The effectiveness of predischarge home assessment visits: a systematic review

Effects of Using a Video-Sharing Application on Multidisciplinary Staff During Pre-discharge Home Assessment Visits for Elderly Hospitalized Patients

Background

Pre-discharge home assessment visits for elderly hospitalized patients are conducted by the hospital staff to ensure a smooth transition to home care and are effective in preventing falls and reducing the rehospitalization rates. However, the effect of an application that enables the viewing of videos of the patient's home activities during the pre-discharge visit on the multidisciplinary professionals who provide services to the patient has not yet been fully clarified.

Methods

Multidisciplinary professionals at 23 facilities located in western Tottori Prefecture who used a video-sharing application (Patto-Mie Net) were invited to be interview participants. Those who agreed were interviewed about the usefulness of the application in their work and its effect on multidisciplinary collaboration. A verbatim transcript was made, and thematic analysis was conducted using the qualitative analysis software NVivo.

Results

Twenty-eight people participated in the interviews, including nurses, care managers, rehabilitation specialists, care workers, and other social care professions. Fourteen themes and five categories were generated from the analysis: comprehensive information visualization and transferability, identification of changes over time and prognostic prediction, promoting multidisciplinary collaboration, patient and family reality, and disadvantages and concerns.

Conclusion

The use of an application that allows video-sharing of a patient's home movement status during a pre-discharge visit has revealed a variety of benefits for multiple professionals in hospitals and other facilities. In particular, the results were characterized by the psychological closeness between multiple professionals, promotion of interprofessional communication, and sharing of reality, including the psychosocial background of the patient and family.

Home Assessment Visits within the Acute Setting: a Discussion and Literature Review

The emphasis on the effective and efficient use of finite resources within acute hospitals has led to close attention being paid to the length of patients' hospital stay and the assessment of risk in facilitating timely hospital discharge. Occupational therapy home assessment visits are valued by the multidisciplinary team as a means of assessing a patient's level of function and environmental risk to ensure safe discharge from hospital.

Occupational therapists' education and training and experience mean that they are well placed to predict levels of function postdischarge and to anticipate any problems that may occur in activities of daily living. However, for patients the home assessment visit can be a stressful and bewildering experience. The short-term focus on equipment provision combined with limited postdischarge intervention may not meet patient and carer expectations or concerns with longer-term issues.

Although there is a body of evidence to support this intervention, the requirement for evidence-based practice means that there is a need for additional research around the areas of optimal timing, selection of patient groups, therapist's rationale, patient and carer perspectives and any effect that home assessments may have on readmission rates. This paper discusses the literature in relation to the practice of home assessment visits from the acute setting.

Occupational Therapy Predischarge Home Visits: A Study from a Community Hospital

The characteristics of 79 patients in a community hospital having an occupational therapy home visit during a period of one year were monitored. The processes of the home visit were examined and, in particular, the relationships of diagnosis and overall measures of levels of functioning – the Physical Self-Maintenance (PSM) and Instrumental Activities of Daily Living (IADL) scales – with the recommendations of the occupational therapists were analysed.

The 79 patients had a mean age of 78.5 years; 27 (34.2%) were male and 58 (73.4%) lived alone. The mean time spent in the home by the occupational therapist was 49 minutes and the mean time for the whole visit including travelling time was 108.4 minutes. Only one patient (1.3%) was completely independent in all six PSM categories and no patient was completely independent in all eight IADL items. Seventy-two (91.6%) patients were eventually discharged to a non-institutional setting, mainly the patient's own home.

Current diagnosis, except for cerebrovascular disease, was not significantly related to higher overall dependency, recommended equipment or carer visit frequency. Higher overall dependency showed significant relationships with recommended carer frequency and time spent assessing the patient in the home, but not consistently with recommended equipment or home adaptations. When specific categories of equipment were considered, for example that for use in the kitchen, overall low dependency was significantly related to the recommendation for this type of equipment.

