Early supported discharge following mild stroke: a qualitative study of patients' and their partners' experiences of rehabilitation at home

Experiences and needs of older patients with stroke in China involved in rehabilitation decision-making: a qualitative study

BACKGROUND

Shared decision-making is recommended for stroke rehabilitation. However, the complexity of the rehabilitation modalities exposes patients to decision-making conflicts, exacerbates their disabilities, and diminishes their quality of life. This study aimed to explore the experiences and needs of older patients with stroke in China during rehabilitation decision-making, providing a reference for developing decision-support strategies.

METHODS

A qualitative phenomenological design was used to explore the experiences and needs of older patients with stroke in China. Purposive sampling was used to recruit 31 older Chinese patients with stroke. The participants participated in face-to-face, semi-structured, and in-depth interviews. Data were analyzed using inductive thematic analysis.

RESULTS

The key themes identified include (1) mixed feelings in shared decision-making, (2) multiple barriers hinder the possibility of participating in shared decision-making, (3) Delegating rehabilitation decisions to surrogates, (4) gaps between reality and expectation, and (5) decision fatigue from lack of continuity in the rehabilitation health care system.

CONCLUSIONS

Older patients with stroke in China have complex rehabilitation decision-making experiences and needs and face multiple obstacles when participating in shared decision-making. They lack an effective shared decision-making support system to assist them. Providing patients with comprehensive support (such as emotional and informational), strengthening the construction of a continuous rehabilitation system, alleviating economic pressure, and promoting patient participation in rehabilitation decision-making are necessary.

Physiotherapists' and occupational therapists' experiences with cross-sectoral coordination of rehabilitation for people with mild stroke - a qualitative interview study

PURPOSE

To meet the needs of people with mild stroke, multidisciplinary, person-centred, cross-sectoral rehabilitation is internationally recommended. However, there seem to be gaps in the rehabilitation process. The aim of this study was to investigate how occupational therapists and physiotherapists experience working in cross-sectoral rehabilitation for people with mild stroke.

MATERIALS AND METHODS

Data were generated through interviews with occupational therapists and physiotherapists working in four different Danish rehabilitation settings. Four group interviews and two individual interviews with a total of 19 participants were conducted. Ricoeur's theory of interpretation was used to interpret and discuss the data.

RESULTS

Four themes were identified: the risk of overlooking symptoms: better safe than sorry; varying degrees of involvement of people with mild stroke; spontaneous involvement of relatives; and contextual challenges for coherence in the rehabilitation process.

CONCLUSION

The therapists experienced challenges in coordinating rehabilitation across sectors due to the timing of the needs assessment and contextual challenges. They used a preventive strategy of sending a plan or referral for later re-assessment. The therapists involved people with mild stroke to varying degrees. They involved relatives spontaneously. For successful rehabilitation, ongoing assessment, recognition of collaboration factors and relative involvement are essential.

Coming home in the context of very early supported discharge after stroke - An interview study of patients' experiences

OBJECTIVES

To explore patients' experiences of coming home and managing everyday life within the context of very early supported discharge after stroke (VESD).

STUDY DESIGN

An explorative qualitative study using semi structured interviews.

METHOD

This study was nested within a randomised controlled trial,; Gothenburg Very Early Supported Discharge (GOTVED), comparing a home rehabilitation intervention given by a coordinated team (VESD) with conventional care. Eleven participants with a median age 70.0 years (range 63-95) of which nine scoring 0-4 on the NIHSS indicating no symptoms or minor stroke were interviewed on average 12 days after discharge. Data was analysed using thematic analysis.

RESULTS

The diversity of patients' experiences was reflected in the overarching main theme Very Early Supported Discharge after stroke - a multifaceted experience, built upon five themes: "Conditions surrounding the discharge", "Concerns about the condition", "Confronting a new everyday life", "Experiences of the intervention" and the "Role of next of kin".

CONCLUSIONS

The respondents were largely satisfied with the very early supported discharge which might be expected, given that it was well planned regarding timing, individualisation and content. The patients need to be aware of the purpose of the VESD intervention. Due to the unpredictability of the stroke and its consequences, interventions need to be flexible. Goal setting is important but must be comprehensible. The role and burden of next of kin should be addressed and negotiated, and the ending of the intervention must be planned, with seamless transition to further rehabilitation and social support including the issue of participation in everyday life.

Experiences with hospital-to-home transitions: perspectives from patients, family members and healthcare professionals. A systematic review and meta-synthesis of qualitative studies

PURPOSE

Multiple studies have explored the needs and experiences of patients, family members, and healthcare professionals regarding hospital-to-home transitions. Our study aimed to identify, critically appraise, and summarize these studies in a qualitative meta-synthesis.

MATERIALS AND METHODS

Medline, CINAHL and Embase were systematically searched to identify eligible articles from inception to June 2024. Qualitative studies were included and critically appraised using the Critical Appraisal Skills Program. Insufficient-quality papers were excluded. We performed a meta-synthesis following (1) open coding by two independent researchers and (2) discussing codes during reflexivity meetings.

RESULTS

Ninety-eight studies were appraised, of which 53 were included. We reached thematic saturation, four themes were constructed: (1) care coordination and continuity, (2) communication, (3) patient and family involvement, and (4) individualized support and information exchange. For patients and families, tailored information and support are prerequisites for a seamless transition and an optimal recovery trajectory after hospital discharge. It is imperative that healthcare professionals communicate effectively within and across care settings to ensure multidisciplinary collaboration and care continuity.

