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Managing care pathways for patients with complex care needs
Linköping University, Department of Management and Engineering, Logistics & Quality Management. Linköping University, Faculty of Science & Engineering.
2019 (English)Licentiate thesis, comprehensive summary (Other academic)
Abstract [en]

One of the central challenges for the healthcare system today is how to manage care for patients with complex needs. This patient group is not well-defined but covers patients with serious diseases and comorbidities, or with a limited ability to perform basic daily functions due to physical, mental or psychosocial challenges. This group has a high service and resource utilisation resulting in high costs for the healthcare system and, typically, poor health outcomes. To improve care for these patients, it is necessary to implement strategies to manage the differentiated care needs, the additional support needs, the uncertainty in care delivery, and the coordination needs of the involved providers and the patient.

Care pathways are increasingly used internationally to make care more patient-centred and to structure and design care processes for individual patient groups. Important elements in care pathways include structuring care activities, by defining their content and sequence; coordinating between providers and professionals; and involving patients in their care process. In this thesis, care pathways are proposed as the overall strategy for managing care for patients with complex care needs.

The purpose of this thesis is thus to contribute with knowledge on how care pathways can be managed for patients with complex care needs. This is achieved by analysing how the practices coordination, standardisation, customisation and personalisation can support management of care pathways and by discussing how these practices influence quality of care. The quality of care dimensions discussed are accessible, timely, equitable, and patient-centred care.

The empirical context in this thesis is the Standardised Cancer Care Pathways (CCPs) which were implemented in Sweden from 2015 to 2018. CCPs is the umbrella term for the national initiative to shorten waiting times, decrease regional differences and reduce fragmentation in care processes. CCPs include elements such as diagnosis-specific pathways and guidelines, introduction of CPP coordinators, and mandatory reporting of waiting times. Focus has been on implementing care pathways for 31 cancer diagnoses in all Swedish healthcare regions.

Both qualitative and quantitative research methods have been used. A case study was conducted to examine standardised and customised care pathways, and coordination and multidisciplinary work in care pathways. A document study of regional reports on CCPs was analysed to study effects of care pathways on accessibility, timeliness and equitability. Finally, a national survey was conducted to deepen the understanding of the role of coordination, as performed by coordinators, in care pathways.

This thesis argues that standardised and customised care pathways should be combined to manage care for patients with complex care needs. The customised pathway in particular benefits patients with serious unspecific symptoms, unknown primary tumour or more complex care needs, while patients with care needs that can be treated independently of the main diagnosis benefit from following a standardised care pathway.

Coordinators are an important means to manage coordination, customisation and personalisation in the care pathway. The coordinators’ role is twofold: the first role is to manage care pathways by customising the care pathway and coordinating involved providers; the second role is to support and guide patients through the care pathway. This can be achieved by adapting interpersonal communication with patients through personalisation.

This thesis further argues that care pathways have most potential to positively influence accessibility, timeliness, equitability, and patient-centredness. Accessibility has been positively influenced, especially for patients with ambiguous symptoms where symptoms indicating cancer have improved their chances of accessing cancer diagnostics. A negative aspect of prioritising patients who follow CCPs has been the potentially longer waiting times for other patient groups in equal need of urgent care. Notwithstanding, prioritised access to care is perceived to positively influence timeliness for patients following CCPs. Care pathways are perceived to have positively influenced patient-centredness by shifting the focus from what to deliver to how to deliver it.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. , p. 55
Series
Linköping Studies in Science and Technology. Licentiate Thesis, ISSN 0280-7971 ; 1839
Keywords [en]
Quality management, Care pathways, Complex care needs, Cancer care, Healthcare, Coordination, Standardization, Customization, Personalization, Timely, Equitable, Accessible, Patient-centred
Keywords [sv]
Standardiserade vårdförlopp, SVF, Cancervård
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:liu:diva-156836DOI: 10.3384/lic.diva-156836ISBN: 9789176850695 (print)OAI: oai:DiVA.org:liu-156836DiVA, id: diva2:1315587
Presentation
2019-05-29, Planck, Fysikhuset, Campus Valla, Linköping, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2019-05-14 Created: 2019-05-14 Last updated: 2019-05-15Bibliographically approved
List of papers
1. The management of cancer care pathways in a coordination centre
Open this publication in new window or tab >>The management of cancer care pathways in a coordination centre
2018 (English)Conference paper, Published paper (Refereed)
Abstract [en]

PurposeCoordination, patient centeredness and accessibility of care are important aspects for patients with complex care needs. Variations in symptoms, morbidity, care needs, and individual prerequisites are large within these patient groups which complicates diagnostics and treatment. New ways of organising health care is needed to handle these challenges and the use of solutions as multidisciplinary cancer centres and coordination centres are becoming more common.The purpose of this paper is to study how health care can be organised to care for patients with complex care needs. This is done by describing how one coordination centre works with management and coordination of care pathways in cancer care.

