Handover communication and continuity of care for chronic disease patients in India: a mixed-methods investigation

This thesis research investigated handover communication and continuity of care for patients with chronic, non-communicable diseases (NCDs) in Himachal Pradesh and Kerala states, India. A systematic review explored the literature on quality of handover communication and interventions for handover communication in low and middle-income countries (LMICs). Mixed-methods were employed to investigate the following in Himachal Pradesh and Kerala states, India: handover and healthcare communication within and between levels of care for chronic NCD patients, the association between quality of discharge handover communication and chronic NCD patient outcomes, healthcare provider (HCP) training and protocols for handover communication and possible strategies to improve the storage and exchange of healthcare information for chronic NCD patients. The systematic review found a relative dearth of LMIC literature and that sub-optimal recording and/or transfer of patient information was a commonly reported issue in all areas of handover communication (i.e. shift-change, discharge, referrals and transfers). A number of system, organisational cultural and individual healthcare provider issues were described as affecting the quality of each area of handover. The majority of interventional studies were non-randomised, of medium to low quality and reported improvements in handover communication. Regarding handover and healthcare communication in Himachal Pradesh and Kerala states, India, the mixed-methods outpatient and quantitative inpatient studies evidenced that most patients who visited public healthcare outpatient clinics (OPC) and who were discharged from public hospitals received unstructured patient-held medical documents that contained deficient information for facilitating effective continuity of care. In the mixed-methods outpatient and the qualitative and prospective inpatient studies, patient reports indicated notable inconsistencies regarding HCP healthcare management communication. In the mixed-methods outpatient, qualitative inpatient and cross-sectional HCP studies, HCP reports revealed a lack of standardised procedures for handover communication between levels of care across public and private healthcare facilities. Factors affecting the quality of handover communication were also identified; HCPs in the mixed-methods outpatient study reported that public healthcare OPCs did not maintain in-house patient records. In both the mixed-methods outpatient and qualitative inpatient studies the following factors were identified by HCPs/patients: time constraints, inconsistent referral practices, unstructured medical documents, inconsistent patient transportation of medical documents and deficient HCP handover training. In the cross-sectional HCP study, the following factors were most frequently reported as “highly applicable” to referral and discharge communication: excessive workload and poor health systems and integration. Regarding discharge handover communication and patient outcomes, the prospective inpatient study evidenced significant associations between low-quality documented discharge communication and death (AOR=3.00; 95% CI 1.27,7.06) and low-quality verbal discharge communication and self-reported deterioration of chronic NCD/s (AOR=0.46; 95% CI 0.25,0.83) within 18 weeks of follow-up. Regarding HCP training and protocols, the majority of HCPs in the cross-sectional HCP study reported that they had not received structured training for shift-change, discharge or referral. HCPs in both the mixed-methods outpatient and qualitative inpatient studies also reported an absence of handover training and structured referral protocols. One private tertiary hospital in Kerala was found to have policies and structured documents for clinical handover. Other than standards/guides for voluntary quality accreditation schemes, no further handover-specific protocols, policies, guidelines or training documents were identified across Himachal Pradesh and Kerala. Regarding strategies for improving handover communication, HCPs in the qualitative inpatient study reported the following: increased public healthcare resources, formal referral systems and computerised “e-health” systems. In both the mixed-methods outpatient and qualitative inpatient studies, patients and HCPs supported the idea of structured patient-held booklets for storing and transporting medical documents. In conclusion, the findings suggest that continuity and safety of chronic NCD patient care are likely being compromised by suboptimal recording and transfer of patient information, as well as a lack of standardised handover communication protocols and HCP training. They have also highlighted a context-relevant and acceptable intervention for improving patient information exchange and the need for further highquality handover communication research in India and other LMICs