AT THE INTERFACE OF HEALTH AND COMMUNITY CARE: DEVELOPING LINKAGES BETWEEN AGED CARE SERVICES IN A...

INTRODUCTION

Over the past two decades in Australia the field of agedcare has been transformed through the implementation ofnumerous reform strategies,1 which have impacted on thekind of care provided to the rural elderly and the expecta-tions of rural health providers. An integral component ofthese reforms has been the introduction of Aged CareAssessment Teams (ACAT). Aged Care Assessment Teamsare multidisciplinary groupings that take a primary role inassessing the medical, psychological, social and func-tional status of aged clients in order to make recommen-dations for appropriate services. These responsibilities

necessarily locate ACAT assessors’ practice across amultitude of contexts where the aged receive care andsupport. They signify that they are one of the few groupsthat work at the interface of health, community and resi-dential sectors in aged care.

The intersectoral function of ACAT is of increasingsignificance, with the emphasis on the expansion of teammembers’ roles to include a focus on developing networksamong and linkages between different service providers inthe field.2 Many authors acknowledge the appropriatenessof ACAT taking a primary role in the development of link-ages, suggesting that their strategic position workingacross the interface of sectors means they are ideallyplaced to perform this function.3–7 In the 1990s, this roleis of increasing importance as it is widely acknowledgedthat fundamental problems exist in the coordination of andlinkages between health and community care services.8–10

Indeed, both Commonwealth4,6,11 and State bureaucrats,7

consumer groups12–14 researchers5,15 and professionals in

Aust. J. Rural Health (1999) 7, 172–180

Correspondence: Andrew Robinson, Tasmanian School ofNursing, Anne O’Byrne Centre, University of Tasmania, 287–291Charles Street, Launceston, Tas. 7250, Australia. Email:<[email protected]>

Accepted for publication July 1998.

AT THE INTERFACE OF HEALTH ANDCOMMUNITY CARE: DEVELOPINGLINKAGES BETWEEN AGED CARESERVICES IN A RURAL CONTEXT

Tasmanian School of Nursing, University of Tasmania, Tasmania, Australia

ABSTRACT: This paper explores issues concerning the development of linkages across the interface between acuteand community aged care services in a small regional Australian city. It addresses a participatory action researchproject that took place over a 2 year period involving an Aged Care Assessment Team (ACAT). Aged Care AssessmentTeams are multidisciplinary teams whose members mediate between hospitals and the aged care system in thecommunity and have a key role in developing networks and linkages between various service providers in the field. Inan age of economic rationalist-inspired reform agendas in health and community care, rural infrastructures havebeen compromised to such a degree that the role of rural ACAT in developing linkages between sectors has never beenmore important. This paper takes up this issue and addresses the project findings, which highlight a fieldcharacterised by ineffective linkages within and between the various sectors, a lack of understanding of the operationof the rural aged care system among nurses working in regional hospitals, and the efficacy of ACAT workingcollaboratively with nurses to create new and more effective linkages in aged care.

KEY WORDS: aged care, linkages, participatory action research, rural health care.

Andrew Robinson

Original Article

DEVELOPING LINKS BETWEEN AGED CARE SERVICES IN A RURAL CONTEXT: A. ROBINSON 173

the field16 have expressed concerns regarding the need todevelop linkages between sectors that provide care andsupport for the aged. However, despite a growing recogni-tion of the desperate need for change, the efforts of gov-ernment to remedy the situation have been described as,at best, piecemeal.8

