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Age and Ageing 2023; 52: 1–12
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QUALITATIVE PAPER
Facilitators and barriers to implementing an
acute geriatric community hospital in the
Netherlands: a qualitative study
Marthe E. Ribbink1,Wieteke C.B.M. de Vries-Mols1,Janet L. MacNeil Vroomen1,Remco Franssen1,
Melissa N. Resodikromo1,Bianca M. Buurman1,2,the AGCH study group
1Amsterdam University Medical Centre, Univer sity of Amsterdam, Depar tment of Inter nal Medicine, Section of Ger iatric Medicine,
Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
2ACHIEVE- Centre of Applied Research, Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, The
Netherlands
Address correspondence to: Marthe E. Ribbink, Amsterdam UMC, University of Amsterdam, Department of Internal Medicine,
Section of Geriatric Medicine, Room D3-335, PO Box 22600, 1100 DD Amsterdam, The Netherlands. Tel: (+31) 20 5661647.
Email: m.e.ribbink@amsterdamumc.nl
Abstract
Background: there is a trend across Europe to enable more care at the community level. e Acute Geriatric Community
Hospital (AGCH) in the Netherlands in an acute geriatric unit situated in a skilled nursing facility (SNF). It provides hospital-
level care for older adults with acute medical conditions. e aim of this study is to identify barriers and facilitators associated
with implementing the AGCH in a SNF.
Methods: semi-structured interviews (n=42) were carried out with clinical and administrative personnel at the AGCH and
university hospital and stakeholders from the partnering care organisations and health insurance company. Data were analysed
using thematic analysis.
Results: facilitators to implementing the AGCH concept were enthusiasm for the AGCH concept, organising preparatory
sessions, starting with low-complex patients, good team leadership and ongoing education of the AGCH team. Other
facilitators included strong collaboration between stakeholders, commitment to shared investment costs and involvement
of regulators. Barriers to implementation were providing hospital care in an SNF, financing AGCH care, difficulties selecting
patients at the emergency department, lack of protocols and guidelines, electronic health records unsuited for hospital care,
department layout on two different floors and complex shared business operations. Furthermore, transfer of acute care to the
community care meant that some care was not reimbursed.
Conclusions: the AGCH concept was valued by all stakeholders. e main facilitators included the perceived value of the
AGCH concept and enthusiasm of stakeholders. Structural financing is an obstacle to the expansion and continuation of this
care model.
Keywords: community hospital, intermediate care, qualitative research, implementation science, older people
Key Points
•e Acute Geriatric Community Hospital (AGCH) is an acute geriatric unit providing hospital-level care in a skilled nursing
facility.
•is qualitative study provides insight into facilitators and barriers to the implementation of this model of care.
•e main facilitators included the perceived value of the AGCH concept and enthusiasm of all involved stakeholders.
•Major barriers were providing hospital care in the setting of a skilled nursing facility and financing AGCH care.
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M. E. Ribbink et al.
Introduction
Recent European long-term care reforms have focused on
‘aging in place’ by providing more care in the community
[1]. Prior to these reforms, alternative models of care like
Hospital-at-Home (Hah) or outpatient management were
developed to care for aging populations living in the com-
munity and to prevent functional decline, delirium and
hospital readmissions [2–7]. Clinical outcomes and patient
satisfaction with these models of care are similar to or better
than those for conventional hospitalisation are [5,7,8]. Hah
has been evaluated in multiple studies and has had significant
uptake internationally [7–10]. A process evaluation of Hah
in the United States identified strategic planning, involving
stakeholders, and strong partnerships with outside vendors
as key facilitators for this care concept [11].
In the Netherlands, a program has been implemented
that enables aging in place, with health insurers financing
alternative models of hospital care [12]. e Acute Geriatric
Community Hospital (AGCH) was inspired by this program
and is located in a skilled nursing facility (SNF; [6,13]).
It provides hospital-level care for older adults with acute
medical conditions. Hospital-level care is treatment that is
usually provided in an in-patient hospital setting, except for
surgery and intensive care. Admission criteria for the AGCH
are presented in Table 1 [13,14]. Treatment at the AGCH
includes a comprehensive geriatric assessment [15] and early
rehabilitation [16,17]. e AGCH model is similar to that
of Hah, except care is provided in an SNF and not at home.
e facilitators and barriers to implementing this model of
care in this setting are still unknown.
Understanding the facilitators and barriers to implement-
ing the AGCH is critical for the evaluation of the AGCH
care concept, and will inform the implementation of similar
care models. To fill this knowledge gap, our research question
was: what facilitators and barriers exist to implementation of
the AGCH care model? We used the theoretical model of
adaptive implementation as a framework to identify these
barriers and facilitators (Figure 1a;[18–20]). is model
describes influencing factors, facilitators and barriers at dif-
ferent phases (preparation, execution and continuation) and
levels (micro, meso and macro) of implementation. e
micro level involves healthcare professionals, the meso level
involves collaboration between care organisations and the
macro level involves the legal and financial framework [18].