CONCLUSIONS

This study identifies essential elements of optimal transitional care. These findings could be supportive to researchers and healthcare professionals when (re)designing transitional care interventions to ensure care continuity after hospital discharge.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Rural caregivers' preparedness for detecting and responding to the signs of worsening health conditions in recently hospitalised patients at risk for readmission: a qualitative descriptive study

OBJECTIVES

This study aimed to explore informal rural caregivers' perceived preparedness to detect and respond to the signs of worsening health conditions in patients recently discharged from hospital and at risk for readmission.

DESIGN

A qualitative descriptive design and semistructured interviews were used. Data were thematically analysed.

SETTING

Data collection occurred in 2018 and 2019 in rural communities in Southwestern and Northeastern Ontario, Canada.

PARTICIPANTS

The study included sixteen informal caregivers who were all family members of a relative discharged from hospital at high risk for readmission following hospitalisation mostly for a medical illness (63%). Participants were mostly women (87.5%), living with their relative (62.5%) who was most often a parent (56.3%).

RESULTS

Three themes were identified: (1) warning signs and rural communities, (2) perceived preparedness, and (3) improving preparedness. The first theme elucidates informal caregivers' view that they needed to be prepared because they were taking over care previously provided by hospital healthcare professionals yet lacked accessible medical help in rural communities. The second theme captures informal caregivers' perceptions that they lacked knowledge of how to detect warning signs and how to respond to them appropriately. The last theme illuminates informal caregivers' suggestions for improving preparation related to warning signs.

CONCLUSIONS

Informal caregivers in rural communities were largely unprepared for detecting and responding to the signs of worsening health conditions for patients at high risk for hospital readmission. Healthcare professionals can anticipate that informal caregivers, particularly those whose relatives live far from medical help, need information on how to detect and respond to warning signs, and may prioritise their time to this aspect of postdischarge care for these caregivers.

Virtual Multidisciplinary Stroke Care Clinic for Community-Dwelling Stroke Survivors: A Randomized Controlled Trial

BACKGROUND

Stroke survivors constantly feel helpless and unprepared after discharge from hospitals. More flexible and pragmatic support are needed for their optimized recovery. We examined the effects of a virtual multidisciplinary stroke care clinic on survivors' health and self-management outcomes.

METHODS

A randomized controlled trial was conducted. Survivors were recruited from 10 hospitals and randomized at 1:1 ratio into the intervention or the control groups. Intervention group participants received the Virtual Multidisciplinary Stroke Care Clinic service (monthly online consultations with a nurse, follow-up phone calls, and access to an online platform). Control group participants received the usual care. Outcomes of self-efficacy (stroke self-efficacy questionnaire; primary), self-management behaviors (Stroke Self-Management Behaviors Performance Scale), social participation (reintegration to normal living index), and depression (Geriatric Depression Scale; secondary) were measured at baseline, and 3 and 6 months after commencing the intervention (post-randomization). A generalized estimating equations model was used to compare the differential changes in outcomes at 3 and 6 months with respect to baseline between 2 groups.

RESULTS

Between July 2019 and June 2022, 335 eligible participants were enrolled in the study. Participants (intervention group; n=166) showed significantly greater improvements in outcomes of self-efficacy (group-by-time interaction regression coefficient, B=4.60 [95% CI, 0.16 to 9.05]), social participation (B=5.07 [95% CI, 0.61 to 9.53]), and depression (B=-2.33 [95% CI, -4.06 to -0.61]), and no significant improvement in performance of self-management behaviors (B=3.45, [95% CI, -0.87 to 7.77]), compared with the control group (n=169) right after the intervention (6 months after its commencement). Hedges' g effect sizes of the intervention on outcomes: 0.19 to 0.36.

CONCLUSIONS

The results provide some positive evidence on the usefulness of the Virtual Multidisciplinary Stroke Care Clinic service. The effect sizes are regarded as small to medium, which may not be of clinical relevance. The baseline levels in outcomes were in favor of the control group, the intervention effects might be overestimated. The service must be tested further to determine its effectiveness.

REGISTRATION

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR1800016101.

Effect of very early supported discharge versus usual care on activi-ties of daily living ability after mild stroke: a randomized controlled trial

OBJECTIVE

To examine the ability to perform basic and instrumental activities of daily life after very early supported discharge vs usual discharge and referral routine during the first year after mild stroke.

DESIGN

A secondary analysis of data from the Gothenburg Very Early Supported Discharge randomized controlled trial.  Patients: A total of 104 patients (56% men; mean (standard deviation) age 75 (11) years) who had experienced a first stroke classified as mild.

METHODS

The primary outcome was the Activities of Daily Living Taxonomy score. Stroke Impact Scale (activities of daily living, and mobility) scores was a secondary measure. Patients were randomized to either very early supported discharge with 4 weeks of home rehabilitation provided by a multidisciplinary stroke team, or a control group discharged according to usual routine (referral to primary care when needed). Assessments were performed at discharge, 4 weeks post-discharge, and 3 and 12 months post-stroke.

