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Facilitators and barriers to implementing an acute geriatric community hospital in the Netherlands: a qualitative study



Background: there is a trend across Europe to enable more care at the community level. The 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. The 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. The 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.
Age and Ageing 2023; 52: 112
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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
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.
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
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.
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 [27]. 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 [710]. 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;[1820]). 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].
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
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 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
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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 [1820]. (B) eoretical model of
adaptive implementation applied to the AGCH context, including themes that emerged in the analysis [1820]. Key themes are
presented in bold. AGCH, Acute Geriatric Community Hospital; ED, emergency department.
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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
- 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.
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
Inuencing factors and preconditions
Influencing factors and preconditions concern factors
that influence the implementation process during all
the phases (preparation, execution and continuation) of
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
(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
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
(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
(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
(ii) Unstable admission rate to the
(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
(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
(i) Working processes of community
care are too slow for delivering acute
(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.
(i) Laboratory and pharmacy partner
were not used to delivering hospital
(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
(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
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
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
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-
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
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.
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
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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.
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
1. SBR S, Coster S, Ghailani D, Peña-Casas R, Vanhercke B.
Challenges in Long-Term Care in Europe. A Study of National
Policies. Brussels European Commission, 2018. (1
November 2021, date last accessed).
2. Boyd CM, Landefeld CS, Counsell SR et al. Recovery of
activities of daily living in older adults after hospitaliza-
tion for acute medical illness. J Am Geriatr Soc 2008; 56:
3. Buurman BM, Hoogerduijn JG, de Haan RJ et al. Geriatric
conditions in acutely hospitalized older patients: prevalence
and one-year survival and functional decline. PLoS One 2011;
6: e26951.
4. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly
people. Lancet 2014; 383: 911–22.
5. Conley J, O’Brien CW, Leff BA, Bolen S, Zulman D. Alter-
native strategies to inpatient hospitalization for acute medical
conditions: a systematic review. JAMA Intern Med 2016; 176:
6. Colprim D, Martin R, Parer M, Prieto J, Espinosa L, Inzitari
M. Direct admission to intermediate care for older adults
with reactivated chronic diseases as an alternative to con-
ventional hospitalization. J Am Med Dir Assoc 2013; 14:
7. Shepperd S, Butler C, Cradduck-Bamford A et al. Is com-
prehensive geriatric assessment admission avoidance hospi-
tal at home an alternative to hospital admission for older
persons? : A randomized trial. Ann Intern Med 2021; 174:
8. Federman AD, Soones T, DeCherrie LV , Leff B, Siu AL. Asso-
ciation of a bundled hospital-at-home and 30-day postacute
transitional care program with clinical outcomes and patient
experiences. JAMA 2018; 178: 1033–40.
9. Shepperd S, Doll H, Angus RM et al. Admission avoidance
hospital at home. Cochrane Database Syst Rev 2008; 4:
10. Shepperd S, Iliffe S, Doll HA et al. Admission avoidance
hospital at home. Cochrane Database Syst Rev 2016; 9:
11. Brody AA, Arbaje AI, DeCherrie LV, Federman AD, Leff B,
Siu AL. Starting up a hospital at home program: facilitators
and barriers to implementation. J Am Geriatr Soc 2019; 67:
Downloaded from by guest on 03 February 2023
Facilitators and barriers to implementing an acute geriatric community hospital
12. Dutch Ministry of Health D.eRightCareattheRight
Place 15th of October 2019, https://www.dejuistezorgopde (1 November 2021,
date last accessed).
13. Ribbink ME, Macneil-Vroomen JL, van Seben R, Oudejans I,
Buurman BM. Investigating the effectiveness of care delivery
at an acute geriatric community hospital for older adults
in the Netherlands: a protocol for a prospective controlled
observational study. BMJ Open 2020; 10: e033802.
14. Ribbink ME, Gual N, MacNeil-Vroomen JL et al. Tw o E u r o -
pean examples of acute geriatric units located outside of a
general hospital for older adults with exacerbated chronic
conditions. J Am Med Dir Assoc 2021; 22: 1228–34.
15. Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne
P. Comprehensive geriatric assessment for older adults admit-
ted to hospital: meta-analysis of randomised controlled trials.
BMJ 2011; 343: d6553.
16. de Morton NA, Keating JL, Jeffs K, Cochrane Muscu-
loskeletal Group. Exercise for acutely hospitalised older med-
ical patients. Cochrane Database Syst Rev 2007; 2010:
17. Martinez-Velilla N, Casas-Herrero A, Zambom-Ferraresi F et
al. Effect of exercise intervention on functional decline in very
elderly patients during acute hospitalization: a randomized
clinical trial. JAMA Intern Med Jan 1 2019; 179: 28–36.
18. Meiland FJ, Dröes RM, De Lange J, Vernooij-Dassen MJ.
Development of a theoretical model for tracing facilitators and
barriers in adaptive implementation of innovative practices
in dementia care. Arch Gerontol Geriatr Suppl 2004; 38:
19. Meiland FJ, Droes RM, de Lange J, Vernooij-Dassen MJ.
Facilitators and barriers in the implementation of the meeting
centres model for people with dementia and their carers.
Health Policy 2005; 71: 243–53.
20. Van Mierlo LD, Meiland FJ, Van Hout HP, Dröes RM.
Towards personalized integrated dementia care: a qualita-
tive study into the implementation of different models of
case management. BMC Geriatr 2014; 14: 84. https://doi.o
21. Hennink M, Hutter I, Baily A. Qualitative Research Methods.
London: SAGE, 2015.
22. Tong A, Sainsbury P, Craig J. Consolidated criteria for report-
ing qualitative research (COREQ): A 32-item checklist for
interviews and focus groups. Int J Qual Health Care 2008;
19: 349–57.
23. Patrick Jeurissen HM. e market reform in Dutch health
care: results, lessons and prospects. In: e European Observa-
tory on Health Systems and Policies. United Kingdom: World
Health Organization, 2021.
24. Siddiqi N, Harrison JK, Clegg A et al. Interventions
for preventing delirium in hospitalised non-ICU patients.
Cochrane Database Syst Rev 2016; 3: Cd005563. https://
25. Brown H, Terrence J, Vasquez P, Bates DW, Zimlichman E.
Continuous monitoring in an inpatient medical-surgical unit:
a controlled clinical trial. Am J Med 2014; 127: 226–32.
26. Pearson M, Hunt H, Cooper C, Shepperd S, Pawson R,
Anderson R. Providing effective and preferred care closer to
home: a realist review of intermediate care. Health Soc Care
Community 2015; 23: 577–93.
27. Verhaegh KJ, MacNeil-Vroomen JL, Eslami S, Geerlings SE,
de Rooij SE, Buurman BM. Transitional care interventions
prevent hospital readmissions for adults with chronic illnesses.
Health Aff (Millwood) 2014; 33: 1531–9.
28. van Seben R, Geerlings SE, Verhaegh KJ, Hilders CG, Buur-
man BM. Implementation of a Transfer Intervention Pro-
cedure (TIP) to improve handovers from hospital to home:
interrupted time series analysis. BMC Health Serv Res 2016;
16: 479.
29. Busetto L, Kiselev J, Luijkx KG, Steinhagen-iessen E, Vri-
jhoef HJ. Implementation of integrated geriatric care at a
German hospital: a case study to understand when and why
beneficial outcomes can be achieved. BMC Health Serv Res
2017; 17: 180.
30. Wensing M, Grol R. Implementation Effective Improve-
ment of Patient Care (in Dutch). Implementatie: Effec-
tieve verandering in de patientenzorg. 7ed edition. Houten:
Houten Bohn Safleu van Loghum, 2017.
31. Braun V, Clarke V. Using thematic analysis in psychology.
Qual Res Psychol 2006; 3: 77–101.
32. Griffiths PD, Edwards MH, Forbes A, Harris RL, Ritchie
G, Cochrane Effective Practice and Organisation of Care
Group. Effectiveness of intermediate care in nursing-led in-
patient units. Cochrane Database Syst Rev 2007; CD002214.
33. Koopmans R, Pellegrom M, van der Geer ER. e Dutch
move beyond the concept of nursing home physician special-
ists. J Am Med Dir Assoc 2017; 18: 746–9.
