University of Twente Student Theses


Optimization of the integrated care process of hip fracture patients at Medisch Spectrum Twente

Swinderen, M.M. van (2010) Optimization of the integrated care process of hip fracture patients at Medisch Spectrum Twente.

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Abstract:Introduction/problem description One of the major problems in health care is the lack of coordination between hospitals and follow-up care. They work independently, which results in fragmentation and inefficiency (van der Linden, et al., 2000). Integrated care focuses on the cooperation between caregivers and is specified as: care attuned to the needs of the patient, provided on the basis of cooperation between primary and specialized caregivers, with shared overall responsibility and the specification of delegated responsibilities (National council for public health & National board for hospital facilities, 1995). Managing the cooperation between those various caregivers is a real challenge. In Medisch Spectrum Twente (MST), patients deal with long access times to follow-up care after medical treatment in the hospital. Objective In this study we focus on one specific patient group: hip fracture patients who need short term rehabilitation care after medical treatment in MST. The study focuses on hospital MST and nursing homes AriënsZorgpalet location Eschpoort (AZP Eschpoort) and Zorggroep Sint Maarten location Oldenhove (ZGS Oldenhove). We provide a detailed description of the integrated care process of hip fracture patients at MST and at the nursing homes, identify and analyze factors that influence the integrated care process and access time to follow-up care, and formulate recommendations. Approach We base our process description mainly on interviews with the involved employees. The performance analysis is based on data collection from four databases: X-care, Transferpunt database, and databases of the two nursing homes. The data spans the period January 2008 to August 2009. The process and performance analysis considers 8 phases: patient arrival at MST, admittance, treatment, post treatment, discharge from MST, admittance into nursing home, rehabilitation, and discharge from nursing home. From this process description we identify process factors that negatively influence the integrated care process. To predict medical treatment duration in the future, we describe characteristics of hip fracture patients that influence the integrated care process: functional decline, delirium, malnutrition by using three measuring instruments: Identification of Seniors at Risk (ISAR), Delirium Observation Scale (DOS), and Short Nutritional Assessment Questionnaire (SNAQ). We also describe the age of patients related to the medical treatment duration in MST and the length of stay in the nursing homes. To categorize the bottlenecks and the corresponding recommendations we propose a planning and control model that addresses three main areas of integrated care: demand planning, information and communication coordination and network coordination. Results 287 (60% at the surgery- and 40% at the orthopaedic department) hip fracture patients are admitted in 2008, and 208 (66% at the surgery- and 34% at the orthopaedic department) in the period of January to august 2009. 3 Of the 287 admitted patients, 153 patients (53%) are applied for short term rehabilitation care after medical treatment in MST. Of the 208 admitted patients, 118 patients (57%) are applied. Hip fracture patients are mostly elderly people with multiply care problems. According to the ISAR-score, 92% of the screened patients are regarded as vulnerable. The DOS-score shows that for 26% of the screened patients symptoms of delirium are present. Malnutrition, tested by SNAQ-score, is present for 21% of the screened patients. All those percentages of the hip fracture patients are higher than the percentages of other patients treated by the surgery and orthopaedic department. MST strives to apply patients within 2 days after arrival at the hospital. The time to apply a patient for short term rehabilitation care from the moment of admittance takes too long. The average registration time is 8.05 days in 2008 and 6.23 days in the first eight months of 2009 for all hip fracture patients applied for short term rehabilitation, due to lack of routine for nurses. MST strives for medical treatment duration of 6 days. In 2008, the average medical treatment for all hip fracture patients applied for short term rehabilitation takes 12.13 days. In 2009, this takes 10.02 days. MST has no univocal criteria to assess whether a patient no longer needs medical treatment. The rehabilitation time in nursing homes varies highly from 11 days to 485 days. Patients at nursing home AZP Eschpoort in general need shorter rehabilitation time than patients at nursing home ZGS Oldenhove. However, patients from ZGS Oldenhove are mostly discharged to their home and patients from AZP Eschpoort are sooner transferred to other types of care. For a proper information flow between the various caregivers a proper information system is required. In the integrated care process MST uses two main database systems: X-care and Transferpunt database. Transferpunt database is a separate system to arrange follow-up care for patients after medical treatment in MST. Unfortunately those systems cannot be linked, which results in evaluating problems when describing the whole process from admittance in the hospital till discharge to follow-up care. Within the Transferpunt database a total overview per diagnoses group is not available. One can only search per follow-up care type. The systems require manual data entry. As nursing homes are typed in many different ways, analysis becomes very difficult. There are insufficient beds for patients who need short term rehabilitation care at a nursing home. During the writing of this report, MST and AZP Eschpoort have been negotiating about reserving a number of beds especially for hip fracture patients discharged from MST. Only the number of required beds is not known. We have proposed a simulation model that can be used to analyze the optimal number of beds. Recommendations Hip fracture patients face high variability in the duration of medical treatment as a result of age, physical condition, and other health problems. Creating homogeneous sub groups by evaluating and monitoring the characteristics of patients following the clinical pathway can lead to a better prediction of the duration of medical treatment in the hospital as well as the rehabilitation time in nursing homes. 4 To use criteria to determine what type of follow-up care a patient needs. To determine rules for the moment a patient needs to be applied for follow-up care. To use control instruments to determine whether application of a patient for follow-up care is actually applied and as a result reduces the time for registration. To implement drop-down-lists to create an overview per patient group and reduce manual input of data. This improves the possibility to evaluate and monitor the data. We propose a simulation model to analyze the optimal number of beds that must be reserved for hip fracture patients discharged from MST. We have implemented two strategies: with blocking and no blocking o With blocking, in case no bed is available, the patient will be directly applied to another care organization. Reserving 33 beds for hip fracture patients at AZP Eschpoort leads to a bed occupation of 81.47% for AZP Eschpoort, and only 3.72% of the patients are refused and must be discharged to other follow-up care organizations. o No blocking, regardless of availability of beds, all patients wait for discharge to AZP Eschpoort. Reserving 36 beds for hip fracture patients at AZP Eschpoort leads to a bed occupation of 78.08% for AZP Eschpoort and only 4.4% of the patients must wait for an available bed. To use a planning and control model to determine at what management level and management area bottlenecks are present. Management action is first of all mainly required on the tactical level and the decision made on the tactical level must be followed-up on the operational level. This concerns medical, demand and information coordination planning. Network coordination planning is an important management area in the future, when collaboration between MST and AZP Eschpoort is started.
Item Type:Essay (Master)
Medisch Spectrum Twente
Faculty:BMS: Behavioural, Management and Social Sciences
Subject:85 business administration, organizational science
Programme:Business Administration MSc (60644)
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