A Pilot Study on Health Care Utilization: Outpatient Aftercare for Geriatric Patients and Their Relatives ()
1. Introduction
Due to increasing life expectancy with higher risks of multimorbidity and dementia, patient centered care has become increasingly challenging.
During the last decades research in Gerontology has focused mainly on a positive perspective on ageing. Recommended models of care and treatment for the elderly, seek to preserve or even enhance quality of life by activating available resources [1-3]. Aging process nevertheless may lead to recurrent inpatient stays of older patients at Geriatric hospital wards. Repeated assignments to the hospital by general practitioners as well as recurrent selfhospitalization point towards supply shortage of psychosocial services. Practice based institutions as well as outpatient therapy offers fall short of sufficient facilities providing post treatment.
After discharge from the hospital, outpatient care is of great importance in order to sustain the stabilization reached during the stay. Additional emphasis on nursing relatives seems equally important [4].
Different after-care concepts, such as daytime clinics or outpatient therapy centers provide supporting structures for geriatric patients, although they mainly exist in urban environments and entail rather high costs. Ambulant care by interdisciplinary teams is another popular and frequent procedure, offered to predominantly multimorbid patients with considerable physical disabilities. These offers are likewise costly and cause significant organizational efforts [5].
Geriatric outpatient care delivered within the logistic structure of the hospital (involving medical and therapeutical treatments) is a rather innovative and sparsely researched method [6], combining cost efficiency with high acceptance by the elderly.
The areal, temporal and individual-related close link to the inpatient stay can help avoid time-consuming handovers or repeated admissions to subsequent social support services. This continuity in therapy may encourage compliance and reduce anxiety [7]. Group interventions aim at behaviour modification and the recovery and preservation of autonomy. The main priority however is a more positive mental state.
Results of a benchmarking survey in a number of geriatric wards in Austria showed that nearly 29% of multimorbid geriatric patients were diagnosed with depression [8]. Depressive symptoms were highly associated with lack of social contacts—especially in elderly women who constituted 85% of the examined (polled) patients [9]. These findings justify the choice of group interventions for those patients.
Essential for successful rehabilitation is the basic assessment of the patient’s current condition within the five domains, such as mobility, cognition, self-efficiency, social contacts and emotional state as well as interdisciplinary teamwork in therapeutic-rehabilitative interventions [10]. The staff appointment scheme for clinical psychologists at geriatric wards in Austria considers a single position per 100 patients. Out-patient after-care settings are even more under-staffed.
2. Development of Contents for Group-Interventions
This offer for aftercare can be described as process of exploration, decision-making and problem-solving regarding age-specific problems. This pilot study included a practical step by step approach, resulting in a comprehensible and transparent list of possible interventions. In addition to imparting general psychological information, topics were meant to cover the relevant troubles of patients. Individual social skills and the ongoing group process have to be considered.
2.1. Structure
The aftercare is divided in theme-oriented steps of intervention, comparable to a modular construction system. These individual subject areas are selected following motivation, problem awareness and attentiveness of patients. Depending on the respective requirements of the group, some topics may be more popular than others.
The different topics are presented in various settings: 1) group intervention, includes conveying important information to all participants, problem-solving within the group and mutual development of coping-strategies; 2) personal consultation, e.g., emphasis on specific personally relevant topics, individual problem solving and development of coping-strategies as well as motivation; and 3) homework, for example preparation and reinforcement of specific topics and trying out, practicing and strengthening new strategies and skills.
2.2. Prerequisite for the Realization of the After-Care Project
During in-patient stay at the geriatric ward at the hospital in Waiern, the interdisciplinary team presented the aftercare project to the patients and their relatives. Criteria for inclusion were: 1) age over 60 years; 2) place of residence in the vicinity of the hospital (time of travel not more than 30 minutes); 3) assessment of dementia (MMSE-score > 21) [11]; and 4) willingness to participate.
For relatives no criteria were defined, anybody interested was provided with information folders. All prospective participants signed informed consent forms after having been assured of anonymity and protection of privacy.
2.3. Intervention
After informing patients and relatives in person as well as by written information, the intervention started with a first meeting of the group. Patients attending the group had been dismissed from hospital in the week preceding the intervention.
The group sessions mostly had the following timetable:
1) After a general address of welcome and some loosening exercises, the participants were asked to present possible requirements and questions. Subsequently the group session took place.
2) The chosen topics (see Table 1) were dealt with by the group according to logic chronology.
3) In addition to psychological interventions, medical or social services as well as individual consultation were offered after the group sessions.
4) After the individual supplementary interventions (medical treatments, consultancy by social services, personal counseling) the group got together again for cake and coffee.
5) At the end of the afternoon, the next meeting was planned (time, location, relevant topics, question etc.).
3. Methods
3.1. Objective
A collection of group themes for multi-morbid patients and their relatives was compiled in cooperation with the Alpen-Adria University of Klagenfurt and the geriatric ward of the Hospital Waiern. The goal focused on meeting the complex problems of the elderly. The pertinent questions for this pilot study can be summarized as follows:
1) Which of the offered interventions will be accepted by the patients and their relatives (utilization behavior)?
2) To what extent can the outpatient aftercare treatment contribute to the stabilization of the former patients?
3) Are (caring) relatives a separate target group for specific interventions?
3.2. Survey Instruments
A group observation sheet for the estimation of treatment effects was designed to assess criteria such as: interest in a subject, attention and discussion participation. A simple socio-metric recording method was used to observe the group dynamics, based on an overall assessment of a foreign observer. The review of the effectiveness of this project was based on conversations and interviews with patients and family members (e.g. collection of individual problems, needs, goals) and quantitative methods from the
basic geriatric assessment (e.g. MMSE, GDS [12]), to do a preand post comparison.