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Abstract

In 2012, the Australian Commonwealth Government introduced a series of reforms for the aged care sector including the implementation of the National Prioritisation System for a flexible, accessible and demand-driven approach to home care services for older people. Nevertheless, an increasing number of older people continue to wait for months to be assigned home care packages on the national prioritisation queue, a component of the National Prioritisation System. There is limited evidence on the impact of the national prioritisation queue on discharge planning practices of social workers in supporting older people returning home from hospital admission. The aim of the research described in this paper is to explore the perceptions of social workers from rural and urban health services areas on how the introduction of the national prioritisation queue has influenced discharge planning of older people who are still waiting assignment of home care packages.

This study protocol establishes the need for this qualitative study and provides an overview of the theoretical framework underpinning the research; discusses and describes the methods for sampling/recruitment and data collection, the approach to be utilised for qualitative analysis and the planned dissemination strategy.

Understanding how social workers respond to the perceived challenges to discharge planning posed by the national prioritisation queue and the implications arising from the research have the potential to inform the development of best practice approaches and further enhance social work response to identified issues.

Keywords

home care services discharge planning patient discharge social workers aged

Background

In most hospitals, social workers are routinely relied upon by the multidisciplinary team to facilitate discharge planning for patients returning home from hospital admission (Sims-Gould et al., 2015). Discharge planning is the process of assessment, evaluation and service coordination to facilitate continuity of patient care and safe transition from hospital to the community (Australian Association of Social Workers [AASW], 2016). Social workers conduct psychosocial assessments to identify the strengths and weaknesses of a person’s social network and evaluate the necessary support required to maintain resilience and independence on return home from hospital admission (Judd & Sheffield, 2010). Social workers possess expertise and critical skills to negotiate social services, support and advocate for families and patients with complex care needs throughout the discharge planning process (Craig & Muskat, 2013). These specialised skills in linking and negotiating formal support between hospital and community systems contribute to the reduction in patient hospital length of stay (LOS) (Lechman & Duder, 2009) and can enhance timely and efficient hospital discharge (Galati et al., 2011). However, the changing policy context in the Australian public health system has extended the social work role to addressing carer stress and managing complex issues (Cleak & Turczynski, 2014), which has proven to be an important key to minimizing hospital re-admission (Barber et al., 2015). The lack of formal and informal carers to adequately support older people returning home from hospital could contribute to carer stress, or hospital emergency re-presentation, hospital re-admission or premature entry to residential care for the older person (Bryan, 2010; Rand & Malley, 2014). Insufficient community resources, lack of formal carers, family conflict and the complex social issues which impede discharge planning and contribute to prolonged hospital stays have heightened the pressure on social workers to facilitate a swift patient discharge to free beds (McAlynn & McLaughlin, 2008). The demand for shorter hospital admissions has been attributed to funding pressures from hospitals that strive to remain financially viable (Auerbach et al., 2008). In an environment with limited hospital beds and reduced funding, older people could potentially be discharged from hospital early with limited options for managing their own care at home (Glasper, 2012).

In Australia, the Commonwealth Government (2011) adopted the recommendations within Caring for Older Australians Report, an inquiry conducted by the Productivity Commission aimed at reforming and simplifying the social services system for older people toward a consumer-directed care (CDC) model in anticipation of increasing future demands for home care services. To investigate the validity of introducing this model to home care services, the Australian Commonwealth Government (2012) initiated a pilot study releasing a total of 1,000 non-ongoing home care packages (500 in 2010–2011 and 500 in 2011–2012) through competitive invitation process. This pilot was a segue from an agency-controlled service model into a consumer demand-driven service delivery model. In the past, home care service providers received annual block funding from the Commonwealth Government to manage and deliver services in an agency-controlled or provider driven service delivery model (DeLoitte Access Economics, 2015). The CDC pilot study, however, created doubts, uncertainty and confusion among consumers and this was attributed to the limited understanding and information disseminated prior to the introduction of the social service reforms (Australian Government, 2016d; Day et al., 2016; Gill et al., 2018). Despite the initial confusion, the pilot study revealed older consumers value having the choice, flexibility and control over home-based care services (McCaffrey et al., 2015) and were satisfied with the CDC model (Australian Government, 2012). Although there was general support (in principle) for the implemented social services reforms, older consumers and providers were still concerned over accessibility, equity, the lack of clear information (Australian Government, 2017c) and the waiting period to receive home-based services (Day et al., 2016).

