Experiences of ambulatory care for frail, older people and their carers during acute illness: a qualitative, ethnographic study

Increased age is associated with increased Emergency Department attendance and emergency hospital admissions but there is evidence that the acute hospital environment is unsuited to older, frail people. There are policy imperatives to increase the acute care delivered outside traditional hospital settings. For some patients, acute care can be delivered on an ambulatory basis, but the impact on them is uncertain.

Ambulatory care aims to provide equivalent medical care outside traditional hospital settings. The acute care pathway at ambulatory care units in Oxfordshire, UK is targeted at frail, older people. Patients are referred by primary care physicians (from the patient’s practice or out of hours service) or paramedics responding to emergency calls. The units provide rapid assessment and interventions unavailable in primary care, closer to patients’ homes.

Methods
We investigated frail, older people’s experiences and perceptions of two ambulatory care units, adopting a qualitative, ethnographic approach, recruiting patients and carers in the units and observing their care. This method is particularly suitable for exploring care journeys, as it captures events and thoughts about those events as they occur. We produced “thick description” of patients’ care journeys and conducted informal interviews with recruited patients/carers while in the units, resulting in very detailed accounts around each patient. We carried out follow‐up semi‐structured interviews with patients post‐ discharge from ambulatory care. Field notes and interview transcripts were thematically analysed. There was ongoing discussion within the team about emerging themes and their interpretation.

Results
We recruited 23 patients (13 males and 10 females) and 8 carers. Age range was 68 ‐ 91 years (17 of the patients were 80+). Of our sample 11 lived alone, 11 with spouse/family and one in a care home. Markers of frailty in our participants included falls, difficulties with mobility or everyday tasks, receiving a package of care at home and memory difficulties. The most common reasons for referral were exacerbations of Heart Failure or Chronic Obstructive Pulmonary Disease, suspected infections, reduction in mobility, falls and pain. Altogether, we undertook 217 hours of observation. Full details of patient visits are included in Table 1. At the units, patients and carers perceived their care as personal and friendly:
The carer found…care was “personal”, staff were “not aloof and didn’t disappear” [Carer of patient 10]
The relaxed atmosphere was appreciated when older people were unwell:
The patient said…“it makes you feel at home, like coming to visit friends, like a family circle” [Patient 11]
Patients were pleased with the assessment and treatment they received:
I think this place serves a very useful function. Everything’s being sorted out. [Patient 18]
and appreciated quick access to further specialist care:
The unit had been able to sort out things today that the patient had been waiting for, for months – the respiratory nurses and the nebuliser. [Carer of patient 6]
Patients liked attending a local unit which could provide the treatment they needed:
“This is much more convenient. They seem to have all the skills I need” [Patient 2]
They saw ambulatory care as a way of saving a hospital admission:
“It was ideal…it would have been ridiculous to have put me in a bed” [Patient 14]
and would be happy to attend again:
“If I had to come back in…I’m a very lucky man to go back” [Patient 12]
However, patient visits could often be long:
“we were literally in for four hours…it’s quite a long time but then they keep on doing things” [Patient 13]
Patients sometimes needed to return for follow‐up visits. Some were positive about this:
“Just as well for me to be at home and come in when necessary…a more relaxed way of doing things” [Patient 21]
For others, this was challenging:
I found it quite tiring yes…I used to come home and go to sleep [Patient 18]
Overall patients were very pleased with their care and felt that it fitted their needs and priorities well: The carer thought that ambulatory care was
“a good way to go for older people” [Carer of patient 23, field notes]

Conclusions
Acute care in ambulatory settings was regarded as an acceptable alternative to hospital admission. However, long visits and the need for return visits impose an additional burden overlooked by policy makers. This study shows ethnography as a feasible research approach with frail, older people, and can transform awareness of what constitutes appropriate care. The ethnographic approach powerfully highlights the perceptions and concerns of older people, which could equip health services to respond better to their needs during acute medical treatment outside hospital settings.