Authors

1. Joseph, Rincy MS, RN, FNP-BC, NP-C
2. Brown-Manhertz, Durline MS, RN, FNP-BC
3. Ikwuazom, Stella MS, RN, FNP-BC, NP-C, CCRN
4. Santomassino, Michelle DNP, RN, FNP-BC
5. Singleton, Joanne K PhD, RN, FNP-BC, FNAP, FNYAM

Abstract

Review question/objective: The specific review questions to be addressed are:

What is the effectiveness of structured interdisciplinary collaboration versus usual care on hospital admission and re-admission rates for adults receiving home hospice services?

What is the effectiveness of structured interdisciplinary collaboration versus usual care on patient satisfaction with services in adults receiving home hospice services?

Background: Rapidly rising health care costs have become an international concern resulting in government agencies, health care organizations, individuals, and groups of providers examining current practice and searching for areas of practice improvement.1 Worldwide efforts have been emphasized over the past several years on containing costs and improving quality of health care. Globally, the accepted two outcomes that are core measures of success in the healthcare system include patient satisfaction and hospital re-admission rates.1

The rise in hospice home care services internationally requires incorporation of interdisciplinary-based approaches to healthcare. The ability of hospice teams to successfully collaborate has an impact on both the quality of patient care, as well as the experience of patients and families.2,3 Within the hospice home care setting patients receive twenty-four hour care from various interdisciplinary professionals to ensure coordination of care to improve patient satisfaction and prevent conditions that may result in hospital re-admissions. Effective collaboration of two or more disciplines to achieve higher quality outcomes in hospice home care settings may be essential to healthcare professions around the world to focus on practice improvement.

Patient satisfaction is defined as the extent to which the patient's general health care and specific condition needs are met.4It is recognized as the patient's perception of the care they are receiving.1 Patient satisfaction is an important and widely used indicator for measuring the quality of health care. It results in positive clinical outcomes, efficient and patient centered delivery of quality health care.5Patient satisfaction surveys have an impact on any health care delivery system in measuring the success of its services in order to learn where improvement is needed to ensure better outcomes. Patient satisfaction is measured in both hospital and home care settings with the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey which is accepted in countries such as Singapore, Belgium, Japan, Korea and the Netherlands and also has been translated into Spanish for use in the United States.6 CAHPS is defined as a series of patient surveys used in evaluating and rating patient experiences with health care.7 The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey is a standardized survey instrument and data collection methodology which is used to measure patients' perspectives of hospital care.6Home Healthcare Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) is a standardized survey tool that is used to measure patient perceptions of care in home care settings. This survey is used worldwide as a reference for quality assessment and analysis for home health care services.8The translated Arabic version of the self-administered survey questionnaire, originally in English, was used in Jordan to measure the patient satisfaction and quality of care in home care settings.8

A quantitative, non-experimental study using Survey methodology, showed that hospital type, care transitions, and discharge readiness were found to significantly predict patient satisfaction with home care after discharge from hospital.9 The Reid-Gundlach Satisfaction with Services instrument was used to measure patient satisfaction, rating overall satisfaction with services, perception of service providers, and likelihood of positive recommendations of services to others. This instrument has been employed in previous studies examining satisfaction with end-of-life.10 Therefore, effective communication among interdisciplinary team may play a role in reducing hospitalization.

Hospital admission is defined as being admitted to the hospital during the study. Hospital re-admission is defined as returning to the same hospital or another acute hospital following a prior admission within one year.8Hospital admission and re-admission rates are outcome indicators for home hospice quality; thus the providers aim is to provide the safest and best quality care to patients in order to enhance and improve health outcomes. The literature shows that re-admission rates were significantly lower among palliative care patients discharged with hospice care (1.1%) than comparison patients (6.6%).11 Home hospice services with adequate care coordination appear to substantially reduce the likelihood of hospital re-admission.11 Hospital re-admissions may reflect suboptimal quality of care during hospitalization and lack of support or coordination in the transition to home and post discharge care.12Acute hospital re-admission of older adults receiving hospice care is not aligned with hospice goals.13 Re-admission within 30 days of initial discharge to hospice is associated with several measures of care and care planning.13 The primary goals of home care are to discharge the patient to home and avoid subsequent hospitalization. Hospital re-admission is a significant factor among the home hospice team because it allows interdisciplinary team to assess the quality of home care which may impact patient satisfaction and hospital re-admissions.

Re-admission can be the result of inadequate care, poor discharge coordination, incomplete treatment, or poor discharge planning.14, 15Hospital re-admissions are frequently used to gauge the quality of patient care. The Center for Medicaid and Medicare's Risk Standardized Re-admission Rates Model (RSRR) is a tool used in the United States (US) to measure hospital re-admission rates and has been known to be very effective.16The RSRR model is endorsed by the National Health Quality Forum and gives a measure of hospital performance based on re-admission rates.16Many organizations use them as a metric for institutional or regional quality of care.17The re-admissions are very costly. In 2004, almost one fifth of the US Medicare patients were readmitted within 30 days and the cost of these re-admissions was $17.4 billion, out of $102.6 billion in total hospital payments.18The widespread public reporting of hospital re-admissions and their use in consideration for funding implicitly suggest a belief that re-admissions indicate the quality of care provided by particular physicians and institutions.19Identifying and reducing avoidable re-admissions will improve patient safety, enhance the quality of care, and lower health care spending.20 Effective communication among the interdisciplinary team and patient education play a role in preventing hospital re-admissions.