Following the pilot study, the Australian Government introduced further amendments to the Aged Care Act 2013 (Increasing Choice in Home Care) to nationalise and streamline the allocation and prioritisation of home care packages based on need (Australian Government, 2016b). A home care package is a suite of coordinated care services provided to older Australians to suit their specific needs (Australian Government, 2015). Home care packages are categorised as lower level or basic/low care (annual funding of approximately $9,000–$15,750) and higher level or intermediate/high care (annual funding approximately $34,500–$52,250). The National Prioritisation System was introduced as part of the amendment to the Act, designed to offer flexibility, portability and accessibility of home care packages to older people in the order of priority of need (Australian Government, 2016c). The National Prioritisation System comprises of two components: the national prioritisation queue, which determines the order of allocation of home care packages to eligible clients and the home care package release process, which determines the number and type of packages that can be assigned to clients on the queue at a point in time (Australian Government, 2017d). These reforms were introduced to meet the anticipated growth in demand for social services as the older population increases in the coming years.

The Australian Government through the Department of Health has released periodic Home Care Package Data Reports since the National Prioritisation System was launched in February 2017. These data reports consistently show an increasing number of older people awaiting assignment of the approved home care package level on the national prioritisation queue despite periodic releases of care packages (Australian Government, 2017a, 2017b, 2018a, 2018b, 2018c, 2018d, 2019a, 2019b, 2020a, 2020b). The most recent data report suggests that at that time, 103,599 older people were awaiting assignment for their approved level of home care package on the national prioritisation queue between 3 to 12 months or more (Australian Government, 2020a). These statistics represent three groups: 1) older consumers who had been assigned an interim lower level package but are still awaiting their approved higher level; 2) those who have been offered interim or approved level but have not taken up the offer and; 3) those who have not been offered interim nor assigned a home care package. Some older consumers could have access to existing informal support from carers or family members and/or formal supports such as the entry level Commonwealth Home Support Program (CHSP), Department of Veterans Affairs (DVA) funded services or private carers. The expanding number of older people on the national prioritisation queue is evident of the Australian Government’s ongoing challenge to meet the critical level of demand for home care packages.

The availability of community resources and services necessary to meet the needs of older people is often limited in regional areas due to geographical challenges. The lack of infrastructure developments, limited economic activities, fragmentation of social services and provider issues such as workforce retention, operational costs and competition as a result of complex national funding schemes are some of the contributing factors to the scarce community resources in Australian regional areas (Howard et al., 2016). On the other hand, older people living in densely populated metropolitan areas could equally experience several challenges such as social exclusion, economic deprivation and ageism despite the benefits of access and proximity to health and social services (Phillipson & Ray, 2016). For older people with complex care needs, the lack of a coordinated approach between hospital and community services and the absence of home care services could delay hospital discharge, resulting in hospital re-admission or premature entry to residential aged care (Challis et al., 2014; Mitchell et al., 2010). Despite the geographical differences, older people, whether rural or urban dwellers, may encounter similar challenges due to scarcity of resources, limited access, and availability of community support. The challenges currently experienced in Australian regional, rural and remote communities as well as metropolitan areas are, therefore, multi-factorial and are not necessarily confined to limited availability and access to funded resources. Further exploration is therefore necessary to fully understand how these challenges have affected hospital discharge planning under the introduced reforms on community-based aged care services.

The research outlined in this paper aims to address this gap and contribute to the understanding of the impact of the national prioritisation queue on social work discharge planning to support older people returning home after hospital admission.

Research Question

The key research question is:

How does the national prioritisation queue influence social work discharge planning for older patients in rural and urban Australian hospitals?

Aims and Objectives

The aims of the research are to:

Explore the perceptions of social workers on the impact of the national prioritisation queue on discharge planning of older people in Australian metropolitan and regional areas.

Explore the perceptions of social workers on the barriers and enablers to best practice approaches to discharge planning for older people since the introduction of the national prioritisation queue.

The research objectives are to:

Identify the strategies social workers employ to support older people who are awaiting assignment of home care packages.

Identify what social workers perceive as enablers and barriers to practice approaches in regional and metropolitan health settings as a result of the national prioritisation queue.

Determine opportunities for an enhanced social work practice to support the specific needs of older people who are awaiting home care package assignment.

Explanation and Justification of Method

Theoretical Framework

The study adopts an interpretive phenomenological stance to achieve its aim in the social co-construction of the participants’ experience of the phenomenon.

