Care Coordination/Home-Telehealth for Veterans with Stroke and Their Caregivers: Addressing an Unmet Need

The supportive care needs of stroke patients: A scoping review

The aims of the current review were to identify the current supportive care needs of stroke patients, categorize those needs according to the supportive care needs framework (SCNF), and to form a SCNF of stroke patients. Preferred Reporting Items for Systematic Reviews and Meta-Extension for Scoping Reviews (PRISMA-ScR) and Guidance for conducting systematic scoping reviews were followed. Ten databases were searched, including six English databases: PubMed, Embase, Web of Science, Cumulative Index to Nursing Allied Health Literature, Cochrane Library, and PsycINFO, and four Chinese databases: China National Knowledge Infrastructure, Wan Fang, China Biology Medicine Database and Chongqing VIP. The search period covers from the establishment of the database to December 31, 2022. Three thousand twenty-nine hits were screened resulting in the inclusion of 34 articles in the final literature review. The greatest need identified by stroke patients was information, followed by psychological, social, rehabilitation, practical, physical, emotional, and spiritual needs. The supportive care needs of stroke patients were identified. A preliminary SCNF of stroke patients was developed according to Fitch's SCNF. The multitude of existing needs of stroke patients need to be addressed. This review may represent the first time that SCNF for stroke patients has been developed. This work may lay the foundation for future research on the supportive care needs of stroke patients and provide a framework for the implementation of supportive care in clinical stroke units.

What works and why in the implementation of eRehabilitation after stroke - a process evaluation

BACKGROUND

Implementation of an eRehabilitation intervention named Fit After Stroke @Home (Fast@home) - including cognitive/physical exercise applications, activity-tracking, psycho-education - after stroke resulted in health-related improvements. This study investigated what worked and why in the implementation.

METHODS

Implementation activities (information provision, integration of Fast@home, instruction and motivation) were performed for 14 months and evaluated, using the Medical Research Council framework for process evaluations which consists of three evaluation domains (implementation, mechanisms of impact and contextual factors). Implementation activities were evaluated by field notes/surveys/user data, it's mechanisms of impact by surveys and contextual factors by field notes/interviews among 11 professionals. Surveys were conducted among 51 professionals and 73 patients. User data (n = 165 patients) were extracted from the eRehabilitation applications.

RESULTS

Implementation activities were executed as planned. Of the professionals trained to deliver the intervention (33 of 51), 25 (75.8%) delivered it. Of the 165 patients, 82 (49.7%) were registered for Fast@home, with 54 patient (65.8%) using it. Mechanisms of impact showed that professionals and patients were equally satisfied with implementation activities (median score 7.0 [IQR 6.0-7.75] versus 7.0 [6.0-7.5]), but patients were more satisfied with the intervention (8.0 [IQR 7.0-8.0] versus 5.5 [4.0-7.0]). Guidance by professionals was seen as most impactful for implementation by patients and support of clinical champions and time given for training by professionals. Professionals rated the integration of Fast@home as insufficient. Contextual factors (financial cutbacks and technical setbacks) hampered the implementation.

CONCLUSION

Main improvements of the implementation of eRehabilitation are related to professionals' perceptions of the intervention, integration of eRehabilitation and contextual factors.Implication for rehabilitationTo increase the use of eRehabilitation by patients, patients should be supported by their healthcare professional in their first time use and during the rehabilitation process.To increase the use of eRehabilitation by healthcare professionals, healthcare professionals should be (1) supported by a clinical champion and (2) provided with sufficient time for learning to work and getting familiar with the eRehabilitation program.Integration of eRehabilitation in conventional stroke rehabilitation (optimal blended care) is an important challenge and a prerequisite for the implementation of eRehabilitation in the clinical setting.