RESULTS

Instrumental activities of the Activities of Daily Living Taxonomy scores (the lower the better) in the very early supported discharge and control groups were median 4 and 6 (p = 0.039) at 4 weeks post-discharge and 3 and 4.5 (p = 0.013 at 3 months post-stroke, respectively. Stroke Impact Scale (Mobility) median scores (the higher the better) in the very early supported discharge and control groups at 3 months were 97 and 86 (p = 0.040), respectively. There were no group differences in the 2 outcomes at 12 months post-stroke.

CONCLUSION

Compared with usual discharge routine, team-based rehabilitation during the first month at home is beneficial for instrumental activity in the subacute phase, in patients with mild stroke. One year post-stroke both groups show equal results.

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.

Informal Caregiver Stroke Program in Geriatric Rehabilitation of Stroke Patients: A Qualitative Study

This study aimed to understand and gain insight into an informal caregiver program for caregivers of older stroke patients, which incorporates both skills training and education, in relation to caregiver burden. Semi-structured, in-depth interviews with individual informal caregivers were conducted at admission, at discharge, and six weeks after discharge. The program consisted of informal caregiver meetings, walk-in days, psychoeducation, and weekend leave after admission to a rehabilitation stroke unit in a nursing home. Eleven informal caregivers participated in the study. The informal caregiver meetings and walk-in days provided more insight into the (level of) functioning of the stroke patients, more skills in guiding them, and better communication with the multidisciplinary care team. During weekend leave, caregivers experienced what their roles as caregivers entailed. Six weeks after discharge, caregivers said that they did not miss any guidance during admission and that they were positive about the future. About half of the caregivers found the caregiver situation disappointing, and combining care tasks with daily tasks appeared to be difficult. Offering informal caregivers a tailor-made program during rehabilitation and good communication helps to diminish caregiver burden in the post-discharge phase when their relatives are back home.

A qualitative evidence synthesis exploring people after stroke, family members, carers and healthcare professionals' experiences of early supported discharge (ESD) after stroke

OBJECTIVE

Early supported discharge (ESD) after stroke has been shown to generate significant cost savings and reduce both hospital length of stay, and long-term dependency. This study aimed to systematically review and synthesise qualitative studies of the experiences and views of ESD from the perspective of people after stroke, their family members, carers and healthcare professionals.

METHOD

A systematic search of eleven databases; CINAHL, PubMed Central, Embase, MEDLINE, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journal, The Cochrane Library, PsycARTICLES and SCOPUS, was conducted from 1995 to January 2022. Qualitative or mixed methods studies that included qualitative findings on the perspectives or experiences of people after stroke, family members, carers and healthcare professionals of an ESD service were included. The protocol was registered with the Prospero database (Registration: CRD42020135197). The methodological quality of studies was assessed using the 10-item CASP checklist for qualitative studies. Results were synthesised using Thomas and Harden's three step approach for thematic synthesis.

RESULTS

Fourteen studies were included and five key themes were identified (1) ESD eases the transition home, but not to community services, (2) the home environment enhances rehabilitation, (3) organisational, and interprofessional factors are critical to the success of ESD, (4) ESD is experienced as a goal-focused and collaborative process, and (5) unmet needs persisted despite ESD.

CONCLUSION

The findings of this qualitative evidence synthesis highlight that experiences of ESD were largely very positive. The transition from ESD to community services was deemed to be problematic and other unmet needs such as information needs, and carer support require further investigation.

Factors that influence the provision of home-based rehabilitation services for people needing rehabilitation: a qualitative evidence synthesis

BACKGROUND

To increase people's access to rehabilitation services, particularly in the context of the COVID-19 pandemic, we need to explore how the delivery of these services can be adapted. This includes the use of home-based rehabilitation and telerehabilitation. Home-based rehabilitation services may become frequently used options in the recovery process of patients, not only as a solution to accessibility barriers, but as a complement to the usual in-person inpatient rehabilitation provision. Telerehabilitation is also becoming more viable as the usability and availability of communication technologies improve.

OBJECTIVES

To identify factors that influence the organisation and delivery of in-person home-based rehabilitation and home-based telerehabilitation for people needing rehabilitation.

