The transition from hospital to home for individuals with acquired brain injury: a literature review and research recommendations

Healthy Days at Home Among Older Medicare Beneficiaries With Traumatic Brain Injury Requiring Inpatient Rehabilitation

OBJECTIVE

The objectives of this study were to characterize and identify correlates of healthy days at home (HDaH) before and after TBI requiring inpatient rehabilitation.

SETTING

Inpatient hospital, nursing home, and home health services.

PARTICIPANTS

Average of n = 631 community-dwelling fee-for-service age 66+ Medicare beneficiaries across 30 replicate samples who were hospitalized for traumatic brain injury (TBI) between 2012 and 2014 and admitted to an inpatient rehabilitation facility (IRF) within 72 hours of hospital discharge.

DESIGN

Retrospective study using data from Medicare claims supplemented with data from the National Trauma Databank.

MAIN MEASURES

The primary outcome, HDaH, was calculated as time alive not using inpatient hospital, nursing home, and home health services in the year before TBI hospitalization and after IRF discharge.

RESULTS

We found HDaH declined from 93.2% in the year before TBI hospitalization to 65.3% in the year after IRF discharge (73.6% among survivors only). Most variability in HDaH was: (1) in the first 3 months after discharge and (2) by discharge disposition, with persons discharged from IRF to another acute hospital having the worst prognosis for utilization and death. In negative binomial regression models, the strongest predictors of HDaH in the year after discharge were rehabilitation Functional Independence Measure mobility score ( β  = 0.03; 95% CI, 0.002-0.06) and inpatient Charlson Comorbidity Index score ( β  = - 0.06; 95% CI, -0.13 to 0.001). Dual Medicaid eligible was associated with less HDaH among survivors ( β  = - 0.37; 95% CI, -0.66 to -0.07).

CONCLUSION

In this study, among community-dwelling older adults with TBI, we found a notable decrease in the proportion of time spent alive at home without higher-level care after IRF discharge compared to before TBI. The finding that physical disability and comorbidities were the biggest drivers of healthy days alive in this population suggests that a chronic disease management model is required for older adults with TBI to manage their complex health care needs.

Priorities for quality of life after traumatic brain injury

BACKGROUND

After traumatic brain injury (TBI), individuals can experience changes to quality of life (QOL). Despite understanding the factors that impact QOL after TBI, there is limited patient-oriented research to understand the subjective priorities for QOL after TBI. This study aims to understand the priorities for QOL after TBI using a group consensus building method.

METHODS

The Technique for Research of Information by Animation of a Group of Experts (TRIAGE) method was used to determine priorities for QOL after TBI. In phase one, expert participants were consulted to understand the context of QOL after TBI. In phase two, participants with TBI completed a questionnaire to broadly determine the factors that contributed to their QOL. In phase three, a portion of participants from phase two engaged in focus groups to identify the most relevant priorities. Data was analyzed thematically. In phase four, expert participants were consulted to finalize the priorities.

RESULTS

Phase one included three expert participants who outlined the complexity and importance of QOL after TBI. Phase two included 34 participants with TBI who described broad priorities for QOL including social support, employment, and accessible environments. Phase three included 13 participants with TBI who identified seven priorities for QOL: ensuring basic needs are met, participating in everyday life, trusting a circle of care, being seen and accepted, finding meaning in relationships, giving back and advocating, and finding purpose and value. In phase four, four expert participants confirmed the QOL priorities.

INTERPRETATIONS

Findings emphasize the critical need to address priorities for QOL after TBI to ensure improved health outcomes.

Reclaiming Agency in Care Decisions and Barriers From the Perspectives of Individuals With Acquired Brain Injury and Their Family Members

BACKGROUND

The ability to self-advocate or have a say in one's care is integral to personalised care after acquired brain injury (ABI). This study aimed to understand what constitutes self-advocacy and associated barriers and facilitators throughout hospital transitions and into the community.

METHOD

Qualitative methodology was employed with semistructured interviews conducted with 12 people with ABI and 13 family members. Interviews were conducted at predischarge (in-person or via telephone) and 4 months postdischarge (via telephone) from the brain injury rehabilitation unit of a tertiary hospital. Data were thematically analysed using a hybrid deductive-inductive approach.

RESULTS

Self-advocacy reflects the process of reclaiming agency or people's efforts to exert influence over care decisions after ABI. Agency varies along a continuum, often beginning with impaired processing of the self or environment (loss of agency) before individuals start to understand and question their care (emerging agency) and ultimately plan and direct their ongoing and future care (striving for agency). This process may vary across individuals and contexts. Barriers to self-advocacy for individuals with ABI include neurocognitive deficits that limit capacity and desire for control over decisions, unfamiliar and highly structured environments and lack of family support. Facilitators include neurocognitive recovery, growing desire to self-advocate and scaffolded support from family and clinicians.

CONCLUSION

Self-advocacy after ABI entails a process of reclaiming agency whereby individuals seek to understand, question and direct their ongoing care. This is facilitated by neurocognitive recovery, growing capacity and desire and scaffolded supports. Research evaluating approaches for embedding self-advocacy skills early in brain injury rehabilitation is recommended.

PATIENT OR PUBLIC CONTRIBUTION

Two caregivers with lived experience of supporting a family member with ABI were involved in the design and conduct of this study and contributed to and provided feedback on the manuscript.

The impact of caregiving on the roles and valued activities of stroke carers: A systematic review of qualitative studies

OBJECTIVE

To understand the experiences of informal carers and the impact of role and activity changes on their health and wellbeing.

METHODS

A systematic search of CINHAL, MEDLINE, Embase, APA PsycInfo, and Web of Science was conducted. Studies were eligible if they included informal stroke carers (≥18 years), used a qualitative methodology, explored the roles and valued activities of stroke carers, and were published in English. The 10-item Critical Appraisal Skills Programme checklist for qualitative studies was used to assess methodological quality. The results of the included studies were thematically synthesised.

RESULTS

A total of 36 qualitative studies were included and four overarching themes were identified: (1) Life adjustment; (2) Changing role and identity; (3) Changing activities: From meaningful to purposeful; and (4) Understanding and supporting carers.

CONCLUSION

The sudden nature of stroke requires major readjustment in the carers life that has implications on their relationships, roles, and activities, subsequently impacting on their health and wellbeing. Health professionals and researchers should collaborate with stroke carers to identify their valued activities and implement realistic strategies to maintain these activities. Future interventions designed for carers should implement education about the importance of participating in valued activities and strategies to maintain these activities.

Mood Tracker: A Randomized Controlled Trial of a Self-Monitoring Intervention for Emotional Distress After Traumatic Brain Injury

OBJECTIVE

Persons with traumatic brain injury (TBI) frequently experience emotional distress (ED) manifested in anxiety and depression. However, they may not access mental health services due to external (eg, access, transportation, and cost) or internal (eg, stigma and discomfort with traditional counseling) barriers. Based on substantial literature indicating that self-monitoring can ameliorate several health conditions, we conducted a randomized, parallel group, wait-list control (WLC) trial of a self-monitoring intervention to decrease ED after TBI.

SETTING

Community in the southwestern United States.

PARTICIPANTS

Persons with medically documented complicated mild, moderate, and severe TBI.

DESIGN

About 127 participants were randomized in blocks of 6 to an active treatment (AT) group, wherein they completed multiple assessments of ED each week over a 6-week period via a smartphone app, or a WLC group in a parallel group, controlled trial. Participants received weekly support calls to promote self-monitoring of ED using ecological momentary assessment.

MAIN MEASURES

ED (Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7), Satisfaction with Life Scale, and Participation Assessment with Recombined Tools-Objective.

RESULTS

Analysis of the primary study outcome at 6 weeks after initiation of treatment for the AT group did not demonstrate that self-monitoring was effective in decreasing ED as compared to the WLC group. Brief support calls made weekly to promote compliance with self-monitoring were effective in achieving the target number of self-assessments. About 80% of support calls lasted less than 5 minutes. Greater ED was associated with lower life satisfaction and lower participation indicating the importance of addressing ED in persons with TBI.

