Physiotherapists' perspectives of barriers and facilitators to effective community provision after hip fracture: a qualitative study in England.

PURPOSE: to investigate physiotherapists' perspectives of effective community provision following hip fracture. METHODS: qualitative semi-structured interviews were conducted with 17 community physiotherapists across England. Thematic analysis drawing on the Theoretical Domains Framework identified barriers and facilitators to implementation of effective provision. Interviews were complemented by process mapping community provision in one London borough, to identify points of care where suggested interventions are in place and/or could be implemented. RESULTS: four themes were identified: ineffective coordination of care systems, ineffective patient stratification, insufficient staff recruitment and retention approaches and inhibitory fear avoidance behaviours. To enhance care coordination, participants suggested improving access to social services and occupational therapists, maximising multidisciplinary communication through online notation, extended physiotherapy roles, orthopaedic-specific roles and seven-day working. Participants advised the importance of stratifying patients on receipt of referrals, at assessment and into appropriately matched interventions. To mitigate insufficient staff recruitment and retention, participants proposed return-to-practice streams, apprenticeship schemes, university engagement, combined acute-community rotations and improving job description advertisements. To reduce effects of fear avoidance behaviour on rehabilitation, participants proposed the use of patient-specific goals, patient and carer education, staff education in psychological strategies or community psychologist access. Process mapping of one London borough identified points of care where suggested interventions to overcome barriers were in place and/or could be implemented. CONCLUSION: physiotherapists propose that effective provision of community physiotherapy following hip fracture could be improved by refining care coordination, utilising stratification techniques, employing enhanced recruitment and retainment strategies and addressing fear avoidance behaviours.

Case management for integrated care of older people with frailty in community settings.

BACKGROUND: Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems. OBJECTIVES: To assess the effects of case management for integrated care of older people living with frailty compared with usual care. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty. DATA COLLECTION AND ANALYSIS: We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS: We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate. Case management compared to standard care may result in little or no difference in the following outcomes. • Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I2 = 11%; 14 trials, 9924 participants; low-certainty evidence) • Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I2 = 0%; 4 trials, 1108 participants; low-certainty evidence) • Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from -6.32 points (95% CI -11.04 to -1.59) to 6.1 points (95% CI -3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence) • Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence) • Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from -0.12 points (95% CI -0.93 to 0.68) to 3.4 points (95% CI -2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence) Case management compared to standard care probably results in little or no difference in the following outcomes. • Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence) • Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care. AUTHORS' CONCLUSIONS: We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others.

What underlies the difference between self-reported health and disability after stroke? A qualitative study in the UK.

BACKGROUND: Levels of self-reported health do not always correlate with levels of physical disability in stroke survivors. We aimed to explore what underlies the difference between subjective self-reported health and objectively measured disability among stroke survivors. METHODS: Face to face semi-structured interviews were conducted with stroke survivors recruited from a stroke clinic or rehabilitation ward in the UK. Fifteen stroke survivors purposively sampled from the clinic who had discordant self-rated health and levels of disability i.e. reported health as 'excellent' or 'good' despite significant physical disability (eight), or as 'fair' or 'poor' despite minimal disability (seven) were compared to each other, and to a control group of 13 stroke survivors with concordant self-rated health and disability levels. Interviews were conducted 4 to 6 months after stroke and data analysed using the constant comparative method informed by Albrecht and Devlieger's concept of 'disability paradox'. RESULTS: Individuals with 'excellent' or 'good' self-rated health reported a sense of self-reliance and control over their bodies, focussed on their physical rehabilitation and lifestyle changes and reported few bodily and post-stroke symptoms regardless of level of disability. They also frequently described a positive affect and optimism towards recovery. Some, especially those with 'good' self-rated health and significant disability also found meaning from their stroke, reporting a spiritual outlook including practicing daily gratitude and acceptance of limitations. Individuals with minimal disability reporting 'fair' or 'poor' self-rated health on the other hand frequently referred to their post-stroke physical symptoms and comorbidities and indicated anxiety about future recovery. These differences in psychological outlook clustered with differences in perception of relational and social context including support offered by family and healthcare professionals. CONCLUSIONS: The disability paradox may be illuminated by patterns of individual attributes and relational dynamics observed among stroke survivors. Harnessing these wider understandings can inform new models of post-stroke care for evaluation.