PROBLEMS WITH LINKAGES

Problems associated with developing more effective link-ages and coordinated care have their origins in manyareas; a primary one being the fragmented array of inter-governmental relations that undermine policy initiativesdesigned to address these concerns.17,18 The impact ofintergovernmental relations in promoting fragmentationwithin health and community care is no more evident thanin the Home and Community Care (HACC) program. Forexample, a study conducted in an urban context foundthat within HACC, ‘local service providers are oftenexhorted to cooperate more closely…[but are] incapableof overcoming the structural underpinnings which serve toisolate individual organisations and fragment the provi-sion of services to people at home’ (p. 153).19 Similarconcerns are also apparent in rural contexts,20,21 wherestructural obstacles are seen to undermine the develop-ment of improved coordination and communicationbetween health and community services.22–24 For exam-ple, problems with coordination are no more apparentthan in Tasmania, where a 1992 study25 found that link-ages between sectors were compromised by poor channelsof communication, competing and unarticulated prioritiesin each sector, multiplicity of assessment and serviceentry points, lack of case management, and a lack of coor-dination between services.

Adding to problems with the operation of linkages hasbeen the emergence of economic rationalist policyagendas, which Duckett26 argues have provoked an era of‘economic accountability within health care’. Indeed, anumber of authors argue that the emergence of thesepolicy agendas has dominated the concerns of governmentto the virtual exclusion of other interests.27–29 It is an erathat has witnessed the implementation of wide rangingreforms, which have been primarily directed at reducingexpenditure, improving efficiency, rationalisation of ser-vices and ensuring greater accountability from healthcareproviders.30–34 It is a time, Rees27 suggests, where theprevailing ethic is for ‘lean, hungry and efficient managers[to] produce lean, hungry and more efficient organisations’(p. 180).

These agendas have been increasingly embracedthroughout Australia. Over the past decade there has been

a radical transformation of the acute healthcare system,which has resulted in increasing numbers of sicker agedpeople, whose care would formerly have been provided inhospital, receiving healthcare services in the commu-nity.6,8 There is a mounting body of evidence which fur-ther highlights concerns that aged clients are nowdischarged from acute hospitals ‘quicker and sicker’,35–39

too early40–42 and without appropriate community sup-ports.43–46 In rural communities the consequences of thesechanges are especially severe. As a number of authorsnote, a relatively poor rural Australia has difficulty com-peting for increasingly scarce resources.47–49 This canrender those often geographically and socially isolatedcommunities especially vulnerable to cutbacks and ration-alisation, which further undermines clients’ access to ser-vices.

However, while there is widespread acknowledgementof these concerns, it appears that the development of link-ages has not captured the interest of the research com-munity. For example, a number of authors report that thereis a relative paucity of research conducted into the devel-opment of intersectoral linkages36,50 and that the researchconducted is ‘pioneering’, ‘often low budget’, ‘emergent innature’ and ‘under resourced’. As such, this field has onlyrecently begun to gain the attention of health profession-als, policy makers and planners.51

Most concerns related to linkages are addressed fromthe perspective of the macro policy environment ratherthan having a focus on what actually makes linkages workat the micro level of practice; that is, while much has beenwritten outlining concerns with linkages at the level ofintergovernmental relations and the fragmentation of ser-vices, little research has been carried out which aims toflesh out strategies that practitioners in the field mightemploy to develop more collaborative arrangementsamong groups of service providers at a local level. This isimportant because, as a number of authors suggest, inboth urban19 and rural20,21 contexts, territorial rivalriesbetween local services providers and different profes-sional groups undermine the development of cooperativerelationships and subsequent efforts to promote morecoordinated forms of care.

THE PROJECT

This paper takes up this issue as it outlines a researchproject involving an ACAT located in a small regionalAustralian city and servicing a rural and remote popula-tion. It describes their efforts in developing linkages at amicro level with nurses working in a regional public hos-

174 AUSTRALIAN JOURNAL OF RURAL HEALTH

THE RECONNAISSANCE: FINDINGS FROMTHE FIELD

Participatory action research begins by undertaking a‘reconnaissance’ of the field, which involves the membersof the research team collaborating to investigate theirissues and concerns. During this stage the ACAT researchteam met fortnightly over a period of 9 months. The authoracted as participant/facilitator during this time. Withapproval, these meetings were audio taped. Transcribedand edited transcripts were returned to each participant ascase notes, thereby facilitating critical reflection on theissues raised.

