Quality and coordination in home care: a national cross-sectional multicenter study – SPOTnat

Homecare services include a wide range of medical treatments and therapies, basic care (e.g., personal hygiene), domestic services (e.g., household support) and social services. However, it has been neglected in most countries compared to hospitals and nursing homes, especially regarding healthcare research. As a result, while many countries see high-quality, sustainable care at home as a high-value goal, there are many knowledge gaps in the homecare setting. For agencies, challenges include an increasing demand combined with a workforce shortage, constant cost pressure, and issues with both care coordination and care quality.
Problematically, owing to a long shortage of research, knowledge of these elements is scant. In this sector, large-scale studies that consider macro-, meso-, and micro-level factors and incorporate multiple perspectives and measurements to capture coordination and quality of care are extremely rare. When the SPOTnat study (Spitex Koordination und Qualität - eine nationale Studie (homecare coordination and quality – a national study)) began, no published study had examined how homecare agencies perform regarding care coordination. More importantly, though, none had determined which factors are associated with care coordination in the homecare setting. Moreover, across the entire health sector, no clear, accepted concept was available either of what exactly constitutes coordination, or of what it entails.
This dissertation is embedded in the SPOTnat study. Preparing it, the overall goal was to deepen our understanding of the homecare sector regarding care coordination and quality. Therefore, a preliminary goal was to clarify the concept of care coordination. Later goals included describing the various financial and regulatory mechanisms operating in the Swiss homecare setting. That information made it possible to explore how those factors relate to homecare agencies’ structures, processes, and working environments, how system and agency factors are related to care coordination, and ultimately how care coordination is related to quality of care.
CHAPTER 1 presents the background, the target research gap and the rationale behind this dissertation. We look closely at the unique challenges of the homecare setting, particularly regarding coordination and care quality.
In CHAPTER 2 we establish a theoretical basis for care coordination and explain how the concept of coordination can be understood and measured. Our newly-constructed COORA (care coordination) framework differentiates clearly between coordination as a process—i.e., tasks people perform to coordinate versus coordination as a state, i.e., the desired outcome of the coordination process. Applying this distinction to both measurement and interpretation of results helps avoid misleading conclusions.
The COORA theoretical framework is based on the full range of influential coordination literature. Iteratively developed in consultation with healthcare professionals, patients and their relatives, it considers the complex relationships between the many factors influencing coordination (as an outcome), and is applicable not only to homecare but across healthcare settings. However, measurement of both care coordination and quality of care remains a challenge. Further research will be necessary to develop and validate a questionnaire that reliably measures care coordination as an outcome.
CHAPTER 3 presents the research protocol for the SPOTnat study, a national multi-center cross-sectional survey in Swiss homecare settings. That study included 88 homecare agencies. Using public records and data from questionnaires sent to those agencies’ 3323 employees (including managers and homecare staff), 1508 clients and 1105 relatives of those clients, the SPOTnat research team gathered data on homecare financing mechanisms, agency characteristics and homecare employees' working environments and coordination activities, as well as staff- and patient-level perceptions of coordination and quality of care.
CHAPTER 4 discusses our analyses of how regulatory and financial mechanisms explain differences in agency structures, processes and work environments. Based on the mechanisms acting on the participating agencies, we divided them into four groups. Our analyses showed considerable inter-group differences, especially in the range and volume of services provided, but also regarding their employment conditions and cost structures. The most prominent inter-group differences related to the conditions of their cantonal and municipal service agreements. Alongside such details, financial incentives must harmonize the care goals, i.e., achieving and maintaining accessible, high-quality homecare, with the regulatory goals, i.e., assuring the quality and financial sustainability of that care.
CHAPTER 5 includes an analysis of how selected explicit and implicit agency-level coordination (process) mechanisms are linked to successful coordination (as an outcome). The results revealed that several implicit mechanisms, i.e., communication/information exchange, role clarity, mutual respect/trust, accountability/predictability/common perspectives, and knowledge of the health system, all correlate with employee-perceived coordination ratings. We also found that certain coordination mechanisms mediated the effects both of agency characteristics (i.e., staffing/ workload and overtime) and of external factors (i.e., regulations).
In CHAPTER 6, the final included study gives insights regarding how both homecare employees’ and clients’ coordination-relevant perceptions relate to one another’s quality-of-care ratings. Our analyses indicate that employee-perceived care coordination ratings correlate positively with their own ratings of their quality of care, while client-perceived care coordination problems correlated inversely with client-reported quality of care. Client-perceived coordination problems also correlated positively with hospitalizations and unscheduled urgent medical visits, but not significantly with emergency department visits. No associations were found between employee-perceived coordination and either healthcare service utilization or client quality-of-care ratings. Alongside these relationships, various coordination deficiencies, for example, poor information flow, also became apparent.
To conclude, CHAPTER 7 provides a synthesis of the main findings and discusses the results in relation to practical, political and research implications. While contributing further to the understanding of care coordination via the COORA framework, this dissertation also raises various methodological issues. From a practical perspective, measuring and operationalizing both coordinating processes and quality of care outcomes remain challenging issues. While our qualitative results suggest that improving coordination will lead to higher-quality care, testing and ultimately exploiting any such relationship will require not only improved financial and technical structures, but the abandonment of outmoded siloed attitudes regarding the entire homecare sector.