A qualitative study of patient-centered goal-setting in geriatric rehabilitation: patient and professional perspectives

"Treat people with human dignity": the perspective of older adults on the quality of geriatric rehabilitation

PURPOSE

The aim of this study was to gain insight into the perspectives of older adults on the quality of geriatric rehabilitation (GR) during the trajectory of GR from admission until six weeks after discharge.

METHODS

We conducted a longitudinal qualitative study. Participants were interviewed three times: at the start of rehabilitation, at discharge, and six weeks after discharge. The data were analysed using a thematic analysis.

RESULTS

In total, 50 interviews were conducted, with 18 participants being interviewed multiple times. The following themes emerged: 1. A bond of trust with health care professionals (HCPs), 2. Being prepared and informed at all stages of GR, 3. Participants emphasise physical and occupational therapy rather than other aspects of care as comprising GR 4. Changing needs regarding (the extent of) involvement in decision-making, 5. Contact with family and peers.

CONCLUSION

For older adults, preparation for and good organisation of rehabilitation and social interaction with HCPs and other older adults were found to be important for the perceived quality of GR. Social interaction is influenced by how HCPs engage with older adults in all the phases of the rehabilitation process. Older adults have varying preferences about involvement in decision-making during GR. These perspectives should be acknowledged and acted upon in clinical practice to further improve the quality of care in GR.

The Role of Neighborhood Socioeconomic Status in Institutionalization of Home Health Care Patients With and Without Alzheimer's Disease and Related Dementias

OBJECTIVES

To assess whether neighborhood socioeconomic status (SES) moderates the association between Alzheimer's disease and related dementias (ADRD) and successful discharge to the community. In addition, to explore whether the role of neighborhood SES on successful discharge for patients with ADRD varies by the severity of ADRD.

DESIGN

This is a retrospective cohort study.

SETTING AND PARTICIPANTS

Medicare Fee-for-service beneficiaries, aged 65 or older, who received home health care in 2019.

METHODS

We used linear probability regression models with successful discharge to the community as the main outcome, and neighborhood SES and ADRD as independent variables. Also, we modified the Functional Assessment Staging Tool (FAST) to measure ADRD severity.

RESULTS

Our study results show ADRD and residing in neighborhoods with lower socioeconomic conditions were independently associated with lower probabilities of successful discharge to the community. We also found that the differences in probabilities of remaining at home between patients with and without ADRD were larger among those in neighborhoods with lower SES (ADRD∗less disadvantaged neighborhood, coeff: -0.01, P < .001; ADRD∗more disadvantaged neighborhood, coeff: -0.02, P < .001; ADRD∗most disadvantaged neighborhood, coeff: 0.032, P < .001). Among patients with ADRD, patients with the most advanced ADRD were less likely to remain in their homes and community when living in neighborhoods with lower SES.

CONCLUSIONS AND IMPLICATIONS

Our study results show that when patients with ADRD receiving home health care live in neighborhoods with lower SES, they face further challenges to remaining in their homes and community. Public health officials and community planners should consider using area-level interventions to improve care and health outcomes for patients with ADRD. Also, further research aimed at identifying the specific factors and resources influencing lower care quality and poorer health outcomes in socioeconomically disadvantaged neighborhoods, particularly for patients with ADRD, can provide valuable insights for the development and implementation of targeted interventions.

Discharge disposition for home health care patients with Alzheimer's disease and related dementia: The role of living arrangements and rural living

PURPOSE

To examine the relationship between living arrangements and discharge disposition, and how this relationship differs by the rural or urban characteristics of the patient's residence among home health care patients with Alzheimer's disease and related dementia (ADRD).

METHODS

This retrospective study used the 2019 Outcome and Assessment Information Set and the Master Beneficiary Summary File. Our study was based on 531,269 Medicare fee-for-service patients with ADRD. We used linear probability regression models to examine the relationship between discharge disposition (to the community vs. an institution) and living arrangements, including an interaction term for rural-urban residence.

FINDINGS

Patients in rural areas (19.8%) were more likely to live alone than those in urban areas (15.2%). Our main results show that patients living at home with others (coefficient: -0.02, p-value < 0.001) or alone (coefficient: -0.03, p-value < 0.001) were less likely to be discharged to the community compared to patients who lived in congregate settings. Also, for patients with ADRD who lived in rural areas, living at home with others (rural*home with others; coefficient: -0.02, p-value < 0.001) or living alone (rural*home alone; coefficient: -0.03, p-value<0.001) were associated with additional lower probabilities of being discharged to their communities.

CONCLUSIONS

A multidimensional approach considering living arrangements to support home health care patients with ADRD could be critical to achieving better health outcomes. Furthermore, implementing area-specific target interventions could be important for improving the care and health of patients with ADRD as well as reducing rural-urban disparities in discharge disposition.

Goal Setting for Participatory Person-Centered Geriatric Rehabilitation-From Function-Centered Rehabilitation towards Digitally Supported Personalized and Integrated Care for Older People

As chronic illness is common among older people, self-care practices for older people are needed to control health status, to prevent possible complications and to ensure optimal quality of life. The literature has demonstrated that integrated care approaches are one key success factor for delivering person-centered and sustainable care for older people, with rehabilitation being a cornerstone in tertiary care prevention for older citizens. The current paper addresses the state of the literature for person-centered geriatric rehabilitation (GR) and the importance of personalized and participatory goal setting. In accordance with the bio-psycho-social model of the International Classification of Functioning, Disability and Health (ICF), social participation and the related goals are of particular importance for the entire rehabilitation process. The social participation of individuals enrolled into GR is therefore one of the milestones to be achieved during GR. Personalized goal setting during the entire rehabilitation process, Comprehensive Geriatric Assessment (CGA) and shared decision making allow a comprehensive care approach separate from solely function-based rehabilitation. The review also focusses on recent developments in digitalization in healthcare and delivers insights into how healthcare professionals' collaborative practice supports sustainable rehabilitation results in patients of advanced chronological age.

