Referral to geriatric rehabilitation: Exploring triage

Summary Older hospital patients are vulnerable to adverse outcomes of hospital stay. In aging societies, post-acute care (PAC) programs were developed to support functional recovery. This thesis focuses on the referral of older or frail hospital patients to geriatric rehabilitation (GR). GR consists of integrated, multidisciplinary care programs, targeted at older, vulnerable or multimorbid patients with acute functional decline. Across European countries the mean age of patients was 80 years . National GR-capacity and the duration of GR-stay varied greatly. Length of stay varied from 7 to 65 days. In 2013 geriatric rehabilitation was invested in the Netherlands with more than 50.000 GR trajectories each year. The eligibility for geriatric rehabilitation and triage, the decision making process concerning this referral is the subject of this thesis. Most patients are admitted to GR following a hospital stay. In Dutch hospitals, liaison nurses assess the eligibility of patients for GR and present candidates to GR-facilities. Admissions can be refused by the post-acute care facility for alleged absence of rehabilitation goals, patient complexity or medical instability. The outcome of hospital triage decisions can thus represent a source of tension between ‘sending’ and ‘receiving’ care settings, especially because responsibilities are not clear. Consensus in GR referral decision making, would support cooperation and allow for evaluation of GR patient flow, case mix and rehabilitation outcome. The triage instrument for geriatric rehabilitation developed in 2013 by the professional association of elderly care physicians, Verenso, mentions six conditions or patient-criteria to qualify for GR: 1.) vulnerability, 2.) rehabilitation needs, 3.) a positive functional prognosis 4.) learnability 5.) sufficient endurance to train and 6.) motivation . With the introduction of short-term recovery care (STRC, ‘Eerstelijnsverblijf’) in 2017 a decision aid was developed. The Verenso triage instrument nor the STRC decision aid has been evaluated. This thesis explored the evidence supporting a referral decision as well as the ‘triage assessment’ The research questions were: 1. What are older patients’ attitudes and thoughts regarding follow-up care at hospital discharge? A multi-method qualitative study, chapter 2. 2. What items, instruments and methods concerning referral of hospital patients to GR are reported in literature? A scoping review, chapter3. 3. What are the characteristics of hospital patients referred to GR in comparison with patients not referred? An observational cohort study, chapter4 4. Which hospital and/or rehabilitation professionals are involved in GR referral decision making and what triage items and methods are used? An observational cohort study, chapter 5. 5. What are core elements of a best practice referral to GR in the Netherlands? A national survey, chapter 6. These exploratory triage studies aimed to contribute to the quality of referral decision making by presenting a conceptual model of the multilevel triage process with its professional and organizational aspects. In the general discussion, the problem of GR-triage is depicted and the results of the triage studies as well as the limitations we encountered are reflected upon. Triage as a subject has characteristics of a ‘wicked problem’. Based on the results of the triage studies, elementary steps of a GR-triage process are described. Components are further depicted in three dimensions: 1) patient care; 2) professional competence; 3) organizational features. This conceptual triage model has not yet undergone a field consultation nor has it been evaluated in a wider context by stake holders, such as older patients, caregivers, residents, multidisciplinary GR teams, hospital and care facility managers, health insurance companies and policy makers. Implementation of the conceptual triage model could support the quality of decision making and facilitate evaluation of GR-triage practice. Implementation and evaluation underly a stepped process towards the development of a field standard.