SEARCH METHODS

We searched PubMed, Global Health, the VHL Regional Portal, Epistemonikos, Health Systems Evidence, and EBM Reviews as well as preprints, regional repositories, and rehabilitation organisations websites for eligible studies, from database inception to search date in June 2022.  SELECTION CRITERIA: We included studies that used qualitative methods for data collection and analysis; and that explored patients, caregivers, healthcare providers and other stakeholders' experiences, perceptions and behaviours about the provision of in-person home-based rehabilitation and home-based telerehabilitation services responding to patients' needs in different phases of their health conditions.   DATA COLLECTION AND ANALYSIS: We used a purposive sampling approach and applied maximum variation sampling in a four-step sampling frame. We conducted a framework thematic analysis using the CFIR (Consolidated Framework for Implementation Research) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach.  MAIN RESULTS: We included 223 studies in the review and sampled 53 of these for our analysis. Forty-five studies were conducted in high-income countries, and eight in low-and middle-income countries. Twenty studies addressed in-person home-based rehabilitation, 28 studies addressed home-based telerehabilitation services, and five studies addressed both modes of delivery. The studies mainly explored the perspectives of healthcare providers, patients with a range of different health conditions, and their informal caregivers and family members.  Based on our GRADE-CERQual assessments, we had high confidence in eight of the findings, and moderate confidence in five, indicating that it is highly likely or likely respectively that these findings are a reasonable representation of the phenomenon of interest. There were two findings with low confidence. High and moderate confidence findings Home-based rehabilitation services delivered in-person or through telerehabilitation  Patients experience home-based services as convenient and less disruptive of their everyday activities. Patients and providers also suggest that these services can encourage patients' self-management and can make them feel empowered about the rehabilitation process. But patients, family members, and providers describe privacy and confidentiality issues when services are provided at home. These include the increased privacy of being able to exercise at home but also the loss of privacy when one's home life is visible to others.  Patients and providers also describe other factors that can affect the success of home-based rehabilitation services. These include support from providers and family members, good communication with providers, the requirements made of patients and their surroundings, and the transition from hospital to home-based services. Telerehabilitation specifically Patients, family members and providers see telerehabilitation as an opportunity to make services more available. But providers point to practical problems when assessing whether patients are performing their exercises correctly. Providers and patients also describe interruptions from family members.  In addition, providers complain of a lack of equipment, infrastructure and maintenance and patients refer to usability issues and frustration with digital technology. Providers have different opinions about whether telerehabilitation is cost-efficient for them. But many patients see telerehabilitation as affordable and cost-saving if the equipment and infrastructure have been provided. Patients and providers suggest that telerehabilitation can change the nature of their relationship. For instance, some patients describe how telerehabilitation leads to easier and more relaxed communication. Other patients describe feeling abandoned when receiving telerehabilitation services.  Patients, family members and providers call for easy-to-use technologies and more training and support. They also suggest that at least some in-person sessions with the provider are necessary. They feel that telerehabilitation services alone can make it difficult to make meaningful connections. They also explain that some services need the provider's hands. Providers highlight the importance of personalising the services to each person's needs and circumstances.

AUTHORS' CONCLUSIONS

This synthesis identified several factors that can influence the successful implementation of in-person home-based rehabilitation and telerehabilitation services. These included factors that facilitate implementation, but also factors that can challenge this process. Healthcare providers, program planners and policymakers might benefit from considering these factors when designing and implementing programmes.

Experiences of individuals with acquired brain injury and their families interacting with community services: a systematic scoping review

PURPOSE

This scoping review aims to (1) synthesise the research findings on the experiences of individuals with acquired brain injuries, and their families, when interacting with, or accessing, community-based services and (2) identify where gaps in service provision may exist and their cause.

METHODS

A systematic search strategy was employed across multiple databases to identify all studies relating to the experiences of individuals with acquired brain injuries and their families when interacting with, or accessing, community-based services. Inclusion was assessed by at least two reviewers at each stage and data extraction was completed by one researcher and validity checked by another. A narrative synthesis was employed.

RESULTS

A total of 101 papers met the inclusion criteria with the narrative synthesis identifying three main themes of (1) unmet needs, (2) types of access, and (3) barriers to access.

CONCLUSIONS

The results identify that those with acquired brain injuries, and their families, experience significant difficulties interacting with community-based services and often do not receive appropriate access. Many barriers to access were identified including a lack of knowledge of the long-term effects of acquired brain injury amongst professionals working in health and social care services.Implications for rehabilitationBrain injury is a leading cause of disability worldwide with a range of physical, cognitive, emotional, and behavioural difficulties.It is important that service users and families are given appropriate information about the long-term difficulties associated with ABI so they are better informed about the types of support they may need upon discharge from hospital.Rehabilitation professionals need to ensure they have good level of knowledge of the difficulties associated with ABI to ensure appropriate access to services for individuals and their families.Understanding more about unmet needs allows community rehabilitation services to be tailored and person-centred.

How is the environment integrated into post-stroke rehabilitation? A qualitative study among community-dwelling persons with stroke who receive home rehabilitation in Sweden

Studies have shown a need to consider environmental factors to best support the rehabilitation and recovery process after a stroke. In addition, despite intentions to increase individuals' participation in care and rehabilitation, patients and family members report weak participation. The aim of this study was to explore how the environment was integrated into rehabilitation at home from the perspective of patients after a stroke. We conducted as a qualitative study with 17 patients rehabilitated at home. Data on the participants' experiences of the rehabilitation process and their perceptions of how the environment was considered in the process were collected via interviews and analysed using qualitative content analysis. The main category that was constructed from the data was "Partial integration of person- environment dynamics in the rehabilitation", which was informed by three subcategories: (a) I recover in my home: Challenges and opportunities in the environment, (b) Following a generic approach to therapy: Limited integration of the environment, and (c) Informed more than involved. Our study showed that the environment was integrated in a limited manner. The participants were more informed about than involved in their planning of the rehabilitation. The results are important for informing the ongoing development of rehabilitation at home and person-centred care strategies.

Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study

Background

In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway.

Objectives

To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness.

Design

A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes.

Setting and interventions

Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England.

Participants

Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services.

Data and main outcome

Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness.

Results

A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway.

Limitations

Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory.

Conclusions

The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness.

Trial registration

Current Controlled Trials ISRCTN15568163.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.

