A comparison of a hospital-based and two home-based rehabilitation programmes

Multidisciplinary Home-Based Rehabilitation Program for Individuals With Disabilities: Longitudinal Observational Study

BACKGROUND

Disability affects a significant portion of the global population nowadays, necessitating innovative approaches to access rehabilitation processes. Home-based rehabilitation has emerged as a beneficial approach, offering comfort and context-specific therapy.

OBJECTIVE

This study aims to evaluate the impact of a multidisciplinary home-based rehabilitation program for individuals with moderate neuromusculoskeletal disabilities in terms of motor function and mood.

METHODS

A total of 270 participants with median age of 66 (IQR 20-98) years were recruited from the National Disability Registry of Chile. The intervention involved a multidisciplinary team composed of 49 health care professionals providing personalized treatment plans over 4 months (32 sessions for physical therapy, 8 sessions for occupational therapy, 4 sessions for nutrition, 8 sessions for psychology, and 4 sessions for nursing and podiatry). This program also included 2 medical evaluations (at the beginning and the end) to monitor clinical progress in terms of motor function and mental health, using the Berg Balance Scale and Beck Depression Inventory, respectively.

RESULTS

The home-based rehabilitation program showed significant improvements (P<.001) in motor function and balance with a reduction in fall risk. Specifically, the Berg Balance Scale score decreased close to 15% after the home-based rehabilitation program for all enrolled participants. On the other hand, depression levels showed no significant changes (P=.27), with percentages of variation less than 8% between the 2 assessed conditions. In this sense, participants remained with the same mild depression level (14 of 63) concerning the Beck Depression Inventory score.

CONCLUSIONS

This study concludes that personalized home-based rehabilitation programs are effective in enhancing motor function and balance, particularly in individuals with neurological conditions. On the other hand, the findings in terms of mood advocate for further exploration of psychological support within such programs to enhance overall patient well-being.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06537791; https://clinicaltrials.gov/study/NCT06537791.

Re/connecting with "home": a mixed methods study of service provider and patient perspectives to facilitate implementing rehabilitation in the home for reconditioning

PURPOSE

To explore the views of healthcare professionals and patients about the advantages and disadvantages of rehabilitation in the home (RITH) for reconditioning, and identify factors that should contribute to the successful implementation of a consensus-based RITH model for reconditioning.

MATERIALS AND METHODS

Interviews with 24 healthcare professionals and 21 surveys (comprising Likert scale and free text responses) of inpatients undergoing rehabilitation for reconditioning provided study data. Interpretive thematic analysis was used to analyse interview data; descriptive statistics analysed Likert scale responses; patient written responses assisted with the interpretation of themes developed from the interview data.

RESULTS

Two major themes were elicited in this study: the home is a physical setting and the home is a lived space. Advantages and disadvantages of RITH for patients, carers and healthcare professionals were identified within these themes. Appropriate patient selection; effective communication with patients and carers, and within RITH teams; adequate patient and carer support; ensuring the safety of patients and staff; and education of patients, carers and healthcare professionals are essential for the satisfactory implementation of RITH.

CONCLUSION

The concept of home shapes the delivery of RITH. Recognising the advantages and disadvantages of RITH highlights important considerations needed to successfully implement RITH for reconditioning.

Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis

BACKGROUND

Worldwide there is an increasing demand for Hospital at Home as an alternative to hospital admission. Although there is a growing evidence base on the effectiveness and cost-effectiveness of Hospital at Home, health service managers, health professionals and policy makers require evidence on how to implement and sustain these services on a wider scale.

OBJECTIVES

(1) To identify, appraise and synthesise qualitative research evidence on the factors that influence the implementation of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home, from the perspective of multiple stakeholders, including policy makers, health service managers, health professionals, patients and patients' caregivers. (2) To explore how our synthesis findings relate to, and help to explain, the findings of the Cochrane intervention reviews of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home services.

SEARCH METHODS

We searched MEDLINE, CINAHL, Global Index Medicus and Scopus until 17 November 2022. We also applied reference checking and citation searching to identify additional studies. We searched for studies in any language.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with qualitative data collection and analysis methods examining the implementation of new or existing Hospital at Home services from the perspective of different stakeholders.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the studies, extracted study characteristics and intervention components, assessed the methodological limitations using the Critical Appraisal Skills Checklist (CASP) and assessed the confidence in the findings using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). We applied thematic synthesis to synthesise the data across studies and identify factors that may influence the implementation of Hospital at Home.

MAIN RESULTS

From 7535 records identified from database searches and one identified from citation tracking, we included 52 qualitative studies exploring the implementation of Hospital at Home services (31 Early Discharge, 16 Admission Avoidance, 5 combined services), across 13 countries and from the perspectives of 662 service-level staff (clinicians, managers), eight systems-level staff (commissioners, insurers), 900 patients and 417 caregivers. Overall, we judged 40 studies as having minor methodological concerns and we judged 12 studies as having major concerns. Main concerns included data collection methods (e.g. not reporting a topic guide), data analysis methods (e.g. insufficient data to support findings) and not reporting ethical approval. Following synthesis, we identified 12 findings graded as high (n = 10) and moderate (n = 2) confidence and classified them into four themes: (1) development of stakeholder relationships and systems prior to implementation, (2) processes, resources and skills required for safe and effective implementation, (3) acceptability and caregiver impacts, and (4) sustainability of services.