CONCLUSION

Additional work is needed to develop nontraditional interventions to circumvent barriers that prevent persons with TBI from accessing care for ED. Brief support calls may be an effective, low-cost intervention to improve compliance with self-monitoring or self-management interventions.

Healthcare perceptions of persons with traumatic brain injuries across providers: shortcomings in the chronic phase of care

OBJECTIVE

This investigation sought to examine the perceptions of individuals with mild, moderate, and severe traumatic brain injury (TBIs) toward healthcare providers across rehabilitation contexts (acute, rehabilitation, and chronic).

METHODS

The mCARE-TBI survey was distributed via Qualtrics throughout the US and Canada. Sixty-four survey responses met criteria for analysis. Participants were ≥18 years old, one-year post onset, reported no unrelated neurological deficits prior to the single TBI, and reported no prior diagnosed psychiatric disorders. The mCARE was the primary outcome measure. Comparisons were made between provider ratings on each question.

RESULTS

Significant differences were found between chronic-phase care, compared to acute care and rehabilitation. Group differences were found in transitioning home after discharge and in between each therapy discipline and both nurses and doctors, as well as for really listening and pairwise differences between therapy disciplines and both nurses and doctors. Group effects were found for showing compassion and care and being positive.

CONCLUSIONS

All disciplines need to improve communication, and transition care/discharge planning. Dismissal of ongoing impairments continues to be an area of perceived concern with doctors in particular. Communication training is needed, particularly for nurses and doctors.

IMproving psYchosocial adjustment to Traumatic Brain Injury from acute to chronic injury through development and evaluation of the myTBI online psychoeducation platform: protocol for a mixed-methods study

INTRODUCTION

This protocol describes the myTBI study which aims to: (1) develop an online psychoeducation platform for people with traumatic brain injury (TBI), their family members/caregivers, and healthcare staff to improve psychosocial adjustment to TBI across different phases of injury (acute, postacute, and chronic), and (2) undertake an evaluation of efficacy, acceptability, and feasibility.

METHODS AND ANALYSIS

A three-stage mixed-methods research design will be used. The study will be undertaken across four postacute community-based neurorehabilitation and disability support services in Western Australia. Stage 1 (interviews and surveys) will use consumer-driven qualitative methodology to: (1) understand the recovery experiences and psychosocial challenges of people with TBI over key stages (acute, postacute, and chronic), and (2) identify required areas of psychosocial support to inform the psychoeducation platform development. Stage 2 (development) will use a Delphi expert consensus method to: (1) determine the final psychoeducation modules, and (2) perform acceptance testing of the myTBI platform. Finally, stage 3 (evaluation) will be a randomised stepped-wedge trial to evaluate efficacy, acceptability, and feasibility. Outcomes will be measured at baseline, postintervention, follow-up, and at final discharge from services. Change in outcomes will be analysed using multilevel mixed-effects modelling. Follow-up surveys will be conducted to evaluate acceptability and feasibility.

ETHICS AND DISSEMINATION

Ethics approval was granted by North Metropolitan Health Service Mental Health Research Ethics and Governance Office (RGS0000005877). Study findings will be relevant to clinicians, researchers, and organisations who are seeking a cost-effective solution to deliver ongoing psychoeducation and support to individuals with TBI across the recovery journey.

TRIAL REGISTRATION NUMBER

ACTRN12623000990628.

Efficacy of BETTER transitional care intervention for diverse patients with traumatic brain injury and their families: Study protocol of a randomized controlled trial

OBJECTIVE

The purpose of this study is to examine the efficacy of BETTER (Brain Injury, Education, Training, and Therapy to Enhance Recovery) vs. usual transitional care management among diverse adults with traumatic brain injury (TBI) discharged home from acute hospital care and families.

METHODS

This will be a single-site, two-arm, randomized controlled trial (N = 436 people, 218 patient/family dyads, 109 dyads per arm) of BETTER, a culturally- and linguistically-tailored, patient- and family-centered, TBI transitional care intervention for adult patients with TBI and families. Skilled clinical interventionists will follow a manualized protocol to address patient/family needs. The interventionists will co-establish goals with participants; coordinate post-hospital care, services, and resources; and provide patient/family education and training on self- and family-management and coping skills for 16 weeks following hospital discharge. English- and Spanish-speaking adult patients with mild-to-severe TBI who are discharged directly home from the hospital without inpatient rehabilitation or transfer to other settings (community discharge) and associated family caregivers are eligible and will be randomized to treatment or usual transitional care management. We will use intention-to-treat analysis to determine if patients receiving BETTER have a higher quality of life (primary outcome, SF-36) at 16-weeks post-hospital discharge than those receiving usual transitional care management. We will conduct a descriptive, qualitative study with 45 dyads randomized to BETTER, using semi-structured interviews, to capture perspectives on barriers and facilitators to participation. Data will be analyzed using conventional content analysis. Finally, we will conduct a cost/budget impact analysis, evaluating differences in intervention costs and healthcare costs by arm.

DISCUSSION

Findings will guide our team in designing a future, multi-site trial to disseminate and implement BETTER into clinical practice to enhance the standard of care for adults with TBI and families. The new knowledge generated will drive advancements in health equity among diverse adults with TBI and families.

TRIAL REGISTRATION

NCT05929833.

Perceived service adequacy and unmet need after discharge from brain injury rehabilitation

PURPOSE

The present study aimed to quantify the perceived needs and adequacy of realised access to post-acute services in a sample of people with acquired brain injury in the first 6-months after discharge from inpatient rehabilitation. A secondary focus was the influence of access to funding and specialist transitional rehabilitation on unmet needs.

MATERIALS AND METHODS

Participants were 51 adults with a median age of 50 (IQR 35-57) recruited from an inpatient rehabilitation unit in an Australian tertiary hospital. The sample was those who had an acquired brain injury, including 23 who sustained a traumatic injury and 28 who sustained a non-traumatic injury. Measures were collected via telephone at 3- and 6-months, in a prospective observational cohort design using the Needs and Provisions Complexity Scale. A series of logistic regression models were used to determine the effects of participation in a transitional rehabilitation program and funding pathway on adequacy and unmet needs.

RESULTS

Unmet needs for rehabilitation were most commonly reported (60%), followed by unmet needs in relation to health care (40%), social care (35%), personal care (32%) and environment-related (14%). Participants who attended transitional rehabilitation were more likely to indicate unmet health care needs (OR = 6.40, 95% CI = 1.40-29.24, p = 0.02).

CONCLUSIONS

The study highlights the need to look beyond functional impairment when conceptualising appropriate access. Additionally, the present research highlighted the need for greater work into an expectation of services.IMPLICATIONS FOR REHABILITATIONThe majority of people with an acquired brain injury report unmet needs at 6 months post discharge.Present findings support the utility of patient reported measures when considering treatment evaluation with people with ABI, where assessing the personal appraisal of individuals needs may prove to be a key indicator to facilitate optimal service access.There are specific services that needed and not provided including psychological, speech pathology, family carer needs and vocational rehabilitation, and therefore are a key target for ensuring appropriate support is provided.

Rehabilitation models that support transitions from hospital to home for people with acquired brain injury (ABI): a scoping review

BACKGROUND

Research shows a lack of continuity in service provision during the transition from hospital to home for people with acquired brain injuries (ABI). There is a need to gather and synthesize knowledge about services that can support strategies for more standardized referral and services supporting this critical transition phase for patients with ABI. We aimed to identify how rehabilitation models that support the transition phase from hospital to home for these patients are described in the research literature and to discuss the content of these models.

METHODS

We based our review on the "Arksey and O`Malley framework" for scoping reviews. The review considered all study designs, including qualitative and quantitative methodologies. We extracted data of service model descriptions and presented the results in a narrative summary.

