Overview of Focus Groups and Participants
N=11 focus groups with a total of N=74 participants were conducted. Seven focus group interviews were conducted in non-profit NHs and four in private administrated NHs. The focus group sessions lasted between 20 and 59 minutes, with an average of 39 minutes. 78.8% of all participants were female. Most of the participants were nurses working within the participating NHs (n=48), followed by consulting GPs (n=20). A full overview of the distribution of participants can be seen in Table 1. As the focus groups target on the interdisciplinary team of GPs, nurses and GP assistants as a whole, differences between professions were not analyzed.
Table 1: Overview of participants
|
Male
|
Female
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Total
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General practitioners (GPs)
|
13
|
7
|
20
|
GP assistants
|
0
|
6
|
6
|
Nurses at the NHs
|
3
|
45
|
48
|
Total
|
16
|
58
|
74
|
CoCare
Participants had opinions and associations on all aspects of CoCare, thus eleven main themes (see Table 2) were ascertained: state of implementation; CoCare-Cockpit (CCC); medical rounds; medication check; communication and collaboration; medical specialists; extended availability; case conferences, quarterly and annual meetings; treatment courses; management of catheters; overall assessment. Furthermore, four subthemes were identified. An overview of all main and sub-themes including descriptions and coding rules can be found in Additional File 2.
Table 2: Main themes and sub-themes
Main themes
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Sub-themes
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State of implementation
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Barriers for implementation
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CoCare-Cockpit
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Use and Benefit of the CoCare-Cockpit
|
|
Barriers to use
|
Medical rounds
|
|
Medication check
|
|
Communication and collaboration
|
General practitioner teams
|
Medical specialists
|
|
Extended accessibility
|
|
Case conferences, quarterly and annual meetings
|
|
Standard courses of treatment
|
|
Management of catheters
|
|
Overall assessment
|
|
State of Implementation
As the NHs entered the project at different times, the state of implementation differed across facilities. Furthermore, some participants mentioned that not all the modules could be implemented at once, since the implementation takes some time. However, even if single components had not yet been implemented in the NHs, the participants did emphasize that CoCare builds awareness for the health care of the elderly and specific topics, such as the medication checks. Some focus groups mentioned that some modules, such as the medical rounds, were part of their regular routine even before CoCare, so that they did not see the need to change it within the project CoCare.
Participant 1: “And there are a few things we still need to try. That´s too early to discuss.”
Participant 2: “So, especially the documentation, the CCC, that´s something new. We still kind of tiptoe around it. It is still very new and we need to gain some experience with it during the coming weeks and months.” (Focus group 4).
Barriers for Implementation
According to the participants, the biggest barrier for full implementation was the lack of available resources to devote to the intervention, such as nurses’ time. The issue of understaffing due to sickness or training was repeatedly mentioned.
Furthermore, participants mentioned that there was a great deal of bureaucracy during the project, which accounted for the high workload.
„It would be possible during normal business. But then? Someone gets ill, someone is absent, someone is in training. And then suddenly nobody is here or nobody, who can….nobody has time to do these additional tasks.” (Focus group 1)
CoCare-Cockpit (CCC)
Participants had varying opinions on the CCC (electronic medical records). Overall, the idea of common electronic medical records between GPs and NH was rated positively. Communication between GPs and NH had improved since the implementation of the CCC according to some participants. Improved preparation of medical rounds and reminders for medical rounds, as well as automated treatment recommendations were named as positive aspects of CCC. Additionally, participants suggested some features for future developments, such as a tracking of changes made. However, most NHs would only do basic documentation in the CCC, with the medical rounds and medication being the most documented modules of CoCare.
„You can document all hospitalizations or someone is at the hospital and you get push-up messages from the Cockpit: Please do a medical round for that resident, after he comes back from the hospital! That way, we won´t forget it” (Focus group 3)
Barriers to use
The biggest barrier mentioned was, that NHs and GPs already use their own documentation system in order to comply with regulatory standards. Thus, NHs used up to three different systems including the CCC resulting in double documentation. This double documentation could potentially lead to mistakes, especially as no software interfaces are available.
Furthermore, some participants reported that the NHs struggled with their access to the internet and new network cables had to be installed before the CCC could be used.
„And if you ask me, that would lead to mistakes, because every normal person, when they have written or typed the exact same thing for the third time, they might leave something out, no longer want to…(several other participants agree in the background)…every normal person would do that…” (Focus group 11)
Medical Rounds
According to the participants, the newly implemented weekly medical rounds attended by GPs and nurses were one of CoCare´s most important modules. Even though some NHs had regular medical rounds before the project, most participants still reported positive effects. Holding rounds on the same day each week allowed for better preparation by both nurses and GPs. According to some participants, residents would feel much more comfortable as medical rounds were scheduled regularly. One participant said that the newly implemented GP´s visits were already preventing unnecessary hospitalizations.
„…due to these visits, I know all the patients, know their pathology […] and I would say, that we notice,…even skin changes or if the patient has a mild fever or something similar, so we can really prevent hospitalizations.” (Focus group 7)
Medication Check
In most NHs, medication checks are conducted during medical rounds. Participants stressed the importance of the medication checks, as some residents are given a lot of medication. They valued that the project reminded them to conduct the medication checks regularly. Most participants said that the medication checks are conducted during the regular medical rounds in discussion with attending nurses. Where possible, GPs would include psychiatrists and neurologists to talk about psychotropic drugs, too.
