PhD Studentship: Developing Structured Clinical Handover Tools for Non-communicable Diseases in Ind
Healthcare for many patients involves treatment or assessment by different clinicians in different institutions over time: in the community and hospital, and by generalist and specialist health care providers(HCP). HCPs need to communicate their assessments and plans to each other so that the healthcare delivered is safe and offers continuity for patients. This process is clinical handover. Handover critically involves communication to patients and their families who provide self-care at home. Clinical handover thus enables healthcare institutions to be inclusive and more effective.
Evidence from high-income countries shows that ineffective handover leads to delays in diagnosis, incorrect treatment, life threatening events and hospital re-admission. Limited evidence from low and middle-income countries (LMIC) suggests that poor outcomes due to inadequate handover are even greater. WHO has emphasised the importance of health systems integration and handover processes. The ageing population and adoption of unhealthy life styles is leading to a sharp increase in non-communicable diseases (NCDs) in many LMIC requiring long-term care; India has the highest burden of chronic disease such as diabetes, cardiovascular and respiratory diseases. Current Indian Government is conducting health system reforms with ambitions to strengthen primary care and universal health coverage. This provides an opportunity for innovations to improve integration of care for NCDs.
Our team successfully completed a MRC Health Systems Research Initiative (MRC-HSRI) Grant (2015-16) that investigated the handover process for NCDs in 2 Indian States. We found that communication was poor, public healthcare providers (HCP) did not have functioning information storage and retrieval systems and there were no systems to transfer information other than mostly unregulated pieces of paper/notes to patients at discharge or at clinic visits.
We consulted international experts and senior decision makers in India who reviewed our findings, patient notes models and plans for development of the electronic hospital/patient records. Mobile phone options were explored and found to require a large investment with major issues regarding data confidentiality, access and patient benefit. They concluded that (a) a discharge planning check-list for hospitals, and (b) a chronic patient-held booklets are the most patient-centred intervention options, feasible and cost-effective for effective handover to patients and HCPs.
The PhD researcher will build on this work and collaborations in India to develop the patient-held record and the discharge planning check-list, and to pilot them in the Indian healthcare setting. We intend to submit a proposal to the MRC to evaluate the interventions within a complex health systems improvement package in a cluster-RCT.
Implementing structured handover will enable healthcare institutions to deliver care more inclusively (increased engagement with patients in their own care) and more effectively (coordination across institutions in a care pathway, reduced errors, delays, costs).
- What are optimal format and contents for tools (a) & (b)
- What are barriers/facilitators to their use and implementation in the private and public health care of India from the patient and HCP perspectives
- What are the immediate benefits to improving quality of care for NCD patients
- What are benefits to patient-centred care
- What are methodological innovations related to best ways of delivering qualitative research in such challenging settings (e.g. language/translation issues, recruitment of hard to reach participants, managing cultural/occupational hierarchies, local vs UK researcher collaboration)
We propose to use a novel combination of studies with experts, policy makers/managers, clinicians and patients, using 5 interconnected work packages(WPs):
- Literature review: previous studies or attempts at content of chronic disease/patient-held records & discharge planning tools & implementation challenges
- Qualitative Expert interviews: in the UK and India about the content and implementation of such tools
- This component will develop the student’s understanding of challenges of health system development in a complex setting such as India. S/he will also gain skills in group and consensus decision making e.g. Delphi method (15 mth)
- Develop the 2 tools: enable skills in health service tool development (6 mth)
- Pilot and evaluate the tools in India with patients tracked for 3 months (mixed quantitative & qualitative methods) to improve tools and explore how the interventions would be operationalised by HCPs and patients:
- Develop intervention implementation and evaluation skills, and understand barriers and facilitators that underlie health systems’ change and handover challenges in India as an example of a LMIC (12 mth)
- Definition of methodological innovations related to best ways to deliver qualitative research in LMIC challenging setting