The Unmet Needs of Community-Dwelling Stroke Survivors: A Systematic Review of Qualitative Studies

The unmet needs perceived by community-dwelling stroke survivors may truly reflect the needs of patients, which is crucial for pleasant emotional experiences and a better quality of life for community-dwelling survivors not living in institutionalized organizations. The purpose of the study is to identify the scope of unmet needs from the perspectives of stroke patients in the community. A qualitative meta-synthesis was performed according to the Joanna Briggs Institute method. Six electronic databases were searched from inception to February 2020. A total of 24 articles were involved, providing data on 378 stroke survivors. Eight categories were derived from 63 findings, and then summarized into four synthesized findings based on the framework of ICF: (1) unmet needs regarding with the disease-related information; (2) unmet physical recovery and activity/participation needs; (3) unmet needs for social environmental resources; (4) unmet psycho-emotional support needs. We found the framework of ICF mostly complete, but unmet information needs still remain. The needs that are mainly unsatisfied include physical, psychosocial and informational, as well as the practical support from professional or environment resources. The ever-present unmet needs perceived by community-dwelling stroke survivors who do not live in institutions are discoverable and mitigable. Future studies should focus on quantifying unmet needs comprehensively derived from experiential domains, assessing the rationality of the unmet needs expressed by patients' perspectives and developing flexible strategies for long-term and changing needs.

Why the uptake of eRehabilitation programs in stroke care is so difficult-a focus group study in the Netherlands

BACKGROUND

The uptake of eRehabilitation programs in stroke care is insufficient, despite the growing availability. The aim of this study was to explore which factors influence the uptake of eRehabilitation in stroke rehabilitation, among stroke patients, informal caregivers, and healthcare professionals.

METHODS

A qualitative focus group study with eight focus groups (6-8 participants per group) was conducted: six with stroke patients/informal caregivers and two with healthcare professionals involved in stroke rehabilitation (rehabilitation physicians, physical therapists, occupational therapists, psychologists, managers). Focus group interviews were audiotaped, transcribed in full, and analyzed by direct content analysis using the implementation model of Grol.

RESULTS

Thirty-two patients, 15 informal caregivers, and 13 healthcare professionals were included. A total of 14 influencing factors were found, grouped to 5 of the 6 levels of the implementation model of Grol (Innovation, Organizational context, Individual patient, Individual professional, and Economic and political context). Most quotes of patients, informal caregivers, and healthcare professionals were classified to factors at the level of the Innovation (e.g., content, attractiveness, and feasibility of eRehabilitation programs). In addition, for patients, relatively many quotes were classified to factors at the level of the individual patient (e.g., patients characteristics as fatigue and the inability to understand ICT-devices), and for healthcare professionals at the level of the organizational context (e.g., having sufficient time and the fit with existing processes of care).

CONCLUSION

Although there was a considerable overlap in reported factors between patients/informal caregivers and healthcare professionals when it concerns eRehabilitation as innovation, its seems that patients/informal caregivers give more emphasis to factors related to the individual patient, whereas healthcare professionals emphasize the importance of factors related to the organizational context. This difference should be considered when developing an implementation strategy for patients and healthcare professionals separately.

An integrative review of information and communication technology based support interventions for carers of home dwelling older people

BACKGROUND

A growing number of studies of informal carers of older people reveal positive results concerning support via Information and Communication Technologies (ICT). Systematic examination of factors that have a potential impact on carer outcomes are needed to inform future research.

OBJECTIVE

To explore studies concerning ICT support of adult carers of older people and to identify study characteristics that have a potential impact on carer outcomes.

METHODS

This integrative review includes 123 studies published since 2005. Fundamental questions for designing sensitive support interventions; 'who, what, and how' were applied to a synthesis of the results.

RESULTS

Identified characteristics from the studies responding to the who question included variables of the carers, such as their relationship with the care recipient or their ethnicity. Characteristics related to the what question related to the types of interventions, and the how question concerned the different services or programs offered, the idiosyncratic needs of the carers, and the types of technologies used.

CONCLUSION

Results are discussed according to micro, meso and macro levels of analysis. This extensive review can inform future studies and highlight the evidence in the area for decision makers, practitioners and/or NGOs working with innovative forms of support for carers of older people.

Needs of Stroke Survivors as Perceived by Their Caregivers: A Scoping Review

OBJECTIVE

Caregivers usually are not involved while planning the stroke survivor's medical and rehabilitation goals and interventions. This review aimed to identify the needs of stroke survivors as perceived by their caregivers.

DESIGN

A literature search from 2003 to 2014 was conducted using Medline, CINAHL, PsychINFO, and Google Scholar. Sixty-six studies were included. Most studies excluded did not encompass caregivers' perspectives. Four reviewers screened the titles, abstracts, and full texts of the articles for inclusion. The data extracted from these studies were synthetized into metathemes.

