Interprofessional collaboration in the home care setting: perspectives of people receiving home care, relatives, nurses, general practitioners, and therapists-results of a qualitative analysis.

BACKGROUND: About one million people in need of home care in Germany are assisted by 15,400 home care services. Home healthcare is mostly a complex endeavour because interprofessional collaboration is often challenging. This might negatively impact patient safety. The project interprof HOME aims to develop an interprofessional person-centred care concept for people receiving home care in a multistep approach. In one of the work packages we explored how people receiving home care, relatives, nurses, general practitioners, and therapists (physiotherapists, occupational therapists, and speech therapists) perceive collaboration in this setting. METHODS: Semi-structured interviews were conducted with 20 people receiving home care and with 21 relatives. Additionally, we worked with nine monoprofessional focus groups involving nurses of home care services (n = 17), general practitioners (n = 14), and therapists (n = 21). The data were analysed by content analysis. RESULTS: Three main categories evolved: "perception of interprofessional collaboration", "means of communication", and "barriers and facilitators". People receiving home care and relatives often perceive little to no interprofessional collaboration and take over a significant part of the organisational coordination and information exchange. Interprofessional collaboration in steady care situations does exist at times and mostly occurs in coordination tasks. Contact and information exchange are rare, however, interprofessional personal encounters are sporadic, and fixed agreements and permanent contact persons are not standard. These trends increase with the complexity of the healthcare situation. Joint collaborations are often perceived as highly beneficial. Means of communications such as telephone, fax, or e-mail are used differently and are often considered tedious and time-consuming. No interprofessional formal written or electronic documentation system exists. Personal acquaintance and mutual trust are perceived as being beneficial, while a lack of mutual availability, limited time, and inadequate compensation hinder interprofessional collaboration. CONCLUSIONS: Interprofessional collaboration in home care occurs irregularly, and coordination often remains with people receiving home care or relatives. While this individual care set-up may work sufficiently well in low complex care situations, it becomes vulnerable to disruptions with increasing complexity. Close interactions, joint collaboration, and fixed means of communication might improve healthcare at home. The findings were integrated into the development of the person-centred interprofessional care concept interprof HOME. TRIAL REGISTRATION: This study is registered on the International Clinical Trails registry platform ClinicalTrials.gov as NCT05149937 on 03/11/2021.

Development of an interprofessional person-centred care concept for persons with care needs living in their own homes (interprof HOME): study protocol for a mixed-methods study.

INTRODUCTION: People receiving home care usually have complex healthcare needs requiring the involvement of informal caregivers and various health professionals. In this context, successful collaboration is an important element of person-centred care, which is often insufficiently implemented. Consequences might be found in avoidable hospitalisations. The aim of the study is to develop a care concept to improve person-centred interprofessional collaboration for people receiving home care considering the perspectives of all person groups involved. METHODS AND ANALYSIS: This study uses a mixed-methods design consisting of a literature review, several qualitative inquiries, a cross-sectional quantitative study and a final structured workshop. After a literature review (work package (WP) 1), we will explore the perspectives of people receiving home care (n=20), their relatives (n=20) and representatives of statutory health insurances (n=5) in semistructured interviews (WP2). Moreover, 100 individuals of each group (people receiving home care, relatives, registered nurses, general practitioners and therapists) involved in home care will answer a survey on collaboration that will be analysed descriptively (WP3). Additionally, monoprofessional focus groups (n=9) of registered nurses, general practitioners and therapists, respectively, will discuss current practices. Data will be analysed by qualitative content analysis. Best practice cases (n=8) will be analysed by a case-based qualitative content analysis based on data of observations of home visits and interviews (WP4). The findings of WP2 will be discussed in mixed focus groups (n=4) with 10 participants each (WP5). Considering the results of joint displays of WP3, WP4 and WP5, the interprofessional care concept and its implementation will be elaborated in an expert workshop (WP6). ETHICS AND DISSEMINATION: Ethical approval was obtained from all ethics committees of the project partners. Study results will be disseminated through publications, conference presentations, student education and advanced training of health professionals. TRIAL REGISTRATION NUMBER: NCT05149937.

