Transitions

Patient flow and transition care

Patients moving from hospitals to long-term primary health care and the interaction between these two levels are the main focus of the research project outlined here. When the project was initiated, there was no data on how many and what type of patients that are transferred to long-term primary health care (at home or in nursing homes) from hospitals. Furthermore, we seek data on how patients and informal caregivers experience and evaluate these transitions. Consequently crucial information is lacking to propose improvements or reforms in the sector.

It is striking to see how basic information about patient flows between hospital care and long-term care is lacking - in Norway and elsewhere. Recent research has indicated that better continuity of care during and after hospital discharge may improve patient outcomes, patient satisfaction and overall costs of care and reduce rate of rehospitalization. Improving inter-agency cooperation in health care may yield gains and focusing on the patient with a bottoms-up approach (starting change from the lowest organizational level) has been seen as a major contribution to identify differences and dependencies in the care chain. Patients requiring formal post-hospital care of particular concern are cancer patients, psychiatric patients and the frail elderly. Hospital use of people > 80 years is complex and different from other groups. Patients requiring rehabilitation, nursing home patients and terminal care have fewer admissions but relatively higher hospitalization time consumption.

The aim of this project is to expand our knowledge in three areas: 1) patient flow; 2) user perspectives and 3) inter-agency barriers. The project comprises 31 (of totally 434) municipalities in Norway, stratified by size and region. The project is in collaboration with Norwegian Social Research (NOVA) and the Institute for Nursing and Health Scienfces at the University of Oslo.

Project Manager is professor Tor Inge Romøren.