34. McCullough JM. Declines in spending despite positive returns
on investment: understanding public health’s wrong pocket
problem. Front Public Health 2019; 7: 159.
35. Hildebrandt H, Pimperl A, Schulte T et al. Pursuing the
triple aim: evaluation of the integrated care system Gesundes
Kinzigtal: population health, patient experience and cost-
effectiveness. Bundesgesundheitsblatt Gesundheitsforschung
Gesundheitsschutz 2015; 58: 383–92.
Triple Aim - Evaluation in der Integrierten Versorgung Gesun-
des Kinzigtal - Gesundheitszustand, Versorgungserleben und
36. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander
JA, Lowery JC. Fostering implementation of health services
research findings into practice: a consolidated framework for
advancing implementation science. Implementation Sci 2009;
4: 50.
37. Rogers EM. Diffusion of Innovations. ird edition. New
York: e Free press, 1983.
38. Harvey G, Kitson A. PARIHS revisited: from heuristic to
integrated framework for the successful implementation of
knowledge into practice. Implementation Sci 2016; 11: 33.
39. Moore GF, Audrey S, Barker M et al. Process evalua-
tion of complex interventions: Medical Research Council
guidance. BMJ 2015; 350: h1258.
40. Balane MA, Palafox B, Palileo-Villanueva LM, McKee M,
Balabanova D. Enhancing the use of stakeholder analysis
for policy implementation research: towards a novel framing
and operationalised measures. BMJ Glob Health 2020; 5:
Downloaded from by guest on 03 February 2023
M. E. Ribbink et al.
41. van den Besselaar JH, Hartel L, Wammes JD, MacNeil-
Vroomen JL, Buurman BM. ‘Patients come with two garbage
bags full of problems and we have to sort them.’ A qualitative
study of the experiences of healthcare professionals on patients
admitted to short-term residential care in the Netherlands.
Age Ageing 2021; 50: 1361–70.
Received 23 December 2021; editorial decision 5 July 2022
Downloaded from by guest on 03 February 2023
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
In 2006, The Netherlands embarked upon an ambitious reform of the Dutch health care system based upon the principles of regulated competition. Fiscal sustainability go the system has improved. In many places diversity has increased among providers, insurance policies etc. High levels of universal access are still paramount for the system. However, administrative costs are high and their is few evidence that regulated competition has speed up the increases in quality of care.
Full-text available
Objective Throughout Europe, the number of older adults requiring acute hospitalization is increasing. Admission to an acute geriatric unit outside of a general hospital could be an alternative. In this model of acute medical care, comprehensive geriatric assessment and rehabilitation are provided to selected older patients. This study aims to compare patients' diagnoses, characteristics, and outcomes of 2 European sites where this care occurs. Design Exploratory cohort study. Setting and participants Subacute Care Unit (SCU), introduced in 2012 in Spain, and the Acute Geriatric Community Hospital (AGCH), introduced in 2018 in the Netherlands. The main admission criteria for older patients were acute events or exacerbations of chronic conditions, hemodynamic stability on admission, and no requirement for complex diagnostics. Measures We compared setting, characteristics, and outcomes between patients admitted to the 2 units. Results Data from 909 patients admitted to SCU and 174 to AGCH were available. Patients were admitted from the emergency department or from home. The mean age was 85.8 years [standard deviation (SD) = 6.7] at SCU and 81.9 years (SD = 8.5) (P < .001) at AGCH. At SCU, patients were more often delirious (38.7% vs 22.4%, P < .001) on admission. At both units, infection was the main admission diagnosis. Other diagnoses included heart failure or chronic obstructive pulmonary disease. Five percent or less of patients were readmitted to general hospitals. Average length of stay was 8.8 (SD = 4.4) days (SCU) and 9.9 (SD = 7.5) days (AGCH). Conclusions and Implications These acute geriatric units are quite similar and both provide an alternative to admission to a general hospital. We encourage the comparison of these units to other examples in Europe and suggest multicentric studies comparing their performance to usual hospital care.