Orthopaedic physiotherapists' perceptions of mechanisms for observed variation in the implementation of physiotherapy practices in the early postoperative phase after hip fracture: a UK qualitative study.

OBJECTIVE: to explore physiotherapists' perceptions of mechanisms to explain observed variation in early postoperative practice after hip fracture surgery demonstrated in a national audit. METHODS: a qualitative semi-structured interview study of 21 physiotherapists working on orthopaedic wards at seven hospitals with different durations of physiotherapy during a recent audit. Thematic analysis of interviews drawing on Normalisation Process Theory to aid interpretation of findings. RESULTS: four themes were identified: achieving protocolised and personalised care; patient and carer engagement; multidisciplinary team engagement across the care continuum and strategies for service improvement. Most expressed variation from protocol was legitimate when driven by what is deemed clinically appropriate for a given patient. This tailored approach was deemed essential to optimise patient and carer engagement. Participants reported inconsistent degrees of engagement from the multidisciplinary team attributing this to competing workload priorities, interpreting 'postoperative physiotherapy' as a single professional activity rather than a care delivery approach, plus lack of integration between hospital and community care. All participants recognised changes needed at both structural and process levels to improve their services. CONCLUSION: physiotherapists highlighted an inherent conflict between their intention to deliver protocolised care and allowing for an individual patient-tailored approach. This conflict has implications for how audit results should be interpreted, how future clinical guidelines are written and how physiotherapists are trained. Physiotherapists also described additional factors explaining variation in practice, which may be addressed through increased engagement of the multidisciplinary team and resources for additional staffing and advanced clinical roles.

Social network participation towards enactment of self-care in people with chronic obstructive pulmonary disease: A qualitative meta-ethnography.

BACKGROUND: How people with chronic obstructive pulmonary disease (COPD) engage with supportive social networks to enhance self-care is not understood. The personal rationales for participation in socially directed support have not been addressed in the literature. To determine how people with COPD identify, engage and participate in socially supportive self-care practices, we conducted a systematic review and meta-ethnography of qualitative studies. METHODS: A systematic literature search was conducted between June 2010 and June 2021. Of 3536 articles, 8 fulfilled the inclusion criteria. Using a meta-ethnography approach to the qualitative synthesis, new concepts were derived from the data to identify aligning themes and develop a conceptual model. FINDINGS: Interpretations from the papers yielded concepts of (1) accountability and personal responsibility in self-care, (2) valued positive relationships with clinicians, (3) understanding of illness through shared and personal experiences and (4) acknowledging social networks in fostering self-care engagement in people with COPD. The independence-experience (Index) model of synthesized (third order) interpretations highlighted the processes of social networks and self-care practices: (a) fear or avoidance of dependency, (b) learning from experiences of adaptive self-care behaviours and (c) including valued practices in self-care. Self-care strategies are formed through illness experiences and relatable social encounters. CONCLUSION: The model derived from the third-order interpretations is a framework to describe socially supported self-care and can be used to direct future self-care strategies and target interventions for people with COPD. PATIENT OR PUBLIC CONTRIBUTION: The findings and model were presented to the long-term conditions patient and public involvement group. The manuscript is coauthored by a public representative.

Comparative case studies in integrated care implementation from across the globe: a quest for action.

