Referrer and service provider beliefs and attitudes towards rehabilitation in the home; factors related to utilisation of Early Supported Discharge

Re/connecting with "home": a mixed methods study of service provider and patient perspectives to facilitate implementing rehabilitation in the home for reconditioning

PURPOSE

To explore the views of healthcare professionals and patients about the advantages and disadvantages of rehabilitation in the home (RITH) for reconditioning, and identify factors that should contribute to the successful implementation of a consensus-based RITH model for reconditioning.

MATERIALS AND METHODS

Interviews with 24 healthcare professionals and 21 surveys (comprising Likert scale and free text responses) of inpatients undergoing rehabilitation for reconditioning provided study data. Interpretive thematic analysis was used to analyse interview data; descriptive statistics analysed Likert scale responses; patient written responses assisted with the interpretation of themes developed from the interview data.

RESULTS

Two major themes were elicited in this study: the home is a physical setting and the home is a lived space. Advantages and disadvantages of RITH for patients, carers and healthcare professionals were identified within these themes. Appropriate patient selection; effective communication with patients and carers, and within RITH teams; adequate patient and carer support; ensuring the safety of patients and staff; and education of patients, carers and healthcare professionals are essential for the satisfactory implementation of RITH.

CONCLUSION

The concept of home shapes the delivery of RITH. Recognising the advantages and disadvantages of RITH highlights important considerations needed to successfully implement RITH for reconditioning.

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.

Developing a model for rehabilitation in the home as hospital substitution for patients requiring reconditioning: a Delphi survey in Australia

BACKGROUND

Reconditioning for patients who have experienced functional decline following medical illness, surgery or treatment for cancer accounts for approximately 26% of all reported inpatient rehabilitation episodes in Australia. Rehabilitation in the home (RITH) has the potential to offer a cost-effective, high-quality alternative for appropriate patients, helping to reduce pressure on the acute care sector. This study sought to gain consensus on a model for RITH as hospital substitution for patients requiring reconditioning.

METHODS

A multidisciplinary group of health professionals working in the rehabilitation field was identified from across Australia and invited to participate in a three-round online Delphi survey. Survey items followed the patient journey, and also included items on practitioner roles, clinical governance, and budgetary considerations. Survey items mostly comprised statements seeking agreement on 5-point Likert scales (strongly agree to strongly disagree). Free text boxes allowed participants to qualify item answers or make comments. Analysis of quantitative data used descriptive statistics; qualitative data informed question content in subsequent survey rounds or were used in understanding item responses.

RESULTS

One-hundred and ninety-eight health professionals received an invitation to participate. Of these, 131/198 (66%) completed round 1, 101/131 (77%) completed round 2, and 78/101 (77%) completed round 3. Consensus (defined as ≥ 70% agreement or disagreement) was achieved on over 130 statements. These related to the RITH patient journey (including patient assessment and development of the care plan, case management and program provision, and patient and program outcomes); clinical governance and budgetary considerations; and included items for initial patient screening, patient eligibility and case manager roles. A consensus-based model for RITH was developed, comprising five key steps and the actions within each.

CONCLUSIONS

Strong support amongst survey participants was found for RITH as hospital substitution to be widely available for appropriate patients needing reconditioning. Supportive legislative and payment systems, mechanisms that allow for the integration of primary care, and appropriate clinical governance frameworks for RITH are required, if broad implementation is to be achieved. Studies comparing clinical outcomes and cost-benefit of RITH to inpatient rehabilitation for patients requiring reconditioning are also needed.

Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study

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.

Evaluating the implementation of an early supported discharge (ESD) program for stroke survivors: A mixed methods longitudinal case study

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.

Clinician and client views of utilising early supported discharge services

Background/Aims:

To explore the beliefs and attitudes of potential referrers and referrees regarding the possible utilisation of early supported discharge (ESD) prior to hospital discharge.

Methods:

Semi-standardised one-to-one interviews were conducted with nine consultants and ten dyads, comprising inpatients and corresponding treating staff members involved in referral of these patients to ESD. Content analysis was completed to identify key themes and to group the data into categories.

Results:

Rehabilitation consultants reported safety and the ability to manage at home were the primary considerations in ESD referral decision making. Most patients were extremely likely to agree to referral to ESD. Four main categories were identified in the responses from the patient/staff dyads, which were summarised as: positive and negative aspects of ESD, and barriers and enablers to early discharge. Patients were only willing to return home with ESD once they were ambulant in some capacity. Staff identified considerably more potential disadvantages, and fewer benefits than patients with regard to early discharge. However, there was no indication that staff beliefs had a negative influence on patient views regarding their participation in ESD.

Conclusions:

Patients and staff generally approved of ESD services; however, staff may need to place greater consideration on advantages, such as the potential emotional and mental benefits that some patients associate with returning home sooner with ESD.