"They Know Me and My Situation-Patients' and Spouses' Perceptions of Person-Centered Care in Hospital-at-Home Care"

Realization of person-centered care (PCC) is contextual. How is it perceived at hospital-at-home? Pairwise telephone interviews of patients (n = 27) and their spouses (n = 18) emerged in 4 themes. Care was found to be person-centered when both the principles and activities that underpin the concept PCC were realized.

Self-Management in Stroke Survivors: Development and Implementation of the Look after Yourself (LAY) Intervention

Objective: Self-management is recommended in stroke rehabilitation. This report aims to describe timing, contents, and setting of delivery of a patient-centered, self-management program for stroke survivors in their early hospital rehabilitation phase: the Look After Yourself (LAY) intervention. Methods: After extensive literature search, the LAY intervention was developed by integrating the Chronic Disease Self-Management Program, based on the self-efficacy construct of social cognitive theory, with evidence-based key elements and input from stroke survivors. Results: the LAY intervention aims to implement self-management skills in stroke survivors, enabling them to be active in goal setting and problem solving using action plans and to facilitate the critical transition from hospital to community. It includes both group sessions to facilitate sharing of experiences, social comparison, vicarious learning, and increase motivation and one-to-one sessions focused on setting feasible action plans and on teaching personalized strategies to prevent falls. Standardization is ensured by manuals for facilitators and patients. Conclusion: The LAY intervention is the first Italian program to support early self-management in stroke rehabilitation; it has been experimented and its efficacy proven in improving self-efficacy, mental health, and activities of daily living, and detailed results have been published. The LAY intervention is described according to the TIDieR checklist.

Enablers and barriers in hospital-to-home transitional care for stroke survivors and caregivers: A systematic review

AIMS AND OBJECTIVES

To synthesise qualitative research evidence on the experience of stroke survivors and informal caregivers in hospital-to-home transitional care.

BACKGROUND

Due to a shortened hospital stay, stroke survivors/caregivers must take over complex care on discharge from hospital to home. Gaps in the literature warrant a meta-synthesis of qualitative studies on perceived enablers and barriers during this crucial period.

DESIGN

A systematic review and meta-synthesis.

METHODS

A review was guided by Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) checklist where six databases were searched from April to June 2020 including CINAHL Plus, MEDLINE, PsycINFO, Scopus, Web of Science and ProQuest and ProQuest Dissertations and Theses. There was no date limit to the search. Selected studies were critically appraised. A thematic synthesis approach was applied.

RESULTS

The synthesis of 29 studies identified three major findings. First, partnerships with stroke survivors/caregivers empower discharge preparation, foster competence to navigate health and social care systems and activate self-management capabilities. Second, gaps in discharge planning and the lack of timely postdischarge support contribute to unmet care needs for stroke survivors/caregivers and affect their ability to cope with poststroke changes. Third, stroke survivors/caregivers expect integrated transitional care that promotes shared decision-making and enables long-term self-management at home.

CONCLUSIONS

Hospital-to-home transition is a challenging period in the trajectory of poststroke rehabilitation and recovery. Further research is required to deepen understandings of all stakeholders' views and address unmet needs during transitional care.

RELEVANCE TO CLINICAL PRACTICE

Protocols and clinical guidelines relating to discharge planning and transitional care need to be reviewed to ensure partnership approach with survivors/caregivers in the design and delivery of individualised transitional care. Stroke nurses are in a unique position to lead timely support for survivors/caregivers and to bridge service gaps in hospital-to-home transitional care.

Stroke survivors' experiences with rebuilding life in the community and exercising at home: A qualitative study

Aim

This study aimed to explore how stroke survivors deal with stroke‐related impairments when rebuilding their lives in the community and their experiences of exercising at home.

Design

An explorative and descriptive qualitative study.

Methods

A purposive sample of ten stroke survivors residing at home was recruited to explore experiences of rebuilding their lives in the community and exercising at home. One focus group interview was conducted followed by semi‐structured interviews. Data were analysed using thematic analysis.

Results

Three main themes were identified: “Framing exercise within the context of everyday life” describes how stroke survivors integrate exercise in everyday activities with varying success and the social importance of exercising; “Managing the challenges of physical impairment” describes the taxing undertakings in daily living, loss of concentration and identity; “Long‐term challenges of everyday life” describes how the stroke survivors manage depression and live with a sense of uncertainty.

Quickly home again: patients' experiences of early discharge after minor stroke

BACKGROUND

Patients with minor stroke experience some of the same issues as patients experiencing stroke of increased severity such as fatigue, anxiety and cognitive symptoms. It is current practice that patients with minor stroke receive accelerated treatment and care, yet studies indicate that patients find it difficult to return to their everyday lives after being discharged. We aimed to explore how patients with minor stroke experience the transitional period from the hospital through the first 2-4 weeks after an accelerated care pathway with discharge within 72 hours after stroke onset.

METHODS

A qualitative study consisting of semi-structured interviews with 11 patients experiencing first-time stroke 2-4 weeks after discharge.

RESULTS

The patients struggled to identify themselves as having had a stroke. They strived to find a new everyday life, but were challenged by existential concerns, mental fatigue and the fear of having a stroke again. Unresolved questions and misunderstandings arose, and the patients expressed a need for health professionals to support them and discuss unclear issues after discharge. Patients searched for others with similar issues in order to find a new sense of self.