RESULTS

A total of 3975 studies were reviewed, and 73 were included. Five categories were identified: (1) multidisciplinary home-based teams, (2) key coordinators, (3) trained family caregivers or lay health workers, (4) predischarge planning, and (5) self-management programs. In general, the studies lack in-depth professional and contextual descriptions.

CONCLUSIONS

There is a wide variety of rehabilitation models that support the transition phase from hospital to home for people with ABI. The variety may indicate a lack of consensus of best practices. However, it may also reflect contextual adaptations. This study indicates that health care service research lacks robust and thorough descriptions of contextual features, which may limit the feasibility and transferability to diverse contexts.

"It gave her that soft landing": Consumer perspectives on a transitional rehabilitation service for adults with acquired brain injury

Transitional rehabilitation service models for people with acquired brain injury (ABI) may address sub-optimal support for individuals returning home after hospitalization for ABI. This study investigated perspectives of people with ABI and close others who received transitional rehabilitation. A qualitative study involving semi-structured interviews with 10 individuals with ABI and 12 associated close others was conducted as part of a mixed-method evaluation of an Australian transitional rehabilitation service (TRS) pilot project. Thematic analysis based on the Framework method was conducted independently by two researchers. Three broad themes illustrated participants' experience of the TRS: (1) structure after hospital discharge; (2) a "soft landing"; and (3) equipped for community living. Findings suggest that home-based, interdisciplinary transitional rehabilitation after hospital discharge was perceived as an important stage of rehabilitation by participants. Valued features relate to post-hospital rehabilitation structure: a single point of contact to facilitate organization and information exchange, a known discharge destination, and consistent communication; support and therapy within a familiar home environment; and being equipped with relevant knowledge and strategies to manage ongoing challenges. Further research exploring the experiences of individuals with ABI without close family or social support, and research capturing longitudinal outcomes from transitional rehabilitation is recommended.

Implementation and modification of a service model for community transitional rehabilitation for people with acquired brain injury

OBJECTIVES

To examine the implementation of a novel Acquired Brain Injury (ABI) Transition-Specific Service Model in Queensland, Australia to explore its potential for successful operationalization in a clinical context and what, if any, modifications were indicated.

METHODS

This study is part of a larger evaluation of the ABI Transitional Rehabilitation Service (ABITRS) Pilot Project using a Hybrid Type 1 research design. Data was drawn from a process evaluation nested within the larger study. Stirman et al.'s FRAME guided assessment of modifications made to the proposed Transition-Specific Service Model during implementation.

RESULTS

The proposed Transition-Specific Service Model provided a foundational framework for establishing an ABI transitional rehabilitation service in Queensland. All designated key service delivery features of the model were implemented; context and content modifications occurred in response to the implementation experience. Priority areas for intervention were comprehensively addressed, with significant changes made to the proposed staffing profile to address an identified need for more senior clinicians.

CONCLUSIONS

The ABITRS Pilot Project provided an opportunity to test and refine elements of an ABI Transition-Specific Service Model in a clinical context. Knowledge gained from this process has the potential to inform future design of transitional rehabilitation services for acquired brain injury.

"I Avoid Interactions With Medical Professionals as Much as Possible Now": Health Care Experiences of Individuals With Traumatic Brain Injuries

PURPOSE

This study examined the perceptions of health care experiences by individuals with traumatic brain injuries (TBIs) across the recovery continuum, regarding care received by a variety of health care providers following their TBI. It sought to identify whether perceptions differed across mild, moderate, and severe participants, as well as acute, subacute, and chronic recovery.

METHOD

Eighteen individuals with TBI were interviewed, using the Sydney Psychosocial Reintegration Scale-Second Edition (SPRS-2) and a semistructured interview about health care perceptions. A qualitative investigation employing two methods, interpretive phenomenological analysis (IPA) and Systemic Functional Linguistics (SFL; modality and appraisal analysis), provided a micro and macrolevel discourse analysis.

RESULTS

IPA analyses of SPRS-2 interviews differed across severity levels but included changes to relationships, identity, and changes to social engagement and activity. IPA results revealed three core themes related to the health care experiences across severity that encompassed (a) frustrations with providers and (b) lack of support in the chronic phase, and (c) that finding support is crucial. SFL results provided insight into how individuals appraised such experiences in light of their identity and personal perspectives. Key differences between individuals with mild, moderate, and severe TBI diagnoses were found, with those who experienced a mild TBI expressing the most discontent with services received. Participants were most satisfied with acute care and least satisfied with chronic phase support.

CONCLUSIONS

The results of this study have significant implications for health care professionals interacting with individuals who have experienced a TBI. Facilitating improved communication, referrals, increased access to mental health counseling, and resources such as groups to support identity expression could improve the health care experience.

Exploring Physical Activity During the Discharge Transition Phase in People With Acquired Brain Injury-An Observational Study

Objective

To explore physical activity trajectories during the discharge transition phase after in-hospital rehabilitation after acquired brain injury (ABI).

Design

A cross-sectional observational study.

Setting

Transition from an in-hospital rehabilitation center to community-based living.

Participants

Independently walking patients with ABI (n=10) who were ready for discharge.

Interventions

Not applicable.

Main Outcome Measures

Two weeks of physically active time continuously monitored with an accelerometer and classified by a machine learning algorithm summed as daily average and total active time for each participant and classified into standing, walking, running, bike riding, stair climbing, ambulation, and sedentary time. Physical activity trajectories showing the total daily active time for all participants were inspected before and after discharge, and the average active time per participant was plotted against self-reported scores of potentially explanatory factors.

Results

Average total physically active time was 5:49 hours (range 4:26-7:13 hours). Average daily physically active time for participants appeared to be related to functional independence measure sub scores, fatigue, and pre-morbid physical activity level. Individual physical activity trajectories showed a decreased walking activity after discharge, which increased again after 1-2 days.

Conclusions

Daily total physically active time among participants was higher than expected. Factors expectedly related to physical activity trajectories in the discharge transition phase were explored and showed some relation to functional scores.

Mixed methods study to understand the experiences of adults with acquired brain injury and their family members who receive specialised rehabilitation

BACKGROUND AND AIM

Rehabilitation therapy is a key part of the recovery pathway for people with severe acquired brain injury (ABI). The aim of this study was to explore inpatients' and their family members' experiences of a specialist ABI rehabilitation service.

METHODS

A cross sectional, prospective mixed method study was undertaken at a metropolitan specialist ABI rehabilitation unit in Victoria, Australia. All inpatients and their family members of the service were invited to complete a satisfaction survey. Employing purposive sampling, semi-structured interviews were conducted with inpatients and/or their family members.

RESULTS

In total, 111 people completed the satisfaction survey and 13 were interviewed. High levels of satisfaction with the specialist service were reported; the majority of inpatients (74%) and family members (81%) rated the overall quality of care received in the service as 'high' or 'very high'. Interviews revealed four main themes: (i) satisfaction with rehabilitation services, (ii) inconsistent communication, (iii) variable nursing care, and (iv) strengths and weakness of the rehabilitation environment. Overall, important components of a positive experience were being involved in decision making and discharge planning, effective communication and information processes, and being able to form therapeutic relationships with staff. Key sources of dissatisfaction for inpatients and family members related to inconsistency in care, accessing information about treatments in a format easily understood, and communication.

CONCLUSION

Specialised rehabilitation is valued by inpatients and their family members alike. The findings highlight the importance of exploring inpatient experiences to optimise service delivery in a tailored, specialised rehabilitation programme.