Cost-Effectiveness of Inter-Professional Collaboration to Reduce Hospitalisations in Nursing Home Residents: Results from the German Interprof ACT Trial.

Background: The German multi-centre cluster-randomised controlled trial interprof ACT investigated interventions to increase inter-professional collaboration between nursing home (NH) staff and local general practitioners to reduce hospitalisations and improve nursing homes residents' (NHRs) quality of life. The trial was funded by the German Health Care Innovation Fund. Methods: Cost-effectiveness of interprof ACT interventions was evaluated and compared to current standard of care (SOC) over 12 months, including 622 NHRs in 34 NHs in Germany. Multiplying resource use of healthcare services with German-specific unit costs generated costs. Health outcome was measured in quality-adjusted life-years QALYs), utility by multiplying EQ-5D-5L values with German-specific utility weights. Incremental cost-effectiveness analysis used an intention-to-treat approach and scenario analyses (SAs). Net-benefit-regression and cost-effectiveness acceptability curves addressed uncertainty. A German healthcare insurance perspective was assumed. Results: Base case results showed non-significant cost savings of 851.88€ and non-significant QALY loss of -0,056. Discussion: Dependency levels at baseline were non-significantly higher in IG compared to control group (CG). Lack of baseline costing data eliminated possibility to evaluate changes in costs due to the interprof ACT measures for both groups. Conclusion: Interprof ACT interventions are not cost-effective compared to current SOC.

Cluster randomised trial of a complex interprofessional intervention (interprof ACT) to reduce hospital admission of nursing home residents.

BACKGROUND: Some hospital admissions of nursing home residents (NHRs) might be attributed to inadequate interprofessional collaboration. To improve general practitioner-nurse collaboration in nursing homes (NHs), we developed an intervention package (interprof ACT) in a previous study. OBJECTIVE: To assess the impact of interprof ACT on the proportion of hospitalisation and other clinical parameters within 12 months from randomisation among NHRs. METHODS: Multicentre, cluster randomised controlled trial in 34 German NHs. NHRs of the control group received usual care, whereas NHRs in the intervention group received interprof ACT. Eligible NHs had at least 40 long-term care residents. NHs were randomised 1:1 pairwise. Blinded assessors collected primary outcome data. RESULTS: Seventeen NHs (320 NHRs) were assigned to interprof ACT and 17 NHs (323 NHRs) to usual care. In the intervention group, 136 (42.5%) NHRs were hospitalised at least once within 12 months from randomisation and 151 (46.7%) in the control group (odds ratio (OR): 0.82, 95% confidence interval (CI): [0.55; 1.22], P = 0.33). No differences were found for the average number of hospitalisations: 0.8 hospitalisations per NHR (rate ratio (RR) 0.90, 95% CI: [0.66, 1.25], P = 0.54). Average length of stay was 5.7 days for NHRs in the intervention group and 6.5 days in the control group (RR: 0.70, 95% CI: [0.45, 1.11], P = 0.13). Falls were the most common adverse event, but none was related to the study intervention. CONCLUSIONS: The implementation of interprof ACT did not show a statistically significant and clinically relevant effect on hospital admission of NHRs.

Interprofessional collaboration to support patients with social problems in general practice-a qualitative focus group study.

