Inappropriate admissions or inadequate discharges of frail elderly: Competing program theories and implementation challenges in an intermediate care intervention
Bibliographic record
Abstract
Intermediate care interventions are increasingly being implemented in the health services to avoid hospitalizing elderly frail patients with complex medical issues, often referred to as inappropriate or unwarranted admissions. This paper presents a theory-based stakeholder evaluation of an intervention involving hospitals, community care and general practitioners (GPs) in a Danish region with the overall objective to reduce the number of (inappropriate) hospital admissions for the frail elderly of 65 years or older. In a controlled study design elderly acutely ill patients were randomized to care and treatment either by a district nursing team or in an emergency department (ED) – both interventions with a 48-hour time limit. The district nursing teams were given access to various telemedicine solutions. In the programme theory analysis the stakeholders’ normative theories, situation theories and causal theories were studied. Competing programme theories and barriers and facilitators were identified. Data were collected in interviews with stakeholders (managers, nurses, hospital physicians and GPs) and from the literature. The intervention included a regional hospital, four municipalities and 166 GPs servicing a mixed urban and rural region in Denmark. Four district nursing teams, eight GPs, three hospital physicians and two project managers were interviewed between January and March 2015. The stakeholder’s programme theories were both concordant and competing; the GPs in particular were sceptical of the purported objective of reducing the number of inappropriate hospital admissions; they would rather see a reduction in the number of inappropriate hospital discharges. Our results indicate a compromised implementation process.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.087 | 0.090 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.002 | 0.006 |
| Scholarly communication | 0.004 | 0.004 |
| Open science | 0.003 | 0.006 |
| Research integrity | 0.002 | 0.003 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".