Continuity of care of older people with chronic disease

The European population is ageing leading to a greater burden of chronic diseases. The management of chronic diseases differs from that of acute ones as it requires continuous assistance over time. The healthcare model for this condition must be flexible and able to adapt over time to the elderly’ care needs. Continuity of care responds to these important needs of care by guiding the elderly in their journey across the various settings making them feel accompanied. Despite preliminary research data encourage the implementation of continuity of care, its knowledge base still needs to be strengthened with larger and better quality studies. This thesis will seek, through a systematic review of the literature, an observational study and the validation of a questionnaire, to improve knowledge on continuity of care in older people with chronic diseases. To meet the aims of the research a systematic review and metanalysis on the effectiveness of continuity of care intervention in older people with chronic diseases in reducing short and long term hospital readmission after hospital discharge; an observational study aimed to investigate the consistency between the nursing activities actually observed at patient’s bedside and those documented during discharge describe which nursing activities are observed during the discharge of older patients with chronic diseases; and the adaptation to the Italian context and the validation of the Patient Continuity of Care Questionnaire were carried out. The review demonstrates that continuity of care interventions prevent short-term hospital readmissions in older people with chronic diseases. However, the evidence about the effectiveness of continuity interventions aiming to reduce long-term readmissions is inconclusive, suggesting the need for a stronger focus on it. The results of the observational study show that during discharge of elderly patients with chronic diseases, nurses maintain their advocacy and educational role despite contexts characterised by time constraints, high workloads and complex patients’ needs. However, nursing documentation needs to be improved because of inconsistencies with the observations of the nursing activities. This means that nurses do much more than they record. Finally, the validation study provides a valid and reliable tool that can support health professionals assessing patients’ perception and readiness to discharge in clinical practice, identifying areas of improvement for continuity of care services in primary health care, and tailoring educational interventions aimed to promote continuity of care in older people with chronic diseases. This work developed new knowledge about the effectiveness of continuity of care interventions. The systematic review identified a high number of different interventions of continuity that are often performed simultaneously. Therefore, it is difficult to compare these interventions and even more to test their effectiveness. Hence, the recommendation is to find a common model of continuity of care to support care providers and managers in directing their efforts towards a common, shared theory-based strategy upon which to select and prioritize interventions. Furthermore, this work provides two objective tools: a useful checklist to guide nurses in satisfying the needs of elderly patients with chronic diseases during discharge, and the Italian version of the Patient Continuity of Care Questionnaire. These instruments, unique in Italy, can boost the research on the topic improving health professionals’ understanding of patients’ needs and perceptions about continuity of care, and can enable hospital administrators and healthcare providers to assess and to improve continuity of care services.