Methods
Study design
We conducted one-on-one semi-structured interviews with
professionals and stakeholders, allowing them to fully
describe their individual experiences [21]. Some participants
had similar backgrounds and were interviewed in a small
group. We used the consolidated criteria for reporting
qualitative research, COREQ-checklist [22]toensureall
items relevant to reporting qualitative research were included
(see Appendix 3, Supplementary data are available in Age
and Ageing online). e study protocol was submitted to the
Amsterdam University Medical Centre’s, location Academic
Medical Centre Medical Ethics Research Committee and the
need for official approval was waived as the Medical Research
Involving Human Subjects Act did not apply (file number
W19_386#19.451). e local Research Code guidelines and
European legislation under the General Data Protection
Regulation (GDPR) were followed while conducting this
research. Written informed consent was obtained from all
participants.
Setting
e AGCH is located in an SNF. Geriatricians provide
daily patient care together with a team of nurses and nurse
practitioners. Patients are transferred to the AGCH after
being admitted to the emergency department (ED) of a gen-
eral/university hospital. e admission criteria are presented
in Table 1 [13,14] and the goals and interventions of the
AGCH are presented in Table 2. e AGCH was developed
by three parties: a university hospital, a community care
organisation and a health insurer. ese parties operate in the
Dutch healthcare system, which aims to provide universal
access to healthcare while allowing ‘managed’ competition
between care organisations [23].
Research team
e interviews and analysis were conducted by MER and
WVM. MER is a PhD candidate with training in qualita-
tive research. Student WVM is a 6th-year medical student
trained by MER in qualitative research. BMB and RF are
senior researchers who oversaw the design and conduct of
the study. RF is an internist working at the ED and AGCH.
BMB is also the creator of the AGCH concept was not
involved in conducting interviews or analysing the data until
the final phase of the data analysis. MR is a geriatrician
working at the ED and AGCH and was, together with BMB
and RF, involved in recruiting study participants.
Participants
Participants were eligible for participation if they were
involved in the design and implementation of the AGCH,
were previously or currently working in the AGCH
and/or were key figures with professional knowledge of
the AGCH. A purposive sampling method was used to
obtain participants with different professional backgrounds.
Participants were recruited from the AGCH, ED and
university hospital via email and following a presentation
of the research plan at an AGCH group meeting. Other
professionals and stakeholders were approached by email.
Data collection
e interviews were conducted by MER and WVM between
November 2019 and July 2021, which was 1–3 years after
2
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Facilitators and barriers to implementing an acute geriatric community hospital
Ta b l e 1 . Criteria for admission to the AGCH
Criteria, which should be met upon assessment at the emergency department.
(i) Acute medical problems in older patients that require hospitalisation, e.g. acute events such as pneumonia, exacerbation of chronic conditions such as
heart failure, or minor acute events in very frail patients.
(ii) Hemodynamic stability.
(iii) No need for complex diagnostic testing such as CT or MRI scans during admission.
(iv) Return to previous living situation expected in 14 days.
(v) Geriatric conditions e.g. delirium, cognitive impairment, falls and/or functional impairment.
Figure 1. (A) eoretical model of adaptive implementation applied to the AGCH context [18–20]. (B) eoretical model of
adaptive implementation applied to the AGCH context, including themes that emerged in the analysis [18–20]. Key themes are
presented in bold. AGCH, Acute Geriatric Community Hospital; ED, emergency department.
3
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M. E. Ribbink et al.
Ta b l e 2 . e intervention elements
Goal of the AGCH Intervention
...................................................................................
Identify medical conditions,
geriatric syndromes and care needs
Comprehensive geriatric assessment [15]
Prevent functional decline Early rehabilitation [16,17] through bidaily physiotherapy and function-focused care (ref); adapted environment with
single rooms and open hallways that allow mobilization
Prevent delirium and falls Multi-component intervention [24] including:
- Single rooms;
- Limited number of care professionals to reduce overstimulation;
- Continuous non-contact heart, respiration and position monitoring (Early SenseTM)[25];
- Improving orientation through calendars, clocks and photos of loved ones;
- Family involvement and rooming-in.
Improve patient handover to
primary care and prevent
readmissions
- Involve family during admission by organising meeting within 24 h after admission and before discharge [26];
- Warm handovers (via telephone) to primary care provider (GP and/or home intermediate care organization and/or
physiotherapist) [27];
- Send discharge letters within 24 h after discharge [28];
- Provide medication in a medication sachet for the first post-discharge week.