RESULTS

Fifty-two qualitative, ten quantitative survey, and four mixed-methods studies were included in the final synthesis. The studies came from 11 countries. The data synthesis produced following three metathemes: (a) body functional needs, including psychological function, physical function, cognitive function, and uncertainty related to function; (b) activity and participatory needs, including healthy lifestyle, physical activities, speech, independence, cognitive activities, and uncertainty related to activities and participation; and (c) environmental needs, encompassing support, services, safety, accommodation and accessibility, and uncertainty related to environmental factors.

CONCLUSIONS

This scoping review identified a range of needs of stroke survivors as perceived by their caregivers. Incorporating the caregiver's preferences and values into clinical decisions may improve outcomes among stroke survivors.

Caring for the carer: a systematic review of pure technology-based cognitive behavioral therapy (TB-CBT) interventions for dementia carers

BACKGROUND

Face-to-face delivery of CBT is not always optimal or practical for informal dementia carers (DCs). Technology-based formats of CBT delivery (TB-CBT) have been developed with the aim to improve client engagement and accessibility, and lower delivery costs, and offers potential benefits for DCs. However, research of TB-CBT for DCs has maintained heavy reliance on therapist involvement. The efficacy of pure TB-CBT interventions for DCs is not currently established Methods: A systematic review of trials of pure TB-CBT intervention for DCs from 1995 was conducted. PsycINFO, Cochrane Reviews, Scopus and MedLine databases were searched using key terms related to CBT, carers and dementia. Four hundred and forty two articles were identified, and inclusion/exclusion criteria were applied; studies were only retained if quantitative data was available, and there was no active therapist contact. Four articles were retained; two randomized and two waitlist control trials. Methodological and reporting quality was assessed. Meta-analyses were conducted for the outcome measures of caregiver depression.

RESULTS

Meta-analysis revealed small significant post-intervention effects of pure TB-CBT interventions for depression; equivalent to face-to-face interventions. However, there is no evidence regarding long-term efficacy of pure TB-CBT for DCs. The systematic review further identified critical methodological and reporting shortcomings pertaining to these trials Conclusions: Pure TB-CBT interventions may offer a convenient, economical method for delivering psychological interventions to DCs. Future research needs to investigate their long-term efficacy, and consider potential moderating and mediating factors underpinning the mechanisms of effect of these programs. This will help to provide more targeted interventions to this underserviced population.

Telemedicine in stroke care and rehabilitation

Telemedicine allows prompt assessment of acute stroke patients. This new technology has increased the administration of intravenous recombinant tissue plasminogen activator (rtPA) to eligible patients. In addition, telemedicine is being utilized in the rehabilitation of patients with cerebrovascular disease. This article will review the use of telemedicine in patients with acute ischemic stroke and its implementation in telerehabilitation to patients with residual neurologic deficits.

Using Information and Communication Technology in Home Care for Communication between Patients, Family Members, and Healthcare Professionals: A Systematic Review

Introduction. Information and communication technology (ICT) are becoming a natural part in healthcare both for delivering and giving accessibility to healthcare for people with chronic illness living at home. Aim. The aim was to review existing studies describing the use of ICT in home care for communication between patients, family members, and healthcare professionals. Methods. A review of studies was conducted that identified 1,276 studies. A selection process and quality appraisal were conducted, which finally resulted in 107 studies. Results. The general results offer an overview of characteristics of studies describing the use of ICT applications in home care and are summarized in areas including study approach, quality appraisal, publications data, terminology used for defining the technology, and disease diagnosis. The specific results describe how communication with ICT was performed in home care and the benefits and drawbacks with the use of ICT. Results were predominated by positive responses in the use of ICT. Conclusion. The use of ICT applications in home care is an expanding research area, with a variety of ICT tools used that could increase accessibility to home care. Using ICT can lead to people living with chronic illnesses gaining control of their illness that promotes self-care.

A qualitative analysis of an advanced practice nurse-directed transitional care model intervention

PURPOSE

The purpose of this study was to describe barriers and facilitators to implementing a transitional care intervention for cognitively impaired older adults and their caregivers lead by advanced practice nurses (APNs).

DESIGN AND METHODS

APNs implemented an evidence-based protocol to optimize transitions from hospital to home. An exploratory, qualitative directed content analysis examined 15 narrative case summaries written by APNs and fieldnotes from biweekly case conferences.

RESULTS

Three central themes emerged: patients and caregivers having the necessary information and knowledge, care coordination, and the caregiver experience. An additional category was also identified, APNs going above and beyond.

