Abstract
Introduction: An acute respiratory infection in community-dwelling potentially frail older people is common and generally characterized by diagnostic and prognostic uncertainties. Age and frailty are associated with a higher risk of functional decline and deterioration. Due to inadequately coordinated care, this may often result in unnecessary hospital referrals and prolonged admissions. We aimed to co-create a regional integrated care pathway (ICP) for this population to improve health outcomes, healthcare costs, and most important patient and provider experiences.
Methods: The project ran from January until October 2021. Representatives of all levels of regional care facilities were divided over four theme groups, based on their expertise. They visited two-weekly sessions and every six weeks a plenary session. Four theme groups were: 1 diagnostics; 2 treatment; 3 monitoring and 4 communication. The focus of the meetings was to co-create the ideal patient journey within the theme. Considerations, discussions, and questions were dealt with during the plenary sessions, where consensus was reached. If expertise was missing, a new expert was approached and asked to participate. At plenary sessions two patient representatives were present.
The next step was to form a new theme group to tackle the expected implementation issues for all themes. The final concept version was distributed to the stakeholders in the region, to gather feedback and advice on the feasibility of the ICP in routine practice. All feedback was discussed and incorporated during the last plenary session during which the final ICP was drafted.
Results: Our regional, multidisciplinary ICP includes three patient journeys. The most important journey: treatment at home with the general practitioner in the lead, in close collaboration with a specialist-in-elderly-care-medicine (ECM), an internist, and a pulmonologist for consultation. Although regarded as a major asset by the patient representatives, the diagnostic theme solutions of the proposed new interventions (point-of-care and microbiology testing) were not available for implementation in practice yet. This patient journey includes prescribing a guideline-recommended cephalosporin administered by intramuscular injection, oseltamivir in case of confirmed influenza infection, and oxygen therapy initiated by the GP. Monitoring takes place in collaboration with home care organizations. Within four hours a nurse visits for the first check-in and administers intramuscular antibiotics. Also, a home kit including a saturation device and thermometer should be installed, explained and the measured values monitored. Daily check-ins should be organized for 3-5 days. Regarding the communication theme integrated methods still need to be further developed, existing communication ways will be used. The second journey includes a visit to the Emergency Department of regional hospitals, with a priority assessment. The third journey involves referral to readily available ‘recovery beds in a nursing home, with an ECM specialist in charge.
Conclusion: We were able to co-create an integrated care pathway for community-dwelling potentially frail older people presenting with an acute respiratory infection which includes three patient journeys. We created a regional integrated care agreement for this population at risk and by starting with the ideal situation, three patient journeys are ready to be implemented."