Where Patients Live Matter in Emergency Department Visits in Home Health Care: Rural/Urban Status and Neighborhood Socioeconomic Status

An increasing body of evidence highlights the importance of an individual's place of residence on their health and functional outcomes. This study is based on Outcome and Assessment Information Set data to assess the differences in emergency department visits among Medicare home health care patients by patients' residence location (rural/urban status and neighborhood socioeconomic status). Compared to urban patients, a disproportionately higher proportion of rural patients lived in more or most disadvantaged neighborhoods (83.9% vs. 41.3%). Using linear probability regression models, patients in rural areas (coefficient = .02, p < .001) and disadvantaged neighborhoods (less disadvantaged: coefficient = .02, p < .001; more disadvantaged: coefficient = .034, p < .001; most disadvantaged: coefficient = .042, p < .001) were more likely to experience emergency department visits. Policymakers should consider utilizing area-based target interventions to mitigate gaps in home health care. Also, given that the majority of rural patients reside in disadvantaged neighborhoods, neighborhood characteristics should be considered in addressing rural-urban disparities and improving home health care.

Developing an Online Health Community Platform for Facilitating Empowerment in Chronic Disease Prevention and Health Promotion

This study aimed to develop an online health community platform for facilitating the empowerment of people with chronic diseases dwelling in the community regarding disease prevention and health promotion. The user-centered design approach included four main steps: (1) identifying the health problems and needs of target users, (2) developing the content of the platform, (3) constructing the platform, and (4) pilot testing, refinement, and finalization. An online health community platform available both in a mobile application and a Web-enabled application has been launched to facilitate empowerment and self-management by people with chronic conditions. The main components of the application comprised (1) screening for chronic diseases and health problems, (2) setting personal goals for health promotion and action planning to achieve the goals themselves, (3) offering an online health community with shared group goals that help users engage with their peers to attain their goals, and (4) creating one's own online health community and inviting others to participate. The platform has the potential to encourage people with chronic conditions to proactively engage in their own health promotion. Future studies are needed to determine the impact of the application on self-management and empowerment for its users.

Successful Discharge to Community From Home Health Less Likely for People in Late Stages of Dementia

BACKGROUND AND PURPOSE

Several studies have established the efficacy of home health in meeting the health care needs of people with Alzheimer disease and related dementias (ADRD) and helping them to remain at home. However, transitioning to the community after discharge from home health presents challenges to patient safety and quality of life. The severity of an individual's functional impairments, cognitive limitations, and behavioral and psychological symptoms may compound these challenges. The purpose of this study was to examine the association between dementia severity and successful discharge to community (DTC) from home health.

METHODS

This was a retrospective study of 142 376 Medicare beneficiaries with ADRD. Successful DTC was defined as having no unplanned hospitalization or death within 30 days of DTC from home health. Successful DTC rates were calculated, and multilevel logistic regression was used to estimate the relative risk (RR) of successful DTC, by dementia severity category, adjusted for patient and clinical characteristics. Six dementia severity categories were identified using a crosswalk between items on the Outcome and Assessment Information Set and the Functional Assessment Staging Tool.

RESULTS AND DISCUSSION

Successful DTC occurred in 71.2% of beneficiaries. Beneficiaries in the 2 most severe dementia categories had significantly lower risk of successful DTC (category 6: RR = 0.90, 95% CI = 0.889-0.910; category 7: RR = 0.737, 95% CI = 0.704-0.770) than those in the least severe dementia category. The RR of successful DTC for people with ADRD decreased as the level of independence with oral medication management decreased and when there was an overall greater need for caregiver assistance.

CONCLUSIONS

Patient status at the time of admission to home health is associated with outcomes after discharge from home health. Early identification of people in advanced stages of ADRD provides an opportunity to implement strategies to facilitate successful DTC while people are still receiving home care services. The severity of ADRD and availability of caregiver assistance should be key considerations in planning for successful DTC for people with ADRD.

Achieving Functional Goals During a Skilled Nursing Facility Stay: A National Study of Medicare Beneficiaries

OBJECTIVES

The aims of the study are to describe the frequency that functional goals are documented on the Minimum Data Set and to identify resident characteristics associated with meeting or exceeding discharge goals.

METHODS

We selected Medicare fee-for-service beneficiaries admitted to a skilled nursing facility within 3 days of hospital discharge from October 1, 2018, to December 31, 2019 ( N = 1,228,913). The admission Minimum Data Set was used to describe the discharge goal scores for seven self-care and 16 mobility items. We used the eight self-care and mobility items originally included in a publicly reported quality measure to calculate total scores for discharge goals, admission performance, and discharge performance ( n = 371,801).

RESULTS

For all self-care items, more than 70% of residents had a goal score of 1-6 points documented on the admission Minimum Data Set. Chair/bed-to-chair transfer had the highest percentage of residents with a score of 1-6 points (77.1%) and walking up/down 12 steps had the lowest (23.2%). Approximately 44% of residents had a discharge performance score that met or exceeded their goal score. Older age, urinary incontinence, and cognitive impairment had the lowest odds of meeting or exceeding discharge goals.

CONCLUSIONS

Assessing a resident's functional goals is important to providing patient-centered care. This information may help skilled nursing facilities determine whether a resident has made meaningful functional improvements.

Factors influencing interprofessional collaboration in general and during multidisciplinary team meetings in long-term care and geriatric rehabilitation: a qualitative study

BACKGROUND

Interprofessional collaboration is essential to maintain high-quality care in long-term care and geriatric rehabilitation. However, little is known regarding perceived factors influencing interprofessional collaboration by people involved in care. This concerns both long-term care and geriatric rehabilitation. Moreover, knowledge of using patient outcome measures to enhance interprofessional collaboration during multidisciplinary team meetings is insufficient. This study examined the perceived facilitators of and barriers to interprofessional collaboration in general and during multidisciplinary team meetings, specifically according to healthcare professionals, patients, and informal caregivers. Differences between long-term care and geriatric rehabilitation were also investigated. Finally, it was examined which patient outcome measures were used in multidisciplinary team meetings.

METHODS

A constructivist qualitative study using 10 focus groups and 18 semi-structured interviews with 14 patients, 13 informal caregivers,10 managers, and 22 healthcare professionals from eight Dutch long-term care and geriatric rehabilitation facilities. A combined inductive and deductive approach to a thematic analysis was performed.