During the research meetings the members of the teamexplored many issues; however, they maintained a primaryfocus on identifying and analysing key issues that compro-

pital and two private hospitals, where they sought to chal-lenge the prevailing economic rationalist ethos andexplore possibilities for developing new and creative linksbetween acute and community/residential sectors within arural community.

RESEARCH METHODS: PARTICIPATORYACTION RESEARCH

In order to undertake a project that aimed to explore pos-sibilities for improving the operation of linkages, theACAT research team utilised the action orientatedmethodology of participatory action research (PAR). Par-ticipatory action research comes under the rubric of post-positivist research methods, which are concerned withissues surrounding the conduct of empirical research inan unjust world and which are driven by an imperative to‘both empower the researched and contribute to the gener-ation of change enhancing social theory’ (p. 57).52 Thesemethods are fuelled by a desire to disrupt the dominantpower relations in an effort to recreate new and just socialsituations in a process described as ‘a project of possibil-ity.’53 With this motivation, PAR aims to foster communi-cation between and active participation of all thoseinvolved in the research. A key strategy in facilitatingPAR involves groups of people with common issues andconcerns meeting together to explore these concerns anddevelop action plans to address them. Participatory actionresearch is, therefore, the method of choice when a groupof people want to ‘better understand’ and take action toimprove their situation.54 As such, it is a collaborative,interactive, reflexive process that facilitates the partici-pants in the research, in this case seven members of anACAT, in becoming co-researchers in the project. Further-more, as an action-orientated methodology PAR involvesthe members of the research team working through arecurring helical spiral of planning, action, analysis, andcritical reflection (Fig. 1),55,56 as they seek to addresstheir concerns and, in the process, challenge dominantpower relations that are seen to perpetuate injustice.

In this study these concerns centre around the opera-tion of ineffective linkages between health and communitycare that compromise the adequacy of care received bythe aged in a rural context. A post-positivist methodologylike PAR is appropriate to this endeavour as it promotesthe development of collaborative relations, which as anumber of studies highlight, are central to the successfuloperation of linkages between sectors in health care.57–59

Reconnaissance orpreliminary investigation

Research questionor problem

Plan for action

Reflection

Reflection Take action and collectdata on action

Take action and collectdata on action

Analyse data

Analyse data

Replan

Replan

FIGURE 1: The participatory action research process.

Reproduced from Street and Robinson54 with permission of

Blackwell Science Ltd.


mised the operation of effective linkages between hospi-tals and community/residential care sectors within a ruralcontext. This involved analysing data collected during theresearch team meetings where members discussed theirexperiences of working across sectors, literature from thefield and data collected from the ACAT minimum data setwhere ‘relevant’ information on the team members’ activi-ties is recorded. Among a diverse array of findings thereconnaissance highlighted that in this rural context:(1) There appeared to be a shortage of community andresidential services accessible to the aged following dis-charge from hospital.(2) Linkages between acute and community/residentialsectors were often ineffective.(3) Many staff working in hospitals appeared to experi-ence difficulty accessing community and residential ser-vices on behalf of their clients.(4) The team found hospital staff often held unrealisticexpectations of the capacity of ACAT to link clients to ser-vices, which often resulted in a breakdown of effectivecommunications.(5) The processes employed by ACAT assessors to developnetworks and linkages within the field were ineffective.

Following the completion of the reconnaissance, theACAT research team drew on these insights to develop aseries of action plans that aimed to explore possibilitiesfor developing linkages in both community and acute carecontexts. In order to implement these plans at the actionphase of the project, the team broke into two researchsubgroups, which focused upon implementing pilot link-age projects with either general practitioners or nursesworking in acute care hospitals. These subgroups met reg-ularly during the action phase and also came togetheronce a month to exchange information on progress and tosupport each other’s projects. The subject of the presentpaper is the work of the ‘acute care’ subgroup.