BACKGROUND: Social problems of patients such as family or work-related conflicts as well as financial difficulties affect the individual health situation and the treatment of diseases in general practice. General practitioners (GPs) would like to have direct access to professionals in social care services. In Germany, there are many different social care facilities for people with a wide range of social problems. As the social and health care systems hardly interact collaborations between social professionals (SPs) and GPs are rare exceptions. This study explored perspectives of GPs regarding their patients with social problems in combination with the perspectives of SPs. Aim of this study was to explore how a systematic interprofessional collaboration between GPs and SPs could be realised. METHODS: We carried out a participatory sequential qualitative study design consisting of two focus groups with GPs, two with SPs and two mixed-professional focus groups with GPs and SPs. The focus groups were conducted with semi-structured moderating guidelines and analysed with a qualitative content analysis approach using inductive and deductive categories. RESULTS: GPs view themselves as the first point of contact for their patients' social problems. For persistent social problems, they expressed a desire for support and SPs were willing to provide this. We developed a stepped care implementation model for a systematic cooperation consisting of nine collaboration strategies. These strategies included: index or website of social care services, referrals to the social care system, using flyers and posters of social care services, direct contact/hotline to local social care services, participation in meetings of social care facilities, involving physician assistants, external social care advice service in GP rooms, implementation in education and training and access to volunteers. CONCLUSIONS: Our stepped care implementation model for a systematic cooperation of GPs and SPs could be a feasible need- and resource-oriented approach for the collaborative care of patients with social problems to improve their medical treatment in most western healthcare systems. GPs and SPs are ready to generate the necessary evidence for policy makers in high quality RCTs.

Implementation, mechanisms of change and contextual factors of a complex intervention to improve interprofessional collaboration and the quality of medical care for nursing home residents: study protocol of the process evaluation of the interprof ACT intervention package.

BACKGROUND: To improve interprofessional collaboration between registered nurses (RNs) and general practitioners (GPs) for nursing home residents (NHRs), the interprof ACT intervention package was developed. This complex intervention includes six components (e.g., shared goal setting, standardized procedures for GPs' nursing home visits) that can be locally adapted. The cluster-randomized interprof ACT trial evaluates the effects of this intervention on the cumulative incidence of hospital admissions (primary outcome) and secondary outcomes (e.g., length of hospital stays, utilization of emergency care services, and quality of life) within 12 months. It also includes a process evaluation which is subject of this protocol. The objectives of this evaluation are to assess the implementation of the interprof ACT intervention package and downstream effects on nurse-physician collaboration as well as preconditions and prospects for successive implementation into routine care. METHODS: This study uses a mixed methods triangulation design involving all 34 participating nursing homes (clusters). The quantitative part comprises paper-based surveys among RNs, GPs, NHRs, and nursing home directors at baseline and 12 months. In the intervention group (17 clusters), data on the implementation of preplanned implementation strategies (training and supervision of nominated IPAVs, interprofessional kick-off meetings) and local implementation activities will be recorded. Major outcome domains are the dose, reach and fidelity of the implementation of the intervention package, changes in interprofessional collaboration, and contextual factors. The qualitative part will be conducted in a subsample of 8 nursing homes (4 per study group) and includes repeated non-participating observations and semistructured interviews on the interaction between involved health professionals and their work processes. Quantitative and qualitative data will be descriptively analyzed and then triangulated by means of joint displays and mixed methods informed regression models. DISCUSSION: By integrating a variety of qualitative and quantitative data sources, this process evaluation will allow comprehensive assessment of the implementation of the interprof ACT intervention package, the changes induced in interprofessional collaboration, and the influence of contextual factors. These data will reveal expected and unexpected changes in the procedures of interprofessional care delivery and thus facilitate accurate conclusions for the further design of routine care services for NHRs. TRIAL REGISTRATION: ClinicalTrials.gov NCT03426475 . Registered on 07/02/2018.

Effects of strategies to improve general practitioner-nurse collaboration and communication in regard to hospital admissions of nursing home residents (interprof ACT): study protocol for a cluster randomised controlled trial.