RESULTS

The perceived influencing factors of interprofessional collaboration were classified into two general themes: (1) 'Involvement of patient, informal caregiver, and healthcare professional', categorised into: 'participation of patients and informal caregivers', 'behaviour and attitude of team members', 'expectations of team members towards each other', and 'exchange of information, knowledge, and reciprocity in communication'; and (2) 'A systematic approach to providing care for older people', consisting of: 'coordination of team procedures', and 'coordination of organisational procedures'. Also, one theme for multidisciplinary team meetings was identified: 'Organised participation of patient, informal caregiver, and healthcare professional in multidisciplinary team meeting, categorised into: 'team procedures', 'working systematically', and 'participation in multidisciplinary team meetings. Standardised patient outcome measures were scarcely used in multidisciplinary team meetings.

CONCLUSION

People involved in long-term care and geriatric rehabilitation indicated that, apart from working systematically, being involved in care and multidisciplinary team meetings are essential factors for interprofessional collaboration. These factors must be taken into consideration to provide valuable, high-quality care to older people residing in long-term care and geriatric.

TRIAL REGISTRATION

Not applicable.

Short-Term, Community-Based, Slow-Stream Rehabilitation Program for Older Adults Transitioning from Hospital to Home: A Mixed Methods Program Evaluation

Introduction

Shortened hospital stays have shifted the burden of care for older adults to community, informal (ie, family, caregiver) and formal post-acute care and services, highlighting the need for effective post-hospital stay services and programs. As there is a dearth of information related to community-based, slow-stream rehabilitation program models for older adults transitioning from hospital to home in the Canadian context, the paper describes a mixed methods evaluation of such a program.

Materials and Methods

A mixed methods program evaluation, with process- and outcome-related elements, included 1) review and analysis of program documents; 2) observations to examine fidelity. Observation data were coded and summarized using descriptive statistics. Coded information and data were compared to document review data; 3) quantitative assessment of pre-post changes in physical, social, and psychological outcome measure and instrument scores using descriptive statistics, paired t-tests and confidence intervals (p = 0.05); and 4) exploration of acceptability through interviews and focus groups with 41 of the older adult participants and 17 family caregivers. Thematic analysis was used to examine focus group and interview transcripts.

Results

Observational data indicated alignment with the program document information overall. Statistically and clinically significant positive trends in improvement for physical outcome measure scores were observed (6-minute Walk Test, Life Space Assessment, Short Physical Performance Battery, Rapid Assessment of Physical Activity). Participants and family caregivers identified several positives and benefits of the program, ie, improvement in physical, social and mental well-being, decreased caregiver burden; and areas for improvement ie, need for more information about the program prior to enrollment and individualization, several of which aligned with the observation and quantitative data.

Discussion/Conclusion

This mixed methods program evaluation provided a detailed description of a community-based, slow-stream rehabilitation program for older adults who are transitioning to home post-hospital stay and its participants. Evidence of program fidelity, acceptability, and positive trends in improvement in physical outcome measure scores were found. Information about program strengths and areas for improvement can be used by stakeholders to inform program refinement and enhancement.

The role of collaborative decision-making in discharge planning: Perspectives from patients, family members and health professionals

AIM

To explore discharge planning with a range of key stakeholders in subacute care, including consumers.

DESIGN

Qualitative descriptive study.

METHODS

Patients (n = 16), families (n = 16), clinicians (n = 17) and managers (n = 12) participated in semi-structured interviews or focus groups. Following transcription, data were analysed thematically.

RESULTS

The overarching facilitator of effective discharge planning was collaborative communication, leading to shared expectations by all stakeholders. Collaborative communication was underpinned by four key themes: patient- and family-centred decision-making, early goal setting, strong inter- and intra-disciplinary teamwork, and robust patient/family education.

CONCLUSION

Effective planning for discharge from subacute care is enabled by shared expectations and collaborative communication between key stakeholders.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Effective discharge planning processes are underpinned by effective inter- and intra-disciplinary teamwork. Healthcare networks should foster environments that promote effective communication between and within multidisciplinary team members as well as with patients and their families. Applying these principles to discharge planning may assist in reducing length of stays and rates of preventable readmissions post-discharge.

IMPACT

This study addressed a lack of knowledge about effective discharge planning in Australian subacute care. It found that collaborative communication between stakeholders was an overarching facilitator of effective discharge planning. This finding impacts subacute service design and professional education.

REPORTING METHOD

COREQ guidelines were followed in reporting this study.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution in the design, data analysis or preparation of the manuscript.

Development of a practical guideline for person centred goal setting in geriatric rehabilitation: a participatory action research

PURPOSE

To improve goal setting in Geriatric Rehabilitation (GR), by developing an evidence-based practical guideline for patient-centred goal setting.

METHODS

Participatory action research (PAR) in a cyclical process, with GR professionals as co-researchers. Each cycle consisted of five phases: problem analysis, literature review, development, practical experience, feedback & evaluation. The evaluation was based on video recordings of goal setting conversations, and on oral and written feedback of the GR professionals who tested the guideline.

RESULTS

In two PAR-cycles the guideline was developed, consisting of eight recommendations for setting and using goals, and of practical advices elaborating three of the recommendations, concerning conversational skills specific for goal setting conversations. After the second cycle the research team concluded that the guideline was feasible in daily practice and effective when used consciously.

CONCLUSION

In this study, a practical guideline for setting and using goals in GR was developed. GR teams can improve their patient centred working with goals by discussing the recommendations in their team and choosing the recommendations to work on. This can be supported by the development of an interdisciplinary training. The effect on quality of care should be subject to further investigation.

