The number of older adults is growing, and the burden on healthcare systems is expected to increase proportionally. Managing this in Denmark has resulted in faster hospital treatment for older adults followed by discharge with additional treatment and care at home. However, a new study suggests that this model does not always work among older adults in Denmark. Even if they do not want to be readmitted, inadequate treatment at home and the feeling of responsibility for their continued illness made them feel insecure, resulting in readmission.
There is no place like home. This old saying fits well for older adults who are acutely admitted to hospital. Most people prefer to be at home, and discharging older adults quickly can therefore seem like a good strategy in several ways. This frees up beds in overcrowded hospital wards, and frail older adults come home to secure and familiar surroundings. However, a new research project obtaining in-depth insight from 12 older adults on what being older and ill is like in Denmark shows that part of the problem with readmissions is that older adults do not always feel secure when discharged after an acute admission.
“These older adults thought that the hospital discharged them too soon since they still did not feel well. They worried about how to manage their daily lives and their illness after discharge. Especially those who lived alone said that they felt anxious about being home alone after discharge and that previous negative experiences affected their trust in the health system. Conversely, readmission increased their sense of security, which is why they were readmitted more often. So this strategy produces no winners as currently practised. Getting it to work requires significant improvements to treatment and care resources at home,” explains Mette Elkjær, Postdoctoral Fellow and registered nurse, Department of Emergency Medicine, University Hospital of Southern Denmark, Aabenraa and Department of Regional Health Research, University of Southern Denmark, Odense.
Still feeling ill
The background for the study includes Mette Elkjær’s own experiences with older adults from her work as a nurse. She found that surprisingly many older adults admitted to an emergency department had previously received homecare. She then conducted many research interviews with acutely admitted older adults to obtain deeper insight into their thoughts and challenges.
“Our previous study showed that receiving daily homecare is associated with almost twice the risk of readmission and fourfold greater risk of death after a short emergency admission. These are huge increases. We found that older adults receiving homecare are often burdened with complications that especially affect older people such as polypharmacy and chronic diseases. However, independent of other such complications, receiving homecare before being acutely admitted is a factor that indicates frailty and can be used to predict the risk of readmission,” says Mette Elkjær.
The new study aimed to focus on how older adults receiving homecare experience acute readmission. The researchers therefore conducted in-depth qualitative interviews with 12 older adults who had been readmitted to an emergency department: aged 67–95 years, seven men, five women and eight lived alone.
“We asked them about the days leading up to readmission and their sense of the reason, but we also talked to them about their general health, everyday life, activities, family and need for help in everyday life – to try to understand how they individually experienced why they had been readmitted. The interviews were semistructured and encouraged respondents to feel comfortable and speak freely,” explains Mette Elkjær.
Three themes clearly emerged from the analysis: (1) responsibility and security at home; (2) the role of family, friends and homecare; and (3) the importance of trust.
“These older adults clearly thought that they had been discharged from hospital despite still feeling ill. They thus experienced that the hospital strived for premature discharge even though they were still not well, and they worried about how to manage their daily lives when they returned home,” adds Mette Elkjær.
Failing silent and vulnerable people
Nearly 10 years ago, hospitals in Denmark implemented action plans to reduce overcrowding, introducing fast tracks in which people assessed as requiring admission are transferred to specialist departments and the rest are discharged. For those sent home after a short stay, alternative solutions to hospitalisation were created including outpatient rehabilitation, rapidly notifying homecare services and outpatient treatment.
“Some of these people seem to be victims of this fast-track model, and they described the inadequate competencies of healthcare professionals in the home as contributing to readmission. Especially those living alone experienced feelings of insecurity in the home environment following discharge,” explains Mette Elkjær.
Conversely, readmission increased their sense of security, even if they would have preferred not to be readmitted.
“Although the older adults did not want to be in hospital, the inadequate treatment at home and the feeling of responsibility for their illness made them feel insecure. They also said that earlier negative experiences affected their trust in the health system and their tendency to ask for help. This suggests that some of the readmissions result from a combination of inadequate treatment and observation of their illness at home but especially their experience of insecurity,” says Mette Elkjær.
Whether the family provides support in the process was essential for the older adults’ sense of security when returning home from hospital after acute illness. Active involvement of the family increased their sense of security, whereas those who lived alone said that they felt anxious about being home alone after discharge.
“Although more frequent unnecessary readmissions contradict the desire for a more efficient hospital system, we cannot permit basically leaving these lonely, silent and weak people to fend for themselves. Collaboration between the emergency departments and the primary health care services, the general practitioners and homecare services is absolutely essential to improve the quality of homecare for older adults, thereby enabling us to provide competent treatment and care and, for some, the dignified end of life that everyone deserves,” concludes Mette Elkjær.