Public defence: Cecilie Fromholt Olsen

This thesis draws attention to the topic of person-centered patient pathways for older people in need of home care services. It explores health care providers’ (HCPs) experiences, perceptions and understandings of developing and implementing person-centered care for older people during care transitions from hospital to home and in the home setting.

The “What matters to you?” (WMTY) approach and a care pathway called “Patient Trajectory for Home-dwelling Elders” (PaTH) as tools to improve quality and achieve more person-centered patient pathways are explored.

Methods

The thesis takes an explorative, interpretive qualitative approach based on a constructivist epistemology. Four articles are presented. The first is a qualitative meta-synthesis based on a systematic literature review on HCPs’ experiences of providing patient-centered care in the home of older people.

The three subsequent articles are based on an empirical qualitative study exploring the experiences and understandings of HCPs who took part in a Norwegian quality improvement collaborative (QIC).

Through the 18 months collaborative period, 20 individual semi structured interviews with HCPs from different professions and settings in the pathway from hospital to home in a Norwegian municipality was conducted. Furthermore, three key person interviews as well as participant observation of 22 meetings and four learning sessions in the QIC were performed.

Central documents in the QIC were scrutinized, but not formally analyzed. We employed triangulation to reach an in-depth understanding of the phenomena in question (article 2, 3, 4). The review data (article 1) were analyzed using meta-ethnography and the empirical data were analyzed using thematic analysis (article 2, 3, 4,).

Results

The meta-synthesis showed that HCPs have to strike a balance between older home-dwelling people’s needs and preferences on the one side, and the demands related to the organizational context as well as their own professional standards on the other.

In article 2, we found that the WMTY question was understood as a complex process that needed to be framed competently. Based on different understandings among the HCPs of the purpose of the question, two main approaches became evident:

• A relational approach, which was in line with a person-centered and open approach and where the goals of the patient were not predefined.
• A functional approach, which was more profession-centric and biomedically oriented. Here, goals related to physical function and getting home as quickly as possible came to the forefront, which might be reinforced by organizational and political goals.

Article 3 highlighted that when working to achieve more person-centered patient pathways for older people in the QIC, the HCPs valued patient journey mapping as a way of finding common ground.

In the process, knowledge boundaries between HCPs from different levels of the care system as well as between HCPs and the older patients became apparent. The crossing of knowledge boundaries related to knowing the older patient appeared essential to the achievement of person-centered patient pathways.

The importance of seeing the complete patient pathway and not just one’s own workplace was highlighted and the role of older patients’ perspectives in facilitating this became apparent. There was ambiguity towards implementation of the PaTH checklists.

In article 4, we found that the implementation of the care pathway (PaTH) was understood both as improving patient flow related to a need for fulfillment of political, managerial and professional demands, and as improving the older patient’s journey related to the person-centered aspect of the care pathway.

The HCPs experienced a dilemma between improving patient flow and improving the patient’s journey. The findings are seen in light of partially competing institutional logics. Overall, the findings from all four articles shed light on important overreaching tensions related to micro-, meso- and macro-levels of the healthcare system influencing the implementation of person-centered patient pathways.

Conclusions

This thesis’ contributes important knowledge about HCPs’ work towards more person-centered practices in the pathways of older people from hospital to home and in home care. HCPs understand the purpose of quality improvement tools to facilitate person-centered transitional care practices differently.

Hence, different partially contradicting understandings exist in the field and seem to lead to different ways of enacting care as more or less person-centered. The metaphor of the HCP as a “balance artist” is suitable across the findings.

HCPs have to balance, negotiate and reconcile different logics in the field and the tensions that arise from them. The transitional care context is particularly complex introducing multiple boundaries to person-centered care work across levels.

Consequently, bringing different understandings, dilemmas and tensions to the surface through knowledge sharing and reflection and assuming a shared responsibility for the patient journeys of older people seems crucial.

When implementing person-centered patient pathways, attention to the tacit and situated aspects of HCPs’ and patients’ logics as well as the inherent contextual complexities in the field is central.

Future research could explore different practice situations where the tools examined in this thesis are used.