Interpretive phenomenology entails an exploration of a lived experience and the essence of “being there” (Dasein) to account for multiple perspectives and meanings of a situation (Creswell, 2013). A qualitative approach is adopted to explore these lived experiences toward a particular phenomenon. The semi-structured interviews undertaken for this research focus on the participants’ subjective experiences of discharge planning for older people who are still awaiting assignment of home care packages. The interviews further delve into the participants’ recollection and interactions with situations as they explore ways to facilitate a safe discharge in a resource scarce environment. There are two research sites, each with its own distinct socio-demographic and geographical challenges which could lend to a location specific practice approach. The participants are encouraged to provide their own accounts, perceptions and interpretations of how the phenomenon influenced their practice which have led them to a chosen intervention. Hence, the study is anchored on Heideggerian principle of uncovering the hidden, the everydayness and the forgotten (Vergenssenheit) to elucidate what is real and authentic to the participants.

The four life-world existential dimensions of lived body (experience of bodily senses); lived space (space the phenomenon was experienced); lived time (time the phenomenon was experienced) and the lived human relations (relationships gained/retained) is adopted as the framework for exploring the participants’ lived experiences of the phenomenon (Van Manen, 2016).

Adoption of this existential method is to explore what is universal and inherent in the participants’ world and subjective realities, thereby, unraveling the concealed, what is usually hidden and taken for granted. In exploring lived experiences relative to the phenomenon which the principal investigator is familiar with, a reflexive stance is applied while being open to participants’ narratives, subjective truths and interpretations through bridling (Dahlberg & Dahlberg, 2019) or attentiveness to what is being revealed. Dahlberg and Dahlberg (2020) argue that commonality and past experiences should not be ignored as these are important resources for analysing data. The principal investigator maintains field notes and journals as tools for self-reflection and self-examination on reactions, thoughts and assumptions during the interviews.

Interpretivism supports the expression of subjective meanings within an individual’s conceptualised and contextualised experience of the world. Thus, interpretive phenomenological approach is most suited in exploring and interpreting the social workers’ lived experiences as a way of understanding their chosen practice approaches to discharge planning in response to the impacts of the phenomenon (i.e. the national prioritisation queue).

Settings

Place-based characteristics have been identified as influential to health outcomes (Macintyre et al., 2002). A few studies attribute social and geographical factors as health determinants and some suggest that focus on these factors could reduce health inequalities (Dunn, 2014). The World Health Organisation (2012) identify that living and working conditions are closely linked to health outcomes and people living in low socio-economic areas are more likely to have chronic health conditions, live in crowded dwellings, likely to be unemployed and less likely to have access to health and social support (Australian Government, 2016a). In their study, Duckett and Griffiths (2016) attribute remoteness, social disadvantage and high Indigenous population as best predictors of higher rate of preventable hospital admissions in regional areas compared to metropolitan Queensland.

The regional hospital and health service area covers a large catchment area and is the major public health service provider for the widely dispersed rural and remote communities while the metropolitan hospital and health service area is densely populated and covers a smaller catchment area (State Government of Queensland, 2020). Both health service areas have similar challenges relating to high socio-economic disparities, aging population and increasing demand for health services.

The demographical and cultural differences are notable with 15% of the regional area’s total population identifying as Aboriginal and Torres Strait Islander while approximately 59% of the metropolitan residents come from non-English speaking backgrounds (State Government of Queensland, 2019, 2020). With regard to the varied needs and attitudes toward familial caring and aged care service provision (Australian Institute of Health and Welfare, 2014, 2019), it can be presumed that hospital social workers have to consider these aspects in their local communities to facilitate discharge planning, thus allowing for a more targeted and meaningful approach.

Sampling and Recruitment

Purposive sampling is undertaken to recruit hospital social workers from one regional and one metropolitan health service area in the State of Queensland to compare and contrast the phenomenal experiences between the two geographically distinct research sites. Social workers are assigned in different wards to provide assistance to diverse group of patients, therefore, only those who had experienced supporting older patients waiting for home care packages through the discharge planning process will be included in the study.

Information about the research project will be distributed through departments of social work in the research sites. The study is advertised through internal newsletters/news boards to encourage voluntary participation. The social work departmental staff have estimated that there are around 200 social workers employed in total at both research sites. The study aims to recruit between 10 and 12 social workers from each research site, however, the sample size is continuously evaluated during the research process (Malterud et al., 2016) to establish whether data saturation has been reached and no new theme has emerged.

