An Evaluation of the Role of an Intermediate Care Facility in the Continuum of Care in Western Cape, South Africa

Document Type: Original Article

Authors

1 Public Health Department, Walter Sisulu University, Mthatha, South Africa

2 School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

3 Western Cape Department of Health, Cape Town, South Africa

Abstract

Background
A comprehensive primary healthcare (PHC) approach requires clear referral and continuity of care pathways. South Africa is a lower-middle income country (LMIC) that lacks data on the role of intermediate care (IC) services in the health system. This study described the model of service provision at one facility in Cape Town, including reason for admission, the mix of services and skills provided and needed, patient satisfaction, patient outcome and articulation with other services across the spectrum of care.
 
Methods
A multi-method design was used. Sixty-eight patients were recruited over one month in mid-2011 in a prospective cohort. Patient data were collected from clinical record review and an interviewer-administered questionnaire, administered shortly after admission to assess primary and secondary diagnosis, referring institution, knowledge of and previous use of home based care (HBC) services, reason for admission and demographics. A telephonic questionnaire at 9-weeks post-discharge recorded their vital status, use of HBC post-discharge and their satisfaction with care received. Staff members completed a self-administered questionnaire to describe demographics and skills. Cox regression was used to identify predictors of survival.
 
Results
Of the 68 participants, 38% and 24% were referred from a secondary and tertiary hospital, respectively. Stroke (35%) was the most common single reason for admission. The three most common reasons reported why care was better at the IC facility were staff attitude, the presence of physiotherapy and the wound care. Even though most patients reported admission to another health facility in the preceding year, only 13 patients (21%) had ever accessed HBC and only 25% (n = 15) of discharged patients used HBC post-discharge. Of the 57 patients traced on follow-up, 21(37%) had died. The presence of a Care-plan was significantly associated with a 62% lower risk of death (hazard ratio: 0.38; CI 0.15–0.97). Notably, 46% of staff members reported performing roles that were outside their scope of practice and there was a mismatch between what staff reported doing and their actual tasks.
 
Conclusion
Clients understood this service as a caring environment primarily responsible for rehabilitation services. A Care-plan beyond admission could significantly reduce mortality. There was poor referral to and poor articulation with HBC services. IC services should be recognised as an integral part of the health system and should be accessible.

Keywords

Main Subjects


"Watch the Video Summary"