THE ACAT ACUTE CARE NETWORKINGPROJECT

The members of the acute care subgroup targeted severalwards in a public hospital and two wards in two privatehospitals in a small regional city, in what became knownas the ‘ACAT Acute Care Networking Project’. This pro-ject involved individual team members meeting with nurs-ing staff from the wards to discuss their issues andconcerns regarding the transition of aged clients from theacute context to community and residential settings. Inthe first instance nurses were targeted because, as wasconsistent with the literature,60–62 the reconnaissancehighlighted that they had a primary responsibility for dis-

charge planning, a primary linkage mechanism designedto promote aged clients receiving appropriate services fol-lowing discharge from hospital. Each of the acute carepilot projects involved a series of between 10 and 15meetings with ward nurses that aimed to encourage themto collaboratively explore their concerns regarding: (i)their role in discharge planning; (ii) the operation of theaged care system in a rural context; (iii) the interrelation-ship between aged care services and the acute care sys-tem; and (iv) the ways that ACAT assessors could bestwork with them to facilitate the transition of clients intorural community and residential contexts. In addition,representatives from community agencies attended a num-ber of sessions in order to speak about the services theyprovided.

During the meetings, whenever possible, an attemptwas made to relate the issues under discussion to theneeds of specific clients known to the staff on the targetwards. In effect, the research team members pursued astrategy where they hoped to establish more open lines ofcommunication with ward nurses and collaborate withthem in a process of exploring their issues and concernsrelated to linking aged clients to services in their variousrural contexts following discharge. This approach wasadopted because the reconnaissance highlighted that thepast attempts of ACAT at networking had been designedaround implementing a prescriptive agenda; that is,telling the nurses what ACAT thought they needed toknow. Through implementing a collaborative strategy,team members hoped to facilitate a greater sense ofownership and interest among the nurses in developingnetworks with both ACAT and community and residentialservice providers. Consistent with this approach, theACAT research team member acted as a facilitator andencouraged informal discussions rather than utilising amore traditional lecture style format. Subsequently, ateach introductory session participant nurses were asked toidentify areas of interest or concern regarding the opera-tion of the rural aged care system and their links with thecommunity, with the aim to facilitate discussions thatresponded to the identified areas of interest.

With the support of the author, over the next 5 monthsthe research team members implemented, evaluated andcritically reflected upon the findings of these networkingaction plans. The evaluation processes employed a num-ber of strategies, a primary strategy being the distributionof a short evaluation document to as many as possible ofthe nurses who participated in the networking sessions.This document sought comments on:(1) The effectiveness of the ACAT research team mem-bers in facilitating discussions and presentations.


(2) The value of information gained in relation to dis-charge planning, availability and access to aged care ser-vices.(3) The role and responsibilities of the ACAT.(4) The participants’ interest in attending further sessions.(5) The suggestions for issues to be addressed during anyfurther sessions.

In total, 50 evaluations were completed and it is pri-marily an analysis of the ward nurses’ comments recordedin these documents that inform the findings discussedbelow.

FINDINGS OF THE NETWORKINGPROJECT/DISCUSSION

The first significant finding confirmed those of the recon-naissance and highlighted that, in general, nurses workingon the pilot wards had limited knowledge of: (i) the opera-tion of the aged care system; (ii) how to access particularservices; (iii) the criteria of eligibility for services; and (iv)the specific type of care and support that individual ser-vices offer. Comments such as ‘I knew nothing [about theaged care system] before we started the sessions’ and ‘Iam amazed as to what is available in the community’ bearwitness to these findings. Analysis of data also highlightedthat the nurses experienced difficulty understanding ‘howthe aged care system worked’, and keeping up-to-datewith the changing structure of community and residentialservices. The latter concern added to the difficulties thenurses experienced in maintaining current sources ofinformation. The ongoing changes that have taken place inthe health and community care sectors over the past twodecades, compounded by the complexity of a rural healthand community care system comprising a geographicallyseparate array of services, contribute to these difficulties.

