Designing Transitional Care for Older Adults with Multiple Chronic Conditions
Background: Development of effective interventions to improve health outcomes and reduce unnecessary health service utilization among high risk populations is an urgent healthcare issue. Although care models shown to be effective exist, the specific interventions needed by the fastest-growing population of older adults with MCC have not been thoroughly examined. The purpose of this study was to develop an intervention to assist older adults with MCC by combining transitional care approaches with palliative care principles (i.e., symptom management and advance care planning). The goal was to design an intervention that was evidence-based, and practical and acceptable in a local healthcare system.
Methods: Twenty-six people (12 RNs, 5 MDs, 6 SWs, 2 PAs, 1 patient advocate) who were involved in care of older adults with MCC were identified using snowball sampling and invited to an interview. Seventeen individual and small group interviews were conducted. Participants were given a prototype transitional care intervention for older adults with MCC that was developed based on evidence in the literature by the researcher. They were asked to review and evaluate its acceptability, practicality, and potential efficacy based on their clinical experiences, current practice, and existing healthcare structures. The interviews were audio recorded and analyzed using conventional qualitative content analysis approach (Hsieh & Shannon, 2005). IRB approval was obtained from the researchers’ institution.
Results: Areas of concerns addressed by participants included: 1) different needs required by different patients, 2) discrete and overlapping roles of various disciplines, and 3) existing practices in the healthcare system. Participants described that patients’ needs vary by their bio-psycho-social profile. Diversity in their needs requires flexibility and inclusion of a multi-disciplinary approach in the intervention. Participants also expressed concerns that the new intervention might duplicate or hinder current practice or services. Based on participants’ evaluations, the prototype intervention was modified to be a nurse providing hands-on symptom management and advance care planning in addition to the treatment as usual provided by social workers and other healthcare providers in existing clinical practice.
Implications: Intervention based on existing evidence still needs to be examined in the context of local practice. Development of a clinically useful and effective intervention and testing of its efficacy require careful examination balancing scientific rigor and clinical practicality.