AUTHORS' CONCLUSIONS

Implementing Admission Avoidance and Early Discharge Hospital at Home services requires early development of policies, stakeholder engagement, efficient admission processes, effective communication and a skilled workforce to safely and effectively implement person-centred Hospital at Home, achieve acceptance by staff who refer patients to these services and ensure sustainability. Future research should focus on lower-income country and rural settings, and the perspectives of systems-level stakeholders, and explore the potential negative impact on caregivers, especially for Admission Avoidance Hospital at Home, as this service may become increasingly utilised to manage rising visits to emergency departments.

Cost modelling rehabilitation in the home for reconditioning in the Australian context

BACKGROUND

Inpatient rehabilitation services are challenged by increasing demand. Where appropriate, a shift in service models towards more community-oriented approaches may improve efficiency. We aimed to estimate the hypothetical cost of delivering a consensus-based rehabilitation in the home (RITH) model as hospital substitution for patients requiring reconditioning following medical illness, surgery or treatment for cancer, compared to the cost of inpatient rehabilitation.

METHODS

Data were drawn from the following sources: the results of a Delphi survey with health professionals working in the field of rehabilitation in Australia; publicly available data and reports; and the expert opinion of the project team. Delphi survey data were analysed descriptively. The costing model was developed using assumptions based on the sources described above and was restricted to the Australian National Subacute and Non-Acute Patient Classification (AN-SNAP) classes 4AR1 to 4AR4, which comprise around 73% of all reconditioning episodes in Australia. RITH cost modelling estimates were compared to the known cost of inpatient rehabilitation. Where weighted averages are provided, these were determined based on the modelled number of inpatient reconditioning episodes per annum that might be substitutable by RITH.

RESULTS

The cost modelling estimated the weighted average cost of a RITH reconditioning episode (which mirrors an inpatient reconditioning episode in intensity and duration) for AN-SNAP classes 4AR1 to 4AR4, to be A$11,371, which is 28.1% less than the equivalent weighted average public inpatient cost (of A$15,820). This represents hypothetical savings of A$4,449 per RITH reconditioning substituted episode of care.

CONCLUSIONS

The hypothetical cost of a model of RITH which would provide patients with as comprehensive a rehabilitation service as received in inpatient rehabilitation, has been determined. Findings suggest potential cost savings to the public hospital sector. Future research should focus on trials which compare actual clinical and cost outcomes of RITH for patients in the reconditioning impairment category, to inpatient rehabilitation.

Geriatric home-based rehabilitation in Australia: Preliminary data from an inpatient bed-substitution model

Background

The REStORing health of acutely unwell adulTs (RESORT) is an observational longitudinal cohort, including geriatric rehabilitation inpatients aged ≥65 years admitted to a geriatrician‐led rehabilitation service at a tertiary hospital. The aim of this study is to describe a home‐based bed‐substitution rehabilitation model for geriatric inpatients, including patient phenotype, and health outcomes at preadmission, admission, discharge, and three‐month follow‐up.

Methods

A standardized Comprehensive Geriatric Assessment was performed on admission and discharge, including demographics (home situation, cognitive impairment, medical diagnoses, etc.), frailty (Clinical Frailty Scale (CFS)), mobility (patient‐reported and Functional Ambulation Classification), physical performance (Short Physical Performance Battery (SPPB), handgrip strength), and functional independence (Activities of Daily Living (ADL), Instrumental ADL (IADL)). Service provision data (health care staff visits, length of stay (LOS), and negative events (e.g., falls)) were extracted from medical records. Three‐month outcomes included mobility, ADL and IADL scores, institutionalization, and mortality.

Results

Ninety‐two patients were included with a mean age of 81.1 ± 7.8 years, 56.5% female. Twenty‐nine (31.5%) patients lived alone, 39 (42.4%) had cognitive impairment and the commonest geriatric rehabilitation admission reason was falls (n = 30, 32.6%). Patients received care from nurses, physicians, and a median of four (interquartile range (IQR) 3–6) allied health disciplines for a median LOS of 13.0 days (IQR 10.0–15.0). On a population level, patient mobility and functional independence worsened from preadmission to admission. CFS, SPPB, ADL, and IADL scores improved from admission to discharge, and seven (7.6%) patients fell. At three‐month follow‐up, patient‐reported mobility was comparable to preadmission baseline, but functional independence (ADL, IADL) scores worsened for 27/69 (39.1%) and 28/63 (44.4%), respectively.

Conclusions

Hospitalization‐associated decline in mobility and functional independence improved at discharge and three‐months, but was not fully reversed in the multidisciplinary home‐based geriatric rehabilitation bed‐substitution service. Future research should compare outcomes to equivalent hospital‐based geriatric rehabilitation and evaluate patient perspectives.

