Creating ’good’ hospital to home transfers in the rural north of Sweden: informal workarounds and opportunities for improvement

Figures & data

Table 1. Linking Rural Nursing Theory (RNT) and the beyond periphery model.

RNT Observation (Jakobs, 2021)	Beyond Periphery component
Rural residents value ability to be productive over being free from illness	Productivity of the community can be substantially impacted by the presence or absence of just a few people (detailed), resulting in a heightened sense of responsibility to remain productive Conversations about health status can be delicate to navigate
Rural residents resist accepting care from ‘outsiders’	Rural residents dislike being dependent on others Distance of service providers impacts willingness to seek care Even relatively proximate services may be inaccessible because of the history of discontiguous development
Less anonymity and greater role diffusion in the health and care workforce	‘Standard’ health and care services are disconnected from the realities of rural life Services need to be able to quickly adapt to the diversity and dynamism of rural populations

Figure 1. Municipality of Storuman, showing Tärnaby district and distances to main health services (created by authors).

Table 2. Example of analysis for “role clarity” theme.

Free line-by line coding	Descriptive themes	Analytic theme	Theme
Quote from int: “It can be a knowledge sitting on more than one chair”	Knowing your own role	It is important to know your own role	Role clarity
Observation: Having the experience of working for both Kommun and Region gave a good insight into the entire HHT process, to know your own responsibility and role.
Quote from int: “If everybody just takes responsibility for their own job!”
Observation: Many people feel that the discharge process is unclear	Insecurity in not knowing who is responsible for what	Being properly resourced for doing your job
Content from interview: It is the care staff that executes the rehab plan at home, and the physio and OT can see a pattern it’s not getting done the proper way, either because they don’t take it seriously, don’t have time or feel insecure.	Doing your job right

Table 3. Challenges of HHT, workarounds and proposed responses – summary of research findings.

Theme	Challenge	Workaround	Proposed responses
Role Clarity	One person may fill multiple roles No individual with necessary skills available when needed Roles are versatile and broad in scope Lack of certainty about individual roles in the next HHT process	(Over) reliance on a few people with extensive experience and inter-service connections Limit size of HHT teams, encouraging people to work outside their expertise	Better documentation of good HHT in Tärnaby context Case meetings involving staff from different services Appoint a case manager for each home care client
Communication	Not all actors (especially lay staff) can access required information Proximity of colleagues and multiple roles makes entering data into Prator redundant Concerns about the extent to which different legislative environments for different services allow information exchange	A reliance on ‘on-the-run’ communication Ad-hoc coordination meetings when high risk situation presents Guessing a patient’s needs from past experience Inventing own documentation procedures to subvert official lines of communication	Prator training and using Prator as a check-list system Clear epicrisis and discharge notices available before patient leaves hospital Checklists for what needs to be done at each stage of transfer Feedback channel for local services to inform distant services when expectations were unrealistic Universal patient charting system
Geography	Geography influences distance and availability of services, size of workforce, staff turnover and absences, and ability to gain experience in high risk HHT Home visits are logistically difficult and minimized Releasing staff for training is difficult due to staff shortages and distances to training sites	High use of short term accommodation High rates of hospital re-admissions Ad hoc service (re) design – changing service commitments unpredictably. Leveraging personal relationships with patients and family	Local education and training programs Mechanisms to capture skills and experience even from short-term staff
Understanding of the rural context	Even commonly needed resources (like toilet seats) are not available locally HHT milestones in ‘the city’ (such as discharge times) do not align with routines in Tärnaby Services prescribed in ‘the city’ not available in Tärnaby Statistical significance of one or two poor outcomes far greater than in larger municipalities	Key local feel pressured to work overtime and out of hours High risk aversion leading to lack of patient-centred care	Education and training programs for service providers ‘in the city’ Flexible discharge times accounting for patient needs Greater involvement of local (Tärnaby) actors in discharge process