  1. WHO. Primary health care, report of the international conference on primary health care. Alma-Ata: USSR; 1978:43-48.
  2. Sanders D. PHC 21- Everybody’s business. Main background paper for the meeting: PHC 21- everybody’s business, an international meeting to celebrate 20 years after Alma-ata, Almaty, Kazakhstan, 27-28 November. Geneva: WHO; 1998.
  3. Muldoon LK, Hogg WE, Levitt M. Primary Care (PC) and Primary Health Care (PHC) What is the Difference? Can J Public Health. 2006;97(5):409-411.
  4. South African Department of Health. Primary Healthcare Re-engineering: Discussion document. http://www.phasa.org.za/wp-content/uploads/2011/11/Pillay-The-implementation-of-PHC.pdf.  Published 2011.
  5. South African Department of Health. White paper for the transformation of the health system in South Africa. Notice 667 in the government Gazette No. 17910. http://www.gov.za/documents/download.php?f=187656.  Accessed May 9, 2011. Published 1997.
  6. South African National Department of Health. A Discussion Document on the Development of Subacute Care PolicySDC Policy Guideline. Directorate Health Facility Planning; 2012.
  7. Provincial government of the Western Cape Department of health. Comprehensive service plan for the implementation of Health Care2010. https://www.westerncape.gov.za/text/2007/7/may15,2007-csp_2.pdf.  Published May 2007.
  8. Kane RL. Assessing the effectiveness of postacute care rehabilitation. Arch Phys Med Rehabil. 2007; 88:1500-1504. doi:10.1016/j.apmr.2007.06.015
  9. Buntin MB. Access to postacute rehabilitation. Arch Phys Med Rehabil. 2007;88(11):1488-1493. doi:10.1016/j.apmr.2007.07.023
  10. Ottenbacher KJ, Graham JE. The state of the science: access to postacute care rehabilitation services -- a review. Arch Phys Med Rehabil. 2007;88(11):1513-1521. doi:10.1016/j.apmr.2007.06.761
  11. Buntin MB, Garten AD, Paddock S, Saliba D, Totten M, Escarce JJ. Impact of Levels of Service: How Much Is Postacute Care Use Affected by Its Availability. Health Serv Res. 2005;40(2):414-433.
  12. Deutsch A. Does Postacute care site matter? A longitudinal study assessing functional recovery after a stroke. Arch Phys Med Rehabil. 2013;94(4):630-632. doi:10.1016/j.apmr.2013.02.011
  13. Young J. The development of intermediate care services in England. Arch Gerontol Geriatr. 2009;49 Suppl 2:S21-S25. doi:10.1016/S0167-4943(09)70008-1
  14. Young J. The National Audit of Intermediate Care 2014: under provision remains the issue. NHS England News. 2014. https://www.england.nhs.uk/2014/12/john-young-4/.  Accessed March 5, 2017.
  15. Gibbs A, Pearse EJ, Jayasinha H, Sheehan JA, Meleady KT, Jones N. Projecting subacute inpatient activity in New South Wales. Aust Health Rev. 2009;33(4):601-610.
  16. Giancarlo H. The evolution of subacute services: One facility’s view. Long Term Living Magazine. 2008. http://www.ltlmagazine.com/article/evolution-subacute-services-one-facilitys-view.
  17. Levitt NS, Steyn K, Dave J, Brasdshaw D. Chronic noncommunicable diseases and HIV-AIDS on a collision course: relevance for health care delivery, particularly in low-resource settings-insights from South Africa. Am J Clin Nutr. 2011;94(suppl):1690S-1696S. doi:10.3945/ajcn.111.019075
  18. Norman R, Bradshaw D, Schneider M, et al. A comparative risk assessment for South Africa in 2000: towards promoting health and preventing disease. S Afr Med J. 2007;97(8):637-641.
  19. Peltzer K, Phaswana-Mafuya. Hypertension and associated factors in South Africa. Cardiovasc J Afr. 2013;24(3):66-71. doi:10.5830/CVJA-2013-002
  20. Schneider H, Coetzee D, Van Rensburg D, Gilson L. Differences in antiretroviral scale up in three South African provinces: the role of implementation management. BMC Health Serv Res. 2010;10:S4. doi:10.1186/1472-6963-10-S1-S4
  21. Schneider H, Schaay N, Reid S, et al. Policy Review of De-hospitalised Care Services for the Western Cape Department of health. Technical Report School of Public Health. South Africa: University of the Western Cape; 2012.
  22. Western Cape Government Health: Healthcare 2030. The Road to Wellness 2014. https://www.westerncape.gov.za/assets/departments/health/healthcare2030.pdf.  Accessed September 16, 2014.
  23. Kabore I, Bloem J, Etheredge G, et al. The Effect of Community-based support services on clinical efficacy and health-related quality of life in HIV/AIDS patients in resource limited settings in Sub-Saharan Africa. AIDS Patient Care STDS. 2010;24(9):581-594. doi:10.1089/apc.2009.0307