The study confirms the need for assessments beyond those of diagnosis alone in rehabilitation. Overall measures of levels of functioning, although useful in measuring outcomes, are of less certain value for assessment. Specific subcategories of dependency scales are probably of more value than overall scores for occupational therapy assessment.

Cognitive Assessments for Older Adults: Which Ones are Used by Canadian Therapists and Why

Background. Occupational therapists routinely evaluate cognition in older adults, yet little is known about which assessments they use and for what purposes. Purpose. To examine the standardised and non-standardised assessments used by occupational therapists to evaluate cognition. Method. Arandom sample of 1042 Canadian occupational therapists completed the questionnaire by e-mail, post, or Internet website (n=247, response rate: 24.5%). Results. Respondents reported using 75 standardised and non-standardised measures. The assessments were grouped according to theoretical approach: bottom-up (assessment of cognitive components), top-down (assessment of function) and combined (either of above, plus interview). Theoretical approaches were used similarly across regions, despite differences in reporting of particular assessments. Therapists used more bottom-up assessments that were standardised, identified deficits, and easy to administer. They used more top-down assessments that were non-standardised, predicted function, and fit with their theoretical approach. Conclusion. It is recommended that standardised top-down assessments be developed to support evidence-based occupational therapy.

Measurement properties of the occupational therapy discharge needs screen

BACKGROUND

Pre-discharge home assessments are integral to discharge planning; however, there is no screening tool identifying clients with complex needs.

PURPOSE

To determine the inter- and intrarater reliability and predictive and concurrent validity of the Occupational Therapy Discharge Needs Screen (OTDNS), a screening tool that identifies clients with more complex discharge needs.

METHODS

The OTDNS Functional Independence Measure (FIM) and Functional Autonomy Measurement System (SMAF) were administered to 89 participants.

FINDINGS

Intrarater reliability was ICC = 0.93 (95% CI 0.90 - 0.96) (n = 89). Interrater reliability was ICC = 0.53 (95% CI 0.27- 0.70) (n = 89) with the initial OTDNS instructions, and ICC = 0.91 (95% CI 0.62 - 0.96) (n = 10) with revised OTDNS instructions. The OTDNS had an inverse relationship with the FIM (r = -0.51; p < 0.001) and a positive relationship with the SMAF (r = 0.64; p < 0.001). A score of > 7/28 had a sensitivity = 75% and specificity = 40% when predicting occupational therapy home assessment post-discharge.

IMPLICATIONS

The OTDNS has potential to contribute to continuity and efficiency of the discharge-planning process.

Occupational therapy predischarge home visits for patients with a stroke (HOVIS): results of a feasibility randomized controlled trial

OBJECTIVE

To assess the feasibility of conducting a randomized controlled trial of occupational therapy predischarge home visits for people after stroke.

DESIGN

Randomized controlled trial and cohort study. We randomized eligible patients for whom there was clinical uncertainty about the need to conduct a home visit to a randomized controlled trial; patients for whom a visit was judged 'essential' were enrolled into a cohort study.

SETTING

Stroke rehabilitation unit of teaching hospital.

PARTICIPANTS

One hundred and twenty-six participants hospitalized following recent stroke.

INTERVENTIONS

Predischarge home visit or structured, hospital-based interview.

MAIN OUTCOME MEASURES

The primary objective was to collect information on the feasibility of a randomized controlled trial, including eligibility, control intervention and outcome assessments. The primary outcome measure was the Nottingham Extended Activities of Daily Living Scale at one month after discharge from hospital. Secondary outcomes included mood, quality of life and costs at one week and one month following discharge.

RESULTS

Ninety-three people were allocated to the randomized controlled trial; 47 were randomized to intervention and 46 to control. Thirty-three were enrolled into the cohort study. More people were allocated to the randomized controlled trial as the study progressed. One hundred and thirteen people (90%) received the proposed intervention, although there was a need for stricter protocol adherence. Follow-up was good: at one month 114 (90%) were assessed. There were no significant differences between the groups in the randomized controlled trial for the primary outcome measure at one month. The average cost of a home visit was £208.