The second notable finding highlighted that, as aresult of their participation in the research meetings, thenurses reported numerous benefits. Through having directaccess to the members of both the ACAT and to other ser-vice providers, within a context where the participantswere encouraged to explore each other’s issues and con-cerns, nurses reported a better understanding of the agedcare system within their regional context. The nurses alsoclaimed that this improved understanding facilitated theirability to perform more effective discharge planning. Forexample, comments like ‘I now feel quite knowledgeableregarding services available when discharging patientsback to the community’ and ‘We are able to advisepatients more confidently of services available’ indicatednot only improved understanding of available services butalso a subsequent increased confidence in implementing

discharge planning processes. Furthermore, linked tothese findings were comments such as ‘[Participation in]the sessions enabled me to see the importance of continu-ity of healthcare. We often see a segment while the personis in hospital so it is helpful to understand exactly whatgoes on post-discharge.’ Constructing clients in terms of‘segments’ highlights the narrow focus with which somenurses viewed their ‘patients’. However, it also suggeststhat those nurses’ participation in the research discus-sions broadened their definition of relevant care issues. Inthis way, their understanding of the issues confronting therural aged following their discharge to what is inevitably awide diversity of contexts was enhanced, so too was theirappreciation of the importance of facilitating effectivelinkages with services in those contexts in order to ensurecontinuity of care.

A primary intention of the networking project was toestablish more effective linkages between ACAT and wardstaff, which in part, involved clarifying or renegotiatingassessors’ roles with these staff. Many nurses who partici-pated in the project reported that they developed a betterunderstanding of the role of ACAT and the assessmentprocess in general. Comments included ‘[Participation inthe sessions] familiarises ACAT with nursing staff so thatwe feel more comfortable in dealing with each other’ and‘I feel much more comfortable ringing ACAT. I can nowput faces to names’ demonstrate the benefits of ‘face-to-face’ contact in a context that fosters a collaborativeendeavour. Indeed, such comments suggest the emergenceof a more collaborative partnership which the nursesrecognised as being beneficial. As one participant notedwhen she wrote, ‘…getting to know the ACAT assessorand all the avenues for us to utilise [to link clients to com-munity based services] has been very beneficial. I ammore confident when having to refer patients to outsideservices.’ Here the nurse makes a direct link between theemergence of more collaborative relations with ACAT andthe potential for improving client outcomes through theconduct of more effective discharge planning, a primarylinkage mechanism. It is as if contact with the ACATassessors, who have a good working knowledge of anddirect access to what are often distant and remote ruralhealth and community care services, breaks down thenurses’ isolation from those services.

The nature of this changed relationship and its effectsare in part captured by the comments of one participantwho noted, ‘They [ACAT] have become allies and co-workers instead of an outside dominating force.’ Thedescription of ACAT as an ‘outside dominating force’evokes a powerful image antithetical to a collaborativepartnership and reflects the rivalries that can commonly


exist between different categories of service providers. Itsuggests a recreation of oppressive power relationsthrough devices similar to those traditionally described inthe literature. However, this description supports concernsraised by the research team’s analysis of their previousapproach to networking, an approach that the reconnais-sance highlighted was driven by the imperatives of pre-scription and control. It was such an approach that theteam members sought to reconstruct through the conductof this project.

The change from dominator to ‘ally’ highlights thetransformative potential of working with nurses in waysthat promote collaborative relations and breaks down theboundaries between different professional groups and ser-vices. These ‘ways’ involved an ACAT assessor deliber-ately and strategically facilitating the nurses in a processof identifying their issues and concerns and working withthese in ways that produced a material benefit for every-one involved. In this respect, the efficacy of collaboratingwith nurses to explore the operation of the aged care sys-tem in a rural context in relation to the nurses’ specificconcerns for clients becomes obvious. By their ownreports, many of the nurses accessed important informa-tion regarding the diverse array of services available tothe aged throughout a vast region that included urban,rural and remote areas. In addition, they developed newunderstandings of the operation of those services, gainedvaluable insights and confidence in linking aged clients tothem and concurrently initiated a process of developingcreative partnerships with other healthcare providers. Allthese developments opened opportunities for the nurses tofurther develop their practice for the benefit of the ruralaged.

