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

From Hospital to Home: Validating a Cognitive-Functional Evaluation of Elders (COFEE-HD)

Background. Increase in hospitalizations of older adults emphasizes the need for efficient hospital discharge planning to enable optimal reentry upon returning home. Yet few assessments offer an extensive picture of the older adult's functional-cognitive state. A comprehensive assessment for discharge planning together with a written summary can be beneficial to the older adult and family. Purpose. This quantitative study compared a modified version of a previously validated tool COFEE (cognitive OT functional evaluation of elders), for use in the hospital, HD (hospital discharge) with standard hospitals assessments. Methods. Of the 77 participants recruited in hospital, home assessments were conducted 4 months later on 64 participants. Findings. The COFEE-HD scores (physical functioning, personal and environmental safety and meta cognitive functioning) were significantly correlated with standard hospital measures and with the home assessment. Implications. The COFEE-HD was found to have a high level of validity in a hospital setting, and the resulting evaluation can provide important insights into function, safety and cognitive function for post-discharge behaviors.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

An Early Screening Tool for Discharge Planning Shortened Length of Hospital Stay for Elderly Patients with Community-Acquired Pneumonia

Background

Community-acquired pneumonia is one of the most common diseases in elderly persons and usually results in a prolonged hospital stay. Discharge planning plays an important role in reducing the length of hospitalization. This study was designed to determine whether early screening for risk factors for delayed discharge could improve the quality of discharge planning.

Methods

This retrospective, observational study was conducted in two medical facilities from January 2016 to December 2018. Hospital A used a screening tool on admission (screening group): screening for risk factors for delayed discharge and initiating discharge planning immediately for those for whom it was applicable, and discharge planning in the stable phase for those for whom it was not applicable; and Hospital B initiated discharge planning without screening (usual group). Propensity score-matched pneumonia patients in the two groups were then compared. The primary outcome was length of hospital stay.

Results

A total of 648 patients were enrolled in this study. After adjusting for age, sex, aspiration, comorbidity, pneumonia severity index, and key person, 118 pairs underwent analysis. Length of stay was significantly different (20 days vs 13 days, p<0.001) between the groups. There were no differences in duration of antibiotic treatment, in-hospital mortality, and 30-day readmission (9 days vs 9 days, p=0.744; 10 (8.5%) vs 10 (8.5%), p=1.000; 10 (8.5%) vs 9 (7.6%), p=0.811, respectively).

Conclusion

Early screening for delayed discharge improved the quality of discharge planning by reducing the length of stay in pneumonia patients.

Bibliometric Analysis on Research Trend of Accidental Falls in Older Adults by Using Citespace-Focused on Web of Science Core Collection (2010-2020)

The present study aimed to identify the trends in research on accidental falls in older adults over the last decade. The MeSH (Medical Subject Headings) and entry terms were applied in the Web of Science Core Collection. Relevant studies in English within articles or reviews on falls in older adults were included from 2010 to 2020. Moreover, CiteSpace 5.6.R5 (64-bit) was adopted for analysis with scientific measurements and visualization. Cooper Cyrus, Stephen R Lord, Minoru Yamada, Catherine Sherrington, and others have critically impacted the study of falls in older adults. Osteoporosis, dementia, sarcopenia, hypertension, osteosarcopenia, traumatic brain injury, frailty, depression, and fear of falling would be significantly correlated with falls in older adults. Multiple types of exercise can provide effective improvements in executive cognitive performance, gait performance, quality of life, and can also lower the rates of falls and fall-related fractures. Fall detection, hospitalization, classification, symptom, gender, and cost are the current research focus and development direction in research on falls in older adults. The prevention of falls in older adults is one of the most important public health issues in today’s aging society. Although lots of effects and research advancements had been taken, fall prevention still is uncharted territory for too many older adults. Service improvements can exploit the mentioned findings to formulate policies, and design and implement exercise programs for fall prevention.

Supporting at-risk older adults transitioning from hospital to home: who benefits from an evidence-based patient-centered discharge planning intervention? Post-hoc analysis from a randomized trial

BACKGROUND

Subgroups of older patients experience difficulty performing activities of daily living (ADL) following hospital discharge, as well as unplanned hospital readmissions and emergency department (ED) presentations. We examine whether these subgroups of "at-risk" older patients benefit more than their counterparts from an evidence-based discharge planning intervention, on the following outcomes: (1) independence in ADL, (2) participation in life roles, (3) unplanned re-hospitalizations, and (4) ED presentations.

TRIAL DESIGN AND METHODS

This study used data from a randomized control trial involving 400 hospitalized older patients with acute and medical conditions, recruited through 5 sites in Australia. Participants receive either HOME, a patient-centered discharge planning intervention led by an occupational therapist; or a structured in-hospital consultation. HOME uses a collaborative approach for goal setting and includes pre and post-discharge home visits as well as telephone follow-up. Characteristics associated with higher risks of adverse outcomes were recorded and at-risk subgroups were created (mild cognitive impairment, walking difficulty, comorbidity, living alone and no support from family). Independence in ADL and participation in life roles were assessed with validated questionnaires. The number of unplanned re-hospitalizations and ED presentations were extracted from medical files. Linear regression models were conducted to detect variation in response to the intervention at 3-months, according to patients' characteristics.

