Robert Sarkadi Kristiansson: Samverkan kring äldre personer med multisjuklighet: En studie av hur nationella reformer och nya arbetssätt påverkar återinläggning på sjukhus inom 30 dagar

Abstract

Heart failure poses a significant challenge in healthcare, contributing substantially to morbidity and mortality. The overall aim of the thesis was to investigate how collaboration between different health and social care providers affects hospital readmissions within 30 days among older adults with multimorbidity, with a particular focus on those with heart failure. It investigates the impacts of local and national reforms, and post-discharge care options. Study I explored the effect of heart failure nurses in a Swedish primary care setting on readmission outcomes. Contrary to expectations, the presence of heart failure nurses did not significantly reduce readmission rates. It seems that it might be the role assigned to specific heart failure nurses, rather than simply having this resource that could improve outcomes. Study II evaluated effects of the Swedish Care Coordination Act on persons >65 years with multimorbidity and heart failure. The study found no significant impact on readmission or mortality rates following the implementation of the Care Coordination Act. This suggests that the Care Coordination Act 's structured mandates alone may be insufficient to cater to older persons with more complex care needs, such as those with heart failure. Study III investigated the effect of discharge to a nursing home for older patients with multimorbidity. Discharges to nursing homes resulted in a marked reduction in short-term readmissions and mortality compared to home-based care. The study highlights the central role of monitoring when it comes to older persons with multimorbidity following a hospital admission which may explain why nursing homes offer short time benefits. In the longer term decision-making requires consideration of patient preferences and clinical assessments. Study IV examined healthcare leaders' perspectives on the 30-day readmission indicator. Leaders recognized its widespread use but emphasized the need for more integrated system-level analysis and patient-centered care to achieve meaningful reductions in readmission. They advocated for top-level leadership to set clear goals and ensure system-wide accountability.

Taken together, this thesis identified no positive effects of the local or national interventions, highlighting the difficulty of developing effective policy and interventions to improve post-discharge outcomes for heart failure patients.  Future success may depend on better implementation of coordinated individual plans and concerted efforts across the healthcare system. Patients with the most complex care needs may for instance benefit from dedicated care coordinators responsible for managing and integrating their care.