  24. Osawa E, Kodama T, Kundishora E. Motivation and sustainability of care facilitators engaged in a community home-based HIV/AIDS program in Masvingo Province, Zimbabwe. AIDS Care. 2010;22(7):895-902.
  25. Tomlinson M, Doherty T, Ijumba P, et al. Goodstart: a cluster randomized effectiveness trial of an integrated, community-based package for maternal and newborn care, with prevention of mother-to-child transmission of HIV in a South African township. Trop Med Int Health. 2014;19(3):256-266.doi:10.1111/tmi.12257
  26. Mwai GW, Mburu G, Torpey K, Frost P, Ford N, Seeley J. Role and outcomes of community health workers in HIV care in sub-Saharan Africa: a systematic review. J Int AIDS Soc. 2013 10;16:18586.
  27. Jackson D, Naik R, Tabana H, et al. Quality of home-based rapid HIV testing by community lay counsellors in a rural district of South Africa. J Int AIDS Soc. 2013;16:18744. doi:10.7448/IAS.16.1.18744.
  28. Statistics South Africa. Census 2011: Statistical release (October 30, 2012 Revision). https://www.statssa.gov.za/publications/P03014/P030142011.pdf.  
  29. WHO. A Practical Manual for using the International Classification of Functioning, Disability and Health (ICF). http://www.who.int/classifications/drafticfpracticalmanual2.pdf?ua=1.  
  30. Chen CC, Heinemann AW, Granger CV. Functional Gains and Therapy Intensity during Subacute Rehabilitation: A study of 20 Facilities. Arch Phys Med Rehabil. 2002;83:1514-1523.
  31. Solberg BCJ, Dirksen CD, Nieman FHM, van Merode G, Poeze M, Ramsay G. Changes in hospital costs after introducing an intermediate care unit: a comparative observational study. Crit Care. 2008;12(3):R68. doi:10.1186/cc6903
  32. Salomon JA, Wang H, Freeman MK, et al. Healthy life expectancy for 187 countries, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380(9859):2144-2162. doi:10.1016/S0140-6736(12)61690-0
  33. Kane RL, Lin WC, Blewett LA. Geographic variation in the use of post-acute care. Health Serv Res. 2002;37(3):667-682.
  34. Kane RL, Finch M, Chen Q, Blewett L, Burns R, Moskowitz M. “Post-hospital home health care for medicare patients.” Health Care Financ Rev. 1994;16(1):131-53.
  35. Nishiura H. Socioeconomic factors for tuberculosis in Tokyo, Japan-unemployment, overcrowding, poverty, and migrants. Kekkaku. 2003;78(6):419-426.
  36. Lehmann U, Sanders D. Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. Evidence and Information for Policy, Department of Human Resources for Health. World Health Organisation; 2007. http://www.who.int/hrh/documents/community_health_workers.pdf.  
  37. Marshall IJ, Wang Y, McKevitt C, Rudd AG, Wolfe CDA. Trends in risk factor prevalence and management before first stroke: data from the South London Stroke Register 1995-2011. Stroke. 2013;44(7):1809-1816. doi:10.1161/STROKEAHA.111.000655
  38. Connor M, Bryer A. Stroke in South Africa. In: Steyn K, Fourie J, Temple N, eds. Chronic Diseases of Lifestyle in South Africa: 1995-2005. Cape Town: Medical Research Council; 2006:195-203.
  39. Strachan B, Zabow T, van der Spuy ZM. More doctors and dentists are needed in South Africa. S Afr Med J. 2011;101(8):523-528.
  40. Cleary S, Birch A, Chimbindi N, Silal S, McIntyre D. Investigating the affordability of key health services in South Africa. Soc Sci Med. 2013;80:37-46. doi:10.1016/j.socscimed.2012.11.035
  41. Goudge J, Gilson L, Russel S, Gumede T, Mills A. The household costs of health care in rural South Africa with free public primary care and hospital exemptions for the poor. Trop Med Int Health. 2009;14(4):458-467. doi:10.1111/j.1365-3156.2009.02256.x
  42. Sunderhaus CG. ABC of Postacute care. Case Manager. 2004;15(6):67-69.
  43. McKee M. Routine data: a resource for clinical audit? Quality in Health Care 1993; 2: 104-111.
  44. Dealey C, Brindle CT, Black J, et al. Challenges in pressure ulcer prevention. Int Wound J. 2015;12(3):309-312. doi:10.1111/iwj.12107
  45. Chou R, Dana T, Bougatsos C, et al. Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review. Ann Intern Med. 2013;159(1):28-38. doi:10.7326/0003-4819-159-1-201307020-00006
  46. Wright RE, Rao N, Smith RM, Harvey RF. Risk factors for death and emergency transfer in acute and subacute inpatient rehabilitation. Arch Phys Med Rehabil. 1996;77:1049-1055.
  47. Doherty J, Couper I, Fonn S. Issues in medicine: will clinical associates be effective for South Africa? S Afr Med J. 2012;102(11):833-835.
  48. Stuart-Clark H, Vorajee N, Zuma S, et al. Twelve-month outcomes of patients admitted to the acute general medical service at Groote Schuur Hospital. S Afr Med J. 2012;102(6):549-553.