BACKGROUND: In Germany, up to 50% of nursing home residents are admitted to a hospital at least once a year. It is often unclear whether this is beneficial or even harmful. Successful interprofessional collaboration and communication involving general practitioners (GPs) and nurses may improve medical care of nursing home residents. In the previous interprof study, the six-component intervention package interprof ACT was developed to facilitate collaboration of GPs and nurses in nursing homes. The aim of this study is to evaluate the effectiveness of the interprof ACT intervention. METHODS: This multicentre, cluster randomised controlled trial compares nursing homes receiving the interprof ACT intervention package for a duration of 12 months (e.g. comprising appointment of mutual contact persons, shared goal setting, standardised GPs' home visits) with a control group (care as usual). A total of 34 nursing homes are randomised, and overall 680 residents recruited. The intervention package is presented in a kick-off meeting to GPs, nurses, residents/relatives or their representatives. Nursing home nurses act as change agents to support local adaption and implementation of the intervention measures. Primary outcome is the cumulative incidence of hospitalisation within 12 months. Secondary outcomes include admissions to hospital, days admitted to hospital, use of other medical services, prevalence of potentially inappropriate medication and quality of life. Additionally, health economic and a mixed methods process evaluation will be performed. DISCUSSION: This study investigates a complex intervention tailored to local needs of nursing homes. Outcomes reflect the healthcare and health of nursing home residents, as well as the feasibility of the intervention package and its impact on interprofessional communication and collaboration. Because of its systematic development and its flexible nature, interprof ACT is expected to be viable for large-scale implementation in routine care services regardless of local organisational conditions and resources available for medical care for nursing home residents on a regular basis. Recommendations will be made for an improved organisation of primary care for nursing home residents. In addition, the results may provide important knowledge and data for the development and evaluation of further strategies to improve outpatient care for elderly care-receivers. TRIAL REGISTRATION: ClinicalTrials.gov NCT03426475 . Initially registered on 7 February 2018.

To what extent does therapy of chronic stroke patients address participation? A content analysis of ambulatory physical and occupational therapy based on the International Classification of Functioning, Disability, and Health framework.

Purpose: The study aim was to analyze whether ambulatory therapy of chronic stroke patients contains elements that specifically address "Activity and participation", and to what extent participation as a major goal in rehabilitation is realized in ambulatory care.Method: Qualitative and quantitative content analysis of standard therapy of 71 chronic stroke patients with upper limb impairment. 469 statements on therapy of 34 therapists were analyzed using data-driven and concept-driven coding based on the International Classification of Functioning, Disability and Health framework.Results: Almost half of therapy provided to stroke patients was related to "Upper extremity" (47.5%), as one out of seven identified main categories. Regarding International Classification of Functioning, Disability, and Health framework, 75.1% of therapeutic practices in ambulatory therapy covered "Body functions," but only 13.2% addressed "Activities and participation". Some statements contained specific therapeutic concepts (9.4%) or isolated notes (2.1%) and were not linkable to the International Classification of Functioning, Disability and Health framework.Conclusions: Ambulatory therapy of chronic stroke patients is related, in part, to participation. There is potential for an increase in participation by applying therapeutic approaches, which actively involve the patients in goal-setting and therapeutic exercises to specifically address activities and participation.Implications for rehabilitationTo realize participation as a major goal in the rehabilitation process ambulatory therapy of chronic stroke patients, one should focus on therapeutic approaches and exercises that specifically address activities and participation.Structured goal-setting, which actively involve patients, can be used to identify goals relevant to individual activities and participation.

Stroke patients' and non-professional coaches' experiences with home-based constraint-induced movement therapy: a qualitative study.

OBJECTIVE: To investigate the experiences of chronic stroke patients and non-professional coaches with home-based constraint-induced movement therapy (homeCIMT). DESIGN: Qualitative study embedded within a cluster randomized controlled trial investigating the efficacy of homeCIMT to improve the use of the affected arm in daily activities. SETTING: Patients' home environment. PARTICIPANTS: 13 stroke patients and 9 non-professional coaches' alias family members who had completed the four-week homeCIMT programme in the context of the HOMECIMT trial. INTERVENTIONS: Semi-structured interviews; qualitative data were analysed using the methodology of the hermeneutic phenomenological data analysis. RESULTS: We identified six themes in the qualitative analysis describing the experiences of patients and non-professional coaches with homeCIMT: (1) homeCIMT can be integrated into everyday life with varying degrees of success; (2) training together may produce positive experiences as well as strain; (3) self-perceived improvements during and following homeCIMT; (4) using the affected arm in everyday life is challenging; (5) subjective evaluation of and experiences with homeCIMT-specific exercises; and (6) impact of professional therapists' guidance and motivation during homeCIMT. Statements regarding theme five and six were only provided by patients, whereas the other themes contain both, the experiences of stroke patients and non-professional coaches. CONCLUSION: Patients' and non-professional coaches' narratives offer a detailed insight into the manifold experiences with the practical implementation of homeCIMT that may help improve implementing the homeCIMT programme and similar approaches involving increased training duration and intensity and/or involvement of family members.