Improve patient and caregiver
experience of admission
- Family involvement through frequent meetings with medical team [26];
- Extended visiting hours (10 am–8 pm);
- Eating-in or rooming-in with admitted partner of family member.
the AGCH had opened. Interviews were performed in-
person at the AGCH or by video-call from home (during
the coronavirus disease of 2019, COVID-19 pandemic).
e interview guide was drafted based on literature on
implementation of geriatric care models [11,20,29]. In the
pilot phase of the interviews, we used the implementation
framework described by Grol and Wensing [30]. However,
this framework did not fit well to the levels and phases
of implementation because it did not distinguish between
micro-, meso- and macro-level factors. erefore, we contin-
ued with data collection using the adaptive implementation
framework, which fitted better to our setting [18].
e guide was discussed in the research team prior to the
first pilot interview. After three pilot interviews, the guide
was reviewed and adjusted—new questions were added and
some questions were simplified. e guide was also modified
for each stakeholder group. e general interview guide can
be found in Appendix 2, Supplementary data are available in
Age and Ageing online.
Questions were added during the study on the chronology
of events and phases of implementation. We tried to reduce
the risk of time biases during the COVID-19 pandemic. All
but two interviews were audio-recorded and no interviews
were repeated. e audio-recorded interviews were tran-
scribed verbatim and anonymized. Field notes were made
during and after the interview to capture the participants’
impressions and thoughts. We used two methods of member
checking: a summary was given at the end of each interview
and these interview summaries were returned to participants.
Participants’ comments on the summaries were included in
the analysis.
Data analysis
We conducted a thematic analysis [31] using both a deduc-
tive and inductive approach and structured the analysis
using the theoretical model of adaptive implementation by
Dröes and Meiland [19,20]. Ten selected semi-structured
interviews were coded separately by authors MER and WVM
using an open coding approach. After discussing the codes,
an initial coding structure was created. e preparation phase
was defined as the phase up to 6 weeks after the AGCH
opened, and the execution phase started after this. In the
continuation phase, the AGCH care path was further devel-
oped and the AGCH was secured within regular care. e
remaining interviews were coded by either MER or WVM
using the initial coding structure. If relevant, new codes were
included in the second coding structure. After all interviews
were coded, MER and WVM reviewed the second coding
structure and identified all relevant categories and themes.
If there were not enough data to support initial categories,
these categories were removed. MER and WVM agreed on
a final coding structure, categories and overarching themes.
MAXQDA 2020 (VERBI Software, 2019) was used for
coding. Saturation was reached for each stakeholder group.
e relevance of the material was checked by consulting
involved professionals and by discussing the material in the
research team. Changes were only made to the final coding
structure if they were supported by the data.
Results
Participants
irty professionals responded to the group email and par-
ticipated in the study (54% response rate). ese included
team members of the AGCH (n= 17), ED nurses (n=7)and
staff members of the geriatrics department of the university
hospital (n= 6). Twelve key persons approached by email
also participated in an interview, giving a total participant
number of 42. In total, 31 one-to-one interviews, two dou-
ble interviews and two group interviews were conducted.
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Facilitators and barriers to implementing an acute geriatric community hospital
Interviews lasted 40–70 min. We identified influencing fac-
tors or preconditions and 20 themes including barriers and
facilitators to implementation in the different phases and
levels of implementation (Figure 1b). e seven key themes
and representative quotes are summarised in Tables 3 and 4.
e barriers and facilitators shown in Table 3 were presented
according to Brody et al.[
11], and provide an overview
of challenges, solutions and implications on scalability per
theme.
Inuencing factors and preconditions
Influencing factors and preconditions concern factors
that influence the implementation process during all
the phases (preparation, execution and continuation) of
implementation.
Characteristics of the innovation
Support for the innovation was an important precondi-
tion for implementing the AGCH.e intervention was
developed between 2016 and 2018, when the number of
older adults visiting the ED was increasing. Healthcare staff
noticed that older adults could not go home after visiting
the ED, but that there was no better option—hospitalisation
risked medicalisation and deconditioning and short-term
residential care (STRC) was not available outside office
hours. is, combined with the enthusiasm of the university
professor (BMB) who initiated the project, facilitated devel-
opment of the AGCH. Participants believed strongly that the
AGCH concept had a discrete purpose and would fill a gap
in geriatric care in the Dutch healthcare system. e AGCH
concept is primarily defined by its location (a department
providing hospital care in an SNF) and main goal (to activate
and mobilise older patients during hospital admission).
Organisational conditions
e AGCH was implemented within an existing commu-
nity care organisation that primarily provides chronic care.
erefore, working processes were much slower than those
in the university hospital. In the Dutch healthcare system,
short-term care provided by community care organisations
and care provide by the university hospital are financed by
care insurers through separate billing mechanisms.
Time and other operational preconditions
Designing and opening the first AGCH took ∼2 years. After
the AGCH had opened, geriatricians reported additional
demands on their team because of on-call night and weekend
shifts in the AGCH. e operational facilities of the SNF
were an important factor for implementation; participants
stated that the SNF had fewer resources than a hospital does.
