Consensus on 'core/essential' and 'ideal world' criteria of a pre-discharge occupational therapy home assessment

Effect of occupational therapy home visit discharge planning on participation after stroke: protocol for the HOME Rehab trial

INTRODUCTION

After first stroke, the transition from rehabilitation to home can be confronting and fraught with challenges. Although stroke clinical practice guidelines recommend predischarge occupational therapy home visits to ensure safe discharge and provision of appropriate equipment, there is currently limited evidence to support this recommendation.

METHODS AND ANALYSIS

The HOME Rehab trial is a national, multicentre, phase III randomised controlled trial with concealed allocation, blinded assessment and intention-to-treat analysis being conducted in Australia. The trial aim is to determine the effect and potential cost-effectiveness of an enhanced occupational therapy discharge planning intervention that involves pre and postdischarge home visits, goal setting and occupational therapy in the home (the HOME programme) in comparison to an in-hospital predischarge planning intervention. Stroke survivors aged ≥45 years, admitted to a rehabilitation ward, expected to return to a community (private) dwelling after discharge, with no significant prestroke disability will be randomly allocated 1:1 to receive a standardised discharge planning intervention and the HOME programme or the standardised discharge planning intervention alone. The primary outcome is participation measured using the Nottingham Extended Activities of Daily Living. Secondary outcome areas include hospital readmission, disability, performance of instrumental activities of daily living, health-related quality of life, quality of care transition and carer burden. Resources used/costs will be collected for the cost-effectiveness analysis and hospital readmission. Recruitment commenced in 2019. Allowing for potential attrition, 360 participants will be recruited to detect a clinically important treatment difference with 80% power at a two-tailed significance level of 0.05.

ETHICS AND DISSEMINATION

This study is approved by the Alfred Health Human Research Ethics Committee and site-specific ethics approval has been obtained at all participating sites. Results of the main trial and the secondary endpoint of cost-effectiveness will be submitted for publication in peer-reviewed journalsTrial registration numberACTRN12618001360202.

An exploratory study of discharge planning home visits within an Irish context – investigating nationwide practice and nationwide perspectives

Purpose

Discharge planning home visits (DPHVs) are a routine part of occupational therapy clinical practice. However, there is a dearth of evidence to support or refute their efficacy and limited policies or standards to guide clinical practice. This study aims to investigate current clinical practice during home visits and the value that occupational therapists’ attribute to home visits within an Irish context.

Design/methodology/approach

Data collection was carried out by using a survey questionnaire (postal and electronic options). The study population comprised occupational therapists across 52 sites including acute, rehabilitation and convalescence settings within the Republic of Ireland. In total, 122 occupational therapists that completed the survey questionnaire were recruited for the study.

Findings

Quantitative data identified time spent per visit, departmental size, hospital size, number of visits and report writing times. Information was gathered regarding clinical areas assessed during visits in a Likert scale format. Qualitative data identified benefits, risks, recommendations to improve home visit practice and clinical criteria for home visits. Findings conclude that DPHVs are routinely carried out by occupational therapists and that there is consistency in clinical practice within an Irish setting. Occupational therapists value home visits as clinical assessments and have identified risks during practice, benefits of visits and ways to improve practice.

Originality/value

This study has provided a reflection of clinical practice in the Republic of Ireland. It is the only study of its kind in an Irish setting, and it could be used as a knowledge base regarding current practice on DPHV and occupational therapists’ clinical reasoning regarding home visits. The information gathered in this study could influence policies regarding DPHV and could serve as a comparison to standardise practice and justify the need for DPHV.

Pre-discharge home visits: A qualitative exploration of the experience of occupational therapists and multidisciplinary stakeholders

INTRODUCTION

The evidence base surrounding occupational therapy pre-discharge home visits discusses current practices, potential beneficial outcomes and limitations. However, research is limited, regarding how clinical teams determine which patients receive this service. This study aims to explore perceptions of occupational therapists and multidisciplinary stakeholders concerning pre-discharge home visits through their experiences and current practice in the Australian context.

METHOD

A qualitative descriptive approach, using thematic analysis, was employed. Four focus groups were included, comprising 27 health professionals: novice occupational therapists (n = 6), experienced occupational therapists (n = 8), occupational therapy managers (n = 5), and multidisciplinary team members (n = 8).

RESULTS

Three key themes relating to pre-discharge home visits in clinical practice emerged. The first theme of 'Recognition of Clinical Factors' reflected that aspects of the person's occupational performance, environmental and care needs, were prime indicators considered for a pre-discharge home visit. Secondly, 'Contextual and Pragmatic Influences', described clinical setting realities as being significant considerations and strongly mediating practice. A third theme of 'Perceptions of Value' showed awareness of the utility of pre-discharge home visits, while also recognising need to enhance ongoing practice.