Personal experiences of appropriate access to post-acute care services in acquired brain injury: a scoping review

People with an acquired brain injury (ABI) experience substantial access inequalities and unmet health needs, with many experiencing insufficient access to appropriate rehabilitation in the community. To deepen our understanding of what appropriate access to post-acute care services is for this population, and to facilitate optimal recovery, there is a need to synthesise research from the service user perspective. A scoping review study was conducted to identify key characteristics of 'appropriate' access to post-acute care services, as defined by the personal experiences of adults with ABI. Electronic scientific databases Medline, PsycINFO, Proquest Central and CINAHL were searched for studies published between 2000 and 2020. The initial search identified 361 articles which, along with articles retrieved from reference list searches, resulted in 52 articles included in the final analysis. Results indicated that a majority of the studies sampled participants with an average of over 1 year post-injury, with some studies sampling participants ranging over 10 years in difference in time post-injury. A thematic synthesis was conducted and results indicated a number of dominant elements which relate to (1) the characteristics of services: provider expertise, interpersonal qualities, partnership and adaptability; (2) characteristics of the health system: navigable system, integrated care, adequacy, and opportunity. These findings provide some insight into what might be considered appropriate. However, rigorous research, focused on personalised access to post-acute care services, is recommended to verify and elaborate on these findings.

Identifying models, processes, and components of vocational rehabilitation following acquired brain injury: a systematic scoping review

PURPOSE

Acquired brain injury (ABI) is a complex injury which impacts engagement with worker roles. Return to work (RTW) rates for individuals with brain injury are low and those who do RTW often report job instability. Vocational rehabilitation (VR) can improve RTW rates and job stability; however, service provision is varied, and no gold standard has been identified.

METHODS

A systematic scoping review of the literature was completed to explore research activity in VR for individuals with ABI to address the following three questions: what models have been identified to underpin VR in ABI? What clinical processes have been identified to guide provision of VR in ABI? What components of VR have been described and/or recommended in the ABI literature?

RESULTS

The number of included articles was 57. From these articles, 16 models, nine process steps, eight components, and four service delivery components were identified that were utilised in provision of ABI VR. Implications for practice are discussed.

CONCLUSIONS

Key processes and components of ABI VR have been identified across a range of models and apply to clients at all phases post-injury. Findings may be used to inform service provision across a range of time points and support clinicians in their delivery of VR to adults with brain injury.Implications for RehabilitationPeople with acquired brain injury (ABI), even severe injury, can be successful with return to work (RTW) when provided appropriate supports.A wide range of models, interventions, and service components have been identified in the literature which can be used to guide clinical and policy development in ABI vocational rehabilitation.Vocational rehabilitation for individuals with brain injury involves a complex interaction of factors, and consideration should be paid to not only the person and their abilities but also job demands and the environment (physical, social, cultural).Vocational rehabilitation services should be accessible and timed to maximise chances of a successful RTW, provided by a coordinated interdisciplinary team and should involve active stakeholder engagement.

The association between functional independence and quality of life for individuals with acquired brain injury undergoing community-based rehabilitation and disability support

BACKGROUND: Following acquired brain injury (ABI), cognitive and physical barriers can prevent access to a previously enjoyed lifestyle, reducing quality of life. OBJECTIVE: This study aimed to examine predictors of health-related quality of life (HRQoL) in adults with ABI receiving post-acute community-based rehabilitation and disability support services, using tools developed for this population. METHODS: Retrospective cross-sectional design. Main outcome measures were the Quality of Life after Brain Injury Inventory (QOLIBRI) and Functional Independence and Assessment Measure (FIM + FAM) for adults with ABI (n = 67) undergoing post-acute rehabilitation in Western Australia, 2015–2021. RESULTS: Mean QOLIBRI total score (±standard deviation) was 57.2±17.4, indicating impaired HRQoL, with mood disorders likely prevalent. Regression analysis demonstrated no differences in HRQoL between different age groups, sexes or brain injury types. Shorter time since injury and lower total FIM + FAM score significantly predicted poorer HRQoL in the model. CONCLUSION: This population appears vulnerable to psychological illness, although HRQoL is addressed for a minority of clients during routine post-acute care (19%). As improvement in quality of life is a fundamental goal of rehabilitation post-ABI, understanding the relationship between potentially modifiable factors such as functional independence and HRQoL is critical to improve outcomes and provide the best chance at a satisfying life.

Storytelling as an intervention in traumatic brain injury rehabilitation: a scoping review

PURPOSE

Storytelling interventions are increasingly being proposed as a tool for rehabilitation after Traumatic Brain Injury (TBI). This review aimed to systematically map intervention details as described in the TBI rehabilitation/recovery literature to better understand why, when and how storytelling is being used in rehabilitation.

METHODS

The review team included a storyteller-performer with lived experience of severe TBI, and two academics. Literature searching followed a pre-defined protocol with systematic search strategies and inclusion/exclusion criteria developed through discussion and literature scoping. Included interventions described a deliberate process of creation and sharing of the story.

FINDINGS

Thirteen studies met inclusion criteria, describing eleven distinct interventions fitting into four categories: film production, visual art, written publication and song composition. Rationale for the interventions included identity reconstruction, emotional processing, sense-making, and community (re)engagement. Varying levels of specialist materials and facilities were utilized. Most required facilitation by professionals trained in specialist areas such as narrative, art or music therapy.

CONCLUSION

Intervention models suggest that storytelling is intended for self-identity reconstruction after TBI and that it can create socially acceptable ways to process difficult experiences and (re)connect with peers, clinicians, families, and communities. Larger-scale trials that test intervention efficacy in relation to documented outcomes are needed.IMPLICATIONS FOR REHABILITATIONStorytelling as part of traumatic brain injury rehabilitation is used to assist with self-identity reconstruction, emotional processing, and clinical issues such as communication and executive functioning.Categories of storytelling intervention include film, visual art, written work and song writing.Collaborative facilitation is key to this process for a traumatic brain injury population.

Design, methods, and baseline characteristics of the Brain Injury Education, Training, and Therapy to Enhance Recovery (BETTER) feasibility study: a transitional care intervention for younger adult patients with traumatic brain injury and caregivers

OBJECTIVES

We developed a patient- and family-centered traumatic brain injury (TBI) transitional care intervention, called BETTER (Brain Injury Education, Training, and Therapy to Enhance Recovery), to improve quality of life (via SF-36) of younger TBI patients of different racial groups discharged home from acute hospital care and caregivers. We describe our design, methods, and baseline characteristics for our feasibility study.

METHODS

We co-developed BETTER with input from key stakeholders (TBI patients and caregivers, healthcare providers, and interdisciplinary research team members). BETTER is guided by the Individual and Family Self-Management Theory, our team's prior research, as well as literature used to support, educate, and train patients and families recovering from TBI and other conditions. The intervention is delivered by trained clinical interventionists (transitional care managers), beginning 24-72 h pre-discharge to 16 weeks post-discharge. BETTER offers tailored transitional care support to patient/family dyads, including assessing needs; establishing goals; coordinating post-hospital care, services, and resources; and providing patient/family education and training on brain injury coping skills. The majority of the intervention is delivered remotely via phone and remote video conferencing platform (Clinicaltrials.gov: NCT04584554).

RESULTS

We enrolled 15 dyads (N = 31, 15 patients, 16 caregivers) in this single arm, single center feasibility study. Most patients were men (n = 11, 73.33%), had a mean age of 39.07 (SD: 15.15), and were Black (n = 9, 60%), White (n = 5, 33.3%), or American Indian (n = 1, 0.66%). Injury severities were mild (n = 6, 40%), moderate (n = 4, 26.6%) or severe (n = 5, 33.33%). Most patients were insured (n = 10; 66.7%), had a high school education (n = 6; 40%); and earned $30,000 or less per year (n = 11; 73.3%). Most caregivers were married (n = 9, 56.25%) women (n = 14, 87.5%) with a mean age of 43.38 (SD: 10.45) and were Black (n = 8, 50%), White (n = 7, 43.75%), or American Indian (n = 1, 0.62%). Most caregivers identified as the spouse (n = 7; 43.75%) or parent (n = 6; 37.5%) of the patient.

CONCLUSIONS

BETTER is among the first TBI transitional care intervention to address needs/preferences for younger TBI patients of different racial groups after discharge home from acute hospital care and families. Findings can be used to inform future work.