BACKGROUND: Integrated care is the coordination of general and behavioral health and is a highly promising and practical approach to improving healthcare delivery and patient outcomes. While there is growing interest and investment in integrated care implementation internationally, there are no formal guidelines for integrated care implementation applicable to diverse healthcare systems. Furthermore, there is a complex interplay of factors at multiple levels of influence that are necessary for successful implementation of integrated care in health systems. METHODS: Guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework (Aarons et al., 2011), a multiple case study design was used to address two research objectives: 1) To highlight current integrated care implementation efforts through seven international case studies that target a range of healthcare systems, patient populations and implementation strategies and outcomes, and 2) To synthesize the shared and unique challenges and successes across studies using the EPIS framework. RESULTS: The seven reported case studies represent integrated care implementation efforts from five countries and continents (United States, United Kingdom, Vietnam, Israel, and Nigeria), target a range of clinical populations and care settings, and span all phases of the EPIS framework. Qualitative synthesis of these case studies illuminated common outer context, inner context, bridging and innovation factors that were key drivers of implementation. CONCLUSIONS: We propose an agenda that outlines priority goals and related strategies to advance integrated care implementation research. These goals relate to: 1) the role of funding at multiple levels of implementation, 2) meaningful collaboration with stakeholders across phases of implementation and 3) clear communication to stakeholders about integrated care implementation. TRIAL REGISTRATION: Not applicable.

Disciplinary power and the process of training informal carers on stroke units.

This article examines the process of training informal carers on stroke units using the lens of power. Care is usually assumed as a kinship obligation but the state has long had an interest in framing the carer and caring work. Training carers in healthcare settings raises questions about the power of the state and healthcare professionals as its agents to shape expectations and practices related to the caring role. Drawing on Foucault's notion of disciplinary power, we show how disciplinary forms of power exercised in interactions between healthcare professionals and carers shape the engagement and resistance of carers in the process of training. Interview and observational field note extracts are drawn from a multi-sited study of a training programme on stroke units targeting family carers of people with stroke to consider the consequences of subjecting caring to this intervention. We found that the process of training informal carers on stroke units was not simply a matter of transferring skills from professional to lay person, but entailed disciplinary forms of power intended to shape the conduct of the carer. We interrogate the extent to which a specific kind of carer is produced through such an approach, and the wider implications for the participation of carers in training in healthcare settings and the empowerment of carers.

Systematic review and narrative synthesis of the experiences of individuals with chronic pain participating in digital pain management interventions.

BACKGROUND: The use of digital pain management interventions has grown since the Covid 19 pandemic. The aim of this study was to systematically review and synthesise evidence from qualitative studies regarding the experiences of individuals with chronic pain participating in digital pain management interventions in primary care and community settings. METHODS: Fourteen databases were searched, as well as citation tracking and hand-searching reference lists of included articles. The latest search was completed by 07/07/2023. Qualitative studies of patient and carer perspectives of digital pain management interventions for adults aged 18 and over with non-malignant chronic pain were included. All studies were appraised for quality using the Critical Appraisal Skills Programme Qualitative Checklist. A narrative synthesis approach was used to synthesise the findings. Normalisation Process Theory was used to understand how individuals with chronic pain make sense of digital pain management interventions and incorporate knowledge, skills and strategies learnt into their day-to-day lives. RESULTS: Eleven studies, encompassing both digital applications for use on smartphones/ mobile devices and user-directed online modular programmes, were included in the synthesis. Three main themes and related subthemes were identified from the included studies: 1) Making sense of the digital intervention (Subthemes: Tailoring to user's needs; Human contact and support; Accessibility of the digital intervention; Personal and environmental factors affecting engagement with digital interventions); 2) Initiating and Maintaining Behaviour Change (Subthemes: Planning activity; Being active); and 3) Personal Growth (Subthemes: Gaining understanding and skills; Gaining and acting on feedback; Negotiating a new relationship with pain). CONCLUSION: Recommendations. The key recommendations from our findings are that digital pain management interventions should provide: Specific and tailored information for individual participants.Focus on changing attitudes and behaviours and reframing perceptions of pain.Structured goal setting with prompts to review goals.Potential healthcare professional support alongside the digital intervention.Limitations of the review. To reduce bias, it would have been preferable for more than one author to independently fully analyse each paper and to identify themes and sub-themes. Instead, the identified themes and sub-themes were discussed with two other authors in the team (ES, LW) to reach a consensus view on final themes and sub-themes. One author (JS) received a Research Internship and Research Initiation Award funded by NIHR Applied Research Collaboration (ARC) Wessex (https://www.arc-wx.nihr.ac.uk/) and NHS England (https://www.england.nhs.uk/). The protocol for this review was registered with the National Institute of Health Research (NIHR) PROSPERO international database for registering systematic reviews (PROSPERO Registration Number CRD42021257768).

