A social network analysis to explore collaborative practice in home care: research protocol

Europe’s elderly population has been increasing for several decades and projections show that this phenomenon continues in the future [1]. In Switzerland, in 2020, life expectancy at birth was 85.1 years for women and 81.0 years for men [2], of which 71.7 and 70.7 years should be lived in relatively healthy conditions, respectively [3]. Although people now in general live longer and in better health than a few decades ago, there has been a significant increase in the prevalence of chronic and degenerative diseases over the age of 65 [4, 5]. In Switzerland, about half of all people aged 55 years and over and two thirds of those aged 75 years and over live with at least one chronic disease [6]. Of the very old suffering from chronic diseases, around half have two or more chronic diseases, defined as multimorbidity [6]. The latter is particularly responsible for functional decline and disability [7‐9]. In this context, the number of complex cases to be managed has increased [10]. Due to the continuing demographic transition, the number of dependent older adults [OA] requiring long-term care is expected to rise further in the coming years [11].

Efficiently and effectively addressing the rise of chronic diseases and multimorbidity is one of the major challenges facing Switzerland’s health system [12]. One solution for coping with this development and addressing patients’ long-term care needs requires a shift from hospitalized / institutionalized rehabilitation to home care [HC] [13].

The literature documents different definitions of HC depending on the study, country, or researchers. This study adopts the definition of WHO Europe, which states that “home care can be conceived of as any care provided behind someone’s front door or, more generally, referring to services enabling people to stay living in their home environment” [14].

With an ageing population and more patients diagnosed with multiple chronic conditions, HC’s importance is evolving. HC has expanded significantly in Europe in recent years [15]. To illustrate the Swiss situation, the number of people aged 65 and over receiving HC services in Switzerland increased from almost 122,000 in 2007 to over 245,000 in 2020 [16]. In 2019, people aged 80 and over received an average of 76 h of professional HC per year, or 1 h 28 min of HC per week [17]. This development of HC is not unexpected in view of its many advantages. First, patient care occurs in a familiar setting. Most OAs needing moderate care over the long term want to be treated in the reassuring environment of their home [18]. In addition, HC is often a good alternative to hospitalization, as the literature demonstrates that this is not always well tolerated, even leading to hospital-related disability [19‐22]. This has been shown to be the case for some COPD patients [23], OA stroke patients [24], and patients with acute decompensatory heart failure [25].

Finally, HC makes sense from an economic perspective for the health system. Gonzalez-Jaramillo et al. showed that in addition to reducing the number and duration of hospital visits, and thus, clearly, hospitalization costs, HC reduced overall health care costs in both oncological and non-oncological patients [26]. Di Pollina et al. reported that integrated HC reduces unnecessary hospitalizations and emergency visits among frail elderly patients [27]. Wong et al. reported that a home-based palliative care program was a more cost-effective option than usual palliative care for people with heart failure [28], and Cartoni et al. found similar results, reporting that palliative HC costs were lower than hospital care costs for patients with hematological malignancies [29].

The significant development of HC in recent years has been accompanied by an evolution in its meaning [30]. Professional or policy perspectives generally dominate thinking about HC, meaning that its operational aspects are emphasized [31]. In contrast, the definition of HC preferred by patients and formal and informal caregivers focuses on broader aspects of life, like emotional needs, quality of life, and autonomy [31]. This more holistic approach has gained traction in recent years [31‐33], particularly patient-centered care approaches [34, 35] based on each patient’s individual needs [36], including a consideration of the emotional, psychosocial, environmental, and cultural aspects of HC [31]. The development of HC has also been accompanied by an increase in the number of professionals involved. Today more and more stakeholders, with various roles, are active in HC, resulting in the parallel development of the concepts of collaborative practice, patient preferences, and care management. In addition, information, and communication technologies [37‐39] have further influenced HC and now offer solutions facilitating care delivery, collaborative practice, and training of future professionals.

Coordination and collaboration between different stakeholders intervening in recipients’ homes is a fundamental element of HC’s evolution [40‐45]. A recent scoping review highlighted that interaction and communication between health care professionals were key factors in optimizing HC [46]. Transparent, flexible communication and collaboration between professionals, but also between professionals and care recipients and their families, seem to be necessary ingredients for successful HC [47]. Research has shown that collaborative practice (when different health professionals work with a patient, family, caregivers and the broader health care community) in particular can improve health outcomes for people with chronic diseases, improve overall patient care, and increase patient and caregiver satisfaction [48].

However, achieving good coordination, collaboration, and communication between home caregivers [HCGs] with different care cultures (including different professions) remains a challenge—a challenge that is even greater when it involves treating complex cases with multiple pathologies requiring interventions by several HCGs [10, 49, 50].