CONCLUSION

Patients with minor stroke struggle with everyday life after discharge. There is a need for support after discharge from healthcare professionals with specialised knowledge of stroke. Patients also requested an opportunity to meet other patients with minor stroke.

There Is No Place Like Home: A Survey on Satisfaction and Reported Outcomes of a Home-Based Rehabilitation Program Among Orthopedic Surgery Patients

BACKGROUND

Home-based rehabilitation (HBR) was previously found to be associated with positive outcomes that are equal to inpatient rehabilitation. Few studies have examined the challenges patients are facing during rehabilitation and recovery and their satisfaction from HBR.

OBJECTIVE

The purpose of this study was to examine the overall satisfaction and reported outcomes of HBR.

METHODS

A telephone survey was conducted among 146 orthopedic surgery patients who participated in an HBR program, at the end of the HBR and 6 months after. The questionnaire included information about level of independence, satisfaction from HBR, and difficulties during HBR.

FINDINGS

The overall satisfaction was high (73.1%). Patients reported on improvements in level of independence between the time of hospital discharge, the end of the program (P = .0001), and the 6 months follow-up (P = .004). Long wait for beginning of HBR, being a widower, and residing in a facility or with a nonfamilial caregiver were associated significantly with less general well-being and independence. The repeated measures analysis showed age lower than 71 and private health insurance ownership were associated with a better recovery. The most common difficulties reported were physical difficulties, lack of function, and caregivers' burden.

CONCLUSIONS

Patients and families need more emotional, social, and physical support during HBR. The increase in health services delivered in community settings requires a more clear-cut policy and supervision for HBR and the follow-up services.

A protocol for a qualitative synthesis exploring people with stroke, family members, caregivers and healthcare professionals experiences of early supported discharge (ESD) after stroke

Early supported discharge (ESD) facilitates a person with a stroke to be discharged from the acute hospital environment earlier than conventional care to continue their rehabilitation within the home with members of the multi-disciplinary team. A number of quantitative studies have highlighted benefits of ESD including a reduction in the length of inpatient stay, cost savings, as well as reducing long term dependency. This systematic review and qualitative synthesis explores the perspectives and experiences of those involved in ESD including people with stroke, family members, caregivers as well as the healthcare professionals involved in the delivery of the service. A comprehensive literature search will be completed in the following databases CINAHL, PubMed Central, Embase, Medline, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journals, The Cochrane Library, PsycARTICLES and Scopus. Qualitative or mixed methods studies that include qualitative data on the perspectives and experiences of people with stroke, family members, caregivers and healthcare professionals of an ESD service will be included. Methodological quality will be appraised using the ten-item Critical Appraisal Skills Programme checklist for qualitative research by two independent reviewers with a third reviewer involved should differences of opinion arise. Findings will be synthesised using thematic synthesis.    It is anticipated that the qualitative synthesis will provide a deeper understanding of the experiences of ESD which may serve to inform practice as well as assist in the development of new ESD services. PROSPERO registration: CRD42020135197 - 28/04/2020.

Figuring it out by yourself: Perceptions of home-based care of stroke survivors, family caregivers and community health workers in a low-resourced setting, South Africa

BACKGROUND

In less resourced settings, formal rehabilitation services for stroke survivors were often absent. Stroke survivors were referred to community health workers (CHWs) who were untrained in rehabilitation.

AIM

To describe the experience and perceived needs of stroke survivors, their caregivers and CHWs in a context with limited access to and support from formal rehabilitation services.

SETTING

The Breede Valley subdistrict, Western Cape, South Africa, a rural, less resourced setting.

METHODS

A descriptive exploratory qualitative study. Four focus group interviews were held with purposively selected stroke survivors and caregivers and four with CHWs. A thematic approach and the framework method were used to analyse the transcripts.

FINDINGS

A total of 41 CHWs, 21 caregivers and 26 stroke survivors participated. Four main themes and 11 sub-themes were identified. Because of the lack of knowledge, training and rehabilitation services, the main theme for all groups was having to 'figure things out' independently, with incontinence management being particularly challenging. Secondly was the need for emotional support for stroke survivors and caregivers. Thirdly, contextual factors such as architectural barriers and lack of assistive products negatively impacted care and function. Lastly, the organisation of health and rehabilitation services negatively impacted home-based services and professional support.

CONCLUSIONS

With appropriate training, the CHWs can be pivotal in the training and support of family caregivers and stroke survivors. Care pathways and the role and scope of both CHWs and therapists in home-based stroke rehabilitation should be defined and restructured, including the links with formal services.

Stroke survivors’ occupational performance and cognitive strategy use: A pilot exploration of strengths and difficulties using the Perceive Recall Plan Perform System of Task Analysis

Introduction

The Perceive Recall Plan Perform System of Task Analysis is an ecological assessment of occupational performance and cognitive strategy application. This study aimed to describe occupational performance and cognitive strategies of stroke survivors in an early supported discharge service, compare the assessment with global measures of function and evaluate the feasibility of implementing the assessment in the early supported discharge setting.

Method

This study was a pilot study design and used consecutive sampling. Participants were assessed with the Perceive Recall Plan Perform System of Task Analysis and two global measures: the Functional Independence Measure and the Australian Modified Lawton’s Instrumental Activities of Daily Living Scale. Scores from the Perceive Recall Plan Perform System of Task Analysis were analysed by task mastery, sub-quadrants and quadrants, and correlations between the assessment and global measures were examined.