Medication checks are especially important after a hospital discharge, as hospital doctors would not pay attention to existing medication, changing the medication plan or adding new medication.
Additionally, participants wished that the CCC would issue a warning if two or more medications had negative interaction effects.
But now, sitting down during the visits, looking at the medication plan together and talking about it with every profession. […] Most medications are from the hospital, they stay in the plan or will be continued […] (Focus group 9)
Communication and Collaboration
The project was seen as a team building intervention by many participants. Communication and collaboration are very important in NHs and CoCare might have led to more trust within the team. More time for communication and consultations is left due to the strict framework of the project.
For nurses, the barriers when talking to GPs were lowered, making it easier to agree on a resident’s treatment. Participants said teamwork was more professional in some NHs now and decisions were being made with the whole team being involved. Participants also regarded a consistent contact person within the NHs as positive.
Moreover, the contact to the GP´s assistants was perceived as better and more structured, making it easier to organize treatment and medical rounds.
Again, one participant mentioned that the improved communication within the team had already led to a prevention of unnecessary hospitalizations.
„When I come here, I have a number I can dial, I have someone who has time for me and is my contact person. Furthermore, I need to say: There is some structure. When something is not clear, there is someone I can talk to.” (Focus group 2)
General Practitioner Teams
Positively mentioned was the additional financial compensation CoCare provided to GPs for supplying medical care in NHs. That would have made it easier to recruit GPs for the project.
Furthermore, GPs appreciated the newly set up GP teams for providing consultation at a NH, as visits and treatment planning were made easier. If GPs worked in a team at a NH, they would leave a message for the GP to lead the next visits or short consultations about the treatment planning. In this way, a continuous treatment of residents could be guaranteed. However, GPs would not change the medication plan for a patient if the patient was being mainly treated by another GP. The newly built GP teams are also a relief for the nurses, as they know a GP from the team will be at the NH to provide care more often than before.
„And I do use it in a way, when I see: O.k. a colleague of mine will do a medical round, that I communicate: There is a problem. I´ll be back in only a week. Can you have a look? (Focus group 3)
Medical Specialists
All participants were of the opinion that medical specialists´ consultations, such as psychiatrists or urologists, are important. However, most participants said that it was not easy to find specialists for regular consultations within the NH.
“No other NH believes us when I tell them that we have a neurologist who comes to see our residents regularly. That´s not something you see very often.” (Focus group 1)
Extended Availability
The extended availability of GPs during the evening hours was received very differently among participants. Whilst being accessible even in the evening was natural for some GPs, others refused to do it due to the high workload.
In some NHs with extended GP hours, GPs and nurses had agreed to call the GP first in case of need. Together with the nurses, they would then decide what to do next. Again, one of the participants indicated that this new course of action had already helped prevent hospitalizations.
However, all the participants agreed that, in order to ensure extended accessibility, more GPs would be needed to distribute the workload better.
“There is always someone to approach and we agreed that we would be called before an ambulance is requested. We then come around and have a look, if that is really necessary.” (Focus group 1)
Case Conferences, Quarterly and Annual Meetings
Case conferences as well as quarterly and annual meetings had not yet been implemented in most NHs. Most participants struggled to distinguish between the three kinds of meetings. One participant mentioned that they had been conducting quarterly talks within the framework of the regular medical rounds.
„So the medical rounds usually take a long time and the quarterly talk is supposed to be 90 minutes I think. I think we do that several times per quarter during the medical rounds, right?” (Focus group 4)
Standard Courses of Treatment
When asked about the standard courses of treatment, opinions differed between the participants. For some participants, the standard courses of treatment were too detailed to learn and follow. Moreover, some participants did not know that the pathways were available as a hard copy outside the CCC.
Other participants thought the standard courses of treatment were helpful, noticing that it made GPs mindful of previously overlooked issues. Especially the treatment pathway for the transition from curative to palliative care was mentioned as being particularly helpful. One participant reported that the standard courses of treatment were used as a template for further developments of other pathways, such as a procedure for urinary tract infections. Participants also appreciated the training given before the implementation of the standard courses of treatment.
“I thought the training was interesting, there were examples and categories: the agitated patient, the aggressive patient. That is extremely helpful, because it actually is a simple pattern, giving you a structure for problem solving.” (Focus group 10)
Management of Suprapubic Catheters
The affiliated GP´s had to specifically order a sonography device if they wished to perform the management of suprapubic catheters; some participants mentioned that the delivery took too long. Furthermore, participants criticized that the sonography device can only be used on patients, who consented to take part in CoCare and not for other procedures.
„In CoCare they only play a role for these catheters…[…]. Apart from that we don´t use it really. However, we could use it for other procedures.” (Focus group 9)
Overall Assessment
The overall assessment differed among participants. Some participants regarded the project as “genius”, improving the care of residents in NHs. Due to the additional financial compensation, the GPs said they were in a good position to implement CoCare´s most important modules. Special focus was put on the preventative aspect of CoCare, making it easier to treat residents’ illnesses early. However, some participants stated that most aspects of CoCare were already the standard care in their respective NH. Some participants feared that if CoCare was implemented in standard care, it would pose a bureaucratic hurdle.
“Of course, we want CoCare to be positively evaluated, because the system itself is genius and it would be a pity if it were not to be part of the standard care in future.” (Focus group 7)