The difficulty of coordination and collaborative practice might even be more important between HCGs working independently and not employed by HC agencies. One literature review identified the lack of coordination existing in various European countries when different types of HCGs cared for the same patient in their home [51]. In Switzerland, a study of palliative HC even reported that coordination between services and collaborative practice between specialists and general practitioners were poorly developed [52]. One of the elements that may create tensions and hinder communication and collaborative practice between different stakeholders is their lack of mutual knowledge or misunderstandings about each other’s various professional roles, especially because these have constantly progressed and evolved during the last decade. Yet a clear understanding of each professional’s role in HC management and an in-depth knowledge of their skills from all sides, is fundamental to reinforcing existing collaborative practice and establishing new collaborations that will enhance best practices in optimal HC management [46]. In its charter on collaboration between health professionals, the Swiss Academy of Biomedical Sciences has highlighted the importance of clarifying competencies and responsibilities to ensure optimal patient-centered care, especially among health professionals working in the same organization [53].

Since new types of HCGs are now being incorporated in a field which was previously predominated by nurses and occupational therapists, it has become relevant to define everybody’s role as to optimize existing and future collaborative practices and discover potential missing elements. Define specific needs and explore possible strategies for improving patient-centered HC management and particularly for optimizing collaborative practice are essential conditions for improving HC, which has been little studied so far [51].

Thus, our study aims to: (1) explore existing collaborative HC practice in French-speaking Switzerland at the micro level (level that directly concerns patients and interactions with them [54]), including HCGs not employed by agencies; (2) explore and identify the roles of various HCGs (whether employed by agencies or not) around specific HC recipients in French-speaking Switzerland; (3) identify needs and expectations of all the HCGs and stakeholders in HC (including recipients) to create a clear vision of future optimal HC management; and (4) identify strategies to improve HC management and, particularly, to optimize collaborative practice.

Over the past few decades, demographic evolution has provoked a shift from hospitalized care towards HC. This evolution has been accompanied by the fact that new types of HCGs are now intervening in a field which was in the past predominated by nurses and occupational therapists. In this context, identify the roles of each is very pertinent, as is the way they perceive their roles and how they collaborate. We are convinced that an in-depth examination of each professional’s skills and roles is fundamental to reinforcing existing collaborative practice and to establishing new collaborations that will lead to improvements in the quality of HC management and provision.

Thanks to an analysis of existing collaborations, the roles but also the expectations of HGGs and HC recipients can be illustrated to obtain a good overview of the functioning of collaborative practice in HC in French-speaking Switzerland. This will enable recommendations so that possible means can be implemented to meet the expectations of those concerned. Moreover, thanks to the last phase of the study (qualitative phase exploring strategies), HCGs and HC recipients themselves will be able to directly reflect on potential solutions to improve collaborative practice and thus the quality of care.

Although this study is limited to French-speaking Switzerland, the results will provide an opportunity for reflection that also will benefit other regions of Switzerland. Furthermore, to obtain a complete overview of the functioning of collaborative practice in HC in Switzerland, it would be relevant that the same study be conducted in the other regions of Switzerland in the near future.

In addition, the present study will be a starting point for new projects aiming to establish and test actions to enhance communication and collaborative practice in HC, and ultimately to improve the quality of care. Moreover, our study’s findings will allow to highlight which elements related to the collaborations between the different HC stakeholders need to be optimized. They will, therefore, serve as a basis for developing further studies meeting these specific needs. Furthermore, our results will provide the basis for upcoming interprofessional projects planned in the field of HC and health promotion.

Finally, this study’s findings will be an excellent complement to the study by Möckli et al. [70], which will be carried out in Switzerland at the national level. These authors will focus on the interactions between the macro-, meso-, and micro-factors in care coordination by collecting data from HC agencies [70]. They also plan to explore care coordination’s associations with the quality of care [70]. Good coordination seems to be essential for quality HC [40], so a more detailed analysis of current formal and informal collaborative practice at the micro level is essential. That level directly concerns patients and interactions with them [54], integrating not only the HCGs hired by home care agencies but also independent HCGs. However, independent or free-lance HCGs not employed by HC agencies will not be included in Möckli et al.’s study [70]. Our study, which focuses on both HCGs employed by agencies and HCGs working independently will therefore be of necessary complementary value in exploring and evaluating the strengths and limitations of HC in Switzerland, next to their research. Results of these two complementary studies will provide recommendations for the development of a Swiss collaborative interprofessional model for HC.

Home care is an evolving field in which many different professionals are involved to provide the best possible care to patients. Good communication and collaboration between all the stakeholders involved is an essential condition to provide quality care. In Switzerland, however, there is a lack of data on how these collaborations are currently functioning. The results of our study will allow to collect relevant information on current collaborative practice in home care in French-speaking Switzerland, but also to explore the roles and expectations of each of the concerned stakeholders. It also will enable to propose recommendations and strategies to optimize collaborative practice in home care. Finally, it will serve as a basis for future studies that can be conducted to address the identified needs.