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Wallis JA, Shepperd S, Makela P, Han JX, Tripp EM, Gearon E, Disher G, Buchbinder R, O'Connor D. Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis. Cochrane Database Syst Rev 2024; 3:CD014765. [PMID: 38438114 PMCID: PMC10911892 DOI: 10.1002/14651858.cd014765.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
BACKGROUND Worldwide there is an increasing demand for Hospital at Home as an alternative to hospital admission. Although there is a growing evidence base on the effectiveness and cost-effectiveness of Hospital at Home, health service managers, health professionals and policy makers require evidence on how to implement and sustain these services on a wider scale. OBJECTIVES (1) To identify, appraise and synthesise qualitative research evidence on the factors that influence the implementation of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home, from the perspective of multiple stakeholders, including policy makers, health service managers, health professionals, patients and patients' caregivers. (2) To explore how our synthesis findings relate to, and help to explain, the findings of the Cochrane intervention reviews of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home services. SEARCH METHODS We searched MEDLINE, CINAHL, Global Index Medicus and Scopus until 17 November 2022. We also applied reference checking and citation searching to identify additional studies. We searched for studies in any language. SELECTION CRITERIA We included qualitative studies and mixed-methods studies with qualitative data collection and analysis methods examining the implementation of new or existing Hospital at Home services from the perspective of different stakeholders. DATA COLLECTION AND ANALYSIS Two authors independently selected the studies, extracted study characteristics and intervention components, assessed the methodological limitations using the Critical Appraisal Skills Checklist (CASP) and assessed the confidence in the findings using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). We applied thematic synthesis to synthesise the data across studies and identify factors that may influence the implementation of Hospital at Home. MAIN RESULTS From 7535 records identified from database searches and one identified from citation tracking, we included 52 qualitative studies exploring the implementation of Hospital at Home services (31 Early Discharge, 16 Admission Avoidance, 5 combined services), across 13 countries and from the perspectives of 662 service-level staff (clinicians, managers), eight systems-level staff (commissioners, insurers), 900 patients and 417 caregivers. Overall, we judged 40 studies as having minor methodological concerns and we judged 12 studies as having major concerns. Main concerns included data collection methods (e.g. not reporting a topic guide), data analysis methods (e.g. insufficient data to support findings) and not reporting ethical approval. Following synthesis, we identified 12 findings graded as high (n = 10) and moderate (n = 2) confidence and classified them into four themes: (1) development of stakeholder relationships and systems prior to implementation, (2) processes, resources and skills required for safe and effective implementation, (3) acceptability and caregiver impacts, and (4) sustainability of services. AUTHORS' CONCLUSIONS Implementing Admission Avoidance and Early Discharge Hospital at Home services requires early development of policies, stakeholder engagement, efficient admission processes, effective communication and a skilled workforce to safely and effectively implement person-centred Hospital at Home, achieve acceptance by staff who refer patients to these services and ensure sustainability. Future research should focus on lower-income country and rural settings, and the perspectives of systems-level stakeholders, and explore the potential negative impact on caregivers, especially for Admission Avoidance Hospital at Home, as this service may become increasingly utilised to manage rising visits to emergency departments.
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Affiliation(s)
- Jason A Wallis
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Cabrini Health, Malvern, Australia
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Petra Makela
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jia Xi Han
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Evie M Tripp
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Emma Gearon
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Gary Disher
- New South Wales Ministry of Health, St Leonards, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Ouédraogo F, Auger LP, Moreau E, Côté O, Guerrera R, Rochette A, Kairy D. Acceptability of Telerehabilitation: Experiences and Perceptions by Individuals with Stroke and Caregivers in an Early Supported Discharge Program. Healthcare (Basel) 2024; 12:365. [PMID: 38338250 PMCID: PMC10855122 DOI: 10.3390/healthcare12030365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/25/2023] [Accepted: 12/28/2023] [Indexed: 02/12/2024] Open
Abstract
INTRODUCTION Telerehabilitation (TR) is a promising method for facilitating the delivery and access to post-stroke rehabilitation services. OBJECTIVE The aim of this study was to explore the acceptability of TR and factors influencing its adoption by individuals with stroke and caregivers. METHODS A qualitative descriptive approach was used. Six individuals with stroke and three caregivers participated in individual online interviews. An abductive thematic analysis was employed to analyze the qualitative data, using the Unified Theory of Acceptance and Use of Technology 2 (UTAUT-2) model. RESULTS Participants reported positive experiences with TR, resulting in improvements in functional abilities, such as manual dexterity, balance, and positive interactions with therapists. They found the technology easy to learn and use, facilitating engagement in TR. Participants' prior experiences with technology, along with support from caregivers and therapists, facilitated acceptance and the use of TR. The COVID-19 pandemic also motivated participants to accept TR. However, technical issues, unstable internet connections, and lack of feedback were barriers to the use of TR. CONCLUSION Despite existing obstacles, TR can be used to provide rehabilitation services for individuals with stroke. Addressing these barriers is necessary to promote the widespread and effective use of TR in the context of stroke recovery.