Data Handling

After obtaining consent (written and verbal) from each participant, in-depth, semi-structured interviews are being conducted in a pre-booked private room. The interviews are either tele/video conferenced or conducted face-to-face and digitally recorded in audio format. Participants will be asked to allocate 60–90 minutes for interviews, allowing extra time for the reflective nature of phenomenological research (Holloway & Wheeler, 2010). A follow-up interview via face-to face or tele/video conference may be requested to clarify responses to questions in the light of ongoing analysis. It is anticipated that some participants will be known to the principal investigator as work colleagues. A pre-interview briefing is conducted to discuss the details of the research and the positionality of the principal investigator as an outsider. The principal investigator explains the information being sought and encourages the participant to share real-life examples of their experiences on the subject phenomenon (Quinney et al., 2016).

The interview is conversational in exploring the participants’ lived experiences of the phenomenon and how its impact has been perceived and interpreted (see Table 1).

Table 1.

Interview Guide. This Interview Guide is Not to be Strictly Followed and Only Serves as Prompts to Draw Responses and Encourage Participants to Share their Perceptions and Experiences of the Subject Phenomenon within their Practice Contexts.

–Describe your role as hospital social worker in so far as discharge planning for older person in the facility

–Explain the processes undertaken when discharge planning for an older person.

–What measures are taken to ensure older people waiting for home care package assignment are adequately supported on return home from hospital admission?

–What, if any, are the barriers and enablers to best practice from the introduction of the national prioritization queue?

–What do you think are the differences and similarities in social work practice in regional and metropolitan areas?

–What resources could make innovative models to improve social work practice when discharge planning for older people?

Since the principal investigator has insider knowledge; has personally experienced the subject phenomenon and is known to some participants as a work colleague, there needs to be shared language and an intimate understanding of the nuances, idiomatic expressions and jargon (Quinney et al., 2016). The principal investigator practices self-awareness and openness to essences, which could otherwise be lost and overlooked during interviews.

Thus, the principal investigator shifts between subjectivity and objectivity or bridle what is present and being revealed (Dahlberg & Dahlberg, 2020). To achieve this, the principal investigator maintains field notes throughout the study to record the summary of the interviews. The principal investigator is self-reflective in analysing own thoughts, reactions and conduct in relation to the participant’s revelations. These field notes and journals are used to assist in contextualizing the collected data during the analysis phase.

The data collected is transcribed verbatim to capture pauses, musings and other nuances for interpretation and analysis. A draft copy of the transcript is sent to the participant for review before this document is finalised for analysis. The participants cannot withdraw from the study once the data analysis has commenced. The data collected is stored in a University provided secure data management storage which only the research team (BD, LP and DW) have access to.

Data Analysis

Data analysis is concurrently conducted with data collection. Encounter context themes (ECT), a methodological approach proposed by Daher et al. (2017) is adopted by the research team to socially co-construct the experiences and meanings attributed by participants to the phenomenon. This approach entails reflective thinking by the principal investigator to document the intersubjective encounter with the participant as the first phase. The principal investigator then analyses the contextual dimension (interactional, temporal, spatial and socio-cultural) within which the participants have experienced the subject phenomenon. And thirdly, the research team adopt triangulation strategies (with participants; within the research team and with initial research questions) to capture the essences of the phenomenon as experienced by the participants.

Thus, the discussions among research team focus on the description and interpretation of the experienced phenomenon through the co-constructed lens of each individual participant.

The research team strongly focus on the phenomenon and analyse the data iteratively in a hermeneutic circle of movements between parts and whole.

Dahlberg et al. (2008) outline the first step of gaining a preliminary understanding of parts of data sets against the phenomenon at lower level of hermeneutic circle. The final and higher level would be a comprehensive comparison of all tentative interpretations considered valid at lower level to formulate a new interpretation which bind all interpretations together. Any differences in interpretations are resolved by gaining the opinion of a third member of the team to reach consensus.

Ethical Considerations

Ethical clearance has been granted by the certified Human Research Ethics Committee. Site Specific Assessment (SSA) and governance authorisations have been obtained from the regional and metropolitan governance offices of both research sites. Central Queensland University Human Research Ethics Committee has also granted ethical approval to the research study.

Information sheets and consent forms are provided to those who have expressed interest to participate in the research study. Participation is voluntary and refusal and/or withdrawal from participation does not incur penalty nor loss of employment. The interview times are mutually agreed upon and will not compromise patient/client care.

Signed consent forms are obtained prior to conducting the interviews. Verbal consent is also obtained and digitally recorded to confirm voluntary participation at the time of the interview.

