Demographic characteristics
Twelve participants are selected. See Table 1 for the characteristics of the participants included in the study.
Reasons for older people to contact a healthcare professional
Although medical and functional problems are primary reasons for visiting a general practitioner, cognitive, mental, and social problems are also reported. Medical reasons are commonly cardiac or orthopaedic problems. Functional reasons are fall problems, balance problems and walking disabilities, and not being able to live independently anymore. Cognitive and memory problems, dementia, and fear of falling are mental problems older people indicate. Social reasons are mainly no longer being able to leave the house, less social participation, and loneliness. The burden of the informal caregiver, often the partner, is another reason to contact a general practitioner. During the consultation the general practitioner sometimes detects underlying issues such as reduced cognition.
The initial contact with the physiotherapist usually goes via referral by a general practitioner. Fall problems and mobility are the main contact reasons for physiotherapy, and further cardiac problems, orthopaedic problems, and being isolated.
Nurses are in most cases contacted by the informal carer on referral of the general practitioner. Nurses say that the typical nursing actions such as injections and wound care are often the initial reason for consulting them. Managing medication, hygiene care and burnout of the informal caregiver are also frequent reasons for being contacted. Loneliness is often an underlying factor for appealing a nurse.
The occupational therapist, who is often contacted via social services, express mainly being consulted when functional, social, mobility and/or cognitive problems arise or when the burden on the informal caregiver becomes too heavy. The medical reason is often complex chronical issues, e.g., an older adult with stroke with permanent residual disabilities. Falls problem are often present.
All healthcare professionals report that they usually detect other problems underlying to the initial problem. Healthcare professionals say that when they explore the additional problems, these additional problems often are the main problem.
‘For a start, the reasons they contact us are often physical problems. We are initially consulted for a wound on the coccyx, but it soon becomes apparent that much more is happening, the person is sedentary, he cannot vouch for his self-care, has few social contacts, is lonely, the burden on the family becomes too heavy, ….’ (Registered nurse).
Inter-professional collaboration in general
All healthcare professionals find that there is not enough collaboration in the care of complex chronic issues. They specify that information exchange is essential to adjust the treatment. Information sharing usually limits itself to problems, but it is also important to know what goes well. A general practitioner mentioned a lack of a shared vision on collaboration. Collaboration is still limited too much to contacting only a few professions.
“Collaborating … insufficient. We are trying to make some progress, but that asks joint vision, I notice that we still have too less vision to collaborate. What we do is contact the nurse and physiotherapist. The professions we were taught during our training.” (General practitioner).
Additionally, several health professionals demonstrate that, with the aim of closing the gap, local initiatives are taken to get organized. One healthcare professional argued that not only organized meetings are useful. A talk with other healthcare professionals by co-incidence in the workplace can also be fruitful. One healthcare professional communicated that she resigned due to lack of structured communication and collaboration where it concerned patient matters. She felt that she could not provide the desired quality of care in this way and applied for a job in a team where collaboration was highly regarded.
‘My patients received high-quality physiotherapy treatment, but I noticed that there was more going on and that collaboration with the general practitioner or social worker was necessary. In that practice there was no room for communication with external partners. Now I work in a practice where there is attention for communication and collaboration. I’m convinced this is a precondition in elderly care.’ (Physiotherapist).
Healthcare professionals who work in mono- or multidisciplinary primary care practices regularly participate in internal team meetings on patient related matters. External inter-professional meetings on patient-related matters are sometimes organized upon discharge from the hospital or in complex situations. The care coordination of the health insurance organization organizes these inter-professional meetings. Healthcare professionals from the hospital’s discharge team, the informal caregiver, general practitioner, and registered nurse frequently participate at these inter-professional meetings. Physiotherapists sometimes participate. Occupational therapists are rarely invited to these meetings. One occupational therapist who also has a part-time job as care coordinator of a health insurance organization, signify that, due to task demarcation, she cannot assume her role as occupational therapist in cases where she is asked to act as care-coordinator.