See related Editorial by William J. Hall in this issue.

A compact valveless pressure control source for soft rehabilitation glove

BACKGROUND

Soft pneumatic robots have shown great promises in hand rehabilitation systems as alternatives to conventional rigid systems. However, their application is limited to clinical rehabilitation programs due to their dependency on large-sized compressors as air suppliers. This disadvantage triggered the search for compact portable pneumatic sources.

METHOD

A compact valveless pneumatic source to control the bending angle of a soft actuator is proposed in this paper. The source incorporates two series of serially connected commercially available microcompressors to provide additional pressure and flowrate in two directions. In the proposed design, an inner-loop controller, controls the output characteristics of the source while an outer-loop controller handles the trajectory tracking of the angular position.

RESULTS

Experimental results show that the source is capable of providing up to 160 kPa of output. The controller is able to track up to 2 rad/sec sinusoidal trajectory with a maximum 0.066 rad root-mean-square error.

CONCLUSION

Experimental measurements showed satisfactory results in the maximum ratings and tracking errors whilst relatively low average power was consumed by eliminating control valves.

Clinician and client views of utilising early supported discharge services

Background/Aims:

To explore the beliefs and attitudes of potential referrers and referrees regarding the possible utilisation of early supported discharge (ESD) prior to hospital discharge.

Methods:

Semi-standardised one-to-one interviews were conducted with nine consultants and ten dyads, comprising inpatients and corresponding treating staff members involved in referral of these patients to ESD. Content analysis was completed to identify key themes and to group the data into categories.

Results:

Rehabilitation consultants reported safety and the ability to manage at home were the primary considerations in ESD referral decision making. Most patients were extremely likely to agree to referral to ESD. Four main categories were identified in the responses from the patient/staff dyads, which were summarised as: positive and negative aspects of ESD, and barriers and enablers to early discharge. Patients were only willing to return home with ESD once they were ambulant in some capacity. Staff identified considerably more potential disadvantages, and fewer benefits than patients with regard to early discharge. However, there was no indication that staff beliefs had a negative influence on patient views regarding their participation in ESD.

Conclusions:

Patients and staff generally approved of ESD services; however, staff may need to place greater consideration on advantages, such as the potential emotional and mental benefits that some patients associate with returning home sooner with ESD.

Home-Based versus Hospital-Based Rehabilitation Program after Total Knee Replacement

OBJECTIVES

To compare home-based rehabilitation with the standard hospital rehabilitation in terms of improving knee joint mobility and recovery of muscle strength and function in patients after a total knee replacement.

MATERIALS AND METHODS

A non-randomised controlled trial was conducted. Seventy-eight patients with a prosthetic knee were included in the study and allocated to either a home-based or hospital-based rehabilitation programme. Treatment included various exercises to restore strength and joint mobility and to improve patients' functional capacity. The primary outcome of the trial was the treatment effectiveness measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS

The groups did not significantly differ in the leg side (right/left) or clinical characteristics (P > 0.05). After the intervention, both groups showed significant improvements (P < 0.001) from the baseline values in the level of pain (visual analogue scale), the range of flexion-extension motion and muscle strength, disability (Barthel and WOMAC indices), balance, and walking.

CONCLUSIONS

This study reveals that the rehabilitation treatments offered either at home or in hospital settings are equally effective.

Referrer and service provider beliefs and attitudes towards rehabilitation in the home; factors related to utilisation of Early Supported Discharge

PURPOSE

To investigate the attitudes and beliefs held by referrers and service providers of an Australian Early Supported Discharge (ESD) service called "Rehabilitation in the Home" (RITH); with particular consideration of factors that may influence referral to RITH.

METHODS

A cross-sectional online survey based on the Theory of Planned Behaviour was undertaken.

RESULTS

There were 113 respondents; 90 referrers and 23 service providers. Referrers and RITH staff had a moderately favourable attitude towards RITH. The majority of referrers, and, to a greater degree, RITH staff members, understood and appreciated the advantages ascribed to ESD. However, views varied with regard to some of the factors upon which the decision to refer to RITH rests. Two-fifths of referrers did not think that RITH provided hospital equivalent therapy intensity and over one-fifth of referrers had concerns about the capability of the RITH service to provide specialist stroke rehabilitation. Opinion of RITH staff was also varied on these topics.

CONCLUSIONS

This study provides evidence that there was a level of uncertainty amongst referrers and RITH service providers regarding issues directly and indirectly related to patient eligibility and RITH service capability. This uncertainty needs to be explored in future research.

IMPLICATIONS FOR REHABILITATION

Differences in views held by referrers and ESD service providers were identified in this study that could lead to inconsistencies in patient selection for, and under-utilization of, ESD services. Improved communication between referrers and ESD service providers, for instance attendance of RITH staff at inpatient team meetings, could ameliorate some of these misconceptions. On-going education of referrers about service capability is essential to ensure timely transfer of appropriate clients to ESD services.