Human and nancial resources
e three organisations who initiated the AGCH concept
described a strong collaboration and trust between the
executive leaders of their organisations. Changes in staffing
and the lack of a project team member with experience
in business operations within the community care sector
also affected implementation. AGCH team disciplines and
competencies also influenced implementation; participants
noted that the experience and knowledge of both hospital
and district nurses were important in the AGCH team. ere
was large variation in competency and skills among AGCH
nurses. Supervising geriatricians from the university hospital
were seen as facilitators throughout implementation. Nurse
practitioners and physician assistants were seen as suitable
for the AGCH because they closed the gap between medical
and nursing care. All professionals working at the AGCH
needed time to develop their professional role in this new
care concept.
Concerning ‘financial resources’, the three partnering
stakeholders agreed to share investment cost and financial
risk during implementation of the AGCH. e AGCH was
funded through an experimental financing structure within
the Dutch healthcare system. is meant that the cost of
care made by the community care organisation would be
reimbursed by all Dutch health insurers based on a tariff that
was negotiated between the community care organisation
and the health insurers.
Facilitators and barriers to
implementation in different phases of the
implementation process
Preparation phase
Micro level (care at the AGCH)
Micro-level facilitators during the preparation of the ‘project
and AGCH team’ were (i) formal preparation sessions for
healthcare professionals from the university hospital and the
community care organisation; and (ii) preparation sessions
by geriatricians to develop and discuss working processes at
the AGCH. Barriers were that formal preparation sessions
were no longer continued once the AGCH had opened and
that the nursing team was only hired shortly before the
AGCH opened. is meant that nurses did not participate
in preparatory meetings, which was seen as a disadvan-
tage. Another barrier was that every professional looked at
implementation of the AGCH from their own perspective.
Before the AGCH could deliver care, several weeks were
needed for the team to ‘start-up various processes’. is start-
up was facilitated by clear expectations of the type of care
that needed to be delivered. Interviewees working at the
AGCH stated that starting the AGCH during renovation of
the SNF hampered the start-up. ere was some collabora-
tion between the AGCH and other wards, but the AGCH
operated mostly as an island within the SNF. A frequently
mentioned barrier was the layout of the department—it had
two different floors and no separate office for the nursing
and medical team, which participants found impractical.
Participants also mentioned that adjustments necessary for
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M. E. Ribbink et al.
Ta b l e 3 . Summary of key themes, challenges and solutions, based on Brody et al.[11]
Key theme Examples of challenges Examples of solutions Implications for scalability
...................................................................................
Project and AGCH
team preparation
(i) Two or more organizations
involved in implementation caused
increased complexity.
(ii) e team working at the AGCH
was new and had a heterogeneous
professional background.
(i) Plan preparatory meetings between
professionals from both organizations before
and during the first months after opening; plan
visits to partnering organization by nurses.
(ii) Hire team prior to opening and involve
team members in the preparation phase; plan
schooling sessions prior to opening.
(i) Hospital and community care organization
must work closely together.
(ii) Sufficient funds to pay AGCH team
during preparation phase required.
Selecting patients
at the ED
(i) Uncertainty of which patients
could be admitted safely.
(ii) Low referrals by specialists at the
ED and GPs to the ED.
(i) Start with admitting low-complex patients
and develop professional expertise in selecting
patients.
(ii) Having a geriatrician or geriatric nurse
practitioner at the ED; inform primary care
practitioners/GPs about the AGCH.
(i) Time is required for geriatricians to gain
experience in selecting patients.
(ii) Investment in ‘advocating’ personnel
required.
Patient care process (i) No hospital protocols were
available at the AGCH.
(ii) EHR is not suited to hospital care.
(iii) Not all hospital
diagnostics/services (CT scans,
consulting specialists) are available.
(iv) Discharge to primary care is
complex and slow.
(i) Adjust and transfer hospital protocols to
AGCH prior to opening and allow protocols to
be exchanged between hospital and AGCH.
(ii) Use a hospital EHR or develop working
processes with existing EHR.
(iii) Select patients with no need for complex
diagnostics, ascertain that laboratory results can
be available on time.
(iv) Implement hospital discharge program
Poin t; develop clear guidelines with regards to
discharge.
(i) Requires policy on sharing protocols and
access to a hospital’s internal resources.
(ii) Hospital EHR can be expensive and not
compatible with EHR in intermediate care;
working with existing EHR may not be suited
for delivering hospital-level care.
(iii) Only selected group of low-complex
and/or stable patients can be admitted to the
AGCH.
(iv) Discharge can be improved by using
‘Point’; but discharge problems to other
services exist nationally.
Business operations (i) Sharing business operations
between two organizations was
difficult.
(ii) Unstable admission rate to the
AGCH.
(i) Develop a method and platform for sharing
information on business operations frequently;
do this before opening the AGCH.
(ii) Accept unstable admission rate and be
prepared for acute admission; keep some
‘overcapacity’.
(i) Business controllers and middle
management need to be involved in
implementation before the AGCH opens.