CONCLUSION

A trial is feasible and warranted given the resource implications of predischarge occupational therapy home visits.

Older Adults' Experiences of Occupational Therapy Predischarge Home Visits: A Systematic Thematic Synthesis of Qualitative Research

Background:

Occupational therapists in many countries routinely perform predischarge home visits. Although there have been repeated calls to ascertain whether predischarge home visits are clinically and cost effective, there has been a tendency to neglect users' perceptions and experiences of this intervention.

Objective:

The objective was to conduct a systematic thematic synthesis of older adults' perceptions and experiences of predischarge home visits.

Method:

The search strategy was an electronic database search. Conference proceedings were hand searched and universities and occupational therapy professional bodies within Europe, Australia and North America were contacted.

Results:

Forty-four studies were initially identified, of which 13 studies (7 published, 6 unpublished) were selected for detailed screening. Only three qualitative studies met the inclusion criteria and, from this synthesis, two main themes emerged from the data. The first theme was older adults' perceptions of home visits and the second theme was acceptance of occupational therapy.

Conclusion:

Only a limited body of research has been conducted. This is surprising given the number of predischarge home visits that are performed. This thematic synthesis of qualitative research has highlighted that insufficient attention has been paid to older adults' perceptions of predischarge home visits.

Changes in everyday life after discharge from day care rehabilitation

Community-based day care that provides rehabilitation (DCR) targets elderly people with physical disabilities. The goal of these programmes is mainly to improve physical ability in order to enable participants to remain in their ordinary homes. Knowledge of the outcomes of DCR is limited as well as knowledge of what it is that makes a difference for the individual. The aim of this study was to describe what changes in everyday life elderly persons experienced after discharge from a community-based day care rehabilitation centre and to give possible explanations for these changes. Fifteen elderly people were interviewed after that they had been discharged from DCR. A narrative approach was used for analysing the interview data. Four case stories constitute the findings, each of them with unique descriptions of changes in everyday life as well as possible explanations for these changes. The first case story described resumption of daily activities that made the days more eventful and meaningful. The second described how everyday life became an arena for exercising, which create confidence for the future. The third described how an increased sense of certainty and security in the movements led to an increased appetite for life. Finally, the fourth case story described both the stay at the DCR centre and the promise of a new period there as uplifting that made the days easier. Concerning possible explanations for these changes, the findings indicate that it was a combination of several events that together contributed to the changes. Examples were physical training, counselling about how to live in an active and healthy lifestyle, and socialisation with other patients in formal as well as in informal sessions.

Relationship between pre-discharge occupational therapy home assessment and prevalence of post-discharge falls

RATIONALE, AIMS AND OBJECTIVE

Pre-discharge occupational therapy home assessments are common practice, and considered important for falls prevention in older people. This prospective, observational cohort study describes the association between pre-discharge home assessment and falls in the first month post-discharge from a rehabilitation hospital.

METHODS

342 inpatients were recruited and followed up 1 month post-discharge. Patients were classified into diagnostic groups (cardiac, orthopaedic trauma, spinal, peripheral joint surgery, neurological and deconditioned). Age, gender, falls risk [Falls Risk Assessment Scoring System (FRASS)], functional independence scores (FIM™) and receipt (or not) of a home assessment were recorded. Patients completed a diary to document post-discharge falls. Logistic regression analysis tested the effect on falling of receiving a home assessment, age, gender, diagnostic group, FRASS and FIM™.

RESULTS

Considering all subjects, not receiving a home assessment increased the risk of falling 1 month post-discharge [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.4-4.7, P=0.003]. Neurological and orthopaedic trauma patients had significantly elevated risks of falling [OR (95% CI), respectively, 12.5 (4.7-33.2), 3.4 (1.4-8.4)] relative to the orthopaedic joint group. For all diagnostic groups except neurological, falls risk was mitigated by a home assessment. In non-neurological patients, adjusting for the effect of diagnostic group, FRASS and FIM™ scores indicated a significant association between not receiving a home assessment and falling (OR 4.2, 95% CI 2.1-8.2, P<0.001).