"I never thought I would be an international speaker … but I am": an interpretive qualitative analysis of experiences of a project-based advocacy intervention

Acquired brain injuries (ABI) result in changes to physical, cognitive, psychosocial, and economic domains, which alter an individual's sense of self and identity. Interactions with healthcare providers may further contribute to conceptualization of self after ABI. Cognitive rehabilitation is intended to address cognitive-communication impairments, as well as psychological changes to the sense of self and identity that follow ABI. The present investigation examined a project-based intervention, focused on advocacy. Participants developed a presentation for healthcare providers regarding consequences of ABI, strategies and supports necessary to successfully overcome daily challenges, and insights into the lived experience. Ten individuals with chronic ABI participated in one of three roles (presenter, video contributor, or content developer). Written interviews allowed participants to generate and refine their responses. Interpretive Description qualitative analyses was used to examine interviews. Iterative analysis identified five themes across all participant roles: renewed sense of self, positive impact on providers to care of future individuals with brain injuries, rewarding and humbling, being heard, and alternate personal narratives and identities. The remaining theme applied only to presenters, improved clarity and conciseness. Group, project-based interventions have the potential to positively influence sense of self in combination with narrative therapy techniques in the chronic phase of recovery.

Transitional care programs to improve outcomes in patients with traumatic brain injury and their caregivers: A systematic review and meta-analysis

Background

Effective nursing interventions for caring for patients with moderate to severe traumatic brain injury are still challenging during a transition from hospital to home. Since traumatic brain injury has deep-rooted sequelae, patients and their caregivers require better arrangement and information on the condition to achieve improved outcomes after discharge.

Objective

This study aimed to assess transitional care programs to improve outcomes of patients with traumatic brain injury and their caregivers.

Methods

A systematic review and meta-analysis were performed on studies retrieved from ProQuest, PubMed, Science Direct, CINAHL, and Google Scholar from January 2010 to July 2021. RevMan 5.4.1 software was used for meta-analysis.

Results

Nine studies were systematically selected from 1,137 studies. The standard approaches of interventions used in patients with traumatic brain injury and their caregivers were education, mentored problem-solving, home-and community-based rehabilitation, counseling, skill-building, and psychological support. We observed that there was significant evidence indicating beneficial effects of intervention in increasing the physical functioning of patients with traumatic brain injury (SMD = -0.44, 95% CI -0.60 to -0.28, p <0.001), reducing the psychological symptoms among caregivers (SMD = -0.42, 95% CI -0.59 to -0.24, p <0.001), and increasing the satisfaction (SMD = -0.35, 95% CI -0.60 to -0.11, p = 0.005).

Conclusion

Education, skill-building, and psychological support should be the main components in transitional care nursing programs for patients with traumatic brain injury and their caregivers.

Negotiating the transition from acute hospital care to home: perspectives of patients with traumatic brain injury, caregivers and healthcare providers

Purpose

The purpose is to explore experiences transitioning home from acute hospital care from perspectives of younger traumatic brain injury (TBI) patients, family caregivers and healthcare providers (HCPs).

Design/methodology/approach

The authors conducted 54 qualitative interviews (N = 36: 12 patients, 8 caregivers, 16 HCPs) and analyzed data using conventional content analysis.

Findings

The transition from hospital to home was described as a negotiation, finding a way through these obstacles: (1) preparing for discharge home during acute hospital care; (2) navigating transitions in healthcare and health; (3) addressing recovery concerns, and (4) setting goals to return to normal. Factors influencing the negotiation process included social support, health-related knowledge or training, coping mechanisms, financial stability, and home environment stability.

Originality/value

Younger TBI patients and caregivers have unique needs during the transition home from the hospital. Needed support from HCPs was inconsistently provided. Findings are foundational for integrated care research and practice with TBI.

Cohort profile: the Acquired Brain Injury Community REhabilitation and Support Services OuTcomes CohoRT (ABI-RESTaRT), Western Australia, 1991-2020

PURPOSE

Transition back into the community following acute management of acquired brain injury (ABI) is a critical part of recovery. Post-acute rehabilitation and transitional care can significantly improve outcomes. The Acquired Brain Injury Community REhabilitation and Support Services OuTcomes CohoRT (ABI-RESTaRT) is a novel whole-population cohort formed to better understand the needs of individuals with ABI receiving post-acute rehabilitation and disability services in Western Australia (WA), and to improve their outcomes. To do this a unique combination of (1) internal clinical/rehabilitation data, and (2) externally linked health data from the WA Data Linkage System was used, including hospitalisations, emergency department presentations, mental health service use and death records, to measure longitudinal needs and outcomes of individuals with ABI over 29 years, making this the largest, most diverse post-acute ABI cohort in Australia to date.

PARTICIPANTS

Whole-population cohort of individuals (n=1011) with an ABI who received post-acute community-based neurorehabilitation or disability support services through Brightwater Care Group from 1991 to 2020.

FINDINGS TO DATE

Comprehensive baseline demographic, clinical and rehabilitation data, outcome measures and linked health data have been collected and analysed. Non-traumatic brain injury (eg, stroke, hypoxia) was the main diagnostic group (54.9%, n=555), followed by traumatic brain injury (34.9%, n=353) and eligible neurological conditions (10.2%, n=103). Mean age at admission was 45.4 years, and 67.5% were men (n=682). The cohort demonstrated significant heterogeneity, socially and clinically, with differences between ABI groups across a number of domains.

FUTURE PLANS

ABI-RESTaRT is a dynamic whole-population cohort that will be updated over time as individuals enrol in the service. Future analyses will assess longitudinal brain injury outcomes, the changing health and social needs of individuals with ABI and evaluate and inform post-acute services to best support these individuals.

REGISTRATION

This cohort is not linked to a clinical trial, and is not registered.

Care transitions in the first 6months following traumatic brain injury: Lessons from the CENTER-TBI study

BACKGROUND

No large international studies have investigated care transitions during or after acute hospitalisations for traumatic brain injury (TBI).

OBJECTIVES

To characterise various TBI-care pathways and the number of associated transitions during the first 6 months after TBI and to assess the impact of these on functional TBI outcome controlled for demographic and injury-related factors.

METHODS

This was a cohort study of patients with TBI admitted to various trauma centres enrolled in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study. Number of transitions and specific care pathways were identified. Multiple logistic regression analyses were used to assess the impact of number of transitions and care pathways on functional outcome at 6 months post-injury as assessed by the Glasgow Outcome Scale-Extended (GOSE).

RESULTS

In total, 3133 patients survived the acute TBI-care pathway and had at least one documented in-hospital transition at 6-month follow-up. The median number of transitions was 3 (interquartile range 2-3). The number of transitions did not predict functional outcome at 6 months (odds ratio 1.08, 95% confidence interval 1.09-1.18; P=0.063). A total of 378 different care pathways were identified; 8 were identical for at least 100 patients and characterized as "common pathways". Five of these common care pathways predicted better functional outcomes at 6 months, and the remaining 3 pathways were unrelated to outcome. In both models, increased age, violence as the cause of injury, pre-injury presence of systemic disease, both intracranial and overall injury severity, and regions of Southern/Eastern Europe were associated with unfavourable functional outcomes at 6 months.

CONCLUSIONS

A high number of different and complex care pathways was found for patients with TBI, particularly those with severe injuries. This high number and variety of care pathway possibilities indicates a need for standardisation and development of "common data elements for TBI care pathways" for future studies.

STUDY REGISTRATION

ClinicalTrials.gov NCT02210221.

Caregivers' perspectives of the challenges faced with survivors of traumatic brain injury: A scoping review

INTRODUCTION

Traumatic Brain Injury (TBI) has wide-ranging neuropsychological, physical, social and financial implications. The impact on caregivers of moderate to severe TBI survivors, particularly in low- and middle-income countries, is under-investigated.

AIM

Identify and describe the experiences of caregivers' of moderate to severe TBI survivors postdischarge from healthcare facilities.

METHODS

A scoping review was conducted utilising seven electronic databases. Two reviewers screened articles using eligibly criteria related to setting (postdischarge), caregiving (informal), age of TBI survivors (>  18 years) and injury severity (moderate-severe). Studies published in English between 1999 -2018 were included.

