How do stroke early supported discharge services achieve intensive and responsive service provision? Findings from a realist evaluation study (WISE)

Abstract

Background Stroke Early Supported Discharge (ESD) involves provision of responsive and intensive rehabilitation to stroke survivors at home and it is recommended as part of the stroke care pathway. Core components have been identified to guide the delivery of evidence-based ESD, however, service provision in England is of variable quality. The study sought to understand how and in what conditions the adoption of these components drives the delivery of responsive and intensive ESD services in real world settings. Methods This qualitative study was part of a wider multimethod realist evaluation project (WISE) conducted to inform large-scale ESD implementation. Overarching programme theories and related context–mechanism–outcome configurations were used as a framework to guide data collection and analysis. Six case study sites were purposively selected; interviews and focus groups with ESD staff members were conducted and analysed iteratively. Results We interviewed 117 ESD staff members including clinicians and service managers. Staff highlighted the role of certain core components including eligibility criteria, capacity, team composition and multidisciplinary team (MDT) coordination in achieving responsive and intensive ESD. Regardless of the geographical setting, adhering to evidence-based selection criteria, promoting an interdisciplinary skillset and supporting the role of rehabilitation assistants, allowed teams to manage capacity issues and maximise therapy time. Gaps in the stroke care pathway, however, meant that teams had to problem solve beyond their remit to cater for the complex needs of patients with severe disabilities. Adjusting MDT structures and processes was seen as key in addressing challenges posed by travel times and rural geography. Conclusions Despite variations in the wider service model of operation and geographical location, the adoption of core components of ESD helped teams manage the pressures and deliver services that met evidence-based standards. Findings point to a well-recognised gap in service provision in England for stroke survivors who do not meet the ESD criteria and emphasise the need for a more integrated and comprehensive stroke service provision. Transferable lessons could be drawn to inform improvement interventions aimed at promoting evidence-based service delivery in different settings. Trial registration ISRCTN: 15,568,163, registration date: 26 October 2018.

Healthcare professionals’ experiences of delivering a stroke Early Supported Discharge service – An example from Ireland

“…5 Our findings reflect recent qualitative research with healthcare professionals in the United Kingdom (n = 117) where therapy assistants were described as having a key role to play in the team and development of an interdisciplinary skillset among therapy assistants helped manage capacity issues. 9 Importantly, this study highlighted the need to empower and promote the autonomy of assistant staff through appropriate supervision and upskilling. 9 Other research has confirmed that therapy assistants can improve capacity and efficiency 22 however to date they may be underutilised within community settings.…”

“…9 Importantly, this study highlighted the need to empower and promote the autonomy of assistant staff through appropriate supervision and upskilling. 9 Other research has confirmed that therapy assistants can improve capacity and efficiency 22 however to date they may be underutilised within community settings. 23 Further research is needed to quantify the benefits and cost implications of therapy assistants as part of Early Supported Discharge teams.…”

“…In England where Early Supported Discharge is an available model of care, 8 qualitative research with healthcare professionals has been identified as key to investigating adherence to evidence-based standards and the delivery of effective services in practice. 9 Two qualitative studies 10 , 11 report the Early Supported Discharge experiences of people after stroke in Ireland however no study to date has reported the experiences and perspectives of healthcare professionals in Ireland of the relatively recent development and delivery of this model of care. Given that organisational and interprofessional factors are seen by healthcare professionals 4 , 12 as central to the success of Early Supported Discharge, 4 there is a need to understand the delivery of Early Supported Discharge in Ireland from the perspective of the healthcare professional, particularly in the context of recent service expansion and the COVID-19 pandemic when healthcare services underwent significant reconfiguration.…”

Inpatient Rehabilitation Outcomes after Primary Severe Haemorrhagic Stroke: A Retrospective Study Comparing Surgical versus Non-Surgical Management

“…This finding aligns with another Asian study that reported a discharge rate of 76.8% for stroke patients after inpatient rehabilitation [ 48 ]. The high percentage of patients being able to be discharged home can be attributed to improvement in community resources, Asian close-knit family support systems, ready availability of paid live-in caregivers who are employed as foreign domestic caregivers as well as implementation of early discharge planning [ 49 , 50 ]. These initiatives have facilitated a smoother transition from hospital to home and have provided stroke survivors with the necessary support to continue their recovery in a familiar environment.…”

Feasibility characteristics of wrist-worn fitness trackers in health status monitoring for post-COVID patients in remote and rural areas

“…Patients were recruited from an early supported discharge (ESD) program in Camrose, Alberta, Canada, which has a population of just under 21,000 residents. The ESD program was originally designed to support patients recovering from acute stroke (Chouliara et al, 2023); however, during the COVID-19 pandemic, it was adapted for COVID-19. Patients were referred to the program either directly from hospital (at discharge) or through community clinics.…”