‘Collaboration, yeah, it’s kind of necessary, but in practice it’s very difficult. On the phone, with caregiver services… You pass on the information, but you seldom get information back. There is no exchange of ideas…. I also have a colleague who is a social worker. We both work at same organization. To work efficiently, we sometimes divide the tasks. She does the start-up and subsequently I take it over.’ (Occupational therapist).
The general practitioners mark that they mostly collaborate with primary care nurses, physiotherapists, and the informal caregivers. When a patient is discharged from hospital, general practitioners often have discharge meetings with the hospital staff. Regularly, general practitioners also collaborate with dieticians and the family care service.
The registered nurses collaborate mostly with the general practitioners and family care services. They express sometimes collaborating with physiotherapists, and seldomly with occupational therapists.
‘When we notice someone becoming more dependent, we also try to involve family care service, even if that is only for two hours a week, and in this way, we also try to get a larger network among the patients.’ (Registered nurse).
Physiotherapists also indicate that they collaborate with general practitioners. The physiotherapists, as is the case for nursing, need a referral of the general practitioner.
Occupational therapists mostly collaborate with social workers and family care services. They occasionally are in contact with physiotherapists. Occupational therapists indicate that, during their interventions, they receive a lot of information from family care services. These people know the older adult well because they spend more time at the older adult’s house, and they are sometimes there when the occupational therapist performs his intervention.
Collaboration with lesser-known healthcare professions
Two of the general practitioners, all registered nurses and all physiotherapists indicate that primary care occupational therapy is almost unknown territory for them. One general practitioner has an occupational therapist in their team. This occupational therapist is involved in prevention in general, falls prevention in particular, mobility, and physical posture and ergonomics. Two general practitioners who do not collaborate with an occupational therapist, admit not knowing how to contact them. Also, the nurses and physiotherapists admit not knowing how to contact an occupational therapist.
‘And I think that they do not know what occupational therapy is, what occupational therapists exactly do in primary care … At home with one of my clients where I was consulted for a secondary table, I met the physio. I introduced myself and the physio told me the general practitioner asked him to look for a wheelchair, but he didn’t know anything about wheelchairs. I told him I’d look for it. You see, there’s a demand, but if you don’t meet accidentally…’ (Occupational therapist).
After being informed on the role of occupational therapy in primary care, all healthcare professionals show their interest in referring to and collaborating with an occupational therapist. They confirm that it is desirable that occupational therapists are known in the region.
Two occupational therapists indicate that they regularly inform general practitioners on the occupational therapy intervention, but never receive any response. Although the occupational therapists state that they are seldom invited to an inter-professional consultation, they do advocate the added value of their presence and once general practitioners know them, they show an interest in collaboration. One occupational therapist tells that at an external multidisciplinary meeting where that person acted as case manager, a general practitioner showed interest in the role of the occupational therapist.
‘Last time at a patient meeting, I really had the feeling ‘My advice is finally being heard!‘. The general practitioner responded to something I suggested and emphasized it. And the fact that all other disciplines heard it, gave me a sense of recognition. After all, we all work for the benefit of that one patient. (Occupational therapist)
Occupational therapists communicate that the informal carers, family care service and social workers possess a lot of useful information that may improve the quality of their intervention. Informal caregivers and family care services spend the most time with the older adult and know a lot of that person. The social workers are interesting because they are often the first to map out the complexity of the problem.
Use of health-information technology
Health information technology can support both, inter-professional collaboration and working on an evidence-based manner. It can also be a facilitator to inform patients.
Electronic data registration and sharing
Except for the occupational therapists, all interviewed healthcare professionals use a profession specific labelled electronic patient registration system. The registered nurses of monodisciplinary practices inform that their record is part of the central patient record. The self-employed registered nurse and self-employed physiotherapist declare that they keep data in hard copy as well as electronically. They emphasize that they either don’t have the time to fill in the electronic record correctly or see the electronic registration of data as a barrier. One physiotherapist prints his therapy report to hand over to the general practitioner.
‘A computer between the older adult and myself creates distance when I talk to him. I use pen and paper to write things down and to explain’ (Physiotherapist).