(ii) Allowing ‘empty’ beds does not fit the
traditional business model of community care.
Transferring acute
care to the
community care
sector
(i) Working processes of community
care are too slow for delivering acute
care.
(ii) Hospital medication and
paramedics not reimbursed within
community care.
(i) Create working process allowing the AGCH
to speed-up, whereas other departments
continue operations as usual.
(ii) Create another community care budget to
fund medication that is not reimbursed; or
include additional cost for medication and
paramedics in day tariff.
(i) Allows the AGCH to operate quickly
within ‘slower’ organization; however, does not
improve delivery of acute care in community
care sector as a whole.
(ii) Negotiation with healthcare insurer
required to include additional costs in a higher
day tariff.
Understanding
partnering
organizations
(i) Laboratory and pharmacy partner
were not used to delivering hospital
care.
(ii) Health professionals did not know
what the AGCH was, which slowed
collaboration and patient referral.
(i) Understand services that can be delivered by
external partner and jointly develop guidelines
for service delivery.
(ii) Set up campaign to inform organizations
about the AGCH concept; consider using a
different name in Dutch.
(i) Many different (independent) laboratories
and pharmacies exist in the Netherlands; a
new collaboration is required for each new
AGCH location.
(ii) Variance in naming the AGCH nationally
could hamper structural implementation in
the healthcare system.
Structural funding (i) Structural financing title does not
exist yet, which hampers long-term
implementation.
(i) Initiating organizations develop financing
title with the help of the Dutch care authority.
(i) e AGCH care ‘product’ is neither a
hospital care product nor a community care
product, which may make it difficult to
develop a financing title.
ED, emergency department; EHR, electronic health record.
care delivery were not included in the renovation, such as
a mediation stockroom and a system for providing oxygen.
e lack of supportive services (such as cleaning) when the
AGCH opened was also considered a barrier to implementa-
tion because patient turnover was much higher in the AGCH
than in other departments.
Meso level (collaboration between organisations)
Facilitators on the meso level were intensive collaboration
between the ‘organisations’ who initiated the AGCH and
visits from the university hospital quality manager. ese
visits provided valuable information for the project team
on how to organise working processes. Additional barriers
were not involving the laboratory and pharmacy in the
preparation phase and not informing all physicians in the
community care organisation about the AGCH.
Macro level (structure, law and financial regulations)
A macro-level facilitator was meetings between both
organisations’ legal teams during the preparation phase,
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Facilitators and barriers to implementing an acute geriatric community hospital
Ta b l e 4 . Representative quotes per key theme
Project and AGCH team preparation ‘You have to be aware that it is a different way of working than what you are used to. A step-by-step guide to make everything
clear and a formal implementation plan to identify accountability is strongly recommended and is important I think [. . .] I
think that it just needs to be clear what the goal is, because there are just so many different goals at the AGCH.’
Selecting patients at the ED ‘You really have to be careful that you admit the right patient, it is a real challenge and much more difficult than I anticipated.
e longer you work here [at the AGCH], the more problems you run across when you admit a patient with an unclear
diagnosis because you have limited ability for diagnostics etc. compared to the hospital. is is something that I previously
underestimated, it is more difficult than you think to admit the ‘right’ patients to the AGCH. You should not admit patients
who lack social support or should go to long-term care. So, this is a challenge, but we are getting better at it’.
Patient care process ‘e nursing home electronic health system really sucks, especially if you are trying to deliver acute medical care and treatment’.
Business operations ‘What I find complicated is that there are so many changes through the years, people who come and go, on the side of the
community care organization on the side of the hospital, that is the way it is. e format that we use for presenting [business
information] has only just been developed. And all the different payment places that we use, that does not help either. e
community care organization pays a part, there is the transitional care [government] subsidy, the health insurer pays a part,
and the university hospital pays a part. Despite the enthusiasm for the project, it is not always possible to work everything out
together’.
Transferring acute care to the
community care sector
‘I think we had to deal with many teething problems [. . .], changes in personnel, getting the basics of providing hospital care
in the community organized, that just takes so much time, and it takes more time than you think when you are writing the
concept up’.
Working with external parties ‘e paramedics thought we were a nursing home. ey would just say: well, I am not going to bring a patient from a nursing
home to the hospital, this patient should be transported by his mother or son.’
Structural funding ‘Only then you really have to accept the cost price of a product and say that the product is expensive yes. Look at my Miele
washing machine, yes, it is expensive, but it lasts 15 years, but over time it is a cheap washing machine.
You have to look at the AGCH this way, it is an expensive product, but in the end when looking at the total cost trajectory of a
frail older person, it is a cheaper solution’.
which helped in ‘choosing a legal form’. Another facilitator
was ‘involving regulators’ such as the Dutch care authority
(Nza) early on in the preparation phase, which helped in
designing an experimental payment title for the AGCH.
e enthusiasm of the partnering healthcare insurer helped
involve regulators, which helped in creating an initial
financing title.