CONCLUSIONS

Pre-discharge occupational therapy home assessments are sound post-discharge falls-prevention strategies in non-neurological patients. The decision to conduct a home assessment should consider diagnosis, falls risk and functional independence.

A structural equation modelling approach to the complex path from postural stability to morale in elderly people with fear of falling

PURPOSE

To test a model of the path from Activity Limitation (postural instability) to participation (morale), taking account of the influence of psychological variables of appraisal, emotion and self-efficacy. Also to attempt to define whether elderly people with fear of falling are fearful because they are posturally unstable or because they are generally anxious.

METHOD

Elderly inpatients (n = 153, age: 67-95, 31% men) were assessed shortly before their discharge home. They were invited to complete tests of postural stability and questionnaires about consequences of falling, previous experience of falls, subjective unsteadiness, emotional state, balance confidence, concern and fear about falling and morale. Results were treated with Pearson correlations and structural equation modelling.

RESULTS

All variables related to morale, the highest correlation being with anxiety and depression. However, there was no direct path from postural instability to morale. Balance confidence and fear of falling formed separate end points, neither affecting morale.

CONCLUSIONS

Morale alone is not an adequate outcome of rehabilitation. Increased balance confidence and reduced fear of falling need to be addressed in their own right and assessed independently of morale in elderly rehabilitation.

Policies for reducing delayed discharge from hospital

INTRODUCTION

Delayed discharge from acute hospital has been a cause of concern for the last 10 years. Older people with complex health needs are particularly vulnerable to delayed discharge with negative consequences for their health and wellbeing.

SOURCE OF DATA

Review of the literature on the impact of the Community Care (Delayed Discharge) Act (2003) and subsequent policy initiatives on delayed discharges. Areas of agreement A number of cross-institutional complexities contribute to delayed discharges. Policy measures have contributed positively to reducing delayed discharges. Investment in intermediate care services has provided a range of services to promote maximum independence for older people after acute hospital admission. Joint working between health and social services is necessary to prevent delayed discharges.

AREAS OF CONTROVERSY

Pressure to achieve rapid hospital throughput may be contributing to older people leaving hospital too soon and to recent increases in hospital re-admission rates. Policy measures are extending to older people with mental health problems.

AREAS TIMELY FOR DEVELOPING RESEARCH

Patient and carer experiences of delayed or premature discharge. Quality and equity of access to intermediate care for older people.

Medical day hospital care for the elderly versus alternative forms of care

BACKGROUND

The proportion of the world's population aged 60 or over is increasing. This review sets out to examine the effectiveness and resource implications of geriatric medical day hospital attendance for elderly people. This is an update of a Cochrane review first published in 1999.

OBJECTIVES

To examine the effectiveness of attendance at a medical day hospital for elderly people in preventing death, disability, and institutionalisation and improving subjective health status.

SEARCH STRATEGY

We searched the EPOC group specialist register (March 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2008), MEDLINE (1996 to January 2008), EMBASE (1996 to 2008 week 5), and other databases.

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing attendance at a geriatric medical day hospital with alternative forms of care for elderly medical patients (usually > 60 years).

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed research reports to determine eligibility, categorise trial type and extract data.

MAIN RESULTS

Thirteen trials involving 3007 participants were included. These compared day hospital with a) comprehensive elderly care (five trials), b) domiciliary care (five trials), or c) no comprehensive elderly care (three trials).There were no significant differences between day hospital attendance and the sub-categories of comparison treatments for the outcomes of death, death or requiring institutional care, death or deterioration in ADL. When death or a 'poor' outcome at follow up was examined there was a significant difference in favour of day hospital attendance when compared to no comprehensive elderly care (odds ratio (OR) 0.73; 95% confidence interval (CI) 0.53 to 1.00; P < 0.05).Dependency was measured in 12 trials using a variety of ADL measures; two described short-term improvement for the day hospital group, one reported improved outcome for the comparison group, while in the remaining trials there was no statistically significant difference. Using the outcome of deterioration in ADL among survivors, day hospital patients showed a reduced odds of deterioration when compared with those receiving no comprehensive elderly care (OR 0.60; 95% CI 0.38 to 0.97; P < 0.05).When resource use was examined the day hospital group showed trends towards reductions in hospital bed use and placement of survivors in institutional care.