Findings

In this cohort ( n = 10), the Perceive Recall Plan Perform System of Task Analysis assessment required 47 minutes per task and identified reduced task mastery (mean = 55%, SD = 10%) with common difficulties in the perceive and plan domains. High to moderate correlations were identified between the plan quadrant and global measures ( p < 0.05).

Conclusion

Perceive Recall Plan Perform System of Task Analysis assessment can be successfully implemented by occupational therapists with stroke survivors receiving early supported discharge to measure occupational performance and identify strengths and difficulties in cognitive strategy application.

An integrative review: Challenges and opportunities for stroke survivors and caregivers in hospital to home transition care

AIM

To identify challenges and opportunities for stroke survivors and caregivers in hospital to home transition care.

BACKGROUND

Due to shortened hospital stays, stroke survivors and caregivers must take responsibility for complex care on discharge from hospital to home. Gaps exist in the literature that synthesizes studies on hospital to home transition care.

DESIGN

A systematic integrated review.

DATA SOURCES

Six databases were searched systematically between 18 June 2018 - 31 October 2018 including Medline, CINAHL, Web of Science, ProQuest, Scopus and Science Direct. The search did not have a date limit.

REVIEW METHODS

Studies that met the selection criteria were critically reviewed. Data were extracted from the studies for analyses. A convergent qualitative synthesis approach using inductive thematic synthesis was applied to the review.

RESULTS

The analysis of 23 studies identified three major findings. First, health and social care systems influence transition care by either enabling stroke survivors and caregivers to manage transition care via well-coordinated services or preventing them from accessing services. Second, health professionals' partnership with stroke survivors and caregivers largely decides tailored support for them. Successful partnerships and engagements with stroke survivors and caregivers depend on organizational resources. Third, survivors and caregivers are at different levels of readiness to cope with challenges. Individualized support for them to develop resilience is highly regarded.

CONCLUSION

Stroke survivors and caregivers encounter enormous challenges in self-management of hospital to home transition care. Further research is required to address their expectations of support during transition care.

IMPACT

There is a lack of synthesis of studies on factors affecting hospital to home transition care for stroke survivors. Health and social care system designs, health professionals' commitment to individualized care and the self-management capability of stroke survivors and their caregivers have a profound influence on the transition care experiences.

Occupational engagement following mild stroke in the Australian context using the occupational gaps questionnaire

BACKGROUND

There is a need for research to identify the impact of mild stroke on occupational engagement. The Occupational Gaps Questionnaire (OGQ) measures the difference between a person's actual and preferred occupational engagement.

AIMS/OBJECTIVES

This study aimed to test the feasibility of the English version of the OGQ, and describe occupational gaps of people with mild stroke.

MATERIAL AND METHODS

A mixed methods, cross-sectional study involving 10 people with mild stroke at 1 and/or 9 months after stroke. Quantitative data were summarised descriptively and thematic analysis explored qualitative responses.

RESULTS

Participants reported a mean of 6.7 (SD 5.1) gaps at 1-month and 3.00 (SD 2.1) gaps at 9-months. Outdoor activities, work, sports, and light home and heavy-duty maintenance were identified as gaps at both time-points. Two themes emerged from the qualitative analysis: Drivers of occupation and Occupations can be challenged or enabled. An additional finding in terms of feasibility was drawn from qualitative data: Feasibility of Conducting the OGQ with people with mild stroke.

CONCLUSIONS AND SIGNIFICANCE

The English version of the OGQ was found to be a feasible instrument for identifying occupational gaps following mild stroke and may be suitable to support research and clinical practice with this population.

The lived experience of supporting people with mild stroke

Background: Mild stroke occurrences are rising and in order to comprehensively understand the experience of this health phenomenon, the context in which people with mild stroke live must be explored. Spouses are an important part of the lives of this population, but their experiences are yet to be fully understood.Aims/Objectives: To answer the question: "What is the essence of the mild stroke experience from the perspective of spouses during the first 9-months after acute hospital discharge, in Australia?"Materials and Methods: Qualitative study involving four spouses at 9-months post-acute hospital discharge for their family member. Interpretative phenomenological analysis used to analyze interview transcripts.Results: Two themes identified: (1) Activities gained but time lost, and (2) Small changes but big impacts. The first theme portrays the increase in daily activity that spouses experienced due to caregiving related activities, which impacted on their occupational participation. The second highlights the impact that people with mild strokes' behavioral and emotional changes can have on spouses.Conclusions and Significance: Whilst spouses generally return to their daily routines after a family members' mild stroke, some will experience increased time pressures and occupational disruptions. Health providers should prepare spouses for behavioral and emotional changes in people with mild stroke.

