Perceived quality of an alternative to acute hospitalization: An analytical study at a community hospital in Hallingdal, Norway

Highlights

• Community hospitals can be viable supplements to general hospitals.

• The therapeutic landscape includes the cultural and social context of the location.

• Patients' perceived quality is dependent upon confidence and trust in local care.

• Continuity of care and holistic approach are appreciated values in intermediate units.

• Sense of local ownership is a key success factor regarding community hospitals.

Abstract

There is growing international interest in the geography of health care provision, with health care providers searching for alternatives to acute hospitalization. In Norway, the government has recently legislated for municipal authorities to develop local health services for a selected group of patients, with a quality equal to or better than that provided by hospitals for emergency admissions. General practitioners in Hallingdal, a rural district in southern Norway, have for several years referred acutely somatically ill patients to a community hospital, Hallingdal sjukestugu (HSS). This article analyzes patients' perceived quality of HSS to demonstrate factors applicable nationally and internationally to aid in the development of local alternatives to general hospitals. We used a mixed-methods approach with questionnaires, individual interviews and a focus group interview. Sixty patients who were taking part in a randomized, controlled study of acute admissions at HSS answered the questionnaire. Selected patients were interviewed about their experiences and a focus group interview was conducted with representatives of local authorities, administrative personnel and health professionals. Patients admitted to HSS reported statistically significant greater satisfaction with several care aspects than those admitted to the general hospital. Factors highlighted by the patients were the quiet and homelike atmosphere; a small facility which allowed them a good overall view of the unit; close ties to the local community and continuity in the patient–staff relationship. The focus group members identified some overarching factors: an interdisciplinary and holistic approach, local ownership, proximity to local general practices and close cooperation with the specialist health services at the hospital. Most of these factors can be viewed as general elements relevant to the development of local alternatives to acute hospitalization both nationally and internationally. This study indicates that perceived quality should be one of the main motivations for developing alternatives to general hospital admissions.

Introduction

In Western countries, increasing costs, constrained resources, the increasing number of elderly and the growing demand for health care enforce the development of alternative health care (Hider et al., 2000). In this quest for alternatives, political and organizational reforms have to be evaluated continuously. Reforms that include centralization or decentralization of health services actualize issues of equitable distribution and cultural and qualitative gains and losses assessed against social and economic consequences. Geography of health care provision is a discipline of social science that encompasses many of the issues and approaches that arise through various health reforms and is therefore of increasing importance in many countries of the world (Parr, 2003). Health care aimed at the individual cannot be seen in isolation from the socio-economic and cultural context and this challenges health planners to cope with a great complexity of factors.

The health care system in Norway is currently divided into two levels. The state is responsible for the hospitals, the outpatient services and the specialist health services. The municipalities are responsible for primary health care, including emergency care, general practice, home-based care and nursing homes. Norwegian general practitioners (GPs) are responsible for medical care outside the hospitals, while specialists operate within the hospitals and outpatient clinics. GPs refer patients to hospital, but are not usually involved in hospital treatment.

The National Coordination Reform, which is currently being implemented, challenges this division by instructing the municipalities to develop alternative health care services before, instead of, and after hospital care (Norwegian Ministry of Health and Care Services, 2009), both to reduce the number of admissions to hospitals and to limit the duration of hospital stays. By 2016, all Norwegian municipalities are expected to provide appropriate patient groups with alternatives to acute hospitalization. In its guidelines to local authorities, the Norwegian Directorate of Health states that the quality of these new health services for acute admissions must be equal to or better than that of the hospitals (Norwegian Directorate of Health, 2012a). However, the guidelines do not specify what such quality entails or how it is to be assessed. Furthermore, there is no detailed list of applicable diagnoses of patient groups given. The guidelines emphasize, however, that it pertains to stable patients with clarified diagnosis or patients who need observation or basic investigation and who are not seriously ill.

The Hallingdal valley is a rural region in southern Norway with 20,000 inhabitants in six municipalities. The municipalities each have their own nursing home and home care. Some patients requiring medical treatment are admitted to Hallingdal sjukestugu (HSS), a type of institution that is rather unique in Norway. HSS is administered by the nearest general hospital, Ringerike sykehus (RS), 170 km away and is therefore a part of the specialist health care service. HSS is comparable with cottage or community hospitals in Great Britain. HSS includes a somatic inpatient unit of 14 beds, somatic and psychiatric outpatient clinics, a day treatment center with dialysis and palliative care, a digital X-ray satellite to RS and a base for helicopter and ground ambulances. The somatic inpatient unit at HSS fills a gap between the municipal health care services and the specialist health care provided at the hospital and can be categorized as an intermediate department. The staffing to patient ratios are 1.17 at HSS and 1.30 at the medical department at RS. The intermediate department at HSS is run by two GPs employed by HSS, filling 1.8 positions, with supervision by specialists from RS via phone, telemedicine or in person when the specialists are working at the outpatient clinic at HSS.

There are approximately 600 admissions annually to the intermediate department at HSS, with a mean length of stay of 4.8 days in 2012. The patients can be divided into three equal groups: acute admissions, follow-up treatment after general hospital admissions and rehabilitation. This study focuses on the acute admissions. GPs in the region refer certain groups of acutely ill patients to HSS as an alternative to hospitalization at RS. The patients selected for acute admissions to HSS are in need of observation and treatment with frequent supervision by nurses and doctors; however, they do not need the hospital's specific expertise and equipment. Examples of diagnostic groups are those with pneumonia, chronic diseases with exacerbations, trauma without the need for surgical treatment, various pain conditions and cancer patients with a worsening of symptoms. In an earlier article, the function of HSS was described along with a detailed review of the diagnoses admitted to the intermediate department (Lappegard and Hjortdahl, 2012). The age range was 16–96 years, with 40% under the age of 67 years and 36% over 80 years old.

Acutely ill patients admitted to HSS largely correspond to the selected group of patients the Coordination Reform recommends for alternatives to hospitalization. It is thus of interest to assess the quality of the health services at HSS. Quality of health care is a comprehensive concept. Based on Donabedian's work, several authors have proposed that it is useful to distinguish between quality related to the health service structure, the processes by which health care is provided and the outcome or consequences of the health service (Campbell et al., 2000, Donabedian, 2005, Rademakers et al., 2011). A number of methods for both objective quality analysis and the assessment of subjective, experienced or perceived quality have been developed to measure these different aspects of quality (Fong et al., 2008, Norwegian Directorate of Health, 2010, Norwegian Directorate of Health, 2012b).

This article will evaluate the quality of health care perceived by patients and providers at the intermediate care unit at HSS and compare it with similar services at RS. This in order to identify generalizable factors that influence the quality experienced at intermediate care institutions. Within the field of geography of health care provision, such factors may be significant in the development of strategies for more differentiated health care with alternatives to acute admissions to general hospitals.