[Social problems in primary health care - prevalence, responses, course of action, and the need for support from a general practitioners' point of view]. / Soziale Probleme in der hausärztlichen Versorgung ­ Häufigkeit, Reaktionen, Handlungsoptionen und erwünschter Unterstützungsbedarf aus der Sicht von Hausärztinnen und Hausärzten.

BACKGROUND: Very often patients utilize primary care services for health conditions related to social problems. These problems, which are not primarily medical, can severely influence the course of an illness and its treatment. Little is known about the extent to which problems like unemployment or loneliness occur in a general practice setting. OBJECTIVES: What are the most frequent health-related social problems perceived by general practitioners (GPs)? How are these problems associated with GP- or practice characteristics? How do general practitioners deal with the social problems they perceive and what kind of support do they need? MATERIALS AND METHODS: Cross-sectional, postal questionnaire survey with questions derived from "Chapter Z social problems" of the International Classification of Primary Care - 2nd edition. The questionnaire was mailed to available GP addresses in the federal states of Hamburg (n=1,602) and Schleswig-Holstein (n=1,242). RESULTS: N=489 questionnaires (17.2 %) were analyzed. At least three times a week, GPs were consulted by patients with poverty/financial problems (53.4 %), work/unemployment problems (43.7 %), patients with loneliness (38.7 %) as well as partnership issues (25.5 %). Only rarely did GPs report having perceived assault/harmful event problems (0.8 %). The highest frequency of problems was encountered by practices with a high proportion of a migrant population. CONCLUSIONS: Social problems are a common issue in routine primary care. GPs in Northwestern Germany usually try to find internal solutions for social problems but also indicated further interest in institutionalized support. A possible approach to solving these issues are community-based, locally organized networks.

Interprofessional collaboration in nursing homes (interprof): development and piloting of measures to improve interprofessional collaboration and communication: a qualitative multicentre study.

BACKGROUND: Given both the increase of nursing home residents forecast and challenges of current interprofessional interactions, we developed and tested measures to improve collaboration and communication between nurses and general practitioners (GPs) in this setting. Our multicentre study has been funded by the German Federal Ministry of Education and Research (FK 01GY1124). METHODS: The measures were developed iteratively in a continuous process, which is the focus of this article. In part 1 "exploration of the situation", interviews were conducted with GPs, nurses, nursing home residents and their relatives focusing on interprofessional interactions and medical care. They were analysed qualitatively. Based on these results, in part 2 "development of measures to improve collaboration", ideas for improvement were developed in nine focus groups with GPs and nurses. These ideas were revisited in a final expert workshop. We analysed the focus groups and expert workshop using mind mapping methods, and finally drew up the compilation of measures. In an exploratory pilot study "study part 3" four nursing homes chose the measures they wanted to adopt. These were tested for three months. Feasibility and acceptance of the measures were evaluated via guideline interviews with the stakeholders which were analysed by content analyses. RESULTS: Six measures were generated: meetings to establish common goals, main contact person, standardised pro re nata medication, introduction of name badges, improved availability of nurse/GP and standardised scheduling/ procedure for nursing home visits. In the pilot study, the measures were implemented in four nursing homes. GPs and nurses reviewed five measures as feasible and acceptable, only the designation of a "main contact person" was not considered as an improvement. CONCLUSIONS: Six measures to improve collaboration and communication could be compiled in a multistep qualitative process respecting the perspectives of involved stakeholders. Five of the six measures were positively assessed in an exploratory pilot study. They could easily be transferred into the daily routine of other nursing homes, as no special models have to exist in advance. Impact of the measures on patient oriented outcomes should be examined in further research. TRIAL REGISTRATION: Not applicable.

Interprofessional collaboration in nursing homes (interprof): a grounded theory study of general practitioner experiences and strategies to perform nursing home visits.

