Evidence-based modelling of a generic integrated home care and discharge practice

INTRODUCTION: The focus is to describe the process of evidence-based modelling, and the evaluation of the suitability and the effects of a model. The development and evaluation of a generic integrated home care and discharge practice is used as an example. AIMS: The aims are (1) to develop a generic practice based on scientific and practical knowledge, its evaluation criteria and an embedding method and (2) to evaluate its impacts on clients/patients, relatives (informal caregivers) as well as health and social care personnel. METHODS: Several types of evidence were used in the modelling of a generic good practice. A register-based analysis (the administrative registers on stroke and hip-fracture patients) was used to find out the variance in care and discharge practices between municipalities. Surveys to the directors of social and health services (n=302), personnel of home nursing (n=302), home help (n=302) and hospital wards (n=302) were used to find out service structure, need for development of a new practice and ongoing improvements. Also effective home care and discharge practices were searched by reviewing literature. Earlier mentioned evidence was integrated with practical expertise of home care (home nursing and home help) and hospital personnel in an action research based modelling. RESULTS: The generic model was embedded in the home care services in other municipalities. The impacts of the generic model on clients/patients, relatives, health and social care personnel, and cost effectiveness were evaluated in the design of a cluster randomised controlled trial. That involved 22 municipality-hospital pairs (number of inhabitants, services structure) randomly assigned between trial and non-trial group. The data was gathered using interviews of patients, questionnaires sent to informal caregivers and staff, and other documents. The patients were selected using inclusion and exclusion criteria. Both the trial and the non-trial group aimed to have 385 patients before and after implementation. The modelling produced a generic integrated practice with evaluation criteria and an embedding method for integration in another context (which enable also unit-led implementation). The model improved vertical and horizontal integration: change of information, multidisciplinary teamwork on interfaces of organizations, patient's discharges, especially, discharge practices between hospital and home nursing, hospital and home help, home care and support services improved. Collaboration practices improved in both municipality groups but more improvements were found in the municipalities of the trial group. Continuity of care improved in both municipality groups, but in the trial-group the change was greater and in greater number of activities. Information exchange improved especially between home care and informal care givers, health centres, service houses and support services. CONCLUSION: In conclusion, the embedding of the model improved collaboration between parties in home care and discharging. Also developed methods (model and guidelines) were useful tools in embedding and—the effects on clients are presented in other presentation.