CONCLUSION

This qualitative study provides information on factors influencing decision-making regarding pre-discharge home visits from the hospital setting. Clinical factors were presented as key considerations, but clinicians' experiences and perceptions of contextual influences suggest an explanatory factor for practice variation. While multidisciplinary stakeholders' broadly demonstrated similar rationales for pre-discharge home visits as those of occupational therapists, therapists' decision-making processes for pre-discharge home visits were shaped by their experience level. Clinicians' experience finds pre-discharge home visits to have value and in the absence of clear evidence-based criteria for whom this element of practice should be provided, participants supported the development of a decision-making support tool to assist in decision-making.

Factors influencing occupational therapy home visit practice: a qualitative study

BACKGROUND

Home visits prior to discharge from hospital are an integral part of both occupational therapy practice and the discharge process. However, there is remarkably little understanding as to why they occur in practice and who is thought to best benefit from a home visit. The aims of this research were to explore occupational therapists' perceptions of home visits and to ascertain their clinical reasoning in respect of conducting home visits. Thematic analysis was used to analyse the data.

RESULTS

The research revealed two different types of home visits: one with the patient and one without the patient. Both types aimed to enhance the discharge process. The key deciding factors for the chosen type of home visit were time issues and available resources. The therapist's justification for a home visit was also associated with the patient's living arrangements, impairments, and level of functioning. Occupational therapists rarely consulted patients about their preferred type of visit.

CONCLUSION

This study is the first to identify therapists' reasoning between two types of home visits that occur in practice. Future trials are imperative to ascertain which visit is more effective in terms of both patient outcomes and cost effectiveness.

TRialing individualized interventions to prevent functional decline in at-risk older adults (TRIIFL): study protocol for a randomized controlled trial nested in a longitudinal observational study

BACKGROUND

Functional decline (FD) is a largely preventable feature of aging, characterized as gradual erosion of functional autonomy. This reduces an older person's capacity for safe, independent community living. The healthcare needs of an unprecedented aging population places pressure on health systems to develop innovative approaches to ensuring older people live healthy and independent lives for as long as possible. TRIIFL aims to demonstrate that: 1. Incipient FD in older people can be identified using a simple telephone-screening process within four weeks of discharge from an emergency department presentation for a minor health event; and 2. Early engagement into a person-centered individualized intervention arrests or reduces the rate of FD over the next 12 months.

METHODS/DESIGN

A randomized controlled trial (RCT) nested within a 13-month longitudinal cohort study. The RCT (conducted over 12 months) tests the effectiveness of a novel, early, home-based, personalized program (compared with no intervention) in arresting or slowing FD. TRIIFL focuses on older adults living independently in the community, who have not yet had a serious health event, yet are potentially on the cusp of FD. Participants in the longitudinal cohort study will be recruited as they present to one large tertiary hospital Emergency Department, providing they are not subsequently admitted to a ward. Sample size calculations indicate that 570 participants need to be recruited into the longitudinal study, with 100 participants randomized into the trial arms. Measures from all subjects will be taken face-to-face at baseline (recruitment), then subsequently by telephone at one, four, seven and thirteen months later. Measures include functional abilities, quality of life, recent falls, mobility dependence, community supports and health service usage. Specific to the nested RCT, the quality of life tool (SF12) applied at one month, will identify individuals with low mental component quality of life scores, who will be invited to enter the RCT.Assessors will be blinded to RCT arm allocation, and subjects in the RCT will be blinded to the intervention being received by other subjects.

TRIALS REGISTRATION

Australian & New Zealand Clinical Trials Registry: ACTRN12613000234718.

Occupational therapy discharge planning for older adults: a protocol for a randomised trial and economic evaluation

BACKGROUND

Decreased functional ability is common in older adults after hospitalisation. Lower levels of functional ability increase the risk of hospital readmission and nursing care facility admission. Discharge planning across the hospital and community interface is suggested to increase functional ability and decrease hospital length of stay and hospital readmission. However evidence is limited and the benefits of occupational therapists providing this service has not been investigated.This randomised trial will investigate the clinical effectiveness of a discharge planning program in reducing functional difficulties of older adults post-discharge. This trial will also examine the cost of the intervention and cost effectiveness when compared to in-hospital discharge planning.

METHODS/DESIGN

400 participants admitted to participating hospitals will be recruited. Participants will be 70 years of age and over, have no significant cognitive impairment and be independently mobile at discharge. This study protocol was approved by the ethics committee of Ryde Rehabilitation Human Research Ethics Committee, Western Sydney Local Health District (Westmead Campus) Human Research Ethics Committee, Alfred Health Human Research ethics committee for the randomised trial and NSW Population and Health Service Human Research Ethics Committee for data linkage. Participants will provide informed written consent.Participants will be randomly allocated to the intervention or control group. The intervention group will receive discharge planning therapies primarily within their home environment while the control group will receive an in-hospital consultation, both provided by trained occupational therapists. Primary outcome measures will be the Nottingham Extended Activities of Daily Living Scale (NEADL) and the Late Life Disability Index (LLDI) which will measure functional independence, and participation and limitation in daily life activities.

DISCUSSION

This trial will investigate the effectiveness and cost effectiveness of occupational therapy discharge planning in reducing functional difficulties. Results will have a direct impact on healthcare practice and policy.

TRIAL REGISTRATION

ACTRN12611000615987.