A macro-level barrier was ‘estimating the day rate for the
AGCH’ because the AGCH was a new concept and the
exact daily expenses were unknown. Another barrier was the
former name of the AGCH ‘Buurtziekenhuis’ (community
hospital) because using the Dutch word for ‘hospital’ did not
fit with the national policy of exchanging in-hospital care for
care closer to home.
Execution phase
Micro level (care at the AGCH)
Micro-level facilitators and barriers were experienced when
‘selecting and admitting patients at the ED’ during the exe-
cution phase. When the AGCH started admitting patients,
there was uncertainty among geriatricians on which patients
could be admitted safely—geriatricians wanted to select the
‘right’ patients and prevent acute unplanned transfers back
to hospital. A further barrier was that most patients were not
referred by other specialists.
Facilitators for selecting the ‘right’ patients were admit-
ting low-complex patients and having access to different
diagnostics at the ED. Creating a steady flow of admis-
sions was facilitated by informing other specialists about the
AGCH and having a geriatric emergency care nurse specialist
act as an ‘ambassador’ for the AGCH at the ED. Another
facilitator was an ambulance service that transferred patients
from the ED to other care organisations, which decreased
waiting times for transfer to the AGCH.
A barrier to selecting and admitting patients was that lab-
oratory services at the AGCH were not operating frequently.
Furthermore, patients who should have been admitted to
STRC were referred to the AGCH. e true barrier here
was the unavailability of STRC during out-of-office hours.
Another barrier was that few low-complex patients that geri-
atricians had expected to admit to the AGCH presented at
the university hospital ED. is may have been because gen-
eral practitioners (GPs) were used to referring older patients
with low-complex problems to other hospitals. Another
barrier was that it was difficult to recruit patients from a
second university hospital ED that was added as referring
hospital because other projects were recruiting patients from
this ED. A new and unexpected barrier was the COVID-19
pandemic; the AGCH was not suited to admitting patients
infected with SARS-Cov2.
Micro-level facilitators of the ‘patient care process’
involved the home-like environment of the AGCH, flexi-
bility of professionals and ongoing education of the AGCH
team. e discharge process was facilitated by ‘Point’—
a software interface used by hospitals to communicate
with primary care providers. Barriers to the ‘patient care
process’ were (i) the absence of protocols, (ii) no direct
access to hospital services such as consulting specialists
and more complex diagnostics, (iii) an electronic health
record (EHR) that was not suited to hospital care, (iv)
the high administrative and housekeeping burden, (v)
insufficient skills in the nursing team and (vi) unclear
discharge pathways. e EHR and electronic prescribing
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M. E. Ribbink et al.
program were designed for providing residential care and
were not well suited for acute care settings. Also, the
university hospital used a different EHR, which made it
impossible to share information directly. A solution to the
high administrative and housekeeping burden was hiring
medical secretaries and nursing aides. Some stated that a
high level of nursing competency was required and that not
all team members had sufficient skills, such as placing IV
catheters. Structured communication between nurses and
doctors was also important. ere were also many barriers to
successful discharge, such as knowledge gaps within the team
and unclear discharge pathways. ese barriers increased the
amount of time spent arranging discharge.
On the micro level, ‘managing the department’ was facil-
itated by having a dedicated department manager and nurse
manager. Other facilitators were improving working pro-
cesses within the AGCH team and the flat hierarchy within
the team. is allowed professionals to influence how work
was done in the AGCH. Barriers to managing the depart-
ment were the time needed for the social transition of
district and hospital nurses and the time needed to hire and
train new nurses. Moreover, because patient turnover was
much higher in the AGCH, the community care organi-
sation had to continuously change its operations, logistics
and billing for the AGCH. On some occasions, it was
not clear whether the community care organisation or the
university hospital was responsible for facilitating new care
processes.
Meso level (collaboration between organisations)
During the execution phase, meso-level facilitators were
‘managing the project’ with involved stakeholders; sharing
costs between the university hospital and community care
organisation; working with GPs and the pharmacist visiting
the AGCH each week for a medication review. Managing
the project was facilitated by regular meetings between (i)
AGCH management and the university hospital and (ii)
management and executive leadership from the university
hospital, the community care organisation and the health-
care insurer.
Barriers on the meso level were the running of ‘business
operations’ by two organisations, the project being unknown
to some GPs, and working with ‘external partners’ that were
not used to providing hospital-level care. e AGCH invest-
ment costs were higher than the project team expected and
the running of ‘business operations’ by both the community
care organisation and the hospital was complex.
Some external partners such as GPs did not know
what the AGCH was because of its name—the Dutch
name ‘WijkKliniek’ (neighbourhood clinic) does not imply
what kind of care the AGCH delivers. Another important
barrier was that the laboratory could not meet the hospital-
level needs of the AGCH. For example, laboratory results
would only become available at the end of the day. e
pharmacy partner was used to working in primary care
rather than hospital care, and was not able to follow
some hospital pharmacy protocols or provide certain
medication.