RESULTS

Fourteen articles met the inclusion criteria. Articles reporting on the same sample were merged during data charting. The final analyses included 11 articles comprised of qualitative, quantitative and mixed-methods studies. Ten themes were identified: psychological distress, social functioning, financial burden, family experiences, coping strategies, access to services, time burdens and physical, cognitive and behavioural difficulties. Characteristics of caregivers and TBI survivors were also reported.

CONCLUSION

Caregivers of moderate to severe TBI survivors experience challenges in various life domains, and there is limited research concerning caregivers in low- and middle-income countries. Future research should focus on understanding more nuanced experiences across various environments, which may increase comprehensive, flexible and long-term support.

Experiences of inpatient rehabilitation from the perspective of persons with acquired brain injury

BACKGROUND

Perspectives of individuals with acquired brain injury (ABI) regarding inpatient rehabilitation experiences can inform patient-centered care; however, these voices are under-represented in the literature.

PURPOSE

To explore the experiences, needs, and preferences of patients from an ABI inpatient rehabilitation program in Ontario.

METHODS

Using an interpretive description approach, we interviewed 12 participants and analyzed the transcripts inductively to generate themes.

FINDINGS

We identified three major themes: (1) Life Rerouted - participants felt their lives diverted due to ABI, with rehabilitation seen as a way to return to pre-injury life, (2) Autonomy within Rehab highlighted the perceived importance of personal autonomy in decision-making within rehabilitation, and (3) Life (and Recovery) Go On reflected an ongoing recovery process after discharge - leading to mixed emotions. An overall message, "re-establishing personal identity is important to the recovery process," reflected theories of biographical disruption and relational autonomy.

IMPLICATIONS

Our findings provide a patient perspective for clinicians and administrators to consider. We found that ABI was significantly disruptive to personal identity - resulting in tensions in autonomy while attempting to reclaim a sense of identity. We suggest counseling services and strategies supporting post-injury adjustment, along with ways for rehabilitation professionals to enhance patient autonomy where possible.Implications for rehabilitationSustaining an ABI can significantly disrupt personal identity and sense of autonomy - especially as persons occupy the role of "patient" while in inpatient rehabilitation.Psychological support is recommended to address the impacts of ABI on patients' sense of identity, as well as on family members.Strategies of support might include, providing formal psychotherapy, as well as creating opportunities for patients and family members to discuss the changes they are experiencing, and to establish their personal narratives (e.g., through writing or art) or peer mentorship programs between discharged and current patients.Clinicians can enhance patient autonomy by increasing opportunities for communication with patients about choice; educating patients and family members on the rehabilitation team's decision-making process, and other methods that increase communication and provide consistent up-to-date information to patients and their family members.

Barriers and facilitators linked to discharge destination following inpatient rehabilitation after traumatic brain injury in older adults: a qualitative study

PURPOSE

To identify facilitators and barriers associated with returning home for older adults having received inpatient rehabilitation after traumatic brain injury (TBI).

METHODS

A qualitative design was used. Five older patients with TBI and four family caregivers were interviewed and six healthcare professionals participated in a focus group.

RESULTS

Main facilitators to returning home highlighted by all participants were: (1) Patient's adequate health condition and functional status, (2) Access to health and other services at home, (3) Availability of help from a family caregiver. Conversely, if one of these factors was not met, it represented a barrier. Other facilitators identified were (4) Attachment to one's home, (5) Feeling of commitment toward a loved one, (6) Having the possibility of going through a transitional phase, (7) United front between the patient and the family caregiver towards a return home. Additional barriers to returning home included: (8) Incongruent perspectives, and (9) Unclear knowledge about available health and other services at home.

CONCLUSION

The results of this study could be translated into a practical tool to guide patients, families and professionals in the decision about returning home or exploring an alternative option after inpatient rehabilitation for TBI in older adults.IMPLICATIONS FOR REHABILITATIONWhen orienting an older patient home or to an alternative living environment after a traumatic brain injury (TBI), the perspective of rehabilitation professionals can differ from that of patients and caregivers.Professionals tend to emphasize security, whereas patients and caregivers' focus on the well-being associated with home and on the importance of being with their loved one.Integrating the views, values and wishes of older patients with TBI and their caregivers will support a shared decision-making approach for orientation after rehabilitation.

"Just tell me in a simple way": A qualitative study on opportunities to improve the transition from acute hospital care to home from the perspectives of patients with traumatic brain injury, families, and providers

OBJECTIVE

The purpose of this study was to identify areas to improve the transition from acute hospital care to home for patients with traumatic brain injury and their families.

DESIGN

Qualitative, descriptive.

SETTING

Level I trauma centered located in the Southeastern United States.

SUBJECTS

A total of 36 participants (12 patients with traumatic brain injury, 8 family caregivers, 16 providers).

MAIN MEASURES

We conducted 55 semi-structured interviews with participants and used conventional content analysis to analyze the data.

RESULTS

Findings showed patients, families, and providers recommend three areas for improvement in the transition home from acute hospital care, described in three themes. Theme 1 was "improving patient and family education," with the following sub-themes: (a) TBI-related information and (b) discharge preparation. Theme 2 was "additional provider guidance," with the following sub-themes: (a) communication about patient's recovery timeline and (b) recovery roadmap development. Theme 3 was "increasing systems-level support," with the following sub-themes: (a) scheduling follow-up appointments, (b) using a patient navigator, (c) creating a provider follow-up structure, (d) linking pre-discharge care with post-discharge resources, and (e) addressing social issues.

CONCLUSIONS

These findings delineate multiple areas where patients and families need additional support and education during the transition from acute hospital care to home in ways that are currently not being addressed. Findings may be used to improve education and support from providers and health systems given to patients with traumatic brain injury and families and to inform development and testing of transitional care interventions from acute hospital care to home.

Prevalence, Patterns, and Predictors of Multimorbidity in Adults With Acquired Brain Injury at Admission to Staged Community-Based Rehabilitation

OBJECTIVES

To describe the prevalence, patterns, and predictors of multimorbidity in adults with an acquired brain injury (ABI) on presentation to a community-based neurorehabilitation service.

DESIGN

Retrospective cohort study using routinely collected admissions and clinical data.

SETTING

Community-based neurorehabilitation.

PARTICIPANTS

Individuals (N=263) with non-traumatic brain injury (NTBI; n=187 [71.1%]) versus traumatic brain injury (TBI; n=76 [28.9%]).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Comorbidity was defined as the co-occurrence of at least one chronic condition in conjunction with a primary diagnosis of ABI. Multimorbidity was defined as the co-occurrence of 2 or more chronic conditions across 2 or more body systems, in conjunction with a primary diagnosis of ABI.

RESULTS

Comorbidity was present in 72.2% of participants overall, whereas multimorbidity was present in 35.4% of the cohort. The prevalence of comorbidity (76% vs 63%; P=.036) and multimorbidity (40% vs 24%; P=.012) was higher in NTBI compared with participants with TBI. Participants with NTBI had a higher prevalence of physical health multimorbidities, including cardiovascular (44% vs 6%; P<.001) and endocrine (34% vs 10%; P=.002) disease, whereas participants with TBI had a higher prevalence of mental health conditions (79% vs 48%; P<.001). Depression (36.3%) and hypertension (25.8%) were the most common diagnoses. Increasing age was the only significant predictor of multimorbidity.

CONCLUSIONS

Most participants experienced multimorbidity. Effective management of multimorbidity should be included as part of individual rehabilitation for ABI and planning of resource allocation and service delivery. The results of this study can help guide the provision of treatment and services for individuals with ABI in community-based rehabilitation. Our study highlights access to mental health, cardiovascular, endocrine, and neurology services as essential components of rehabilitation for ABI.