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Affiliation(s)
- Fatimata Ouédraogo
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, QC H3N 1X7, Canada; (A.R.); (D.K.)
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, QC H3S 1M9, Canada;
| | - Louis-Pierre Auger
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, QC H3S 1M9, Canada;
- Institute of Health Sciences Education, Faculty of Medicine, McGill University, Montréal, QC H3G 1A1, Canada
| | - Emmanuelle Moreau
- Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal, Centre Intégré Universitaire de Santé et Services Sociaux (CIUSSS) du Centre-Sud-de-l’Île-de-Montréal, Montréal, QC H3S 2J4, Canada; (E.M.); (O.C.); (R.G.)
| | - Odile Côté
- Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal, Centre Intégré Universitaire de Santé et Services Sociaux (CIUSSS) du Centre-Sud-de-l’Île-de-Montréal, Montréal, QC H3S 2J4, Canada; (E.M.); (O.C.); (R.G.)
| | - Rosalba Guerrera
- Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal, Centre Intégré Universitaire de Santé et Services Sociaux (CIUSSS) du Centre-Sud-de-l’Île-de-Montréal, Montréal, QC H3S 2J4, Canada; (E.M.); (O.C.); (R.G.)
| | - Annie Rochette
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, QC H3N 1X7, Canada; (A.R.); (D.K.)
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, QC H3S 1M9, Canada;
- Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal, Centre Intégré Universitaire de Santé et Services Sociaux (CIUSSS) du Centre-Sud-de-l’Île-de-Montréal, Montréal, QC H3S 2J4, Canada; (E.M.); (O.C.); (R.G.)
| | - Dahlia Kairy
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, QC H3N 1X7, Canada; (A.R.); (D.K.)
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, QC H3S 1M9, Canada;
- Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal, Centre Intégré Universitaire de Santé et Services Sociaux (CIUSSS) du Centre-Sud-de-l’Île-de-Montréal, Montréal, QC H3S 2J4, Canada; (E.M.); (O.C.); (R.G.)
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Cox R, Kyle G, Suzuki A, Wishart L, McCusker M, McConnell A, Ward EC, Ross L, Webb C. Patient and multidisciplinary health professional perceptions of an Australian geriatric evaluation and management and rehabilitation hospital in the home service. J Health Serv Res Policy 2024; 29:31-41. [PMID: 37897739 DOI: 10.1177/13558196231193863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/30/2023]
Abstract
OBJECTIVES Hospital in the Home models are rapidly expanding in response to increasing bed pressures. This study examined patient and multidisciplinary health professional perceptions of a new geriatric evaluation and management and rehabilitation hospital in the home service in Australia. The service was unique, as adults of all ages with a variety of rehabilitation or geriatric evaluation and management needs were within scope. METHODS A qualitative descriptive approach was used with a consumer co-researcher and a consumer advisor being integral to decision-making. Patient feedback was collected via a paper-based patient satisfaction survey between August 2020 and February 2022. Additionally, interviews with current and past staff were conducted from July to November 2021. Reflexive thematic analysis was conducted for qualitative data and descriptive statistics used for quantitative data. RESULTS Patient surveys were analysed (n = 199, 42.2% response rate) with 60.8% of participants aged 75 years or over and 26.6% speaking a language other than English. High satisfaction was expressed. Feelings of comfort, familiarity, convenience, and reassurance were voiced. A person-centred approach enhanced involvement in care. Challenges included carer burden and clear communication. Sixteen staff (33% response rate) were interviewed. In general, staff said the service was inclusive and responsive, and the home environment beneficial, particularly for patients from culturally diverse backgrounds. A strong hospital partnership and comprehensive multidisciplinary approach were vital. Challenges included fragmentation due to part-time roles and combining with a pre-existing acute hospital in the home service. CONCLUSIONS This qualitative exploration of staff and patients' perceptions of a geriatrician-led, multidisciplinary geriatric evaluation and management and rehabilitation hospital in the home service demonstrated that it was person-centred and optimised patients' control and ownership of care. The inclusive service parameters ensured responsiveness to diverse needs whilst allowing earlier return home from hospital, both of which are vital for quality patient care.