Full-text available
Background Policy is shaped and influenced by a diverse set of stakeholders at the global, national and local levels. While stakeholder analysis is a recognised practical tool to assess the positions and engagement of actors relevant to policy, few empirical studies provide details of how complex concepts such as power, interest and position are operationalised and assessed in these types of analyses. This study aims to address this gap by reviewing conceptual approaches underlying stakeholder analyses and by developing a framework that can be applied to policy implementation in low-and-middle income countries. Methods The framework was developed through a three-step process: a scoping review, peer review by health policy experts and the conduct of an analysis using key informant interviews and a consensus building exercise. Four characteristics were selected for inclusion: levels of knowledge, interest, power and position of stakeholders related to the policy. Result The framework development process highlighted the need to revisit how we assess the power of actors, a key issue in stakeholder analyses, and differentiate an actor’s potential power, based on resources, and whether they exercise it, based on the actions they take for or against a policy. Exploration of the intersections between characteristics of actors and their level of knowledge can determine interest, which in turn can affect stakeholder position on a policy, showing the importance of analysing these characteristics together. Both top-down and bottom-up approaches in implementation must also be incorporated in the analysis of policy actors, as there are differences in the type of knowledge, interest and sources of power among national, local and frontline stakeholders. Conclusion The developed framework contributes to health policy research by offering a practical tool for analysing the characteristics of policy actors and tackling the intricacies of assessing complex concepts embedded in the conduct of stakeholder analyses.
Full-text available
Introduction Hospital admission in older adults with multiple chronic conditions is associated with unwanted outcomes like readmission, institutionalisation, functional decline and mortality. Providing acute care in the community and integrating effective components of care models might lead to a reduction in negative outcomes. Recently, the first geriatrician-led Acute Geriatric Community Hospital (AGCH) was introduced in the Netherlands. Care at the AGCH is focused on the treatment of acute diseases, comprehensive geriatric assessment, setting patient-led goals, early rehabilitation and streamlined transitions of care. Methods and analysis This prospective cohort study will investigate the effectiveness of care delivery at the AGCH on patient outcomes by comparing AGCH patients to two historic cohorts of hospitalised patients. Propensity score matching will correct for potential population differences. The primary outcome is the 3-month unplanned readmission rate. Secondary outcomes include functional decline, institutionalisation, healthcare utilisation, occurrence of delirium or falls, health-related quality of life, mortality and patient satisfaction. Measurements will be conducted at admission, discharge and 1, 3 and 6 months after discharge. Furthermore, an economic evaluation and qualitative process evaluation to assess facilitators and barriers to implementation are planned. Ethics and dissemination The study will be conducted according to the Declaration of Helsinki. The Medical Ethics Research Committee confirmed that the Medical Research Involving Human Subjects Act did not apply to this research project and official approval was not required. The findings of this study will be disseminated through public lectures, scientific conferences and journal publications. Furthermore, the findings of this study will aid in the implementation and financing of this concept (inter)nationally. Trial registration number NL7896; Pre-results.