The participants are professional clinicians with potentially high volume of complex cases and work under pressure and in stressful environments. Should participants show signs of distress, fatigue, anxiety or appear unwell during the interview, they are given the option to continue at a later date. Participants are also provided information on where to access support through employer funded, community or private counseling services and are encouraged to seek professional supervision.

The participants’ details and collected data is protected at all times. Participant information is de-identified to protect their privacy. Demographic variables only pertaining to the level of education, job classification level and length of professional experience are included as descriptions of the sample population. Any other information collected which could be identifiable (such as participant details collected during recruitment) is electronically stored separate from the research data. Where a variable information may identify a particular participant, this is removed or minimised to protect privacy at the point of analysis and dissemination of findings.

Rigor

The study adheres to the trustworthiness criteria introduced by Guba and Lincoln (1989).

Credibility—The principal investigator adopts Peshkin’s “I” and the situational self through reflexive journals (Bradbury-Jones, 2007) to heighten self-awareness of subjectivity, prior knowledge and personal experiences of the phenomenon. The participants are sent a draft copy of the transcript for their perusal and review before the data is analyzed. A follow up interview is made to clarify certain points raised by the participant. Reflexivity is an ongoing process throughout the research and involves regular supervision with the research team.

Transferability—The sample population has been described and are homogenous in professional characteristics with similar exposure to the subject phenomenon. Contextual information about the research sites in terms of its socio-demographic and geographical differences and similarities has also been provided.

Dependability—The principal investigator achieves dependability through field note write-ups to journalise and summarise post interview thoughts and reactions. In doing so, decisions made throughout the study are traceable and auditable.

Confirmability—The supervision sessions involve discussions to reach a combined perspective of the meaning and intentionality of the collected data (Araten-Bergman et al., 2016). Supervision sessions are video recorded to evidence the detailed and transparent rationale to decisions made throughout the research.

Dissemination Plan

The findings will be presented to participating research sites with proposals for inclusion to quality improvement processes. The quality improvement activity could involve reviewing current practices, identifying and selecting knowledge to enhance approaches within the geo-demographic context of social work practice for a focused and tailored intervention to support older Queenslanders optimise health outcomes. This could be conducted as a pilot study in conjunction with social workers in research sites with plans for ongoing reviews, monitoring and customization from feedbacks/comments within local context. As the knowledge is synthesised and adopted suitable to the local practice and appropriate to the care needs of the older patients, this may be translated into work instructions for hospital social workers to guide their daily clinical practice.

As the research focusses on a nationwide issue that impact the lives of a number of older Australians, the results will be shared with consumer and advocacy groups and peak bodies as evidence to some of the care trajectories of older people who are still waiting on the national prioritisation queue at the time of their discharge from hospital.

This study has the potential to inform future State and Federal government policy directions in enhancing aged care experiences of older Australians. With a better understanding of the challenges and enablers for safe and sustainable discharge planning, the recommendations/findings of this study have the potential to guide policy makers around decisions on additional resources required, where these are needed, how these can be delivered, when these should be introduced and which agency is best placed or could be partnered with to provide such resources.

The research papers will also be submitted for publication in stages as core chapters of the study in peer reviewed journals and will also be presented at conferences and symposia on aging.

Conclusion

In 2012, the Commonwealth Government of Australia introduced several reforms to the social services system including the adoption of a consumer directed care model and streamlined distribution and allocation of home care packages for older people around the country. The National Prioritisation System was implemented to ensure home care services are prioritised and assigned to older people with the most urgent need. The escalating number of older people on the national prioritisation queue has the potential to influence discharge planning processes in a resource scarce environment. With the unrelenting demand to clear hospital beds in an environment with limited community supports, hospital social workers are under heightened pressure to facilitate swift discharge planning for older people who are still waiting for home care packages on the national prioritisation queue. This can lead to negative impacts for older people, their families, and the hospital system. The knowledge gained from this study has the potential to inform and determine ways to harness community resources in further enhancing social work discharge planning approaches within specific practice contexts.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research study is funded by Central Queensland University under the Australian Commonwealth Government Research Training Program.

ORCID iD

Bernadette Dimla

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A Qualitative Study on How Social Workers From Regional and Metropolitan Queensland,Australia Perceive the Impact of the National Prioritisation System on Hospital Discharge Planning: A Study Protocol

Abstract

Keywords

Background

Research Question

Aims and Objectives

Explanation and Justification of Method

Theoretical Framework

Settings

Sampling and Recruitment

Data Handling

Data Analysis

Ethical Considerations

Rigor

Dissemination Plan

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

References