Healthcare professional and commissioners' perspectives on the factors facilitating and hindering the implementation of digital tools for self-management of long-term conditions within UK healthcare pathways.

Physical activity is important in the self-management of long-term conditions (LTCs). However, implementing physical activity into clinical practice is challenging, due to complex barriers including access to programmes, time pressures, and transport costs, for people with comorbidities, managing multiple responsibilities. Various digital tools exist to overcome these barriers and support wide-scale implementation to help people stay physically active. We explored the experiences, needs and preferences of healthcare professionals and commissioners, regarding the use of digital tools to support people with LTCs to self-manage using physical activity. This included barriers and facilitators to implementing digital tools to support people with LTCs in NHS settings. Semi-structured interviews were conducted (April 2021 to January 2022) in Wessex, southern England, UK. Purposive sampling was used to recruit general practitioners and healthcare professionals, and convenience sampling to recruit commissioners (n = 15). Transcripts were coded to develop conceptual themes allowing comparisons between and among perspectives, with the Normalisation Process Theory (NPT)'s four constructs used to aid interpretation. Results showed that most digital tools supporting physical activity for LTCs, are not well implemented clinically. Current digital tools were seen to lack condition-specificity, usability/acceptability evidence-base, and voluntary sector involvement (i.e., NPT: coherence or 'making sense'). Healthcare professionals and commissioners were unlikely to engage with use of digital tools unless they were integrated into health service IT systems and professional networks (i.e., NPT: cognitive participation), or adaptable to the digital literacy levels of service users and staff (i.e., NPT: collective action-needs for implementation). In practice, this meant being technically, easy to use and culturally accessible (i.e., NPT: collective action-promoting healthcare work). COVID-19 changed professional attitudes towards digital tools, in that they saw them being viable, feasible and critical options in a way they had not done before the pandemic. Implementation was also influenced by endorsement and trustworthiness enhancing the perception of them as secure and evidence-based (i.e., NPT: reflective monitoring). Our findings highlight that consideration must be given to ensuring that digital tools are accessible to both healthcare professionals and patients, have usability/acceptability, and are adaptable to specific LTCs. To promote clinical engagement, digital tools must be evidence-based, endorsed by professional networks, and integrated into existing health systems. Digital literacy of patients and professionals is also crucial for cross-service implementation.

Social prescribing for people living with dementia (PLWD) and their carers: what works, for whom, under what circumstances and why - protocol for a complex intervention systematic review.

INTRODUCTION: Dementia is a complex medical condition that poses significant challenges to healthcare systems and support services. People living with dementia (PLWD) and their carers experience complex needs often exacerbated by social isolation and challenges in accessing support. Social prescribing (SP) seeks to enable PLWD and their carers to access community and voluntary sector resources to support them address such needs. Existing research, however, does not describe what SP interventions are currently in place in dementia care. Little is known about the needs these interventions are designed to address, the reasons that lead PLWD and their carers to participate in them, their effectiveness and the extent to which they could increase positive health outcomes if adopted and how. METHODS AND ANALYSIS: A complex intervention systematic review of SP for PLWD and/or their carers will be conducted using an iterative logic model approach. Six electronic (MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus and Cochrane/CENTRAL) and two grey literature databases (EThOS and CORE) were searched for publications between 1 January 2003 and June 2023, supplemented by handsearching of reference lists of included studies. Study selection, data extraction and risk of bias assessment, using Gough's Weight of Evidence Framework, will be independently performed by two reviewers. A narrative approach will be employed to synthesise and report quantitative and qualitative data. Reporting will be informed by the Preferred Reporting Items for Systematic Review and Meta-Analysis Complex Interventions extension statement and checklist. ETHICS AND DISSEMINATION: No ethical approval is required due to this systematic review operating only with secondary sources. Findings will be disseminated through peer-reviewed publications, conference presentations and meetings with key stakeholders including healthcare professionals, patient and carer groups, community organisations (eg, the Social Prescribing Network and the Evidence Collaborative at the National Academy for Social Prescribing), policymakers and funding bodies. PROSPERO REGISTRATION NUMBER: CRD42023428625.

