Bridging gaps across levels of care in rehabilitation of patients with rheumatic and musculoskeletal diseases: Results from a stepped-wedge cluster randomized controlled trial

Use of primary healthcare services before and after specialized rehabilitation and its relation to changes in health and functioning: a longitudinal cohort study

OBJECTIVE

To examine patients' use of primary healthcare (PHC) before and after specialized rehabilitation and its relation with self-reported health and functioning.

DESIGN

Longitudinal cohort study.

PARTICIPANTS

451 rehabilitation patients.

METHODS

Register data were used to measure the frequency of visits to the general practitioner (GP) and physiotherapist (PT) in PHC 3 years before and after rehabilitation. Patients reported health (EQ-VAS) and functioning (SF-36) before rehabilitation and at 1 and 3 years after. Data are described for the total study cohort and subgroups with musculoskeletal disease (MSD) and cardiovascular disease (CVD).

RESULTS

There was an increase in GP and PT visits preceding rehabilitation and a gradual decrease thereafter. An exception was GP visits among patients with CVD, with few diagnosis-specific visits before but an increase after. Lower levels of health and functioning tended to be related to more frequent GP and PT visits. An indication of clinically important improvement was found among those with frequent GP visits in the MSD subgroup, and among those with 1-2 GP visits in the CVD subgroup.

CONCLUSIONS

The diverse relationship between health and functioning, and the use of PHC services at follow-up, may imply that additional factors besides healthcare use explain long-term improvement following rehabilitation.

Examining the Building Blocks of Health Behavior Change in Rheumatology Rehabilitation: A Theory-Driven Qualitative Study

Purpose

To identify and describe behavior change techniques (BCTs) used in rehabilitation for patients with rheumatic and musculoskeletal diseases (RMDs), according to their own perceptions. Further, to examine patients' descriptions of their capability, opportunity, motivation, and readiness for health behavior change.

Patients and Methods

Patients were adults in need of specialized, multidisciplinary rehabilitation services due to inflammatory rheumatic disease, systemic connective tissue disease, or fibromyalgia / chronic widespread pain. Semi-structured interviews of 21 patients were analyzed with deductive qualitative content analysis applying three theoretical frameworks: the Behavior Change Technique Taxonomy, the transtheoretical model and stages of change, and the capability, opportunity, and motivation model of behavior.

Results

Forty-six BCTs aggregated within 14 BCT groups were identified used by either patients, healthcare professionals (HPs), or both. Goals and planning, feedback and monitoring, social support, shaping knowledge, repetition and substitution were most frequently used to facilitate behavior change. Twenty patients had reached the action stage and made specific lifestyle changes concerning more than half of their goals. Concerning other goals, 6 of these patients reported to be contemplating behavior change and 15 to be preparing for it. The rehabilitation process appeared to strengthen capability, opportunity, motivation, and the desired behaviors. Patient-reported barriers to behavior change were connected with restrictions in physical capability resulting from an unpredictable and fluctuating disease course, weakened motivation, and contextual factors, such as lack of access to healthcare support and training facilities, and high domestic care burden.

Conclusion

The rehabilitation process seemed to strengthen individual and contextual prerequisites for behavior change and facilitate the use of required techniques and engagement in the desired behaviors. However, patients with RMDs may need prolonged support from HPs to integrate healthy lifestyle changes into everyday life. The findings can be used to optimize rehabilitation interventions and patients' persistent engagement in healthy behaviors.

Delivery of a quality improvement program in team-based rehabilitation for patients with rheumatic and musculoskeletal diseases: a mixed methods study

PURPOSE

To investigate how a quality improvement program (BRIDGE), designed to promote coordination and continuity in rehabilitation services, was delivered and perceived by providers in routine practice for patients with rheumatic and musculoskeletal diseases.

METHODS

A convergent mixed methods approach was nested within a stepped-wedge, randomized controlled trial. The intervention program was developed to bridge gaps between secondary and primary healthcare, comprising the following elements: motivational interviewing; patient-specific goal setting; written rehabilitation-plans; personalized feedback on progress; and tailored follow-up. Data from health professionals who delivered the program were collected and analyzed separately, using two questionnaires and three focus groups. Results were integrated during the overall interpretation and discussion.

RESULTS

The program delivery depended on the providers' skills and competence, as well as on contextual factors in their teams and institutions. Suggested possibilities for improvements included follow-up with sufficient support from next of kin and external services, and the practicing of action and coping plans, standardized outcome measures, and feedback on progress.

CONCLUSIONS

Leaders and clinicians should discuss efforts to ensure confident and qualified rehabilitation delivery at the levels of individual providers, teams, and institutions, and pay equal attention to each component in the process from admission to follow-up.

Does follow-up really matter? A convergent mixed methods study exploring follow-up across levels of care in rehabilitation of patients with rheumatic and musculoskeletal diseases

PURPOSE

To explore what patients with rheumatic and musculoskeletal diseases (RMDs) need and receive of follow-up care after specialized rehabilitation, and whether received follow-up is associated with health outcomes after 1 year. Further, to compare these findings with patients' experiences to improve the understanding of how follow-up takes place.

METHODS

In a mixed methods study, patients received a rehabilitation programme designed to improve the continuity in rehabilitation across care levels. A total of 168 patients completed questionnaires, of which 21 were also interviewed.

RESULTS

At discharge, most patients reported needs for follow-up. These needs were largely met within 1 year, mainly resulting from patients' initiatives to re-connect with previous contacts. The degree of received follow-up was not associated with goal attainment, quality of life, or physical function. Factors related to providers (competence, communication skills), context (delays, limited access to care), and patients (motivation, life situation, preferences) seemed to be decisive for the progress of the rehabilitation process over time.

CONCLUSIONS

The results provide evidence that access to follow-up care is crucial to patients with RMDs. However, it also highlights several factors that may influence its impact. These results can be used to optimise design and implementation of future follow-up interventions.