Design/methodology/approachThis paper is based on a qualitative single case study where the implementation of CCPs was studied in the Region of Östergötland. Three main data collection methods were used: semi-structured interviews, observations and document studies. Sixteen interviews were held with three physicians, seven nurses, two care unit managers, two general practitioners and the coordination centres two project leaders. Ten observational studies in the form of participative and non-participative observations in meetings were conducted. A retrospective document study was also conducted where internal public documents were systematically reviewed. Pilot study reports and implementation reports, during the period 2014 to 2018 were read and analysed by conducting content analysis.

FindingsThe UCCD was designed to take care of all potential cancer patients under ‘one roof’. This implied the need to find routines for handling a large amount of patients, with several different cancer diagnoses, and widely diverse care needs. The organisational design resulted in two diagnostic pathways: a standardised and a customised. The standardised diagnostic pathway works well for patients with clear symptoms and care needs with low complexity where the care can be standardised to follow rules and guidelines. The customised diagnostic pathway works well for patients with ambiguous symptoms care needs with high complexity where the care pathway need to be tailored and diagnostics are done by problem solving based on intuition and experience.

Originality/Value of paperThis paper contributes with knowledge on how coordination centres can work with care pathways to improve health care coordination and quality for patients with complex care needs.

Keywords
Health care, cancer care pathways, coordination centre, patient centeredness, standardisation
National Category
Reliability and Maintenance
Identifiers
urn:nbn:se:liu:diva-155094 (URN)
Conference
21st QMOD conference, Cardiff UK, 22-24 August, 2018
Available from: 2019-03-18 Created: 2019-03-18 Last updated: 2019-05-14
2. The effects of cancer care pathways on waiting times
Open this publication in new window or tab >>The effects of cancer care pathways on waiting times
2019 (English)In: International Journal of Quality and Service Sciences, ISSN 1756-669X, E-ISSN 1756-6703, Vol. 11, no 2, p. 204-216Article in journal (Refereed) Published
Abstract [en]

Purpose

The Swedish health-care system currently implements cancer care pathways (CCPs) for better and more timely cancer diagnostics. The purpose of this paper is to elucidate and define “crowding out” effects associated with the CCP implementation.

Design/methodology/approach

A document study based on implementation reports and action plans from Swedish county councils (n = 21) and a case study in one county council were conducted. Qualitative data collection and analysis were used to acquire more knowledge about the “crowding out” effects associated with the CCP implementation.

Findings

Three effects discussed under “crowding out” were defined. The first effect, called the push-out effect, occurs when other patients have to wait for care longer in favour of CCP patients. Another effect is the inclusion effect, whereby “crowding out” is reduced for vulnerable patients due to the standardised procedures and criteria in the referral process. The final effect is the exclusion effect, where patients in need of cancer diagnostics are, for some reason, not referred to CCP. These patients are either not diagnosed at all or diagnosed outside CCP by a non-standard process, with the risk of longer waiting times.

Originality/value

“Crowding out” effects are an urgent topic related to CCP implementation. While these effects have been reported in international research studies, no shared definition has been established to describe them. The present paper creates a common base to measure the “crowding out” effects and support further development of CCPs to avoid the negative effects on waiting times.

Place, publisher, year, edition, pages
Emerald Group Publishing Limited, 2019
Keywords
Health care, Standardisation, Patient care, Quality management, Health care management, Quality of health care
National Category
Reliability and Maintenance Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-154049 (URN)10.1108/IJQSS-04-2018-0041 (DOI)000479227600004 ()2-s2.0-85058658565 (Scopus ID)
Available from: 2019-01-24 Created: 2019-01-24 Last updated: 2019-08-27Bibliographically approved

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