Evaluating a volunteer 'Health Champions' intervention supporting people with severe mental illness to manage their physical health: feasibility hybrid randomised controlled trial.

BACKGROUND: People with severe mental illness (SMI) have worse physical health than the general population. There is evidence that support from volunteers can help the mental health of people with SMI, but little evidence regarding the support they can give for physical health. AIMS: To evaluate the feasibility of an intervention where volunteer 'Health Champions' support people with SMI in managing their physical health. METHOD: A feasibility hybrid randomised controlled trial conducted in mental health teams with people with SMI. Volunteers delivered the Health Champions intervention. We collected data on the feasibility of delivering the intervention, and clinical and cost-effectiveness. Participants were randomised by a statistician independent of the research team, to either having a Health Champion or treatment as usual. Blinding was not done. RESULTS: We recruited 48 participants: 27 to the intervention group and 21 to the control group. Data were analysed for 34 participants. No changes were found in clinical effectiveness for either group. Implementation outcomes measures showed high acceptability, feasibility and appropriateness, but with low response rates. No adverse events were identified in either group. Interviews with participants found they identified changes they had made to their physical health. The cost of implementing the intervention was £312 per participant. CONCLUSIONS: The Health Champion intervention was feasible to implement, but the implementation of the study measures was problematic. Participants found the intervention acceptable, feasible and appropriate, and it led them to make changes in their physical health. A larger trial is recommended, with tailored implementation outcome measures.

How is physical healthcare experienced by staff, service users, and carers in adult community mental health services in a south London mental health trust? A service evaluation.

Background: Adults with a serious mental illness (SMI) are at greater risk of physical health morbidity and premature death than the general population, largely as a result of preventable physical health issues. Staff working in mental health services have a role to play in addressing these inequalities, but little is known about how they perceive their role and how this impacts on their practice. Understanding this better would enable services to improve their approach and support better health outcomes for SMI patients. A service evaluation was undertaken to investigate how physical healthcare is approached within adult community mental health teams (CMHTs) at a South London (UK) Mental Health Trust. Methods: This was a prospective, cross-sectional evaluation design. Interviews and focus groups were conducted with clinical staff, service users and carers (non-professional caregivers e.g., family or friends, of adults living with an SMI), to understand their experiences and to identify key barriers and facilitators to supporting physical healthcare support for adults with SMI. Thematic analysis was conducted to identify key themes which were classified into five main categories. Results: 50 participants took part in the study, 38 were clinical staff, eight were service users and four were carers. We found staff widely recognised the importance of supporting physical healthcare. However, there was variability in how staff approached physical healthcare in routine practice, and differences in how physical healthcare is experienced by service users and carers. Staff were keen to engage in changes to the way physical healthcare is delivered in CMHTs. However, they sought clearer guidance on their roles and responsibilities, and wanted to better understand the rationale for changes in community mental health practice, such as increased screening for physical healthcare. Service users and carers felt equally that the role of CMHTs in physical healthcare was unclear, which limited their ability to access it and understand the benefit for their overall care. Staff articulated gaps in leadership and training that impacted on their ability to implement the overall vision for physical healthcare within the Trust. Conclusion: Mental health staff recognise the role they play in supporting the physical health of adults living with SMI. This evaluation provides insight into common barriers and facilitators faced by staff, service users and carers when providing or accessing physical healthcare within adult CMHTs. These findings indicate a more comprehensive and better articulated approach to physical healthcare in mental health Trusts is needed to ensure service users and their carers understand what support is available and how to access it and to equip staff to provide and sustain that care in routine practice.