The effect of access to a designated interdisciplinary post-acute rehabilitation service on participant outcomes after brain injury

OBJECTIVE

This study aimed to determine the influence of participation in a designated acquired brain injury (ABI) transitional rehabilitation service (ABI TRS) on outcome, in the context of a historical comparison group (HIST). Design: A cohort study, with retrospective comparison. Participants: 187 persons with ABI. Measures: The Depression, Anxiety and Stress Scale (DASS-21), Mayo-Portland Adaptability Index (MPAI-4) and Sydney Psychosocial and Reintegration Scale (SPRS) were completed at discharge and 3 months after discharge. Participation in the ABI TRS involved interdisciplinary rehabilitation, 2-4 times per week, for 3 months after hospital discharge. Results: There was evidence that at 3 months, participants with ABI TRS showed stabilized psychological wellbeing, and improvements in MPAI-4 ability and participation scores; in addition to improvements in SPRS occupational activity and living skills scores. Conclusion: A designated ABI TRS may improve the transition from hospital to home, and could form an important part of the brain injury rehabilitation continuum, between the inpatient and community setting.

Time between acquired brain injury and admission to community-based rehabilitation: differences in cognitive and functional gains

OBJECTIVE

To determine differences in rehabilitation gains made by people with an acquired brain injury undergoing staged community-based brain injury rehabilitation (SCBIR) at different times between injury and admission.

METHOD

Retrospective cohort analysis of routinely collected demographic and rehabilitation data from clients admitted to SCBIR service 2011-2017 (n=92). Outcome measures: Mayo-Portland Adaptability Inventory-4 (MPAI-4) and UK Functional Assessment Measure (UK FIM+FAM) collected on admission and annually thereafter until discharge. Analysis was stratified by time since injury on admission: 'Early' (<1 year (n=36)), 'Middle' (1-2 years (n=34)) and 'Late' (>2 years (n=22)). Between-group differences were tested using bootstrapped one-way ANOVA. Within-group differences were tested using paired T tests.

RESULTS

Total cohort made significant gains in MPAI-4 and UK FIM+FAM total and all subscales (p = .001). Early group made greatest change in all subscales of both outcome measures (p < .01). Middle cohort improved significantly in all subscales (p < .02) excluding MPAI-4 Adjustment. Late cohort still made statistically significant gains in all UK FIM+FAM subscales (p < .05) and MPAI-4 Participation (p < .01). Item level changes are presented.

CONCLUSION

More than 2 years after injury, people are able to make improvements in participation and functional independence following SCBIR.

Defining discharge-readiness from subacute care from all stakeholders' perspectives: a systematic review

Purpose: Research to date has focused on clinicians' views on patients' discharge readiness from acute hospital settings.This study aims to synthesise the literature on discharge readiness from sub-acute (rehabilitation) hospital settings from all stakeholders' perspectives.Methods: Electronic databases (MEDLINE, CINAHL, Ageline, AMED and Global Health) were systematically searched for post-2000 publications on discharge readiness of adult inpatients in sub-acute settings. After screening, quantitative and qualitative studies were assessed for bias using the Downs and Black checklist and McMaster critical assessment tool respectively, and narrative analysis conducted.Results: From the 3516 papers identified, 23 were included in the review. Overall quality of articles was rated as adequate. Narrative synthesis identified three main themes: the importance of functional outcomes; confounding factors impact on discharge destination and length of stay and barriers and facilitators to discharge.Conclusion: Despite limited literature defining sub-acute patients' discharge-readiness from all stakeholders' perspectives, synthesis of available findings identified major themes for consideration when determining when a patient is ready to leave hospital. Limitations include the heterogeneity of the studies located impacted on data extraction and quality appraisal.IMPLICATIONS FOR REHABILITATIONDischarging patients from hospital is complex, discharge too early may lead to poor medical outcomes or readmission, while discharge too late may increase the risk of hospital-based adverse events.Multiple factors need to be considered when considering the discharge readiness of an inpatient.Ensuring adequate social support is key to maximising transition from hospital to home.Combining the use of functional outcome measures with clinical decision-making allows for quantifying readiness for discharge.

Experiences of Occupational Performance in Survivors of Stroke Attending Peer Support Groups

BACKGROUND.

Survivors of stroke often experience environmental isolation and decreased occupational performance after discharge from the hospital. Peer groups benefit psychological, social, and cognitive functioning, though few studies have examined their influence on occupational performance of survivors of stroke.

PURPOSE.

This study explores the experiences of occupational performance in survivors of stroke attending an outpatient peer support group.

METHOD.

An interpretive qualitative study using semi-structured interviews was conducted with seven survivors of stroke attending an outpatient peer support group. Data was thematically analyzed.

FINDINGS.

Four themes related to the experience of peer support on occupational performance emerged: finding hope to return to meaningful occupation, a place for belonging, problem-solving occupational concerns, and finding purpose beyond oneself.

IMPLICATIONS.

This research adds to the existing literature that peer support groups help survivors of stroke reengage in meaningful occupations, manage their stroke experience, and move positively through recovery.

A Qualitative Study on the Transition Support Needs of Indigenous Australians Following Traumatic Brain Injury

Objective:

A growing body of qualitative literature globally describes post-hospital experiences during early recovery from a traumatic brain injury. For Indigenous Australians, however, little published information is available. This study aimed to understand the lived experiences of Indigenous Australians during the 6 months post-discharge, identify the help and supports accessed during transition and understand the gaps in service provision or difficulties experienced.

Methods and Procedure:

Semi-structured interviews were conducted at 6 months after hospital discharge to gain an understanding of the needs and lived experiences of 11 Aboriginal and Torres Strait Islander Australians who had suffered traumatic brain injury in Queensland and Northern Territory, Australia. Data were analysed using thematic analysis.

Results:

Five major themes were identified within the data. These were labelled ‘hospital experiences’, ‘engaging with medical and community-based supports’, ‘health and wellbeing impacts from the injury’, ‘everyday living’ and ‘family adjustments post-injury’.

Conclusions:

While some of the transition experiences for Indigenous Australians were similar to those found in other populations, the transition period for Indigenous Australians is influenced by additional factors in hospital and during their recovery process. Lack of meaningful interaction with treating clinicians in hospital, challenges managing direct contact with multiple service providers and the injury-related psychological impacts are some of the factors that could prevent Indigenous Australians from receiving the supports they require to achieve their best possible health outcomes in the long term. A holistic approach to care, with an individualised, coordinated transition support, may reduce the risks for re-admission with further head injuries.

Beyond Broken Bodies and Brains: A Mixed Methods Study of Mental Health and Life Transitions After Brain Injury

Purpose: Clients with an acquired brain injury (ABI) are at risk of mental health problems and it has been argued that transitions throughout the rehabilitation process are a challenge for rehabilitation practice; however, the link between transitions and psychosocial outcome has been under-researched. Therefore, this study aims to (1) investigate the status of clients with moderate or severe ABI two-year post-discharge on the following outcomes variables: Physical and cognitive function, depression, quality of life, civil and work status, (2) examine correlations between these outcomes and (3) explore through qualitative interviews the subjective experiences of individuals with ABI in order to increase our understanding of clients’ perspectives on this outcome and its relation to life transitions in a two-year period.

Method: 37 individuals aged 18–66 with moderate or severe ABI were interviewed two years after discharge. At this time, they also completed standard measures of depression (MDI), quality of life (WHOQOL-bref) and functional independence (FIM™). Historical data of their FIM™ status at discharge were obtained for comparison.

Results: We found psychological problems two years post-hospitalization, especially depression (35.1%) and decreased psychological QOL (61%). Analysis of interviews found six main factors perceived as important for psychosocial outcome: family relations, return to work, waiting lists, psychological support, fatigue and personal competences.

Conclusions: Clients’ status two years post-hospitalization is often characterized by psychological problems. Based on clients’ accounts, we found a connection between psychosocial outcome and life transition experiences and developed a model of factors that are perceived as helping and hindering positive outcome.