The healthcare professionals working in a multidisciplinary team indicate that they use a central record where each professional add the relevant information for his discipline. The healthcare professional only has access to that part of the information that is relevant for their intervention.
The occupational therapists register their data into a central patient record system of their place of employment to the degree that is possible. Some occupational therapists individually developed a digital occupational therapy record form. This digital record can either be a structured electronic tool or single Word-template.
Safely sharing electronic data among all healthcare professionals is limited possible in Belgium. The data exchange e.g., occupational therapists and physiotherapists often initially takes place by telephone, by mail or – where applicable – during an inter-professional consultation. Within the multidisciplinary group-practices, certain data is shared through the central electronic patient record. Healthcare professionals admit not being aware of all the possibilities of electronic patient records. Two healthcare professionals who have a professional IT-registration tool indicate that they do not use them consistently. The reason they give is low usability. They feel like distancing themselves from the patient using IT during the consultation.
Aspects that are perceived as useful, are the automatic registration of the number of treatment sessions the patient got, the electronic diary and – in the case of mono- or multi-disciplinary group practices- sharing data.
One healthcare professional declares a refusal to share data electronically out of respect for the patient’s privacy. This healthcare professional believes contacting other healthcare professionals over the phone to be a better alternative.
Health-information technology to support quality of care
Except for one person, the term evidence-based practice is known by all interviewed healthcare professionals. The application of electronic devices to implement the evidence-based practice (EBP) principles varies among the various professional groups.
General practitioners use electronic databanks with evidence-based data. Two of the interviewed general practitioners have IT-tools that automatically link the evidence-based data to the electronic health record of the patient (Evidence linker). These healthcare professionals also use an electronic Decision Support System (DSS). The physiotherapists indicate they rely on the information and training that their scientific professional association provides. The registered nurse who works in a structured primary care organization indicates the team members contact the organization’s central office when they require scientifically supported information for an intervention. This nursing organization develops protocols on which the at-home registered nurses base their treatment. The occupational therapists indicate attending training and searching evidence-based information on their own through several databases. They also indicate that finding this information is difficult as their search usually does not provide the expected results.
“The guidelines within our inter-professional practice are ‘you work evidence-based’ and that’s where it ends. We expect that everyone who works in the practice works evidence-based. With all due respect to what others think about that, I don’t think that what we say is the only truth but what we do is based on that (EB).’ (General practitioner).
Incentives and barriers for sustainable collaboration
The interviewed healthcare professionals identified success factors and barriers for collaboration, which we listed according to the various levels of healthcare of Grol and colleagues (2004).
Innovation
Concerning electronic data sharing, healthcare providers indicate that the electronic record must be accessible both, in the office and at the patient’s home. A smooth use of the device, meaning no errors in the program and easy to use, such as clicking on pre-programmed rubrics, is also a precondition. Pre-programmed rubrics are preferrable provided that all necessary information is covered within these rubrics.
“An additional problem is the internet connection at the home of the older adult. Hardly any older adult I visit has an internet connection. Only when a younger person lives at the same place, there is internet connection.“ (Physiotherapist).
All healthcare professionals indicate that it must be possible to decide tailor-made which data to share with who, but this depends always on the condition the patient allows data to be shared. Respecting privacy is the highest priority for all interviewed healthcare professionals.
A threshold that is indicated, is the accessibility of lesser-known professional groups. General practitioners, registered nurses and physiotherapists indicate they are not familiar with contacting occupational therapists. They often do not know local primary care occupational therapists and do not know how to find them. They indicate that if they do not know the way, it will be almost not possible for the older adult to contact an occupational therapist.
“Honestly, no service has ever suggested working with an occupational therapist … Sometimes I think “occupational therapy will be helpful in this case”, but how should I reach them? I really do not know it. Not knowing a local primary care occupational therapist is a barrier for referring.” (General practitioner).