AUTHORS' CONCLUSIONS

Medical day hospital care for the elderly appears to be more effective than no intervention but may have no clear advantage over other forms of comprehensive elderly medical services.

Length of stay: an inappropriate readout of the success of enhanced recovery programs

BACKGROUND

Enhanced recovery after surgery (ERAS) programs are designed to reduce hospital length of stay by shortening the postoperative recovery period. The intended effect of an accelerated recovery on the length of stay may be frustrated by a delayed discharge. This study was designed to assess the influence of an ERAS program on the proportion, appropriateness, and extent of delay in discharge.

METHODS

Patients who enrolled in the ERAS program (n = 121) between 2003 and 2006 were compared with 52 patients who were managed traditionally in 2001.

RESULTS

Ninety percent of the pre-ERAS patients and 87% of the ERAS patients were not discharged on the day that discharge criteria were fulfilled. The additional stay of 59% of the pre-ERAS patients and 69% of the ERAS patients was inappropriate. Wound care (15% in the pre-ERAS and 3% of the ERAS group) and observation of any symptoms pointing to an anastomotic leakage (10% in both groups) were the most important reasons for a medical appropriate delay of discharge. The extent of delay in discharge decreased significantly from a median of two days in the pre-ERAS group to a median of 1 day in the ERAS group (p = 0.004).

CONCLUSIONS

Reductions in length of stay up to a median of 2 days after start of an enhanced recovery program may relate to changes in organization of care and not to a shorter recovery period. Recovery statistics should replace or at least be added to the length of stay as outcome of enhanced recovery programs.

Occupational Therapy Home Assessments: More than Just a Visit? An Audit of Occupational Therapy Practice in Oncology and Palliative Care

Occupational therapists at a specialist cancer centre found home assessments to be the most time-consuming intervention. To evaluate the breakdown of time and total time use for this intervention, 15 occupational therapists working in the area of oncology and palliative care participated in an audit. A total of 107 home assessments was audited. The results indicated that the total time for an average home assessment in the audit ranged between 3.31 hours and 5.59 hours. They also highlighted that the time spent in preparation and follow-up was similar to the time spent in travel and the visit itself.

Feasibility and results of a randomised pilot-study of pre-discharge occupational therapy home visits

Background

Pre-discharge home visits aim to maximise independence in the community. These visits involve assessment of a person in their own home prior to discharge from hospital, typically by an occupational therapist. The therapist may provide equipment, adapt the home environment and/or provide education. The aims of this study were to investigate the feasibility of a randomised controlled trial in a clinical setting and the effect of pre-discharge home visits on functional performance in older people undergoing rehabilitation.

Methods

Ten patients participating in an inpatient rehabilitation program were randomly assigned to receive either a pre-discharge home visit (intervention), or standard practice in-hospital assessment and education (control), both conducted by an occupational therapist. The pre-discharge home visit involved assessment of the older person's function and environment, and education, and took an average of 1.5 hours. The hospital-based interview took an average of 40 minutes. Outcome data were collected by a blinded assessor at 0, 2, 4, 8 and 12 weeks. Outcomes included performance of activities of daily living, reintegration to community living, quality of life, readmission and fall rates.

Results

Recruitment of 10 participants was slow and took three months. Observed performance of functional abilities did not differ between groups due to the small sample size. Difference in activities of daily living participation, as recorded by the Nottingham Extended Activities of Daily Living scale, was statistically significant but wide confidence intervals and low statistical power limit interpretation of results.