IMPLICATIONS

APNs implemented individualized approaches and provided care that exceeds the type of care typically staffed and reimbursed in the American health care system by applying a Transitional Care Model, advanced clinical judgment, and doing whatever was necessary to prevent negative outcomes. Reimbursement reform as well as more formalized support systems and resources are necessary for APNs to consistently provide such care to patients and their caregivers during this vulnerable time of transition.

The crisis of stroke: experiences of patients and their family caregivers

PURPOSE

Approximately 4.8 million stroke survivors are living in the community with some level of disability requiring the assistance of family caregivers. Stroke family caregivers are often unprepared for the demands required of them. The purpose of this grounded theory study was to explore the needs of stroke patients and their family caregivers as they transitioned through the stroke care continuum from acute care to inpatient rehabilitation to home.

METHODS

Thirty-eight participants, 19 recovering stroke patients (11 male, 8 female), 15 primary family caregivers (14 spouses, 1 mother), and 4 adult children were interviewed during their stay at a rehabilitation facility and within 6 months of discharge. Interview questions were loosely structured and focused on the stroke experience and how patients and caregivers were managing postdischarge. Data were analyzed using dimensional and comparative analysis.

RESULTS

Findings were organized in a conceptual framework illustrating the trajectory of the crisis of stroke. Stroke survivors and their caregivers faced enormous challenges as they moved through 3 phases of the trajectory: the stroke crisis, expectations for recovery, and the crisis of discharge. Findings from this study suggest that as caregivers move through the phases of the trajectory, they do not have a good understanding of the role to which they are committing, and they are often underprepared to take on even the basic tasks to meet the patients' needs on discharge.

CONCLUSION

Stroke survivors and their caregivers do not have adequate time to deal with the shock and crisis of the stroke event, let al.one the crisis of discharge and all of the new responsibilities with which they must deal.

A review of the evidence for the use of telemedicine within stroke systems of care: a scientific statement from the American Heart Association/American Stroke Association

The aim of this new statement is to provide a comprehensive and evidence-based review of the scientific data evaluating the use of telemedicine for stroke care delivery and to provide consensus recommendations based on the available evidence. The evidence is organized and presented within the context of the American Heart Association's Stroke Systems of Care framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class of evidence. Evidence-based recommendations are included for the use of telemedicine in general neurological assessment and primary prevention of stroke; notification and response of emergency medical services; acute stroke treatment, including the hyperacute and emergency department phases; hospital-based subacute stroke treatment and secondary prevention; and rehabilitation.

Human factors in the development and implementation of telerehabilitation systems

Telemedicine services must be designed and implemented with the users in mind. When conducting telerehabilitation, factors such as age, education and technology experience must be taken into account. In addition, telerehabilitation must also accommodate a range of potential patient impairments, including deficits in language, cognition, motor function, vision and voice. Telerehabilitation technology and treatment environments should adhere to universal design standards so as to be accessible, efficient, usable and understandable to all. This will result in improved access to a wider range of telerehabilitation services that will facilitate and enhance the rehabilitative treatment and recovery of people living with varying levels of injury, impairment and disability.

"Timing It Right": a conceptual framework for addressing the support needs of family caregivers to stroke survivors from the hospital to the home

OBJECTIVE

Discuss family caregivers of stroke survivors' changing needs for education and support across the care continuum.

METHODS

Conceptual review.

RESULTS

Stroke is a serious, sudden onset illness requiring care across the care continuum. The focus of care, the individuals primarily responsible for providing that care, and patients' self-care abilities change across care environments. Often family members who provide support also experience changes in their caregiving role. To date, however, interventions for family caregivers have not explicitly considered their changing support needs. Our "Timing It Right" framework highlights family caregivers changing experiences and corresponding support needs across the care continuum. Five different phases of caregiver support are discussed: (1) event/diagnosis; (2) stabilization; (3) preparation; (4) implementation; (5) adaptation. The first two phases occur during acute care, the third occurs during acute care and/or in-patient rehabilitation, and the final two phases occur in the community.

CONCLUSIONS

Application of this framework has the potential to benefit future intervention efforts by identifying gaps in caregiver education, training, and support.

PRACTICE IMPLICATIONS

Recognition of family caregivers changing support needs across the care continuum will assist health care professionals to provide more timely and appropriate support.