Professional care at home: Patient-centredness, interprofessionality and effectivity? A scoping review

The aim of this scoping review was to describe the state of knowledge on professional care at home with regard to different perspectives on patient-centredness, content of care, interprofessional collaboration, competence framework and effectivity. A scoping review, n = 35 papers, from four databases (EBSCO, CINAHL, Medline, Swemed) were reviewed between May and August 2018 using the terms: hospital-at-home, hospital-in-the-home, advanced home healthcare, hospital-based home care or patient-centered medical home. Criteria for inclusion in this review included full text papers, published between 2001 and 2018, in English, Swedish or Finnish. A descriptive content analysis was conducted. Patient-centredness appears to be one aim of professional care at home, but clarity is lacking regarding patient recruitment and the planning and evaluation of care. Content depends, to a certain degree, on the type of care at home and how it is organised: the more non-acute care needs, the more nurse-coordinated care and family involvement and the less interprofessionality. The competence framework presupposed for care at home was extensive yet not explicit, varying from maturity, clinical experience, collaboration skills, ongoing clinical assessment education to Master's studies or degree. The effectivity of care at home services was discussed in terms of experiential, clinical and economic aspects. Patients and their family caregivers were satisfied with care at home, but there was no consensus on clinical or economic outcomes compared with inpatient care. In the context of professional care at home, there is still a lot to do regarding patient-centredness, patient recruitment, patient and care staff education, the organisation of interprofessional collaboration and the analysis of effectivity.

"Just got to live life as it comes": A case study of the spousal-dyad longitudinal mild stroke transitional experience

Objective: To longitudinally explore the transition home for a spousal dyad following mild stroke, in the context of a mild stroke-specific health service. Research Design: A case study approach, using an Interpretative Phenomenological Analysis (IPA), was identified as suitable for this study, as it enabled the essence of the phenomenon to be examined. Method: Participants were purposively chosen from a Randomised Control Trial (RCT), to reflect the average age, gender and marital status of the mild stroke population. The participants were a male (age 64) and his wife (age 62). Participants received the RCT intervention. Semi-structured interviews were completed separately with participants at 1-, 3-, 6- and 9- months post stroke. Results: Two themes were identified: (1) The Unexpected, Undesirable and Short-Lived, and (2) The New 'Normal'. The first theme reflects the confusion, adjustment and adaptation that occurred for the couple, especially during the first month at home. The second represents the couple's journey back to their everyday lives following hospital discharge, but also the questions and changes that remained present at 9-months post-discharge. Conclusions: Themes demonstrate an ongoing process of adjustment and the contextual nature of the transitional experience. Results also indicate the need to ensure that individuals have access to mild-stroke specific information across the transition continuum.

Understanding the Experience of Early Supported Discharge from the Perspective of Patients with Stroke and Their Carers and Health Care Providers: A Qualitative Review

A systematic review of qualitative studies that examined the experience of early supported discharge (ESD) from the perspective of patients with stroke and their caregivers and health care providers revealed an emphasis on psychosocial aspects-the patient-provider relationship, the value of the home environment, and the ability to tailor treatment to meet patient-oriented goals. Patients, caregivers, and providers stressed the importance of clear and systematic communication throughout the ESD process to support transitions, prevent duplication of services, foster trust in relationships, and ensure that patients and caregivers have the knowledge and skills required to manage a chronic condition long term.

From Hospital to Home to Participation: A Position Paper on Transition Planning Poststroke

Based on a review of the evidence, members of the American Congress of Rehabilitation Medicine Stroke Group's Movement Interventions Task Force offer these 5 recommendations to help improve transitions of care for patients and their caregivers: (1) improving communication processes; (2) using transition specialists; (3) implementing a patient-centered discharge checklist; (4) using standardized outcome measures; and (5) establishing partnerships with community wellness programs. Because of changes in health care policy, there are incentives to improve transitions during stroke rehabilitation. Although transition management programs often include multidisciplinary teams, medication management, caregiver education, and follow-up care management, there is a lack of a comprehensive and standardized approach to implement transition management protocols during poststroke rehabilitation. This article uses the Transitions of Care (TOC) model to conceptualize how to facilitate a comprehensive patient-centered hand off at discharge to maximize patient functioning and health. Specifically, this article reviews current guidelines and provides an evidence summary of several commonly cited approaches (Early Supported Discharge, planned predischarge home visits, discharge checklists) to manage TOC, followed by a description of documented barriers to effective transitions. Patient-centered and standardized transition management may improve community integration, activities of daily living performance, and quality of life for stroke survivors while also decreasing hospital readmission rates during the transition from hospital to home to community.

Professional groups driving change toward patient-centred care: interprofessional working in stroke rehabilitation in Denmark

BACKGROUND

Patient-centred care based on needs has been gaining momentum in health policy and the workforce. This creates new demand for interprofessional teams and redefining roles and tasks of professionals, yet little is known on how to implement new health policies more effectively. Our aim was to analyse the role and capacity of health professions in driving organisational change in interprofessional working and patient-centred care.

METHODS

A case study of the introduction of interprofessional, early discharge teams in stroke rehabilitation in Denmark was conducted with focus on day-to-day coordination of care tasks and the professional groups' interests and strategies. The study included 5 stroke teams and 17 interviews with different health professionals conducted in 2015.

RESULTS

Professional groups expressed highly positive professional interest in reorganised stroke rehabilitation concerning patients, professional practice and intersectoral relations; individual professional and collective interprofessional interests strongly coincided. The corresponding strategies were driven by a shared goal of providing needs-based care for patients. Individual professionals worked independently and on behalf of the team. There was also a degree of skills transfer as individual team members screened patients on behalf of other professional groups.

CONCLUSIONS

The study identified supportive factors and contexts of patient-centred care. This highlights capacity to improve health workforce governance through professional participation, which should be explored more systematically in a wider range of healthcare services.