Disparities in Successful Discharge to the Community Following Use of Medicare Home Health by Level of Neighborhood Socioeconomic Disadvantage

Considering the importance of social and structural support and resources in recovering health, where people reside could lead to differences in health outcome in Medicare home health care. We used the 2019 Outcome and Assessment Information Set and Area Deprivation Index to examine the association between neighborhood context and successful discharge to community among older Medicare home health care users. Based on the multivariable logistic regression (OR: 0.84; 95% CI, 0.83-0.85) and conditional logistic regression models stratified by home health agency (OR: 0.95; 95% CI, 0.94-0.95), patients living in the most disadvantaged neighborhoods were less likely to experience successful discharge to community than others. Furthermore, the predicted probability of successful discharge to community decreased as the percentage of patients from the most disadvantaged neighborhoods within a home health agency increased. Policymakers should consider using area-level interventions and supports to reduce disparities in Medicare home health care.

The quality of geriatric rehabilitation from the patients' perspective: a scoping review

BACKGROUND

the efficacy and outcomes of geriatric rehabilitation (GR) have previously been investigated. However, a systematic synthesis of the aspects that are important to patients regarding the quality of GR does not exist.

OBJECTIVE

the aim of this scoping review was to systematically synthesise the patients' perspective on the quality of GR.

METHODS

we followed the Scoping Review framework and gathered literature including a qualitative study design from multiple databases. The inclusion criteria were: a qualitative study design; a geriatric population; that patients had participated in a geriatric rehabilitation programme and that geriatric rehabilitation was assessed by the patient. The results sections of the included studies were analysed using a thematic analysis approach.

RESULTS

twenty articles were included in this review. The main themes identified were: (i) the need for information about the rehabilitation process, (ii) the need for telling one's story, (iii) the need for support (physical, psychological, social and how to cope with limitations), (iv) the need for shared decision-making and autonomy, (v) the need for a stimulating rehabilitation environment and (vi) the need for rehabilitation at home.

CONCLUSION

in this study, we identified the aspects that determine the quality of rehabilitation from the patient's perspective, which may lead to a more holistic perspective on the quality of GR.

Person- and family-centred goal-setting for older adults in Canadian home care: A solution-focused approach

Goal-setting with older adults in home care is often inhibited by a lack of structure to support person- and family-centred care planning, paternalistic decision-making and task-oriented delivery models. The objective of this research study was to determine how goal-setting practices for older adults could be re-oriented around individuals' self-perceived goals, needs and preferences. Solution-focused semi-structured key informant interviews were conducted with older adult home care clients aged 65 years and older (n = 13) and their family/friend caregivers (n = 12) to explore changes, solutions and strategies for person- and family-centred goal-setting. Participants were recruited through community advertisement in a single region of Ontario, Canada between July and October of 2017. Interviews were conducted in-person and were audio-recorded and transcribed verbatim. Thematic analysis was guided by a multi-step framework method. Four themes emerged from the data: (1) seeing beyond age enables respect and dignity; (2) relational communication involves two-way information sharing; (3) doing 'with' instead of doing 'for' promotes participation and (4) collaboration is easier when older adults and caregivers lead the way. Older adults and caregivers want to be actively engaged in dialogue during care planning to ensure their preferences are included. The findings from this study add the direct perspectives of older adults and their caregivers to literature on solutions to address ageism, improve communication, enhance information sharing and promote collaboration in geriatric care. Next steps for this work could involve testing the changes, solutions and strategies that emerged to determine the effect on person- and family-centred home care delivery.

‘Is my journey destination home?’ Exploring the experiences of older adults who undertake a transition care programme: a qualitative study

Transition care programmes (TCP) provide older adults with goal-oriented rehabilitation after hospitalisation. However, limited research has focused on understanding older adults' experiences when undertaking TCP. Using a phenomenological approach, we explored the lived experience of older adults undertaking a TCP at a transition care facility in Australia. A purposive sample (N = 33 participants: 16 older adults, four family members and 13 staff) was recruited. Semi-structured interviews were undertaken at three time-points during admission and inductive thematic analysis was utilised. Older adults reflected on their TCP experiences through an emotional lens through which they deliberated, ‘is my destination home?’ Fear of losing independence and uncertainty about their discharge destination strongly influenced older adults' perspectives regarding their TCP experience. Emotional responses, both positive and negative, were influenced by expectations prior to admission, level of family support and staff behaviour. Staff and family concurred that many older adults were confused about their admission to the facility and initially were unprepared to engage in the rehabilitation provided. Older adults experienced TCP as a time of great uncertainty and feared the unknown when discharged from hospital to transition care. They expressed grief at the loss of existing life roles and anxiety about the possibility of being unable to return home. Health professionals need to inform and tailor rehabilitation for older adults to better support this transient time of life.

Ability to Participate in Social Activities of Rheumatoid Arthritis Patients Compared with Other Rheumatic Diseases: A Cross-Sectional Observational Study

OBJECTIVES

To compare the ability to participate in social activities among rheumatoid arthritis patients with other rheumatic disease patients and identify potentially implicated factors.

PATIENTS AND METHODS

Between June and November 2019, we consecutively selected patients aged ≥18 years with RA (defined according to ACR/EULAR 2010), SpA (ASAS/EULAR 2010), and SLE (ACR 1997).

MAIN OUTCOME MEASURES

Ability to participate in social roles and activities evaluated using the PROMIS score v2.0 short-form 8a (PROMIS-APS).

SECONDARY OUTCOMES

Participation in social activities according to a series of variables (mobility, depression, satisfaction with social relationships, social isolation, company, emotional support, instrumental support, and support via information). We evaluated the association between the ability to participate in social activities and associated variables using multivariable linear regression analysis.

RESULTS

The study population comprised 50 patients with RA (33.1%), 51 patients (33.8%) with SpA, and 50 patients (33.1%) with SLE. The mean PROMIS-APS scores were similar in the three groups. The multivariable analysis for the whole sample showed that the ability to participate in social activities was inversely associated with depression and directly with social satisfaction, mobility, company, and age. The stratified analysis revealed an inverse association between inflammatory activity and ability to participate in social activities in patients with RA and SpA, but not in those with SLE.

CONCLUSION

All patients with RA, SpA, and SLE had a similar ability to participate in social activities. This was associated with other psychosocial factors (social satisfaction, mobility, company, depression) and clinical factors (age and inflammatory activity).