Frequency, duration, and type of physiotherapy in the week after hip fracture surgery - analysis of implications for discharge home, readmission, survival, and recovery of mobility.

PURPOSE: To examine the association between physiotherapy access after hip fracture and discharge home, readmission, survival, and mobility recovery. METHODS: A 2017 Physiotherapy Hip Fracture Sprint Audit was linked to hospital records for 5383 patients. Logistic regression was used to estimate the association between physiotherapy access in the first postoperative week and discharge home, 30-day readmission post-discharge, 30-day survival and 120-days mobility recovery post-admission adjusted for age, sex, American Society of Anesthesiology grade, Hospital Frailty Risk Score and prefracture mobility/residence. RESULTS: Overall, 73% were female and 40% had high frailty risk. Patients who received ≥2 hours of physiotherapy (versus less) had 3% (95% Confidence Interval: 0-6%), 4% (2-6%), and 6% (1-11%) higher adjusted probabilities of discharge home, survival, and outdoor mobility recovery, and 3% (0-6%) lower adjusted probability of readmission. Recipients of exercise (versus mobilisation alone) had 6% (1-12%), 3% (0-7%), and 11% (3-18%) higher adjusted probabilities of discharge home, survival, and outdoor mobility recovery, and 6% (2-10%) lower adjusted probability of readmission. Recipients of 6-7 days physiotherapy (versus 0-2 days) had 8% (5-11%) higher adjusted probability of survival. For patients with dementia, improved probability of survival, discharge home, readmission and indoor mobility recovery were observed with greater physiotherapy access. CONCLUSION: Greater access to physiotherapy was associated with a higher probability of positive outcomes. For every 100 patients, greater access could equate to an additional eight patients surviving to 30-days and six avoiding 30-day readmission. The findings suggest a potential benefit in terms of home discharge and outdoor mobility recovery. CONTRIBUTION OF THE PAPER.

Interdisciplinary health research: perspectives from a process evaluation research team.

BACKGROUND: Interdisciplinary health research (IDHR) is increasingly encouraged and is often a specific requirement for research grants provided by health research funding councils worldwide. There is consensus that research expertise and scholarship from a diverse range of disciplines are necessary to examine questions relating to complex health and social concerns for which single disciplinary approaches have been found inadequate. METHODS: This paper reports on the experiences of an interdisciplinary process evaluation research team working in the field of stroke care. RESULTS: Realising the perceived benefits is less than straightforward; setting up and conducting IDHR can present researchers with a range of challenges at a strategic, practical and individual level. We identify how differences in disciplinary perspectives and skills impacted on our research practice. CONCLUSIONS: Whilst initially challenging, our different approaches to the research problem and the methods to address it, expanded conceptual and methodological understanding and proved of benefit for the research team and the study outputs.

Multidisciplinary team healthcare professionals' perceptions of current and optimal acute rehabilitation, a hip fracture example A UK qualitative interview study informed by the Theoretical Domains Framework.