Macro level (structure, law and financial regulations)
A facilitator in ‘transferring acute care to the community
care sector’ was that the transfer of low-complex patients to
the AGCH was in line with the university hospital policy
of transferring low-complex patients to other care organisa-
tions. Barriers were that the set daily rate for the AGCH was
too low and that not all the hospital care and medication was
reimbursed based on the experimental financing title that
had been designed. is meant there was no specific funding
for a dietician, occupational therapy and speech therapy.
Continuation phase
Micro level (providing care at the AGCH)
Supporting nurses and relying on nurses’ expertise were
micro-level facilitators for continuing and implementing the
AGCH elsewhere. Writing an implementation plan with
goals for the AGCH before opening and considering the
barriers experienced by the AGCH team was recommended
when opening the AGCH (the first of its kind in the Nether-
lands).
On the micro level, participants had five distinct ‘ideas
on how the AGCH concept could be improved and scaled-
up’ in the continuation phase: (i) implementing a nurse-
led hospital where a nurse practitioner would manage care
instead of a physician [32], (ii) having an older people’s
physician [33] supervise care instead of a geriatrician, (iii)
better integrating AGCH care with community nursing care,
(iv) admitting patients directly from primary care without
transferring them to the ED and (v) admitting patients pri-
marily from general hospitals instead of university hospitals.
Facilitators and barriers to these five ideas are shown in Table
1 of the Appendix, Supplementary data are available in Age
and Ageing online.
Meso level (collaboration between organisations that provide
care)
Meso-level facilitators to continuing the AGCH concept
elsewhere were ‘involving and understanding external
parties’ at an early stage. It also helps if the external
parties have experience delivering hospital care and are well
informed about the AGCH’s goals and working processes.
Another facilitator was having involved professionals observe
the working processes of the university hospital and
community care organisation before opening the AGCH.
Furthermore, clear agreements on how administrative infor-
mation should be shared between partnering organisations
will facilitate transparency and help in ‘controlling revenue’.
Barriers on the meso level concerned ‘controlling revenue’
because of the high investment cost for the community care
organisation. Expenses for the AGCH are much higher than
for STRC, which makes it more challenging for financial
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Facilitators and barriers to implementing an acute geriatric community hospital
controllers and administrative leadership of the community
care organisation to manage and control revenue.
Macro level (structure, law and financial regulations)
Macro-level facilitators are creating a ‘structural financing
title’ for AGCH care and informing healthcare insurers
about the AGCH concept. If structural financing were in
place and reimbursement for admissions were possible, it
would be possible for other hospitals and care organisations
to invest in new AGCHs. Current options for creating
a structural financing title have benefits and limitations.
Also, in the Dutch healthcare system, any cost that may be
saved after AGCH admission in the post-acute phase is not
returned to the community care organisation but is saved by
the healthcare insurer.
Discussion
Summary
e key facilitators to implementation of the AGCH concept
were perceived value of and enthusiasm for the AGCH. Key
barriers were providing hospital care in an SNF and financ-
ing the AGCH care. Key micro-level facilitators included
organising preparatory sessions, starting with low-complex
patients, team leadership, a flat hierarchy, a positive attitude
of professionals and ongoing education of the AGCH team.
Key barriers were difficulties selecting patients at the ED,
the lack of protocols, the administrative burden, an EHR
that was not suited for hospital care, the department layout
and working processes at the SNF, which were designed for
chronic care.
Some factors were both facilitators and barriers. For exam-
ple, having both district and hospital nurses in the team
was a facilitator because of the combined expertise but was
also a barrier because not all team members had the same
level of knowledge and skills. A meso-level facilitator was the
strong collaboration between the university hospital and the
community care organisation. Meso-level barriers were that
the AGCH concept was unknown to many external partners
and that sharing business operations between organisations
was complex, leading to a substantial financial loss in the
first two years after opening. Macro-level facilitators were
the sharing of investment costs by partnering stakeholders
and the involvement of regulators. Barriers were the lack
of a structural financing title and the transfer of acute care
to the community care sector, which led to some care not
being reimbursed. Stakeholders found implementation of
the AGCH complex and demanding but were convinced
that implementation was feasible and that the AGCH inter-
vention was valuable to older patients.
Comparison with existing literature
Brody et al.[
11] also reported that it was important for the
Hah to invest in internal and external partnerships before
starting the intervention. Similar barriers included uncer-
tainty about patient eligibility and the EHR not meeting the
needs of the Hah team [11]. e Hah and the AGCH also
had issues with financing and billing care. For Hah, these
were mostly related to the absence of a method that would
assess how much each organisation should receive for the
care they provided. For the AGCH, these issues were that
some treatments were not reimbursed by the experimental
financing title.
