A qualitative evidence synthesis exploring people after stroke, family members, carers and healthcare professionals' experiences of early supported discharge (ESD) after stroke

Experiences and preferences of people with stroke and caregivers, around supports provided at the transition from hospital to home: a qualitative descriptive study

BACKGROUND

Transitioning home from the structured hospital setting poses challenges for people with stroke (PWS) and their caregivers (CGs), as they navigate through complex uncertainties. There are gaps in our understanding of appropriate support interventions for managing the transition home. In this qualitative study, we explored the perspectives of PWS and their CGs regarding their support experiences and preferences during this period.

METHODS

Between November 2022 and March 2023, and within six months of hospital discharge, audio-recorded, semi-structured interviews were conducted with PWS and CGs. All interviews were transcribed, imported into NVivo software, and analysed using reflexive thematic analysis.

RESULTS

Sixteen interviews were conducted, nine with PWS and seven with CGs. Four themes relevant to their collective experiences and preferences were identified: (i) Need for tailored information-sharing, at the right time, and in the right setting; (ii) The importance of emotional support; (iii) Left in limbo, (iv) Inequity of access. Experiences depict issues such as insufficient information-sharing, communication gaps, and fragmented and inequitable care; while a multi-faceted approach is desired to ease anxiety and uncertainty, minimise delays, and optimise recovery and participation during transition.

CONCLUSIONS

Our findings highlight that regardless of the discharge route, and even with formal support systems in place, PWS and families encounter challenges during the transition period. The experiences of support at this transition and the preferences of PWS and CGs during this important period highlights the need for better care co-ordination, early and ongoing emotional support, and equitable access to tailored services and support. Experiences are likely to be improved by implementing a partnership approach with improved collaboration, including joint goal-setting, between PWS, CGs, healthcare professionals and support organisations.

Coming home in the context of very early supported discharge after stroke - An interview study of patients' experiences

OBJECTIVES

To explore patients' experiences of coming home and managing everyday life within the context of very early supported discharge after stroke (VESD).

STUDY DESIGN

An explorative qualitative study using semi structured interviews.

METHOD

This study was nested within a randomised controlled trial,; Gothenburg Very Early Supported Discharge (GOTVED), comparing a home rehabilitation intervention given by a coordinated team (VESD) with conventional care. Eleven participants with a median age 70.0 years (range 63-95) of which nine scoring 0-4 on the NIHSS indicating no symptoms or minor stroke were interviewed on average 12 days after discharge. Data was analysed using thematic analysis.

RESULTS

The diversity of patients' experiences was reflected in the overarching main theme Very Early Supported Discharge after stroke - a multifaceted experience, built upon five themes: "Conditions surrounding the discharge", "Concerns about the condition", "Confronting a new everyday life", "Experiences of the intervention" and the "Role of next of kin".

CONCLUSIONS

The respondents were largely satisfied with the very early supported discharge which might be expected, given that it was well planned regarding timing, individualisation and content. The patients need to be aware of the purpose of the VESD intervention. Due to the unpredictability of the stroke and its consequences, interventions need to be flexible. Goal setting is important but must be comprehensible. The role and burden of next of kin should be addressed and negotiated, and the ending of the intervention must be planned, with seamless transition to further rehabilitation and social support including the issue of participation in everyday life.

Utilization of early supported discharge and outpatient rehabilitation services following inpatient stroke rehabilitation

BACKGROUND

Studies examining factors associated with patient referral to early supported discharge (ESD)/outpatient rehabilitation (OPR) programs and utilization of ESD/OPR services after discharge from inpatient stroke rehabilitation (IPR) are scarce. Accordingly, we examined utilization of ESD/OPR services following discharge from IPR and patient factors associated with service utilization.

METHODS

Stroke patients discharged from IPR facilities in Alberta between April 2014 and March 2016 were included and followed for one year for ESD/OPR service utilization. Multivariable linear and negative binomial regressions were used to examine association of patients' factors with ESD/OPR use.

RESULTS

We included 752 patients (34.4% of 2,187 patients discharged from IPR) who had 40,772 ESD/OPR visits during one year of follow-up in the analysis. Mean and median ESD/OPR visits were 54.2 and 36 visits, respectively. Unadjusted ESD/OPR visits were lower in females and patients aged ≥ 60 years but were similar between urban and rural areas. After adjustment for patient factors, patients in urban areas and discharged home after IPR were associated with 83.5% and 61.9%, respectively, increase in ESD/OPR visits, while having a right-body stroke was associated with 23.5% increase. Older patients used ESD/OPR less than their younger counterparts (1.4% decrease per one year of older age). Available factors explained 12.3% of variation in ESD/OPR use.

CONCLUSION

ESD/OPR utilization after IPR in Alberta was low and varied across age and geographic locations. Factors associated with use of ESD/OPR were identified but they could not fully explain variation of ESD/OPR use.

Transitioning to home and beyond following stroke: a prospective cohort study of outcomes and needs

INTRODUCTION

Understanding of the needs of people with stroke at hospital discharge and in the first six-months is limited. This study aim was to profile and document the needs of people with stroke at hospital discharge to home and thereafter.

METHODS

A prospective cohort study recruiting individuals with stroke, from three hospitals, who transitioned home, either directly, through rehabilitation, or with early supported discharge teams. Their outcomes (global-health, cognition, function, quality of life, needs) were described using validated questionnaires and a needs survey, at 7-10 days, and at 3-, and 6-months, post-discharge.