OBJECTIVE: To understand multidisciplinary team healthcare professionals' perceptions of current and optimal provision of acute rehabilitation, perceived facilitators and barriers to implementation, and their implications for patient recovery, using hip fracture as an example. METHODS: A qualitative design was adopted using semi-structured telephone interviews with 20 members of the acute multidisciplinary healthcare team (occupational therapists, physiotherapists, physicians, nurses) working on orthopaedic wards at 15 different hospitals across the UK. Interviews were audio-recorded, transcribed verbatim, anonymised, and then thematically analysed drawing on the Theoretical Domains Framework to enhance our understanding of the findings. RESULTS: We identified four themes: conceptualising a model of rehabilitative practice, which reflected the perceived variability of rehabilitation models, along with facilitators and common patient and organisational barriers for optimal rehabilitation; competing professional and organisational goals, which highlighted the reported incompatibility between organisational goals and person-centred care shaping rehabilitation practices, particularly for more vulnerable patients; engaging teams in collaborative practice, which related to the expressed need to work well with all members of the multidisciplinary team to achieve the same person-centred goals and share rehabilitation practices; and engaging patients and their carers, highlighting the importance of their involvement to achieve a holistic and collaborative approach to rehabilitation in the acute setting. Barriers and facilitators within themes were underpinned by the lack or presence of adequate ways of communicating with patients, carers, and multidisciplinary team members; resources (e.g. equipment, staffing, group classes), and support from people in leadership positions such as management and senior staff. CONCLUSIONS: Cornerstones of optimal acute rehabilitation are effective communication and collaborative practices between the multidisciplinary team, patients and carers. Supportive management and leadership are central to optimise these processes. Organisational constraints are the most commonly perceived barrier to delivering effective rehabilitation in hospital settings, which exacerbate silo working and limited patient engagement.

Older adults' perceptions of early rehabilitation and recovery after hip fracture surgery: a UK qualitative study.

PURPOSE: To explore older adult's perceptions of early rehabilitation and recovery after hip fracture, as a complement to the UK standards for acute physiotherapy after hip fracture. METHODS: In-depth semi-structured interviews with 15 adults aged 60 years or more in hospital after hip fracture surgery. A thematic analysis approach with interpretation informed by Bury's biographical disruption theoretical framework. RESULTS: Participants voiced the importance of self-determination, professional support, meaningful feedback, and social capital after hip fracture. Collaborative working with staff was required for meeting the UK standards. Participants voiced anxieties about their hip fracture when considered in conjunction with their age and co-existing conditions, anticipating a disruption to their previous physical and social activities. This new, more dependent, life situation was not acceptable to participants. CONCLUSIONS: This study suggests hip fracture alone, was not perceived as a biographical disruption by older adults although it is presented as a potential tipping point in the loss of independence, contributing to the wider disruption of advancing age and co-existing conditions. For successful implementation of the UK standards, goal setting should consider patients in the wider context of their advancing age and co-existing conditions to empower them to define a fresh narrative of self.Implications for rehabilitationHip fracture was perceived as a potential tipping point in the loss of independence, contributing to the wider disruption of advancing age and co-existing conditions.Participants expressed uncertainty over their ability to recover their previous identity in the absence of professional support and/or social capital.Healthcare professionals need to educate and empower older adults to take charge of their own recovery.For successful implementation of the UK standards for acute physiotherapy, there is a need to contextualize goal setting to empower patients to define a fresh narrative of self.

Establishing a perioperative medicine for older people undergoing surgery service for general surgical patients at a district general hospital.

INTRODUCTION: There is growing recognition of the need for perioperative medicine services for older surgical patients. Comprehensive geriatric assessment and optimisation methodology has been successfully used to improve perioperative outcomes at tertiary centres. This paper describes translation of an established model of geriatrician-led perioperative care to a district general hospital (DGH) setting. METHODS: A mixed methods quality improvement programme was used and included stakeholder co-design, identification of core components, definition of mechanisms for change, and measurement of impact through qualitative and quantitative approaches. RESULTS: Within 18 months, a substantive perioperative service for older people was established at a DGH, funded by the surgical directorate. Key outcomes included reduction in length of stay and 30-day readmission and positive staff and patient experience. DISCUSSION: This study is in keeping with improvement science literature demonstrating the importance of a mixed-methods approach in translating an evidenced-based intervention into another setting, maintaining fidelity and replicating results.

Development and rapid evaluation of services to support the physical health of people using psychiatric inpatient units during the COVID-19 pandemic: study protocol.