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Importance Functional decline is prevalent among acutely hospitalized older patients. Exercise and early rehabilitation protocols applied during acute hospitalization can prevent functional and cognitive decline in older patients. Objective To assess the effects of an innovative multicomponent exercise intervention on the functional status of this patient population. Design, Setting, and Participants A single-center, single-blind randomized clinical trial was conducted from February 1, 2015, to August 30, 2017, in an acute care unit in a tertiary public hospital in Navarra, Spain. A total of 370 very elderly patients undergoing acute-care hospitalization were randomly assigned to an exercise or control (usual-care) intervention. Intention-to-treat analysis was conducted. Interventions The control group received usual-care hospital care, which included physical rehabilitation when needed. The in-hospital intervention included individualized moderate-intensity resistance, balance, and walking exercises (2 daily sessions). Main Outcomes and Measures The primary end point was change in functional capacity from baseline to hospital discharge, assessed with the Barthel Index of independence and the Short Physical Performance Battery (SPPB). Secondary end points were changes in cognitive and mood status, quality of life, handgrip strength, incident delirium, length of stay, falls, transfer after discharge, and readmission rate and mortality at 3 months after discharge. Results Of the 370 patients included in the analyses, 209 were women (56.5%); mean (SD) age was 87.3 (4.9) years. The median length of hospital stay was 8 days in both groups (interquartile range, 4 and 4 days, respectively). Median duration of the intervention was 5 days (interquartile range, 0); there was a mean (SD) of 5 (1) morning and 4 (1) evening sessions per patient. No adverse effects were observed with the intervention. The exercise intervention program provided significant benefits over usual care. At discharge, the exercise group showed a mean increase of 2.2 points (95% CI, 1.7-2.6 points) on the SPPB scale and 6.9 points (95% CI, 4.4-9.5 points) on the Barthel Index over the usual-care group. Hospitalization led to an impairment in functional capacity (mean change from baseline to discharge in the Barthel Index of −5.0 points (95% CI, −6.8 to −3.2 points) in the usual-care group, whereas the exercise intervention reversed this trend (1.9 points; 95% CI, 0.2-3.7 points). The intervention also improved the SPPB score (2.4 points; 95% CI, 2.1-2.7 points) vs 0.2 points; 95% CI, −0.1 to 0.5 points in controls). Significant intervention benefits were also found at the cognitive level of 1.8 points (95% CI, 1.3-2.3 points) over the usual-care group. Conclusions and Relevance The exercise intervention proved to be safe and effective to reverse the functional decline associated with acute hospitalization in very elderly patients. Trial Registration identifier: NCT02300896
Background: Delivering hospital-level care with comprehensive geriatric assessment (CGA) in the home is one approach to deal with the increased demand for bed-based hospital care, but clinical effectiveness is uncertain. Objective: To assess the clinical effectiveness of admission avoidance hospital at home (HAH) with CGA for older persons. Design: Multisite randomized trial. (ISRCTN registry number: ISRCTN60477865) Setting: 9 hospital and community sites in the United Kingdom. Patients: 1055 older persons who were medically unwell, were physiologically stable, and were referred for a hospital admission. Intervention: Admission avoidance HAH with CGA versus hospital admission with CGA when available using 2:1 randomization. Measurements: The primary outcome of living at home was measured at 6 months. Secondary outcomes were new admission to long-term residential care, death, health status, delirium, and patient satisfaction. Results: Participants had a mean age of 83.3 years (SD, 7.0). At 6-month follow-up, 528 of 672 (78.6%) participants in the CGA HAH group versus 247 of 328 (75.3%) participants in the hospital group were living at home (relative risk [RR], 1.05 [95% CI, 0.95 to 1.15]; P = 0.36); 114 of 673 (16.9%) versus 58 of 328 (17.7%) had died (RR, 0.98 [CI, 0.65 to 1.47]; P = 0.92); and 37 of 646 (5.7%) versus 27 of 311 (8.7%) were in long-term residential care (RR, 0.58 [CI, 0.45 to 0.76]; P < 0.001). Limitation: The findings are most applicable to older persons referred from a hospital short-stay acute medical assessment unit; episodes of delirium may have been undetected. Conclusion: Admission avoidance HAH with CGA led to similar outcomes as hospital admission in the proportion of older persons living at home as well as a decrease in admissions to long-term residential care at 6 months. This type of service can provide an alternative to hospitalization for selected older persons. Primary Funding Source: The National Institute for Health Research Health Services and Delivery Research Programme (12/209/66).
Background Short-term residential care (STRC) facilities were recently implemented in the Netherlands to provide temporary care to older adults with general health problems. The aim of STRC is to allow the individual to return home. However, 40% of patients are discharged to long-term care facilities. In-depth data about characteristics of patients admitted and challenges in providing STRC are missing. Objective To obtain perspectives of STRC professionals on the patient journey from admission to discharge. Design Qualitative study. Setting Eight nursing homes and three hospitals. Subjects A total of 28 healthcare professionals. Methods A total of 13 group interviews with in-depth reviews of 39 pseudonymised patient cases from admission to discharge. Interviews were analysed thematically. Results Many patients had complex problems that were underestimated at handover, making returning to home nearly impossible. The STRC eligibility criteria that patients have general health problems and can return home do not fit with current practice. This results in a mismatch between patient needs and the STRC that is provided. Therefore, planning care before and after discharge, such as advance care planning, social care and home adaptations, is important. Conclusions STRC is used by patients with complex health problems and pre-existing functional decline. Evidence-based guidelines, appropriate staffing and resources should be provided to STRC facilities. We need to consider the environmental context of the patient and healthcare system to enable older adults to live independently at home for longer.