BACKGROUND: Interprofessionalism, considered as collaboration between medical professionals, has gained prominence over recent decades and evidence for its impact has grown. The steadily increasing number of residents in nursing homes will challenge medical care and the interaction across professions, especially nurses and general practitioners (GPs). The nursing home visit, a key element of medical care, has been underrepresented in research. This study explores GP perspectives on interprofessional collaboration with a focus on their visits to nursing homes in order to understand their experiences and expectations. This research represents an aspect of the interprof study, which explores medical care needs as well as the perceived collaboration and communication by nursing home residents, their families, GPs and nurses. This paper focusses on GPs' views, investigating in particular their visits to nursing homes in order to understand their experiences. METHODS: Open guideline-interviews covering interprofessional collaboration and the visit process were conducted with 30 GPs in three study centers and analyzed with grounded theory methodology. GPs were recruited via postal request and existing networks of the research partners. RESULTS: Four different types of nursing home visits were found: visits on demand, periodical visits, nursing home rounds and ad-hoc-decision based visits. We identified the core category "productive performance" of home visits in nursing homes which stands for the balance of GPs´ individual efforts and rewards. GPs used different strategies to perform a productive home visit: preparing strategies, on-site strategies and investing strategies. CONCLUSION: We compiled a theory of GPs home visits in nursing homes in Germany. The findings will be useful for research, and scientific and management purposes to generate a deeper understanding of GP perspectives and thereby improve interprofessional collaboration to ensure a high quality of care.

Home-based constraint-induced movement therapy for patients with upper limb dysfunction after stroke (HOMECIMT): a cluster-randomised, controlled trial.

BACKGROUND: Constraint-induced movement therapy (CIMT) is recommended for patients with upper limb dysfunction after stroke, yet evidence to support the implementation of CIMT in ambulatory care is insufficient. We assessed the efficacy of home CIMT, a modified form of CIMT that trains arm use in daily activities within the home environment. METHODS: In this parallel, cluster-randomised controlled trial, we selected 71 therapy practices in northern Germany that treat adult patients with upper limb dysfunction after stroke. Practices were stratified by region and randomly allocated by an external biometrician (1:1, block size of four) using a computer-generated sequence. 37 practices were randomly assigned to provide 4 weeks of home CIMT and 34 practices to provide 4 weeks of standard therapy. Eligible patients had mild to moderate impairment of arm function at least 6 months after stroke and a friend or family member willing to participate as a non-professional coach. Patients of both groups received 5 h of professional therapist contact in 4 weeks. In the home CIMT group, therapists used the contact time to instruct and supervise patients and coaches in home CIMT. Patients in the standard therapy group received conventional physical or occupational therapy, but additional home training was not obligatory. All assessments were done by masked outcome assessors at baseline, after 4 weeks of intervention, and at 6 month follow-up. The primary outcomes were quality of movement, assessed by the Motor Activity Log (MAL-QOM, assessor-assisted self-reported), and performance time, assessed by the Wolf Motor Function Test (WMFT-PT, assessor-reported). Primary outcomes were tested hierarchically after 4 weeks of intervention and analysed by intention to treat, using mixed linear models. This trial is registered with ClinicalTrials.gov, NCT01343602. FINDINGS: Between July 11, 2011, and June 4, 2013, 85 of 156 enrolled patients were assigned home CIMT and 71 patients were assigned standard therapy. 82 (96%) patients in the home CIMT group and 71 (100%) patients in the standard therapy group completed treatment and were assessed at 4 weeks. Patients in both groups improved in quality of movement (MAL-QOM; change from baseline 0·56, 95% CI 0·41-0·71, p<0·0001 for home CIMT vs 0·31, 0·15-0·46, p=0·0003 for standard therapy). Patients in the home CIMT group improved more than patients in the standard therapy group (between-group difference 0·26, 95% CI 0·05-0·46; p=0·0156). Both groups also improved in motor function performance time (WMFT-PT; change from baseline -25·60%, 95% CI -36·75 to -12·49, p=0·0006 for home CIMT vs -27·52%, -38·94 to -13·94, p=0·0004 for standard therapy), but the extent of improvement did not differ between groups (2·65%, -17·94 to 28·40; p=0·8152). Nine adverse events (of which six were serious) were reported in the home CIMT group and ten (of which seven were serious) in the standard therapy group; however, none was deemed related to the study intervention. INTERPRETATION: Home-based CIMT can enhance the perceived use of the stroke-affected arm in daily activities more effectively than conventional therapy, but was not superior with respect to motor function. Further research is needed to confirm whether home CIMT leads to clinically significant improvements and if so to identify patients that are most likely to benefit. FUNDING: German Federal Ministry of Education and Research.