Conclusion

Evaluation of pre-discharge home visits by occupational therapists in a rehabilitation setting is feasible, but a more effective recruitment strategy for a main study is favored by application of a multi-centre setting.

The evaluation of health and social care partnerships: an analysis of approaches and synthesis for the future

At a time when health and social care partnerships are continuing to occupy a central role within the UK government's policy strategy, researchers are increasingly being required to evaluate such organisational entities. This paper looks at a wide range of approaches which have been utilised to evaluate health and social care partnerships, and suggests that theory-led strategies are better able to address the complexities associated with such forms of evaluation. In particular, the author suggests that a combination of theories of change and realistic evaluation seems to be the most fruitful in tackling the evaluation difficulties associated with partnerships. Despite both being theory-led evaluation strategies, they fulfil quite different and complementary roles. However, both these approaches have been found to have some limitations in practice. Therefore, this paper suggests that interpreting these approaches through a framework of critical realism may overcome a number of these difficulties.

Evidence of the efficacy of occupational therapy in different conditions: an overview of systematic reviews

OBJECTIVE

To summarize the research evidence available from systematic reviews of the efficacy of occupational therapy (OT) for practitioners, researchers, purchasing organizations and policy-makers.

DATA SOURCE

The search for systematic reviews was conducted in PubMed and the Cochrane Library (October 2004).

METHODS

The reviews included were those that utilized a systematic search for evidence with regard to OT for specific patient groups. Data were summarized for patient group, interventions, outcome domains, type of study designs included, method of data synthesis and conclusions.

RESULTS

Fourteen systematic reviews were included. Three reviews related to rheumatoid arthritis, four reviewed stroke and four focused on elderly people. Reviews of Parkinson's disease, multiple sclerosis, Huntington's disease, cerebral palsy and mental illnesses were also identified. The reviews of rheumatoid arthritis, stroke and elderly people showed evidence of the efficacy of OT in increasing functional abilities. Positive results were presented for quality of life and social participation in elderly people and stroke respectively. The efficacy of OT in all other patient groups is unknown due to insufficient evidence.

CONCLUSION

This summary shows that elderly people and people with stroke or rheumatoid arthritis can expect to benefit from comprehensive OT. Evidence of the efficacy of specific interventions is sparse and should be addressed in future research. The evidence that does exist should be incorporated into OT practice.

Pre-discharge home visits with older people: time to review practice

The present review paper uses the available evidence to make a case for a reconsideration of the practice of undertaking pre-discharge home visits with frail older people as part of decisions regarding a return home. This practice is embedded into the routine activity of acute medical wards for older people and occupies a large proportion of the time of hospital employed therapy staff, with consequent financial and resource implications. Assessments are often conducted to provide information on safe discharge rather than being located in the interests of the older person and their carer. The introduction of a new range of services bridging hospital and home raises the need for an urgent, critical appraisal of this practice.

Too many pre-discharge home assessment visits for older patients? A postal questionnaire survey

OBJECTIVE

To investigate current practice of pre-discharge home assessment visits for older patients.

DESIGN

Postal questionnaire survey.

SETTING

NHS Trust hospitals in the United Kingdom.

SUBJECTS

Occupational therapy departments in 265 NHS Trust hospitals which admit acutely ill older patients.

MAIN OUTCOME MEASURES

The number of pre-discharge home visits done, who went, and therapy time spent on home visits.

RESULTS

Of 265 NHS Trusts contacted, 239 (90%) replied. Of 238 units, 155 (65%) do between 11 and 40 visits per month, with 25 (11%) doing more than 60. The equivalent of one day per week or more is spent doing home visits by Senior I occupational therapists in 107 (45%) units and by Senior II staff in 126 (53%) units. Carers or relatives, unqualified occupational therapists, social workers and home care managers accompany the patient and occupational therapist on most home visits.

CONCLUSION

Therapy perception is that pre-discharge home assessment visits are increasing in number, complexity and involvement of professional time despite little evidence for their effectiveness. Controlled trials are required to assess which patients are likely to benefit.