Within a rural context, the study demonstrates theimportance of face-to-face contact in developing collab-orative partnerships among different service providers,especially as many services are geographically isolated.However, within a healthcare system driven by economicrationalist imperatives and preoccupied with achievingimproved efficiencies, where the pursuit of a competitiveadvantage compels managers to ‘spend time massagingthe numbers…misrepresenting what they do to make thenumbers look good’,63 such issues are often relegated to amarginal status. Like other healthcare providers, ACATare caught within this nexus. For the ACAT involved inthe study, the ‘numbers’ concerned the total number ofassessments performed by each assessor within a speci-fied time frame. However, in order to maintain competitiveparity, this immediately set up an imperative for eachassessor to maintain an output of assessments regardlessof the degree of congruence between assessed need and

services actually received. As a result, the members of theresearch team came to describe these as the ‘assessmentsto nowhere’, such were the extent of problems identified inactually linking clients to services; that is, ACAT staffrecognised the futility of ‘making the numbers look good’when this actually undermined the allocation of resourcesto the development of linkages and networks that poten-tially facilitated access of the rural aged to services fol-lowing the ACAT assessment process.

CONCLUSION

The findings of this project provide an insight into theoperation of linkages at the micro level of a ward in aregional hospital, through the discharge planning practiceof nurses. They suggest that linkages are compromisedbecause nurses have limited understanding of the struc-ture and operation of the aged care system in rural Aus-tralia. This undermines their ability to both advise agedclients on their options following discharge and facilitatetheir access to what are often distant community/residen-tial services, of which many nurses have at best limitedaccess and very little knowledge. However, given thestructural fragmentation within and between health andcommunity care and the ongoing change in service struc-ture and availability provoked by the rationalisation ofhealth and community services in rural contexts, it shouldcome as little surprise that nurses experience such diffi-culties.

The project also highlights the importance of nursesworking in regional hospitals in rural Australia havingaccess to both the providers of services to whom they referpatients and groups like ACAT, whose role definitionmeans they traverse the historical boundaries that delin-eate acute, residential and community care. Such accessprovides nurses with the opportunity to develop theirunderstandings of the aged care system in a rural context,the function of various government and local governmentservice providers in the provision of these services and tokeep up-to-date with their changing structure and opera-tional parameters. These understandings can facilitatenurses employed in regional hospitals to develop a betterworking knowledge of these services. This in turn can fos-ter their ability to conduct discharge planning and linkclients to what were, previously, unknown and remotefacilities more effectively and with greater confidence.

In this sense, the findings also suggest the need torefocus attention in rural healthcare contexts both to sup-port and to adequately resource those people who materi-ally enact linkage processes, so that they can better assistthe rural aged in the transition from hospital to what are


often isolated community and residential care contexts.This is especially important in rural areas, such as that inwhich this study was conducted, where ongoing rationali-sation of the health and community care infrastructurecompromises the ability of the rural aged to gain access toservices at all. Similarly, the findings also suggest thatdeveloping more effective linkages in these contexts isfacilitated by health professionals employed in differentsectors coming together and working cooperatively toexplore the dimensions of their various roles and to iden-tify issues of mutual concern. The collaborative partner-ships that result hold a possibility for developing morecoordinated forms of care as the different professionalgroups work more effectively together to facilitate thesmooth transition of the aged from regional hospitals to adiverse range of rural and remote contexts. This approachchallenges the rhetoric that reform must be imposed fromabove. Rather, it highlights that reform should also be sit-uated at a grass roots level with rural healthcare practi-tioners in the field and that the processes employedshould foster a genuinely participatory approach so thatthose who are expected to carry out the practices have theopportunity to collaborate in determining their construc-tion.

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