Creating structural funding when implementing new care
models is challenging [11,20]. e experimental financing
title that was created for the AGCH was an important
facilitator for implementation. At the same time, AGCH care
was more expensive than expected and any costs that were
saved in the post-acute care phase by preventing readmission
were not returned to the community care organisation that
had invested in AGCH care. is is known as the ‘wrong
pockets problem’ [34] and is not specific to the Dutch care
system; it can occur in any care systems that do not have
integrated financing [35].
Participants also mentioned the importance of the overall
attitude in the team and the enthusiasm of the stakeholders,
which affect the willingness of the professionals/stakeholders
to fully engage in the implementation process [36]. e
enthusiasm of stakeholders may be explained by the per-
ceived value and ‘relative advantage’ of the AGCH [18,37].
Compared with in-hospital care for older adults, many stake-
holders described how the AGCH would be better suited to
providing care for older patients, both on the patient level
(better outcomes) and the system level (expectation of lower
societal costs).
Strengths and limitations
A strength of this study is the purposive sampling to recruit
participants, which ensured the sample was representative
and enough data was obtained. However, the heterogene-
ity of interviewees’ backgrounds complicated our analy-
sis. Another limitation was that not all interviewees were
involved in the implementation from the start and that some
interviews had to be conducted via video-call because of
the COVID-19 pandemic. However, this made it easier to
arrange interviews. Furthermore, although the framework
of adaptive implementation [18] allowed us to analyse our
data in a structured manner, other conceptual frameworks
have been developed more recently [38]. However, we do not
think that using these frameworks would have changed our
findings. Finally, it may not be possible to generalise some
of our findings to the implementation of other AGCHs or
care models [39]. For example, the problems we encoun-
tered concerning the department layout could be specific to
the SNF.
Implications for science, practice and policy
Further research should focus on facilitators and barriers to
implementing AGCHs elsewhere, particularly in rural areas.
When implementing an AGCH, practitioners and local
9
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M. E. Ribbink et al.
policy makers should consider the facilitators and barriers
reported here. A formal stakeholder analysis and analysis
of potential facilitators and barriers before implementation
could also help [30,40]. is is especially important because
our study shows that implementing an AGCH in the Dutch
healthcare system is more complex than was expected. Fur-
thermore, training and educating the nursing team at the
start of implementation will assure sufficient knowledge of
acute and geriatric care and will ensure that all nurses have
the necessary skills. Policy makers involved in regulating and
funding hospital and community care in the Netherlands
should consider the regulatory and financial barriers to pro-
viding hospital care closer to or at home. Providing hospital-
level care for low-complex patients outside the hospital does
not happen overnight, and does not automatically reduce
costs because investment is required. At the same time,
the demand for care out-of-office hours and/or for acute
geriatric care will increase as more older adults are living
at home for longer [12]. is warrants a holistic approach
both at the patient and healthcare system level, which means
STRC availability and resources in community care need to
be improved. Patient needs rather than service availability
should be the leading factor when selecting patients for
admission to either a STRC or AGCH ward [41]. Continued
research into cost-effectiveness of the AGCH is warranted.
AGCH costs should be lower or equal to conventional
hospitalisation and the AGCH should achieve similar or
better outcomes.
Conclusion
is qualitative process evaluation shows that implementing
an AGCH is feasible in the Netherlands. e most important
facilitator to implementation was the perceived value of the
AGCH concept. Major barriers were providing hospital care
within the community care sector and financing AGCH
care. ese insights may be helpful for implementing an
AGCH elsewhere and for developing solutions for these
barriers during the preparation phase of implementation.
is will support working processes and operations during
the execution phase.
Supplementary Data: Supplementary data mentioned in
the text are available to subscribers in Age and Aging online.
Acknowledgements of Collaborative Authorship: We
would like to thank the members of the AGCH study
group—these are the clinicians who work at the Geriatrics
Department of the Amsterdam University Medical Centres
and/or the ACGH. e AGCH study group members are: R
H A van den Broek; W J Frenkel; M J Henstra; K J Kaland;
M Koelé; M A van Maanen; C J M Melkert, J L Parlevliet;
E P van Poelgeest; E Potgieter; I Oudejans; A Smorenberg;
P M A van Rijn; N van der Velde; S van der Woude; H C
Willems and D Wyatt
Declaration of Conflicts of Interest: None.
Declaration of Sources of Funding: e Acute Geriatric
Community Hospital (AGCH; Amsterdam University Med-
ical Centre’s) research receives funding from ZonMw, the
Netherlands Organization for Health Researchand Develop-
ment (project number: 808393598041) and the PVE-fund.
Moreover, care provided at the AGCH is financially sup-
ported by and provided in a partnership between Cordaan—
a community, intermediate and home care organization and
the Amsterdam University Medical Centre, location Aca-
demic Medical Centre. e AGCH is financially supported
by Zilveren Kruis—a health insurance company. Zilveren
Kruis and funders did not play a role in the design of this
research.
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