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Affiliation(s)
- Ruth Cox
- Occupational Therapy Department, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Greg Kyle
- Centre for Functioning and Health Research, Metro South Health, Brisbane, QLD, Australia
| | - Anya Suzuki
- Occupational Therapy Department, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Laurelie Wishart
- Centre for Functioning and Health Research, Metro South Health, Brisbane, QLD, Australia
| | - Melissa McCusker
- Community and Oral Health, Metro South Health, Brisbane, QLD, Australia
| | - Alexander McConnell
- Consumer Partner, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Elizabeth C Ward
- Centre for Functioning and Health Research, Metro South Health, Brisbane, QLD, Australia
- School of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Leo Ross
- Division of Allied Health, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
| | - Clare Webb
- Occupational Therapy Department, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
- Division of Allied Health, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD, Australia
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Fisher RJ, Chouliara N, Byrne A, Cameron T, Lewis S, Langhorne P, Robinson T, Waring J, Geue C, Paley L, Rudd A, Walker MF. Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway.
Objectives
To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness.
Design
A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes.
Setting and interventions
Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England.
Participants
Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services.
Data and main outcome
Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness.
Results
A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway.
Limitations
Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory.
Conclusions
The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness.
Trial registration
Current Controlled Trials ISRCTN15568163.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rebecca J Fisher
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Niki Chouliara
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Adrian Byrne
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Trudi Cameron
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Thompson Robinson
- Department of Cardiovascular Sciences and National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Justin Waring
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Claudia Geue
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, King’s College London, London, UK
| | - Anthony Rudd
- Sentinel Stroke National Audit Programme, King’s College London, London, UK
| | - Marion F Walker
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
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Gearon E, O'Connor D, Wallis J, Han JX, Shepperd S, Makela P, Disher G, Buchbinder R. Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Emma Gearon
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
- Monash Department of Clinical Epidemiology; Cabrini Institute; Malvern Australia
| | - Denise O'Connor
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
- Monash Department of Clinical Epidemiology; Cabrini Institute; Malvern Australia
| | - Jason Wallis
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
- Monash Department of Clinical Epidemiology; Cabrini Institute; Malvern Australia
| | - Jia Xi Han
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
- Monash Department of Clinical Epidemiology; Cabrini Institute; Malvern Australia
| | - Sasha Shepperd
- Nuffield Department of Population Health; University of Oxford; Oxford UK
| | - Petra Makela
- Department of Health Services Research and Policy; London School of Hygiene & Tropical Medicine; London UK
| | - Gary Disher
- New South Wales Ministry of Health; St Leonards Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
- Monash Department of Clinical Epidemiology; Cabrini Institute; Malvern Australia
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Hitch D, Leech K, Neale S, Malcolm A. Evaluating the implementation of an early supported discharge (ESD) program for stroke survivors: A mixed methods longitudinal case study. PLoS One 2020; 15:e0235055. [PMID: 32579574 PMCID: PMC7313954 DOI: 10.1371/journal.pone.0235055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 06/08/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Early supported discharge (ESD) models of care for stroke survivors coordinate inpatient and community services, with the aim of reducing length of stay. While there is an established evidence base around the clinical outcomes of ESD), less is known about the implementation of this approach into existing stroke care service. The aim of this case study was to describe staff perceptions of the implementation of an ESD model of care for stroke survivors at a large metropolitan public hospital in Australia. METHODS This case study utilised a mixed methods design, which was designed in explicit alignment with the Consolidated Framework for Implementation Research (CFIR). Participants included staff that referred patients for ESD, and staff involved in the planning, implementation or delivery of ESD. Survey data was collected at three time points (ESD commencement, 3 months and 6 months), and focus groups were undertaken at the conclusion of the study. All quantitative data was analysed descriptive, while qualitative data was evaluated using thematic analysis. RESULTS Results from both sources of data identified changes in staff perceptions of ESD implementation over time. While very few changes were statistically significant, they were diverse patterns of change across the CFIR constructs over time. The characteristics of individuals and ESD characteristics attracted consistently positive perceptions, while patient needs and resources was the most prevalent theme within the data. While perceptions of factors related to the inner setting were mixed, there was a steady improvement in perceptions about the process across the later stages of implementation. CONCLUSIONS The sophistication of knowledge translation and implementation in modern complex healthcare environments is highlighted by the multiple interactions between the CFIR domains and constructs. While the implementation process described was generally positive and effective, using the CFIR as a framework confirmed that it also entailed some challenges and unanticipated outcomes.
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Affiliation(s)
- Danielle Hitch
- Allied Health, Western Health, Sunshine, Victoria, Australia
- Occupational Therapy, Deakin University, Geelong, Victoria, Australia
- * E-mail:
| | - Kathleen Leech
- Allied Health, Western Health, Sunshine, Victoria, Australia
| | - Sharon Neale
- Allied Health, Western Health, Sunshine, Victoria, Australia
| | - Avetta Malcolm
- Allied Health, Western Health, Sunshine, Victoria, Australia
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