Interprofessional collaboration and communication in nursing homes: a qualitative exploration of problems in medical care for nursing home residents ­ study protocol.

AIM: This study explores the current state of collaboration and communication between nurses and general practitioners in nursing homes, as well as needs and expectations of nursing home residents and their families. Finally, we aim to develop a new model of collaboration and communication. BACKGROUND: Rising numbers of residents in nursing homes present a challenge for general practice and nursing in most Western countries. In Germany, general practitioners visit their patients in nursing homes, where nurses work in shifts. This leads to a big variety of contacts with regard to persons involved and ways of communication. DESIGN: Qualitative multicentre study. METHODS: Study part 1 explores needs and problems in interprofessional collaboration in interviews with nursing home residents and their relatives, general practitioners and nurses. Simultaneously, general practitioners' visits in nursing homes are observed directly. In study part 2, general practitioners and nurses will discuss findings from study part 1 in focus groups, aiming to develop strategies for the improvement of shortcomings in a participatory way. Based on the results, experts will contribute to the emerging model of collaboration and communication in a multi-professional workshop. Finally, this model will be tested in a small feasibility study. The German Federal Ministry of Education and Research approved funding in March 2011. DISCUSSION: The study is expected to uncover deficits and opportunities in interprofessional collaboration in nursing homes. It provides deeper understanding of the concepts of all involved person groups and adds important clues for the interaction between professionals and older people in this setting.

Enhancing activities of daily living of chronic stroke patients in primary health care by modified constraint-induced movement therapy (HOMECIMT): study protocol for a cluster randomized controlled trial.

BACKGROUND: Stroke leads to constant rehabilitation needs even at the chronic stage. However, although many stroke patients receive physical or occupational therapy in primary health care, treatment prescriptions do not generally specify therapeutic goals; in particular, participation is not established as an explicit therapeutic goal in the ambulatory setting. The primary aim of this study is to evaluate the efficacy of a therapy regimen for chronic stroke patients (modified 'constraint-induced movement therapy (CIMT) at home') with impaired hand or arm function with regard to the prerequisites of participation in everyday activities: a sufficient arm and hand function. 'CIMT at home' will be compared with conventional physical and occupational therapy ('therapy as usual'). METHODS/DESIGN: The study is a parallel cluster randomized controlled trial with therapy practices as clusters (n = 48). After written consent from the patients (n = 144), the therapists will be randomly assigned to treat either the intervention or the control group. Blinded external assessors will evaluate the patients using standardized outcome measures before and after the intervention, and six months later. The two coprimary endpoint assessments of arm and hand function as prerequisites for participation (defined as equal involvement in activities of daily living) are the motor activity log (quality of arm and hand use) and the Wolf motor function test (arm and hand function). These assessments are made four weeks post-treatment and relativized to baseline performance. Changes in primary outcomes will be analyzed with mixed models, which consider the hierarchical structure of the data and will be adjusted to the baseline measurements and sex. The primary analysis will be the comparison of the two randomized groups, with respect to the adjusted averages for each of the two coprimary endpoints. To keep an overall significance level of 5%, the two endpoints will be tested at the significance level of 5% each in hierarchical order. DISCUSSION: A modification of the CIMT, feasible in the patients' homes (CIMT at home), appears to be a promising therapeutic approach in the ambulatory care of chronic stroke patients. With proven efficacy and practicality, a participation-oriented, stroke-specific treatment would be available in primary care. TRIAL REGISTRATION: ClinicalTrials.gov NCT01343602.