Dr Malcolm Doupe | Dr Frode F. Jacobsen – Ending the Revolving Door of Emergency Department Visits for Older Adults

‘Health is merely the slowest possible rate at which one can die’ (Anonymous). Old age faces us all (if we are fortunate), but while we are generally living longer, we are not necessarily living that extended time being healthy. Older adults are now the fastest-growing segment of the population worldwide, and internationally, healthcare systems are scrambling to cope with the new demands this will bring. Here, we review the work of long-time research collaborators Dr Malcolm Doupe (University of Manitoba) and Dr Frode F. Jacobsen (Western Norway University of Applied Sciences) to address these fundamental issues.

The Challenges of Healthcare for an Ageing Population

With the increase in life expectancy, older people are living longer but often with multiple long-term health conditions. Of these, heart disease, respiratory diseases, cancers, chronic pain, diabetes and neurological conditions are the most common. These conditions are often combined with various disabilities and/or social care challenges such as isolation, unsuitable housing, and a lack of informal and/or community-based day to day support.

As we would expect, some older people are more likely to use healthcare services such as emergency departments (EDs) and hospitalisations. Without proper discharge planning, healthcare planners are well aware that older patients sent back to the community are very likely to have repeat ED visits and unplanned hospitalisations. Internationally, 22% of all ED visits are made by older people and, while they are discharged back to the community about half of the time, this often results in repeat ED visits and/or hospitalisations to deal with unresolved challenges. Both Norway and Canada demonstrate problems typical of this worldwide picture, where older adult ED visits have increased by 70% in the last decade.

Healthcare systems face complex pressures and human resource strains. These systems are also often ‘disconnected’ from communities leaving gaps in care as older adults transition from EDs or hospitals back home. These gaps in care, coupled with fragmented transition processes, contribute significantly to the everyday challenges that older adults face, thus limiting their ability to live successfully in the community.

Over the past 10 years, internationally collaborative research has been taking place to help improve the healthcare that older adults receive generally. Dr Malcolm Doupe, University of Manitoba, and Dr Frode F. Jacobsen, Western Norway University of Applied Sciences, are leaders in this field of expertise.

A Decade of Collaboration

Dr Jacobsen and Dr Doupe have a long and productive history of academic collaboration, reflecting their strong dedication to the welfare of older people across a range of care settings. In 2010, they were both members of the international ‘Re-imagining Long-term Care Project’, for the Social Sciences and Humanities Research Council of Canada, as part of their ongoing commitment to improving nursing home care. This has continued through extensive co-published research on international comparisons of healthcare standards, nursing practices, models of physician care, and resident choice. Drs Jacobsen and Doupe are also partners on a current Research Council of Norway grant-funded project designed to improve nursing home quality of care. The pair’s close academic relationship has also facilitated closer working links between their academic institutions, the University of Manitoba and Western Norway University of Applied Sciences, which are now instrumental in their ongoing projects.

In 2019, Drs Jacobsen and Doupe began their current research focussed on the emergency department-to-community transition for older people. Their collaboration has led to the successful funding of two key initiatives: iNET: An International Network to Enhance Older Adult Transitions between Emergency Departments and Communities, and iSTEP: An International Student Training and Exchange Project in Transitional Care.

‘Our long-term goal is to become world-class leaders in developing and testing strategies to improve older adult care transitions from the community to emergency departments [and] hospitals and back.’

The Formation of iNET

The international iNET collaboration is described by Dr Doupe as ‘a leading network of academics and healthcare stakeholders (e.g., decision-makers and providers) from Norway and Canada.’ This new cross-sectoral planning and research group aims to upgrade the quality of education and health services research and provision in both countries, building upon and enhancing existing projects.

A key aspect of iNET includes working with two Canadian Universities (namely Alberta and Manitoba) renowned for their international research in older adult care, while ensuring frontline healthcare stakeholders are involved in the research in order to deliver ‘real world’ solutions. Ultimately, the project aims to ‘develop…an innovative and integrated knowledge translation research platform, for continued growth and expansion to additional countries,’ with the goal to become ‘…leaders in developing and testing strategies to improve older adult care transitions from the community to emergency departments [and] hospitals and back.’

iNET is planned to operate for 36 months, and in that time, a structured programme of five workshops, international student exchanges and short-course summer schools, and multiple faculty exchanges will be completed. An international team of researchers, ED and community providers, decision-makers, and patients will initially convene to conduct a thorough review and evaluation of international transition practices and to identify promising approaches. Following this, the team will assess how different healthcare policies and structures impact these interventions, and last of all will identify existing administrative data systems that are currently available to define how these transition practices work.

A range of different approaches has been reviewed from international studies, including risk assessment tools to identify those at potentially higher risk, comprehensive geriatric assessments and follow-ups utilising social workers and healthcare staff, for example. The outcomes, however, have generally been variable, poorly sustained, and have lacked a thorough evaluation to identify where the difficulties lay. Evaluations also have tended to focus only on repeat visits to the ED as the measure, excluding essential factors such as the patient’s wants and needs. Health care interventions should also take into account the broader political environment, culture and healthcare system structures when seeking to optimise their long-term effectiveness.

iSTEP: Preparing Future Academics and Planners

The close academic links forged between the University of Manitoba and Western Norway University of Applied Sciences have been integral to the development of the new iSTEP collaborative initiative. Drs Jacobsen and Doupe have led the project’s developments with colleagues from the major stakeholder organisations involved.

The iSTEP exchange programme will bring together eight graduate students from Norway and Canada to study and work on the iNET project to improve healthcare transitions for older people in each country. iSTEP will provide students with training on the key iNET issues, through planned instructional webinars, opportunities for students to work closely with healthcare planners and providers, and to participate in workshops to review the evidence and plan new approaches. Dr Doupe summarises, ‘Through international comparisons, students will learn how culture, legislation, and political context influences healthcare decision making,’ ensuring their work will be grounded in ‘real-world’ understanding.

iSTEP sets out to fundamentally address a constant challenge for health research, that is flexible and sustainable enough to deliver solutions able to navigate the complexity and inertia integral to healthcare practices and their reform. It is hoped that graduates of the iSTEP programme will be grounded in the actuality of the healthcare environment and have the appropriate leadership, negotiation and change management skills to implement and evaluate change. The first phase of the project will inevitably be a ‘test-bed’ to refine the programme’s content and methods, but Drs Jacobsen and Doupe are keen for the training programme to continue and expand, even in the absence of future funding.

The Potential for an International Solution

With the unstoppable societal changes of an ageing population now in progression, it is vital that healthcare systems adapt and change to meet the new dynamic changes required to cope with our population needs. The work of Dr Doupe and Dr Jacobsen remains one of the few ‘theory into practice’ approaches which recognises and truly aims to capture and address the complexities of healthcare that often undermine even the best programmes for change. We can thus hope that the lessons learnt in Norway and Canada can be delivered on a wider, international stage.