RESULTS

Analyses revealed significant interaction effects for intervention by cognitive status for unplanned re-hospitalization (p = 0.003) and ED presentations (p = 0.021) at 3 months. Within the at-risk subgroup of mild cognitively impaired, the HOME intervention significantly reduced unplanned hospitalizations (p = 0.027), but the effect did not reach significance in ED visits. While the effect of HOME differed according to support received from family for participation in life roles (p = 0.019), the participation observed in HOME patients with no support was not significantly improved.

CONCLUSIONS

Findings show that hospitalized older adults with mild cognitive impairment benefit from the HOME intervention, which involves preparation and post-discharge support in the environment, to reduce unplanned re-hospitalizations. Improved discharge outcomes in this at-risk subgroup following an occupational therapist-led intervention may enable best care delivery as patients transition from hospital to home.

TRIAL REGISTRATION

The trial was registered before commencement (ACTRN12611000615987).

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

INTRODUCTION

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

METHOD

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

RESULTS

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

CONCLUSION

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

The use of the functional independence measure in elderly

OBJECTIVES

To analyze in scientific publications how the Functional Independence Measure (FIM) has been employed to evaluate the elderly.

METHODS

Integrative review of periodical publications between 2011 and 2015, available online in full-text in Portuguese, English and Spanish.

RESULTS

129 articles were found; after the application of the criteria, they resulted in 21. The studies were categorized into two groups: A) follow or compare scores in FIM (cohort studies, case-control, clinical trials), focusing on rehabilitation, evaluation of programs and changes in the functional level after procedures/interventions; and B) measure/associate the functionality of the elderly (cross-sectional studies), focused on evaluation protocols in elderly health and associations to the caregiver burden, hospital stay, balance, satisfaction with life, cognition and clinical/socio-demographic aspects.

CONCLUSION

The FIM was used in several scenarios of healthcare for the elderly, particularly in rehabilitation and outpatient clinics or health centers.

A trial based economic evaluation of occupational therapy discharge planning for older adults: the HOME randomized trial

OBJECTIVE

To compare the cost effectiveness of two occupational therapy-led discharge planning interventions from the HOME trial.

DESIGN

An economic evaluation was conducted within the superiority randomized HOME trial to assess the difference in costs and health-related outcomes associated with the enhanced program and the in-hospital consultation. Total costs of health and community service utilization were used to calculate incremental cost-effectiveness ratios, activities of daily living and quality-adjusted life years.

SETTING

Medical and acute care wards of Australian hospitals ( n=5).

SUBJECTS

A total of 400 people ≥ 70 years of age.

INTERVENTIONS

Participants were randomized to either (1) an enhanced program (HOME), involving pre/post discharge visits and two follow-up phone calls, or (2) an in-hospital consultation using the home and community environment assessment and the Lawton Instrumental Activities of Daily Living assessment.

MAIN MEASURES

Nottingham Extended Activities of Daily Living (global measure of activities of daily living) and SF-12V2, transformed into SF-6D (quality-adjusted life year) measured at baseline and three months post discharge.

RESULTS

The cost of the enhanced program was higher than that of the in-hospital consultation. However, a higher proportion of patients showed improvement in activities of daily living in the enhanced program with an incremental cost-effectiveness ratio of $61,906.00 per person with clinically meaningful improvement.

CONCLUSION

Health services would not save money by implementing the enhanced program as a routine intervention in medical and acute care wards. Future research should incorporate longer time horizons and consider which patient groups would benefit from home visits.

Occupational Therapy Predischarge Home Visits in Acute Hospital Care: A Randomized Trial

OBJECTIVES

To determine whether an enhanced occupational therapy discharge planning intervention that involved pre- and postdischarge home visits, goal setting, and follow-up (the HOME program) would be superior to a usual care intervention in which an occupational therapy in-hospital consultation for planning and supporting discharge to home is provided to individuals receiving acute care.

DESIGN

Randomized controlled trial.

SETTING

Acute and medical wards.

PARTICIPANTS

Individuals aged 70 and older (N = 400).

MEASUREMENTS

Primary outcomes: activities daily living (ADLs; Nottingham Extended Activities of Daily Living) and participation in life roles and activities (Late Life Disability Index (LLDI)).

RESULTS

Occupational therapist recommendations differed significantly between groups (P < .001) (HOME n = 892 recommendations; control n = 329 recommendations). There was no difference between groups in ADLs (Nottingham Extended Activities of Daily Living scale (NEADL): β = -0.17, 95% confidence interval (CI) = -0.99-0.66) or participation (LLDI-Frequency: β = -0.23, 95% CI = -2.05-1.59; LLDI-Limitation: β = -0.14, 95% CI = -2.86-2.58). Both groups maintained prehospital functional status at 90 days, and there was no difference between groups in the number of people with unplanned readmissions (HOME 23.5%, n = 43; control 21.9%, n = 37). When groups were combined, being male (P = .03) or having lower perceived participation because of physical problems (P = .04) resulted in higher risk of unplanned readmissions.

CONCLUSION

HOME discharge planning, which had a strong emphasis on task modification, well-being, and prevention strategies, implemented twice as many occupational therapy recommendations as the in-hospital only consultation, which had a greater emphasis on equipment provision, but HOME did not demonstrate greater benefit in global measures of ADLs or participation in life tasks than in-hospital consultation alone. It is not recommended that home visits be conducted routinely as part of discharge planning for acutely hospitalized medical patients. Further work should develop guidelines for quality in-hospital consultation.