Patient experience and satisfaction with admission to an acute geriatric community hospital in the Netherlands: a mixed method study

Purpose

The acute geriatric community hospital (AGCH) in an intermediate care facility is an alternative to conventional hospitalization. A comprehensive geriatric assessment and rehabilitation are integrated into acute medical care for older patients. This study aims to evaluate patient experience and satisfaction with the AGCH.

Design/methodology/approach

This is a mixed method observational study including a satisfaction questionnaire and qualitative interviews with AGCH patients or informal caregivers.

Findings

A total of 152 participants filled in the questionnaire, and thirteen semi-structured interviews were conducted. Twelve categories and four overarching themes emerged in the analysis. In general, study participants experience the admission to the AGCH as positive and are satisfied with the care they received; there were also suggestions for improvement.

Research limitations/implications

Limitations of this study include possible participation bias. The results show that patients value this type of care indicating that it should be implemented elsewhere. Further research will focus on health outcomes, readmission rates and cost effectiveness of the AGCH.

Originality/value

This is the first study to evaluate care satisfaction with the AGCH. It shows that hospitalized older adults positively value the AGCH as an alternative to hospitalization.

Physical Resilience in Daily Functioning Among Acutely Ill Hospitalized Older Adults: The Hospital-ADL Study

OBJECTIVES

Insight into older adults' physical resilience is needed to predict functional recovery after hospitalization. We assessed functional trajectories in response to acute illness and subsequent hospitalization and investigated baseline variables and dynamic variables associated with these trajectories.

DESIGN

Prospective observational cohort study (Hospitalization-Associated Disability and impact on daily Life Study).

SETTING AND PARTICIPANTS

This study included 207 older adults (aged 79.8 ± 6.9 years, 49% female, 57% frail) acutely hospitalized in 6 Dutch hospitals.

METHODS

Functional disability was assessed using the 15-item modified activities of daily living index retrospectively 2 weeks before admission, and prospectively from admission up to 3 months after discharge. Baseline variables including frailty, somatic, physical, and psychosocial factors were assessed at admission. Dynamic variables (step count, pain, fatigue, and fear of falling) were continuously or repeatedly assessed during hospitalization. We performed individual spline modeling using random effects. Baseline variables and within-person mean levels and variability in the dynamic variables were assessed as predictors of functional trajectories.

RESULTS

Functional disability significantly increased before admission and decreased from admission to 3 months post discharge. Frail participants had a significantly higher increase in functional disability before admission compared with nonfrail participants. Lower step count, higher pain scores, and higher within-person variability in fear of falling were significantly associated with higher increase in functional disability before admission. Higher within-person variability in fear of falling was associated with more recovery.

CONCLUSIONS AND IMPLICATIONS

Older adults increase in functional disability before hospitalization and start to recover from admission onward. Frailty and dynamic variables are associated with a higher increase in functional disability after acute illness. Our findings give more insight into older adults' physical resilience, which may improve the prediction of functional recovery and may improve therapeutic decision-making and rehabilitation strategies to improve functional recovery after acute hospitalization.

The Person-Centered Rehabilitation Model: Framing the concept and practice of person-centered adult physical rehabilitation based on a scoping review and thematic analysis of the literature

OBJECTIVE

To develop a cross-professional model framing the concept and practice of Person-Centered Rehabilitation (PCR) in adult populations, based on a scoping review and thematic analysis of the literature.

DATA SOURCES

Key databases (PubMed, Scopus, CINAHL), snowballing searches, and experts' consultation were the data sources for English-language empirical or conceptual papers, published from January 2007 to February 2020.

STUDY SELECTION

Two independent reviewers selected adult-based papers addressing at least one of the six categories of PCR-related content, a priori specified in the published review protocol. From 6527 unique references, 147 were finally included in the analysis. Of those, 26 were exclusively conceptual papers.

DATA EXTRACTION

Two independent reviewers extracted textual data on what PCR entails conceptually or as a practice. No quality appraisals were performed as is typical in scoping reviews.

DATA SYNTHESIS

A thematic analysis produced thematic categories that were combined into an emergent model (the PCR Model), which was reviewed by five external experts. PCR was framed as a way of thinking about and providing rehabilitation services "with" the person. PCR is embedded in rehabilitation structures and practice across three levels: 1) the person-professional dyad, 2) the micro-system level (typically an interprofessional team, involving significant others) and 3) a macro-system level (organization within which rehabilitation is delivered). Thematic categories are articulated within each level, detailing both the conceptual and practice attributes of PCR.

CONCLUSION

The PCR model can inform both clinical and service organization practices. The PCR Model may benefit from further developments including obtaining wider stakeholders' input, determining relevance in different cultural and linguistic groups, and further operationalization and testing in implementation projects.

Mobility and Self-Care are Associated With Discharge to Community After Home Health for People With Dementia

OBJECTIVES

A priority health outcome for patients, families, and the Centers for Medicare & Medicaid Services (CMS) is a patient's ability to return home and remain in the community without adverse events following discharge from post-acute care services. Successful discharge to community (DTC) is defined as being discharged to the community and not experiencing a readmission or death within 30 days of discharge. The objective of this study was to determine the association between patient factors and successful DTC after home health for individuals with Alzheimer's disease and related dementias (ADRD).

DESIGN

This retrospective study derived data from 100% national CMS data files from October 1, 2016, through September 30, 2017.

SETTINGS AND PARTICIPANTS

Criteria from the Home Health Quality Reporting program were used to identify a cohort of 790,439 Medicare home health beneficiaries, 143,164 (18.0%) with ADRD.

MEASURES

Successful DTC rates with associated 95% confidence intervals (CIs) were calculated for each patient characteristic. Multilevel logistic regression was used to estimate the relative risk (RR) of successful DTC after home health, by ADRD diagnosis, mobility, self-care, caregiver support, and medication management, adjusted for patient demographics and clinical characteristics.

RESULTS

Overall, 79.4% of beneficiaries had a successful DTC. Beneficiaries with ADRD had a significantly lower odds of successful DTC than those without ADRD (RR=0.947, 95% CI=0.944-0.950). This association remained significant after adjustment for caregiver support, assistance with medications, independence in mobility, and level of self-care. Greater need for caregiver support, greater need for assistance with medications, greater dependence in mobility, and greater self-care dependence were all associated with decreased risk of successful DTC.

