusion

Project Organisation

Declarations

References

Tables

Additional Declarations

Supplementary Files

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