The aim of our research was to gain insight in the process of implementation and execution of integrated care in a geriatric hospital. For this we analyzed a large geriatric hospital in Berlin, the Evangelical Geriatric Centre Berlin (EGZB). The EGZB was founded in 1999 and was expressively planned and organized as a multidisciplinary and integrated geriatric care program incorporating a comprehensive spectrum of services for age related conditions.
Today, the hospital of the EGZB consists of 5 floors, each organized in independent multidisciplinary teams consisting of each relevant group of health professionals. Additionally, the EGZB incorporates a day-clinic with 40 beds, a nursing home with 74 beds and a counseling center for people with cognitive impairments and their relatives. Although the EGZB is an independent organization, it serves as an associated partner for the Charité university hospitals.
As such, it is involved in student education and is used for geriatric expertise. Different health professionals who were directly involved in patient care and management (doctors, physiotherapists, occupational therapists, nurses and neuropsychologists) were interviewed about the hospital’s approach of all phases of patient management (hospitalization, diagnosis, intervention and discharge management). Berlin and its surrounding region including the city of Potsdam is the second largest urban area of Germany. In the hospital sector, nearly 100 hospitals are providing health care for all kinds of patients and diseases. Although the EGZB was the first geriatric center in Berlin, over the last couple of years several other geriatric hospitals were established.
The research on integrated care in geriatric condition had two phases. In the first phase a comprehensive literature analysis was conducted based on a search strategy built by the consortium. An expert panel consisting of the most experienced senior scientists developed a list of search terms built into four categories. Additional search terms dedicated to the respective area of expertise of the work package leader were added to the more general terms provided by the expert panel. Original inclusion criteria provided by the expert panel consisted of:
- Publication period from 2002 – 2012
- Quantitative and/or qualitative studies and
- Inclusion of at least two components of the Chronic Care Model.
Exclusion criteria consisted of:
- Condition other than the ones being investigated within the case studies
- Specific target groups other than those that are selected for the case studies (e.g. mother and child care, adolescent care, acute care, homeless people, prisoners) and
- Articles describing solely methods of care delivery (e.g. Planetree/Magnet). The final phrasing was divided into Mesh terms and key word terms.
In the second phase, interviews with different health professions involved in the health care process in the EGZB were held. Interviews with health professionals were conducted according to a semi-structured protocol. The protocol was derived from the templates developed by all work-package leaders. These templates were translated and adapted to the special requirements of the case site and the expected level of knowledge of the participants.
After requesting (and receiving) approval from the local ethical and data protection committee, interviews were organized at the case site. Each interview lasted about 45 minutes. All interviews were recorded, transscripted and subsequently paraphrased, categorized and finally generalized. From the generalized topics, categories of common themes and emergent patterns were derived. Quotations were used to illustrate our findings. We aimed to interview all relevant health professions in the EGZB. Of these, we were not able to obtain any interviews with the groups of social workers and care coordinators.
While every effort was made to involve these two groups, time constraint and organizational issues on behalf of the two groups made any involvement impossible. Therefore the interviews are limited to the health professions of medical doctors, physical and occupational therapists, nurses, neuropsychologists and management.
The following factors seem to be central for a successful implementation and sustenance of an integrated care concept for geriatrics:
A multidisciplinary team approach seems to be imperative for a reasonable concept for geriatric care. All health professions pointed out that the gathering of information from different health professions with different specialties and competencies about a specific patient is crucial for understanding the complex patterns of chronic conditions typical geriatric patients display. Additionally, different health professions were able to help each other in daily routines.
Implementation of formal and encouragement of informal communication channels
Communication was mentioned as well by all health professions as very important. Being able to gather information on a specific patient to be able to deal with this patient, to understand his potential in rehabilitation and to plan or perform an optimal treatment regime was, according to the interviewees, often times only possible based on the information provided by all health professions. In the EGZB, two different, but complementary ways of sharing information were identified.
A clear team structure with defined responsibilities
The task of multidisciplinary work makes clear-defined responsibilities necessary in order to enable a smooth transition of care and rehabilitation and to avoid conflicts due to overlapping competencies or so called “responsibility gaps”.
A suitable process of information sharing
Sharing is a central process in order to be able to integrate care services. This is especially true for geriatric care, were the high prevalence of multimorbidity makes a comprehensive analysis of all information before making any decisions mandatory. The information sharing process should include a suitable ICT-based documentation system, regularly team meetings as well as a communication-friendly team culture.
A suitable ICT system for speeding up bureaucratic tasks
As already mentioned, ICT enables a quick and easy way of sharing relevant information. Additionally, an ICT-system should be able to speed up administrative routines of all health professions, minimizing the time effort necessary to spend in order to have more time with the patients.
Care-Coordination and planning based on the expertise of the multidisciplinary team and structured assessments
As every health profession has its own core competencies, these competencies have to be acknowledged and the care process has to be centered around them. This includes sharing certain responsibilities when more than one health profession is able to deliver specific care and rehabilitation tasks.
A constant process of change taking into account experiences of those at the executional level
As regulatory frameworks for providing care as well as the evidence for care interventions are changing constantly, adaptions of the care process have to be made on a regular basis. Additionally, individual experiences by all staff members provide an opportunity to recheck and overhaul existing treatment regimens; therefore it is very important to provide a professional culture of constant change where everybody is invited to provide his ideas on how to improve every aspect of the team’s work.
There are several lessons to be given to policy makers.
- As the patients to be found in geriatric care do display a wide variety of functional and cognitive abilities, chronic conditions and general health status, the framework regulating geriatric care have to account the need for flexibility without undermining quality of care. Therefore, hospital teams should have more freedom to decide on amount and sort of intervention while at the same time should be obliged to provide the best practice. Documentation of results should be evidence-based.
- The need for multidisciplinary teams has to be reflected in the educational concepts of all health professions so that all participants are prepared for the demands of multidisciplinary work.
Barriers for an effective sharing of information are still too strict. While some models of intersectoral care provide suitable information-sharing processes, the vast majority of patients are still not part of these models of care. Therefore, an effort is needed to make the sharing of information in general easier, more practical and dependably. A gold standard on what information should be shared has to be developed.