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.

Barriers and facilitators in providing home-based rehabilitation for stroke survivors with severe disability in the UK: an online focus group study with multidisciplinary rehabilitation teams.

OBJECTIVES: In the UK, over 20% of stroke survivors leave hospital with severe disability. Limited evidence-based clinical guidance is available to support the rehabilitation of these individuals. Our previous research has focused on establishing consensus regarding the core components of home-based rehabilitation for this under investigated group. This study explores the barriers of providing rehabilitation and identifies strategies to overcome them. DESIGN: Three focus group interviews were conducted with n=20. The context coding framework was employed to organise the transcribed data and to facilitate inductive and deductive analysis and synthesis. SETTING: Online, MSTeams, UK. PARTICIPANTS: A purposive sample of 20 National Health Service clinical staff participants, from 3 multidisciplinary teams providing home-based stroke rehabilitation for this population (n=7, 6 and 7). RESULTS: High levels of need were reported across multiple domains for survivors including continence, communication and physical function. Interventions often required multiagency collaboration in order to optimise the available resources and specialist skills. There was lack of clarity regarding who was ultimately responsible for providing components of rehabilitation for stroke survivors with severe disability. Teams provide rehabilitation for this population but are insufficiently commissioned or resourced to fully meet their needs. In-complete and disjointed pathways with resultant healthcare inequalities were commonly reported. Teams used a variety of strategies to overcome these barriers and optimise rehabilitation opportunities. These included upskilling a diverse range of partners to capitalise on the skills and resources across health, social care and voluntary sector boundaries employing multiagency collaboration. Teams established and engaged networks of stakeholders in order to advocate on behalf of stroke survivors. CONCLUSIONS: Collaboration and partnership working is important in the delivery of rehabilitation for stroke survivors with severe disability. Commissioners need to be aware that cross-agency multidisciplinary expertise is required, if rehabilitation opportunities are to be realised and existing health inequalities addressed.

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

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.

A qualitative study exploring how stroke survivors' expectations and understanding of stroke Early Supported Discharge shaped their experience and engagement with the service.

PURPOSE: To explore how stroke survivors' expectations and understanding of Early Supported Discharge (ESD) helped them make sense of their experiences, and shaped their engagement with the service. METHODS: Data were collected as part of a study of large-scale implementation of stroke ESD: the WISE realist mixed-methods study. Semi-structured interviews were conducted with five purposefully selected stroke survivors from six sites in England implementing stroke ESD (n = 30). Participants were aged 32-88 years (20 males). Interviews were audio recorded, transcribed verbatim and transcripts were analysed using reflexive thematic analysis. RESULTS: Three overarching themes were identified: (1) ESD as a post-stroke recovery tool, (2) desire to recover quickly, (3) psychosocial impact and support. Stroke survivors were uncertain about what to expect when they first entered the service, however, their experience of ESD exceeded their expectations and increased their engagement with the service. Stroke survivors especially valued the goal-oriented approach the team adopted. Rehabilitation at home was perceived as positive and practical, encouraging independence within real-life contexts. Psycho-social support played an important role in the stroke survivors' rehabilitation. CONCLUSIONS: Ensuring stroke survivors are fully informed about ESD and what to expect, optimises engagement with the services, improves experience and could enhance outcomes.IMPLICATIONS FOR REHABILITATIONInforming stroke survivors about what to expect from ESD services could optimise engagement and improve their experience.The provision of personalised and target focussed therapy at home improves stroke survivors' experience and could potentially accelerate recovery.Preparing stroke survivors early for discharge from ESD can reduce anxiety and enhance engagement with the service.

A Qualitative Study Exploring the Lives and Caring Practices of Young Carers of Stroke Survivors.

This study investigated the life transformation of children when a parent returned home from hospital after a stroke. The study explored children's experiences of taking on caring roles in partnership with their well parent and stroke survivors' perceptions of the young carer roles. The study aimed to identify unmet support needs in order to inform future service provision. Semi-structured interviews were conducted separately with stroke survivors (n = 7) (age range 41-60 years, mean 50.6) and their young carers (n = 11) (age range 11-20 years, mean 16). Interviews were audio recorded, transcribed and analysed using reflexive thematic analysis. Three overarching themes were identified: the lives of young carers, impact of stroke, and insulating the family. All the children were providing some level of care. None were in receipt of any formal support. Children moved in and out of the caring role in the absence of an adult, to act as primary carer. Young carers valued the life skills they were gaining but reported gaps in their knowledge and understanding of stroke. The well parent and young carers worked together in a bi-directional partnership to ameliorate the impact of stroke on the family. The study concluded that age appropriate and stroke specific information for children of stroke survivors could enhance agency and optimise positive outcomes of caring.

Evaluating stroke early supported discharge using cost-consequence analysis.

PURPOSE: To evaluate different stroke early supported discharge (ESD) services in different geographical settings using cost-consequence analysis (CCA), which presents information about costs and outcomes in the form of a balance sheet. ESD is a multidisciplinary service intervention that facilitates discharge from hospital and includes delivery of stroke specialist rehabilitation at home. MATERIALS AND METHODS: Data were collected from six purposively sampled services across the Midlands, East and North of England. All services, rural and urban, provided stroke rehabilitation to patients in their own homes. Cost data included direct and overhead costs of service provision and staff travel. Consequence data included service level adherence to an expert consensus regarding the specification of ESD service provision. RESULTS: We observed that the most rural services had the highest service cost per patient. The main costs associated with running each ESD service were staff costs. In terms of the consequences, there was a positive association between service costs per patient and greater adherence to meeting the evidence-based ESD service specification agreed by an expert panel. CONCLUSIONS: This study found that rural services were associated with higher costs per patient, which in turn were associated with greater adherence to the expert consensus regarding ESD service specification. We suggest additional resources and costs are required in order for rural services to meet evidence-based criteria.Implications for rehabilitationThe main costs of an early supported discharge (ESD) service for stroke survivors were staff costs and these were positively associated with greater levels of rurality.Greater costs were associated with greater adherence to ESD core components, which has been previously found to enhance the effectiveness of ESD service provision.The cost-consequence analysis provides a descriptive summary for decision-makers about the costs of delivering ESD, suggesting additional resources and costs are required in order for rural services to meet evidence-based criteria.