RESULTS

72 patients were available at hospital discharge; mean age 70 (SD 13); 61% female; median NIHSS score of 4 (IQR 0-20). 62 (86%), 54 (75%), and 45 (63%) individuals were available respectively at each data collection time-point. Perceived disability was considerable at hospital discharge (51% with mRS ≥ 3), and while it improved at 3-months, it increased thereafter (35% with mRS ≥ 3 at 6-months). Mean physical health and social functioning were "fair" at hospital discharge and ongoing; while HR-QOL, although improved over time, remained impaired at 6-months (0.69+/-0.28). At 6-months cognitive impairment was present in 40%. Unmet needs included involvement in transition planning and care decisions, with ongoing rehabilitation, information, and support needs. The median number of unmet needs at discharge to home was four (range:1-9), and three (range:1-7) at 6-months.

CONCLUSION

Stroke community reintegration is challenging for people with stroke and their families, with high levels of unmet need. Profiling outcomes and unmet needs for people with stroke at hospital-to-home transition and onwards are crucial for shaping the development of effective support interventions to be delivered at this juncture.

ISRCTN REGISTRATION

02/08/2022; ISRCTN44633579.

Getting the message across; a realist study of the role of communication and information exchange processes in delivering stroke Early Supported Discharge services in England

BACKGROUND

Stroke early supported discharge (ESD) involves the co-ordinated transfer of care from hospital to home. The quality of communication processes between professionals delivering ESD and external stakeholders may have a role to play in streamlining this process. We explored how communication and information exchange were achieved and influenced the hospital-to-home transition and the delivery quality of ESD, from healthcare professionals' perspectives.

METHODS

Six ESD case study sites in England were purposively selected. Under a realist approach, we conducted interviews and focus groups with 117 staff members, including a cross-section of the multidisciplinary team, service managers and commissioners.

RESULTS

Great variation was observed between services in the type of communication processes they employed and how organised these efforts were. Effective communication between ESD team members and external stakeholders was identified as a key mechanism driving the development of collaborative and trusting relationships and promoting coordinated care transitions. Cross-boundary working arrangements with inpatient services helped clarify the role and remit of ESD, contributing to timely hospital discharge and response from ESD teams. Staff perceived honest and individualised information provision as key to effectively prepare stroke survivors and families for care transitions and promote rehabilitation engagement. In designing and implementing ESD, early stakeholder involvement ensured the services' fit in the local pathway and laid the foundations for communication and partnership working going forward.

CONCLUSIONS

Findings highlighted the interdependency between services delivering ESD and local stroke care pathways. Maintaining good communication and engagement with key stakeholders may help achieve a streamlined hospital discharge process and timely delivery of ESD. ESD services should actively manage communication processes with external partners. A shared cross-service communication strategy to guide the provision of information along to continuum of stroke care is required. Findings may inform efforts towards the delivery of better coordinated stroke care pathways.

Healthcare professionals' experiences of delivering a stroke Early Supported Discharge service - An example from Ireland

OBJECTIVE

To explore healthcare professionals' experiences of the development and delivery of Early Supported Discharge for people after stroke, including experiences of the COVID-19 pandemic.

DESIGN

Qualitative descriptive study using one-to-one semi-structured interviews. Data were analysed using reflexive thematic analysis.

SETTING

Nine Early Supported Discharge service sites in Ireland.

PARTICIPANTS

Purposive sampling identified 16 healthcare professionals.

RESULTS

Five key themes were identified (1) Un-coordinated development of services, (2) Staff shortages limit the potential of Early Supported Discharge, (3) Limited utilisation of telerehabilitation post COVID-19 pandemic, (4) Families need information and support, and (5) Early Supported Discharge involves collaboration with people after stroke and their families.

CONCLUSIONS

Findings highlight how Early Supported Discharge services adapted during the COVID-19 pandemic and how gaps in the service impacts on service delivery. Practice implications include the need to address staff recruitment and retention issues to prevent service shortages and ensure consistent access to psychology services. Early Supported Discharge services should continue to work closely with families and address their information and support needs. Future research on how telerehabilitation can optimally be deployed and the impact of therapy assistants in Early Supported Discharge is needed.

Building Bridges between People with Stroke, Families, and Health Professionals: Development of a Blended Care Program for Self-Management

Evidence-informed interventions for stroke self-management support can influence functional capability and social participation. People with stroke should be offered self-management support after hospital discharge. However, in Portugal, there are no known programs of this nature. This study aimed to develop a person-centered and tailored blended care program for post-stroke self-management, taking into account the existing evidence-informed interventions and the perspectives of Portuguese people with stroke, caregivers, and health professionals. An exploratory sequential mixed methods approach was used, including qualitative methods during stakeholder consultation (stage 1) and co-production (stage 2) and quantitative assessment during prototyping (stage 3). After ethical approval, recruitment occurred in three health units. Results from a literature search led to the adaptation of the Bridges Stroke Self-Management Program. In stage one, 47 participants were interviewed, with two themes emerging: (i) Personalized support and (ii) Building Bridges through small steps. In stage two, the ComVida program was developed, combining in-person and digital approaches, supported by a workbook and a mobile app. In stage three, 56 participants evaluated prototypes, demonstrating a strong level of quality. Understandability and actionability of the developed tools obtained high scores (91-100%). The app also showed good usability (A-grade) and high levels of recommendation (5 stars).