Delivering, high quality health care requires significant contributions from many parts of the care continuum.21Interdisciplinary collaboration is a concept that is being explored globally. It is defined as an interpersonal process leading to the attainment of specific goals that are not achievable by any one team member alone.22The World Health Organization defines interdisciplinary collaborative practice in healthcare as a process whereby multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, caregivers and communities to deliver the highest quality of care across settings.23 Collaboration in health care is the process where healthcare professionals assume complementary roles and work together cooperatively, share responsibility for problem-solving, and make decisions to formulate and carry out plans for patient care.24, 25Collaborative acts take place as a result of interdependence between team members which occurs as individuals deviate from discipline specific boundaries.26

Furthermore, interdisciplinary collaboration is central to effective patient care in many settings. Research has demonstrated that effective interdisciplinary communication leads to high levels of patient and family satisfaction, symptom control, reductions in length of stay and reduced hospital costs.27 It has been found that better nurse-physician communication and collaboration result in lower mortality, higher patient satisfaction, and lower re-admissions.28There are studies that show a positive correlation between interdisciplinary collaboration and patient outcomes including patient satisfaction and reduced hospitalization. A quantitative study that investigated the exploration of a multidisciplinary care management approach for home based end-of life-care and treatment, identified increased patient satisfaction, significantly fewer emergency department visits, hospital days and skilled nursing facility days.29In a randomized controlled trial that looked at satisfaction and lower cost in the in-home palliative care plus usual care delivered by an interdisciplinary team, a positive correlation was noted. There was increased patient satisfaction, reduced use of medical services and costs of medical care at the end-of-life. On the other hand, effective collaboration and communication within interdisciplinary teams is an essential aspect of modern organizational work and is critical in achieving positive, cost effective outcomes in and across organizational settings.30 Coordination of services and tasks is necessary to increase patient satisfaction, reduce overall health care costs and improve the quality of care. Studies from the United Kingdom, United States and Australia stressed the importance of a culture that supports interdisciplinary collaboration.31

Usual care is defined as the standard care to meet the needs of the patients.10 It is a major concern in the hospice home care setting which results in poor patient outcomes and may cause unintentional harm to patients and their families. The success of interdisciplinary collaboration is based on interprofessional education, role awareness, interpersonal relationship skills, deliberate action, and support.32 The result of interdisciplinary collaboration is beneficial for the patient, the organization, and the healthcare providers worldwide.

Hospice homecare is a critical segment of patient care where interdisciplinary collaboration is fundamental to the patient's ability to achieve optimal health goals. Hospice Care is palliative in nature when curative treatment is no longer desired or beneficial. Hospice is defined as a philosophy of care of a person who lives at home and is facing the end of life.33 The life expectancy of a hospice patient is expected to be six months or less to live. More than one million Americans with a life limiting illness were served by the nation's hospices in 2004.34 Palliative and hospice care has rapidly expanded and in January 2000 there were over 6560 service teams in 87 countries, with 933 teams in the UK, over 3600 in North America and over 350 in Australia.35 One of the core elements of hospice and palliative care is collaboration among the team.36The aim of palliative care teams is to alleviate distress through symptom control and attention to psychosocial concerns. They also seek to coordinate care and improve communication between professionals and with the individual patient and family.37 Hospice and palliative care teams are comprised of physicians, nurses, social workers, chaplains, volunteers, and may also include home health aides, bereavement counselors, dieticians, and pharmacists.26 Hospice care is patient centered because the needs of the patient and family drive the activities of the hospice team.38

In the hospice home care setting, poor coordination of care often results in hospital re-admissions, many of which are avoidable. Structured interdisciplinary collaboration will enable each discipline to contribute to patient plan of care, enhance patient satisfaction and decrease re-admission rate. The goal of hospice care is to provide a trusting relationship between patient and healthcare professionals as well as, maintaining interdisciplinary collaboration among care teams to impact patient satisfaction and reduce re-admission rates. Thus, interdisciplinary team collaboration is essential to the provision of services that enable continuity of care. Continuing education of health professionals may be necessary to promote active learning and collaboration within care teams and improve patient satisfaction and reduce re-admission rate for adults receiving home hospice services.The literature shows that the interdisciplinary collaboration amongst care team members is an important collaborative practice approach that improved patient outcomes, which is a reason for efforts within the healthcare organizations to focus on practice improvement in this area.

A preliminary search of MEDLINE, CINAHL, The JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, and PROSPERO was performed and no systematic reviews were uncovered regarding the proposed topic of interest.