CONCLUSIONS AND IMPLICATIONS

Older adults with ADRD receiving home health had decreased RR of successful DTC. To have a successful DTC, older adults with ADRD need sufficient support from caregivers and independence in functioning.

Goal-setting in geriatric rehabilitation: Can the nursing profession meet patients' needs? A narrative review

STUDY OBJECTIVE

To provide an overview of patients' needs concerning goal-setting, and indications of how those needs can be met by nurses.

METHODS

A narrative review. Pubmed and Cinahl were searched through March 1, 2020 for: patients' experiences concerning goal-setting and the role of nursing in rehabilitation. Additional articles were found through snowballing. A total of 22 articles were reviewed on patients' experiences, and 12 on the nursing role.

RESULTS

Patients need to be prepared for collaborating in goal-setting and to receive an explanation about their part in that process. The multiplicity of disciplines may cloud patients' understanding of the process. The nurse's planning of the rehabilitation process should be aimed at resolving this issue. Goals need to be meaningful, and patients need support in attaining them. The interpretive, integrative, and consoling functions of Kirkevold's nursing role are suitable to meet these needs.

CONCLUSIONS

Both the literature about patients' needs regarding goal-setting and the nursing role make clear that the way nurses work in rehabilitation can gain in clarity. Strengthening the role of nurses will improve the goal-setting process for patients. Interprofessional collaboration, clear work procedures, continuity of care, time and trust, and the physical environment all are important to reinforce this role.

Motivation for Rehabilitation in Patients With Subacute Stroke: A Qualitative Study

Background: Motivation is essential for patients with subacute stroke undergoing intensive rehabilitation. Although it is known that motivation induces behavioral changes toward rehabilitation, detailed description has been lacking. Motivation can be intrinsic or extrinsic; however, it is unclear which type of factors mainly motivates patients' daily rehabilitation.

Purpose: This study aimed to examine the factors influencing patients' motivation and to explore the behavioral changes induced by motivation, especially age-related differences.

Method: Twenty participants (mean age 65.8 years [standard deviation 13.7]) who had a subacute stroke and underwent rehabilitation at a convalescent hospital were recruited using convenience sampling. Semi-structured interviews were conducted by an occupational therapist with an interview topic guide regarding factors influencing motivation and how it affects behavioral change. Interviews were recorded, transcribed to text, and analyzed by three occupational therapists using thematic analysis. The participants were divided into two groups: aged patients (aged ≥ 65 years) and middle-aged patients (aged < 65 years), and data were analyzed according to the groups. This study was conducted according to the consolidated criteria for reporting qualitative research.

Results: Seven core categories were identified as factors influencing patients' motivation: patients' goals, experiences of success and failure, physical condition and cognitive function, resilience, influence of rehabilitation professionals, relationships between patients, and patients' supporters. The first four and last three core categories were further classified as personal and social-relationship factors, respectively. The categories related to intrinsic motivation such as enjoyment of rehabilitation itself were not derived. In both age-groups, motivation affected the frequency of self-training and activity in daily lives. In some aged patients, however, high motivation restrained their self-training to conserve their physical strength for rehabilitation by professionals. Some aged patients do not express their high motivation through their facial expressions and conversations compared to middle-aged patients; therefore, motivation is not always observable in aged patients.

Conclusions: Interventions tailored to extrinsic factors are important for maintaining patients' motivation. Observational evaluation may lead to mislabeling of their motivation, especially for aged patients. Rehabilitation professionals should use validated evaluation scales or patients' narratives to assess patients' motivation.

Conceptualizing the key components of rehabilitation following major musculoskeletal trauma: A mixed methods service evaluation

RATIONALE, AIMS, AND OBJECTIVES

The reorganization of acute major trauma pathways in England has increased survival following traumatic injury, resulting in an increased patient population with diverse and complex needs requiring specialist rehabilitation. However, national audit data indicate that only 5% of patients with traumatic injuries have access to specialist rehabilitation, and there are limited guidelines or standards to inform the delivery of rehabilitation interventions for individuals following major trauma. This group concept mapping project aimed to identify the clinical service needs of individuals accessing our major trauma rehabilitation service, prioritize these needs, determine whether each of these needs is currently being met, and plan targeted service enhancements.

METHODS

Participants contributed towards a statement generation exercise to identify the key components of rehabilitation following major trauma, and individually sorted these statements into themes. Each statement was rated based on importance and current success. Multi-dimensional scaling and hierarchical cluster analysis were applied to the sorted data to produce themed clusters of ideas within concept maps. Priority values were applied to these maps to identify key areas for targeted service enhancement.

RESULTS

Fifty-eight patients and health care professionals participated in the ideas generation activity, 34 in the sorting, and 49 in the rating activity. A 7-item cluster map was agreed upon, containing the following named clusters: Communication and Coordination; Emotional and psychological wellbeing; Rehabilitation environment; Early rehabilitation; Structured therapy input; Planning for home; and Long-term support. Areas for targeted service enhancement included access to timely and adequate information provision, collaborative goal setting, and specialist pain management across the rehabilitation pathway.

CONCLUSION

The conceptual framework presented in this article illustrates the importance of a continuum of rehabilitation provision across the injury trajectory, and provides a platform to track future service changes and facilitate the codesign of new rehabilitation interventions for individuals following major trauma.

Positive Beliefs and the Likelihood of Successful Community Discharge From Skilled Nursing Facilities

OBJECTIVES

To examine the association of patient and direct-care staff beliefs about patients' capability to increase independence with activities of daily living (ADL) and the probability of successful discharge to the community after a skilled nursing facility (SNF) stay.

DESIGN

Retrospective cohort study of SNF patients using 100% Medicare inpatient claims and Minimum Data Set resident assessment data. Linear probability models were used to estimate the probability of successful discharge based on patient and staff beliefs about the patient's ability to improve in function, as well as patient and staff beliefs together. Estimates were adjusted for demographics, health status, functional characteristics, and SNF fixed effects.