An advantage is that the specific value in the context of health and wellbeing of an occupational therapy intervention is confirmed by all interviewed professionals. Another advantage is that an occupational therapist visits the older adult a limited number of times to achieve the stated target. A general practitioner indicates that one or two occupational therapists who operate in one area might increase accessibility and can increase a sustainable collaboration.
Individual professional
All healthcare professionals unanimously agree on the importance of collaboration and emphasize the willingness to collaborate when it concerns the older adult with complex chronic issues. In line with this, they argue that sustainable collaboration requires effort from multiple actors in many areas and that the better you know each other, the easier to communicate and collaborate.
The healthcare professionals are aware of their behavioral routines in contacting the best know professions among which general practitioner, registered nurse, and physiotherapist. Dieticians and occupational therapists are less contacted. In addition, it is not clear how to contact an occupational therapist.
Most of the healthcare professionals do not experience many barriers in electronic data sharing, as long as the patient is informed and gives his consent on which data can be shared with whom, and the healthcare professionals can decide to protect data themselves.
‘Honestly, I do not see downsides to electronic data sharing. Of course, it is the patient who decides what is and what is not shared. The condition is that the patient is informed and gives his consent.’ (General practitioner).
Patient
Healthcare professionals indicate that admitting that one becomes help dependent is a barrier for that person to appeal for supplementary healthcare provision.
“Sometimes I have the feeling that for some older adults, if you do not talk of a problem, the problem does not exist. Even if you are convinced that the person knows the problem. This makes it difficult to refer for supplementary healthcare provision” (Registered nurse).
Healthcare professionals also indicate that knowing the different professions or being introduced to them by someone they trust is a facilitator for the patient to accept that various health professions are involved.
Social context
Two healthcare professionals suggest shadowing another profession for a day to have more insight in, and respect for the other profession.
Several healthcare providers pose that an older adult will accept collaboration with a healthcare provider who is not yet involved more easily, when a trusted healthcare provider or a peer informs them that a certain treatment will be an added value for them.
One general practitioner who works in an inter-professional healthcare team stipulates that working in a team improves job satisfaction. The fact that healthcare providers are surrounded by people with the same opinion, the same way of working prevents burnout.
‘What I sometimes say laughing is that you only have people who feel good at their job simply because you do things together, provide added value together and continuously feel that you are surrounded and supported.’ (General practitioner).
Context of the organization
Healthcare providers who work per performance indicate that their timetable is filled with patients, so there is little time for consultation with external parties. All healthcare professionals confirm that the foreseen resources for these multidisciplinary meetings are not sufficient. Healthcare providers who do not work per performance argue that participating at multidisciplinary meetings cause less of a problem.
The compartmentalization of services is also indicated as a barrier.
One central person or organization who organizes and co-ordinates the inter-professional meetings locally, is perceived as an advantage. This person must be accessible for all local healthcare providers and transcend individual healthcare organizations. Healthcare providers also indicate to have an overview of the local health structure, so that one can see who to contact for which health question. This overview also exposes where the gaps are situated.
The absence of a central secure electronic record in which data can be shared selectively with consent of the patient, is perceived as a deficiency. In the case of the patients’ consent to share data, the system must deliver the possibility to the healthcare provider to determine which data are relevant to share with each individual healthcare provider.
‘What we do is use the inter-professional consultation as a supporting record where the registered nurses, the physiotherapist, the dietician, the podiatrist, and the occupational therapist all work with, this within our healthcare house. What we’re trying to approach is to see this healthcare facility as an organic entity because then you have mutual contacts and that mind-expanding vision, that continual contact, but then you also continually update the records et cetera.’ (General practitioner).
Economic and political context
All healthcare professionals indicate that the current financial regulations do not facilitate inter-professional collaboration. A decent compensation for inter-professional meetings should be provided.
A regional coordinator who organizes and coordinates these meetings is a precondition for a sustainable collaboration on regional level.
‘What are the practical barriers? First at all the patients not knowing the system… If it is a registered nurse that brings it up, when it’s a general practitioner, if it’s a peer, then they’re inclined to follow them. And then you also have the problem of financing.’ (General practitioner).
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