Communicating information and professional knowledge in acquired brain injury rehabilitation trajectories - a qualitative study of physiotherapy practice

Purpose: The communication of information and professional knowledge is paramount during patient transitions, and conveying practice knowledge is an important part of the health professional's role. Physiotherapy interventions in both specialist and primary health care are often necessary to aid persons in rehabilitation following an acquired brain injury (ABI). The aim of this study was to investigate how physiotherapists experience the way patient information is communicated across health care levels in ABI rehabilitation.Methods: We performed interviews with a total of 19 physiotherapists related to the rehabilitation trajectories of 10 people with acquired brain injuries. We performed a systematic text condensation analysis informed by constructionist and interactionist perspectives and theories of learning.Results: The physiotherapists in this study considered the patients to be complex and resource intensive. Written information upon hospital discharge was necessary but not sufficient, and they emphasized the need for verbal communication and closer collaboration across health care levels and clinical settings.Conclusions: The findings in this study indicate the need to improve routines for the communication of information and to clarify issues related to economy and responsibilities. Collaboration across health care levels require reciprocal understanding of the contextual differences in rehabilitation trajectories.Implications for rehabilitationThe discharge process is an important arena for continuous development of collaborative practices in the neurological rehabilitation context.Rehabilitation trajectories should be customized for the specific patient in a manner that is closely connected to contextual limitations and affordances.Communication between health care professionals in the transitional phase of rehabilitation trajectories is important to identify altered prerequisites for providing rehabilitation services in the primary care context.

Family members' experience with in-hospital health care after severe traumatic brain injury: a national multicentre study

BACKGROUND

Family member's experience and satisfaction of health care in the acute care and in-patient rehabilitation are important indicators of the quality of health care services provided to patients with severe traumatic brain injury (TBI). The objective was to assess family members' experience of the health care provided in-hospital to patients with severe TBI, to relate experiences to family member and patient demographics, patients' function and rehabilitation pathways.

METHODS

Prospective national multicentre study of 122 family members of patients with severe TBI. The family experience of care questionnaire in severe traumatic brain injury (FECQ-TBI) was applied. Independent sample t-tests or analysis of variance (ANOVA) were used to compare the means between 2 or more groups. Paired samples t-tests were used to investigate differences between experience in the acute and rehabilitation phases.

RESULTS

Best family members` experience were found regarding information during the acute phase, poorest scores were related to discharge. A significantly better care experience was reported in the acute phase compared with the rehabilitation phase (p < 0.05). Worst family members` experience was related to information about consequences of the injury. Patient's dependency level (p < 0.05) and transferral to non-specialized rehabilitation were related to a worse family members` experience (p < 0.01).

CONCLUSIONS

This study underscores the need of better information to family members of patients with severe TBI in the rehabilitation as well as the discharge phase. The results may be important to improve the services provided to family members and individuals with severe TBI.

What is Known About Transitional Living Services for Adults With an Acquired Brain Injury? A Scoping Review

Transitional living service (TLS) programmes for adults with an acquired brain injury are considered an important part of rehabilitation. However, considerable variability exists in the design and structure of these services, with limited research to guide the development of a programme based on best evidence. A scoping literature review was completed to answer the question ‘What is known about TLS programmes for adults with an acquired brain injury?’ Four electronic databases were systematically searched, followed by a grey literature search (from 1996 to 2015). 3183 articles were screened and 13 articles were included in the final review. Themes that emerged from the literature include the types of residents using TLS programmes, the subjective experience of residents and staff, intervention approaches, programme staffing, and programme outcomes. The research reviewed supports the use of TLS programmes to maximise functional independence and community integration of individuals with an acquired brain injury. Clinical practise recommendations were developed to help support implementation of TLS programmes based on best evidence, these included: to use multiple outcome measures, implement collaborative goal setting, support generalisation of skills learnt in the TLS to the home environment and for eligibility criteria for these programmes to include individuals across all phases of recovery.

Bio-psycho-social effects of a coordinated neurorehabilitation programme: A naturalistic mixed methods study

PURPOSE

Best practice guidelines for neurorehabilitation recommend coordinated rehabilitation programmes to ensure seamless service transitions and comprehensive rehabilitation practices. However, this recommendation for practice and the evidence informing its advancement is based on unexamined assumptions. Therefore, this study investigates bio-psycho-social outcomes and perceptions of a coordinated rehabilitation programme.

METHOD

In a prospective, naturalistic mixed methods study, rehabilitation outcomes for 82 adults (18-66 years) with moderate to severe acquired brain injury were investigated. Clients who received the coordinated rehabilitation programme KORE (n = 27) were compared to clients from the same area who received standard rehabilitation prior to the implementation of the KORE programme (n = 37) and clients who received other coordinated efforts elsewhere (n = 18). The study employed quantitative data from standardized tests (Functional Independence Measure, Major Depression Inventory, Quality of life, and Impact on Participation and Autonomy Questionnaire, as well as information on return to work and qualitative interviews with clients (n = 82) and their relatives (n = 40).

RESULTS

Outcomes did not improve from hospital discharge to two years later. Notably, physiological recovery had probably been achieved to the extent possible, but depression and reduced psychological well-being remained prevalent across groups. Qualitative interviews suggested several barriers to improvement, such as identity dilemmas and unmet needs for psychological support, while rehabilitation services focused on physical and practical training.

CONCLUSION

Coordinated interventions do not guarantee comprehensive rehabilitation and better outcomes for clients with acquired brain injury. Psychological support seems to be important and largely unaddressed.

An Item Bank to Measure Systems, Services, and Policies: Environmental Factors Affecting People With Disabilities

OBJECTIVES

To develop a measure of perceived systems, services, and policies facilitators (see Chapter 5 of the International Classification of Functioning, Disability and Health) for people with neurologic disabilities and to evaluate the effect of perceived systems, services, and policies facilitators on health-related quality of life.

DESIGN

Qualitative approaches to develop and refine items. Confirmatory factor analysis including 1-factor confirmatory factor analysis and bifactor analysis to evaluate unidimensionality of items. Rasch analysis to identify misfitting items. Correlational and analysis of variance methods to evaluate construct validity.

SETTING

Community-dwelling individuals participated in telephone interviews or traveled to the academic medical centers where this research took place.

PARTICIPANTS

Participants (N=571) had a diagnosis of spinal cord injury, stroke, or traumatic brain injury. They were 18 years or older and English speaking.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

An item bank to evaluate environmental access and support levels of services, systems, and policies for people with disabilities.

RESULTS

We identified a general factor defined as "access and support levels of the services, systems, and policies at the level of community living" and 3 local factors defined as "health services," "community living," and "community resources." The systems, services, and policies measure correlated moderately with participation measures: Community Participation Indicators (CPI) - Involvement, CPI - Control over Participation, Quality of Life in Neurological Disorders - Ability to Participate, Quality of Life in Neurological Disorders - Satisfaction with Role Participation, Patient-Reported Outcomes Measurement Information System (PROMIS) Ability to Participate, PROMIS Satisfaction with Role Participation, and PROMIS Isolation.

CONCLUSIONS

The measure of systems, services, and policies facilitators contains items pertaining to health services, community living, and community resources. Investigators and clinicians can measure perceptions of systems, services, and policies resources reliably with the items described here. Moderate relations between systems, services, and policies facilitators and PROMIS and CPI variables provide support for the measurement and theory of environmental effects on social functioning related to participation.

Holistic Practice in Traumatic Brain Injury Rehabilitation: Perspectives of Health Practitioners

Given that the literature suggests there are various (and often contradictory) interpretations of holistic practice in brain injury rehabilitation and multiple complexities in its implementation (including complex setting, discipline, and client-base factors), this study aimed to examine the experiences of practitioners in their conceptualization and delivery of holistic practice in their respective settings. Nineteen health practitioners purposively sampled from an extensive Brain Injury Network in Queensland, Australia participated in individual interviews. A systematic text analysis process using Leximancer qualitative analysis program was undertaken, followed by manual thematic analysis to develop overarching themes. The findings from this study have identified several items for future inter-professional development that will not only benefit the practitioners working in brain injury rehabilitation settings, but the patients and their families as well.