PARTICIPANTS

Fee-for-service Medicare beneficiaries (N=526,432) aged 66 years or older who were discharged to an SNF after hospitalization for stroke, hip fracture, or traumatic brain injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Successful community discharge (discharged alive within 90d of SNF admission and remaining in the community for ≥30d without dying or health care facility readmission).

RESULTS

Patients with positive beliefs about their capability to increase independence with ADLs had a higher adjusted probability of successful discharge than patients with negative beliefs (positive, 63.8%; negative, 57.8%; difference, 6.0%, 95% confidence interval [CI], 5.4-6.6). This remained true regardless of staff beliefs, but the difference in successful discharge probability between patients with positive and negative beliefs was larger when staff had positive beliefs. Conversely, the association between staff beliefs and successful discharge varied based on patient beliefs. If patients had positive beliefs, the difference in the probability of successful discharge between positive and negative staff beliefs was 2.5% (95% CI, 1.0-4.0). If patients had negative beliefs, the difference between positive and negative staff beliefs was -4.6% (95% CI, -6.0 to -3.2).

CONCLUSIONS

Patients' beliefs have a significant association with the probability of successful discharge. Understanding patients' beliefs is critical to appropriate goal-setting, discharge planning, and quality SNF care.

Promoting physical activity in geriatric patients with cognitive impairment after discharge from ward-rehabilitation: a feasibility study

The aim of the present study was to examine adherence and acceptance of a home-based program to promote physical activity (PA) in older persons with cognitive impairment (CI) following inpatient rehabilitation. Sixty-three older persons (≥ 65 years) with mild to moderate CI (Mini-Mental State Examination score 17-26), allocated to the intervention group of a randomized, controlled intervention trial underwent a 12-week home-based PA intervention including (1) physical training and outdoor walking to improve functional fitness and (2) motivational strategies (goal-setting, pedometer-based self-monitoring, social support delivered by home visits, phone calls) to promote PA. Training logs were used to assess adherence to physical training, outdoor walking and to motivational strategies (goal-setting, pedometer-based self-monitoring). Acceptance (subjective feasibility and effectiveness) of the program components was assessed by a standardized questionnaire. Mean adherence rates over the intervention period were 63.6% for physical training, 57.9% for outdoor walking, and between 40.1% (achievement of walking goals), and 60.1% (pedometer-based self-monitoring) for motivational strategies. Adherence rates significantly declined from baseline to the end of intervention (T1: 43.4-76.8%, T2: 36.1-51.5%, p values<.019). Most participants rated physical training, outdoor walking, goal-setting, and pedometer self-monitoring as feasible (68.2-83.0%) and effective (63.5-78.3%). Highest ratings of self-perceived effectiveness were found for home visits (90.6%) and phone calls (79.2%). The moderate to high adherence to self-performed physical training and motivational strategies proved the feasibility of the home-based PA program in older persons with CI following inpatient rehabilitation.

Changes in the ability to participate in and satisfaction with social roles and activities in patients in outpatient rehabilitation

BACKGROUND

One of the main aims of rehabilitation is to improve participation. Patient-Reported Outcomes Measurement Information System (PROMIS®) item banks 'Ability to Participate in Social roles and Activities, (PROMIS-APS) and 'Satisfaction with Social Roles and Activities' (PROMIS-SPS) are promising options to measure participation, but the literature on PROMIS measures of (satisfaction with) participation across diagnoses in rehabilitation is limited. Therefore, the objective of this study was to describe levels of and changes in participation, as assessed with the PROMIS-APS and the PROMIS-SPS short forms, of patients in outpatient rehabilitation.

METHODS

This study had quantitative, observational design with assessments at admission and discharge. Consecutive patients treated between April and August 2018 receiving outpatient multidisciplinary rehabilitation were the population of this study. The following diagnosis categories were included: brain injury (e.g. stroke), spinal cord and nerve injury, neuromuscular disorder (e.g. lateral sclerosis), amputation, musculoskeletal condition (e.g. osteoarthritis) or heart or lung disease (e.g. myocardial infarction, chronic obstructive pulmonary disease). The main patient-reported outcomes (PRO) of this study were the short form of the PROMIS-APS (8 items, Dutch general population reference score 50.6 [SD 9.5]), and PROMIS-SPS (8 items, Dutch general population reference score 47.5 [SD 8.3].

RESULTS

Of the 1279 patients invited, 777 (61%) completed the online forms at admission. Of those, 329 patients were invited at discharge, with 209 (64%) completing the forms. The mean (SD) T-scores of the PROMIS-APS and PROMIS-SPS were lower at admission (42.7 [SD 7.4]; (41.4 [SD 7.7]) and discharge (43.6 [SD 7.2]; (43.7 [SD 7.8]) than the Dutch general population. The change scores of the PROMIS-APS and PROMIS-SPS were 1.2 (95% CI 0.4-1.9; p = 0.004; effect size 0.16), and 2.4 (95% CI 1.6-3.2; p < 0.0001; effect size 0.31), respectively. In all diagnostic subgroups with > 30 paired measurements statistically significant improvements of PROMIS-APS, PROMIS-SPS or both were seen.

CONCLUSIONS

Patients undergoing outpatient rehabilitation had, both at admission and discharge, considerably lower PROMIS-APS and PROMIS-SPS T-scores short forms than the general Dutch population, and showed small T-score improvements at discharge.

Motivational factors mediate the association of general self-efficacy and performance outcomes in acutely hospitalised older patients

Objectives

To study (i) the association of general self-efficacy (GSE) on the course of subjective (i.e. basic and instrumental activities of daily living (ADLs and IADLs) and objective physical performance outcomes (short physical performance battery (SPPB)) among older persons from discharge up to 3 months post-discharge and (ii) the extent to whether motivational factors such as depressive symptoms, apathy and fatigue mediate this association.

Methods

Prospective multi-centre cohort of acutely hospitalised patients aged ≥70 (Hospital-ADL study). Structural equation modelling was used to analyse the structural relationships.