BACKGROUND: People diagnosed with a serious mental illness have worse physical health and lower life expectancy than the general population. Integration of mental and physical health services is seen as one service development that could better support this. This protocol describes the evaluation of the provision of a Virtual Physical Health Clinic (VPHC) and Consultant Connect (CC) services to one UK-based mental health Trust. METHODS: Prospective, formative, pragmatic evaluation using both quantitative and qualitative techniques and driven by implementation science theoretical frameworks. The VPHC and CC are described along with the methodology being used to rapidly evaluate their implementation, effectiveness and potential economic impact in order to inform future roll out. We will assess the implementation process through quantitative data on uptake and reach and through self-reported data to be collected from interviews and the use of validated implementation outcome assessment measures. We will assess implementation strategies using the Expert Recommendations for Implementing Change (ERIC) strategies as a framework. We will assess the health economic impact of both services using established health economic methods including cost comparison scenarios and health service utilisation analyses. DISCUSSION: Supporting the physical health management of people in psychiatric inpatient units is important in improving the physical health of this population. Integration of mental and physical health can help this to happen effectively. This initiative provides one of the first service evaluation protocols of its kind to be reported in the UK at the time of the COVID-19 pandemic.

A feasibility hybrid II randomised controlled trial of volunteer 'Health Champions' supporting people with serious mental illness manage their physical health: study protocol.

BACKGROUND: People with serious mental illnesses (SMI) such as schizophrenia often also have physical health illnesses and interventions are needed to address the resultant multimorbidity and reduced life expectancy. Research has shown that volunteers can support people with SMI. This protocol describes a feasibility randomised controlled trial (RCT) of a novel intervention involving volunteer 'Health Champions' supporting people with SMI to manage and improve their physical health. METHODS: This is a feasibility hybrid II randomised effectiveness-implementation controlled trial. The intervention involves training volunteers to be 'Health Champions' to support individual people with SMI using mental health services. This face-to-face or remote support will take place weekly and last for up to 9 months following initial introduction. This study will recruit 120 participants to compare Health Champions to treatment as usual for people with SMI using secondary community mental health services in South London, UK. We will measure the clinical and cost effectiveness including quality of life. We will measure the implementation outcomes of acceptability, feasibility, appropriateness, fidelity, barriers and enablers, unintended consequences, adoption and sustainability. DISCUSSION: There is a need for interventions to support people with SMI with their physical health. If this feasibility trial is successful, a definitive trial will follow to fully evaluate the clinical, cost and implementation effectiveness of Health Champions supporting people with SMI. TRIAL REGISTRATION: ClinicalTrials.gov, registration no: NCT04124744 .

Barriers and facilitators of mental health programmes in primary care in low-income and middle-income countries.

Integration of services into primary health care for people with common mental disorders is considered a key strategy to improve access to mental health care in low-income and middle-income countries, yet services at the primary care level are largely unavailable. We did a systematic review to understand the barriers and facilitators in the implementation of mental health programmes. We searched five databases and included studies published between Jan 1, 1990, and Sept 1, 2017, that used qualitative methods to assess the implementation of programmes for adults with common mental disorders at primary health-care settings in low-income and middle-income countries. The Critical Appraisal Skills Programme Qualitative Checklist was used to assess the quality of eligible papers. We used the so-called best fit framework approach to synthesise findings according to the Consolidated Framework for Implementation Research. We identified 24 papers for inclusion. These papers described the implementation of nine programmes in 11 countries. Key factors included: the extent to which an organisation is ready for implementation; the attributes, knowledge, and beliefs of providers; complex service user needs; adaptability and perceived advantage of interventions; and the processes of planning and evaluating the implementation. Evidence on implementation of mental health programmes in low-income and middle-income countries is scarce. Synthesising results according to the Consolidated Framework for Implementation Research helped to identify key areas for future action, including investment in primary health-care strengthening, capacity building for health providers, and increased support to address the social needs of service users.