Background Hospital at home (HaH) is a model of care that provides acute‐level services in the home. HaH has been shown to improve quality and patient satisfaction, and reduce iatrogenesis and costs. Uptake of HaH in the United States has been limited, and little research exists on how to implement it successfully. Objectives This study examined facilitators and barriers to implementation of an HaH program. Design A HaH program that included a 30‐day transitional care bundle following the acute stay was implemented through a Centers for Medicare & Medicaid Services Innovations Award. Informants completed a priming table describing initial implementation components, their barriers, and facilitators. These were followed up with semistructured focus groups and individual interviews that were transcribed and independently coded using thematic analysis by two independent investigators. Setting Large urban academic health system. Participants Clinical and administrative personnel from Mount Sinai, the Visiting Nurse Service of New York, and executive leaders at partner organizations (laboratory, pharmacy, radiology, and transportation). Results To facilitate successful development and implementation of a high‐quality HaH program, a number of barriers needed to be overcome through significant teamwork and communication internally with policymakers and external partners. Areas of paramount importance include facilitating work‐arounds to regulatory barriers and health system policies; altering an electronic health record that was not designed for HaH; developing the necessary payment and billing mechanisms; and building effective and collaborative partnerships and communication with outside vendors. Conclusion Development of HaH programs in the United States are feasible but require strategic planning and development of strong, tightly coordinated partnerships.
Importance Hospital-at-home (HaH) care provides acute hospital-level care in a patient’s home as a substitute for traditional inpatient care. In September 2017, the Physician-Focused Payment Model Technical Advisory Committee recommended implementation of an alternative payment model for a new model of HaH that bundles the acute episode with 30 days of postacute transitional care. Objective To report outcomes of this new payment model for HaH care. Design, Setting, and Participants Case-control study of HaH care patients with a concurrent control group of hospital inpatients recruited from emergency departments (EDs) and residences in New York City from November 18, 2014, to August 31, 2017. HaH patients were 18 years or older with fee-for-service Medicare and acute medical illness requiring inpatient-level care. Control patients met HaH eligibility but refused participation or were seen in the ED when a HaH admission could not be initiated. Exposures HaH care or inpatient care. Main Outcomes and Measures Primary outcomes were acute period length of stay (LOS), all-cause 30-day hospital readmissions and ED visits, admissions to skilled nursing facilities (SNFs), referral to a certified home health care agency, and patient experiences with care. Analyses accounted for nonrandom selection using inverse probability weighting. Results Among the 507 patients enrolled (mean [SD] age, 74.6 [15.7] years; 68.6% women), data were available on all patients 30 days postdischarge. HaH patients (n = 295) were older than controls (n = 212) and more likely to have a preacute functional impairment. HaH patients had shorter LOS (3.2 days vs 5.5 days; difference, −2.3 days; 95% CI, −1.8 to −2.7 days; weighted P < .001); lower rates of readmissions (8.6% [25] vs 15.6% [32]; difference, −7.0%; 95% CI, −12.9% to −1.1%; weighted P < .001), ED revisits (5.8% [17] vs 11.7% [24]; difference, −5.9%; 95% CI, −11.0% to −0.7%; weighted P < .001), and SNF admissions (1.7% [5] vs 10.4% [22]; difference, −8.7%; 95% CI, −13.0% to −4.3%; weighted P < .001); and were also more likely to rate their hospital care highly (68.8% [119] vs 45.3% [67]; difference, 23.5%; 95% CI, 12.9% to 34.1%; weighted P < .001). There were no differences in referrals to certified home health agencies. Conclusions and Relevance HaH care bundled with a 30-day postacute transitional care episode was associated with better patient outcomes and ratings of care compared with inpatient hospitalization. This model warrants consideration for addition to Medicare’s current portfolio of shared savings programs.