Results

The analytic sample included 236 acutely hospitalised patients. GSE had a significant total effect on the course of subjective and objective performance outcomes (ADLs: β = −0.21, P < 0.001, IADLs: β = −0.24, P < 0.001 and SPPB: β = 0.17, P < 0.001). However, when motivational factors as mediator were included into the same model, motivational factors (IADLs: β = 0.51, P < 0.001; SPPB: β = 0.49, P < 0.001) but not GSE remained significantly associated with IADLs (β = −0.06, P = 0.16) and SPPB (β = 0.002, P = 0.97). Motivational factors partially mediated the relationship between GSE and ADLs (β = −0.09, P = 0.04). The percentage of mediation was 55, 74 and 99% for ADLs, IADLs and SPPB, respectively.

Conclusions

Motivational factors and GSE are both associated with subjective and objective performance outcomes. However, the relationship between GSE and subjective and objective performance outcomes was highly mediated by motivational factors. Taken together, this suggests that GSE is important to being physically active but not sufficient to becoming more physical active in acutely hospitalised older patients; motivation is important to improving both subjective and objective performance.

Development and usability of a feedback tool, "My Personal Brain Health Dashboard", to improve setting of self-management goals among people living with HIV in Canada

OBJECTIVE

(1) To develop a personalized health outcome profile as a feedback tool to improve self-management in people living with chronic conditions such as HIV and (2) to evaluate the interpretability and usefulness of the feedback tool for setting specific goals.

METHODS

The development of "My Personal Brain Health Dashboard" was inspired by the knowledge-to-action framework. A health outcome profile was computer generated in SAS from the outcome measures, at first and last recorded visits, of each person enrolled in the +BHN cohort from five sites in Canada. The Wilson-Cleary model framed the outcome measurement strategy. Single actionable items with evidence of life impact were chosen. The response option from the original item was the person's value and the optimal level was provided to help persons compare their results to an optimal target. Cognitive interviews were conducted with members of HIV community. Appropriateness of the Dashboard for goal-setting was tested by asking participants to write specific goals according to the Dashboard they were given.

RESULTS

Fifteen respondents were recruited from Montreal and Vancouver. Items most endorsed to be changed were cognition, pain, and body mass index. 80% found the Dashboard useful for setting health-related goals. A total of 85 goals were set, the text of which was mined to create a lexicon for scoring goal quality in future endeavours.

CONCLUSION

This study was the preparatory phase for a future trial on a method to stimulate setting specific goals. The future trial would provide a thorough understanding of the quality of person-defined goals.

Older Adults' Experiences of Goals in Health: A Systematic Review and Metasynthesis

Objective: To synthesize older adults' experiences and perceptions of goal setting and pursuit within health systems. Methods: Six databases were searched to May 2019 using a combination of MeSH and free text terms. Included papers were written in English and reported original qualitative research for participants aged 65 years and older. Participant quotes from the results sections of included studies were gathered for thematic analysis and synthesis. Results: Initial search yielded 9,845 articles, and 134 were identified for full-text review. Fifteen papers were included in the final synthesis. Two main themes were identified: enablers (intrinsic and extrinsic) and barriers (personal and system). Conclusion: Older adults' self-belief is the strongest enabler for goal activities, enhanced by a personalized coaching approach from health staff. Conversely, inconsistent goal terminology confuses patients and reduces engagement. Likewise, fatigue has profound physical and cognitive impact on patients' ability to engage and participate in goals.

"What would you like to achieve?" Goal-Setting in Patients with Dementia in Geriatric Rehabilitation

BACKGROUND

Setting meaningful, individualized rehabilitation goals is an essential part of the rehabilitation process. Even though patients with dementia are a drastically increasing patient group in geriatric rehabilitation, empirical data about meaningful rehabilitation goals and collaborative goal-setting in this target group is missing. Cognitive impairment and lack of insight in current deficits have been discussed as barriers for participation in goal-setting, but require empirical examination. This study investigated the feasibility of a semi-structured versus a structured goal-setting approach and the types of goals, rehabilitation patients with mild to moderate dementia perceive as personally relevant. Insights in acute functional and motor deficits, differentiated by cognitive status were explored.

METHODS

Cohort study in a geriatric rehabilitation center. Semi-structured and ICF-based, structured interviews were applied to explore patients` rehabilitation goals. Patients` insight in deficits was operationalized as the relationship of self-ratings and objective measures of linked clinical assessments for the same functional construct.

RESULTS

Patients (n = 101, MMSE 22 ± 2.6, age 83.9 ± 5.9 years) stated the improvement of mobility-related functions and self-care activities (> 70%) but also psychological well-being such as handling stress or mood (> 38%) as most important rehabilitation goals. The structured interview facilitated goal-setting and provided a broader view of rehabilitation needs. Correlations between self-ratings and clinical assessments were medium to high (rho = 0.29 to 0.83) with highest associations for key motor features. Trend tests identified a significant trend between values of the clinical assessment and categories of self-ratings (p ≤ 0.01) with lower cognitive status derogating this relationship.

CONCLUSIONS

Collaborative goal-setting was feasible, especially when supported by a structured approach and yielded a large spectrum of functional but also psychological rehabilitation needs from the patients` perspective. Patients showed sustained insight in their actual functional impairments, limited in a subgroup of patients with more advanced cognitive impairment.

Differences in the occupational therapy goals of clients and therapists affect the outcomes of patients in subacute rehabilitation wards: a case-control study

[Purpose] This study aimed to examine the effects of differences in the goals recognized by the client and the occupational therapist on patient outcome. [Participants and Methods] A retrospective case-control study was conducted to compare rehabilitation outcomes of cases wherein the occupational therapy goals were matched/unmatched (control) with those of the patients in seven subacute rehabilitation wards in Japan. The outcomes were Functional Independence Measure, number of days of hospitalization, occupational therapy, and total medical cost. [Results] The motor Functional Independence Measure scores in the matched-goal group were significantly higher than those of the unmatched-goal group, and the home discharge rate showed a tendency to increase. It was speculated whether the client had received an explanation about the goal. [Conclusion] Rehabilitation outcome may vary depending on whether occupational therapy goals are matched.