Right people, right time? a qualitative study of service access experiences of adults with acquired brain injury following discharge from inpatient rehabilitation

Home is "a different planet" when transitioning from hospital after acquired brain injury: can digital technology help bridge the two worlds?

PURPOSE

Adjusting to life following an acquired brain injury (ABI) is challenging particularly navigating the timepoint of transitioning from hospital-to-home. Digital technology has been proposed to mitigate broader transitional issues, however whilst still in its infancy more research is recommended within the ABI population. It is important to understand individual experiences in healthcare design. This study aims to identify for people with ABI [1] their unique problems experienced when transitioning hospital-to-home, and [2] how they believe digital technological solutions could solve these issues.

MATERIALS AND METHODS

Interpretive description guided the review of experiences of four participants with ABI from a larger participatory action research project, where co-design workshops explored digital technological solutions supporting the transition home from inpatient ABI rehabilitation. Comparative analysis was used to analyse the data and develop themes.

RESULTS

Six themes emerged including "being told I was ready is different to being ready," "home is a different planet," digital technology can "help connect me to the real word" and "ensure everyone is on the same page."

CONCLUSION

Participants' desire to use tailored digital technology as a transition home strategy highlighted opportunities to manage expectations, and focus on unique preparation needs of participants, rather than organisational discharge goals.

An evidence-informed approach to discharge planning from specialist brain injury rehabilitation: a mixed method study using the PRECEDE-PROCEED model

Background The transition from inpatient rehabilitation to community living is a challenging time for adults with acquired brain injury (ABI). This study aimed to investigate barriers to evidence-based discharge practices in inpatient ABI rehabilitation and to collaboratively design implementation solutions with rehabilitation healthcare professionals. Method We used a theoretical problem-analysis approach guided by the Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) - Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development (PROCEED) model. Participants were healthcare professionals working in inpatient ABI rehabilitation and external stakeholders working with patients with ABI post-discharge. Triangulation of data and methods (audits, surveys, focus groups) were employed to provide a comprehensive analysis of barriers and their causes. Results A total of 47 healthcare professionals (70% female) and 14 external stakeholders (71% female) participated. Factors negatively impacting on discharge were classified as pre-disposing (inconsistent planning, limited staff knowledge of discharge goals), enabling (accommodation and funding) and reinforcing (communication, family, nursing involvement). Suggested facilitators for coordinated discharge included clear and consistent communication, support for patient-family emotional adjustment to disability and discharge plans, and improved early access to funding schemes. Conclusion Theory-informed and collaborative methods led to recommendations including a discharge pathway and checklist, meetings with clear objectives for discharge discussions, and an increase in family and nursing staff involvement to improve discharge processes.

A pilot RCT assessing feasibility of a single values-based versus standard goal-Setting session for community dwellers with acquired brain injury (ABI)

A pilot randomised controlled trial examined the feasibility (i.e., intervention demand, acceptability and initial efficacy) of a single-session (T1) and two-week follow-up (T2) values-based versus standard goal-setting intervention for ABI community dwellers. Twenty four participants (12 in each group) with ABI were recruited, 14 of whom were male (age: M = 61, SD = 9.3). Retention rate was at 92%, and both interventions were rated as acceptable (mean ratings ≥ 80%). Improvements in the primary outcome of wellbeing were greater in the values group (dppc2 = 0.30), while no differences between groups were found for goal attainment or memory of goals. Regarding attitudes towards goals measured at T1, motivation was higher for the values group with a small-to-medium effect size (d = -0.31), whereas confidence and anticipated pleasure from working on the goal were higher for the standard goal-setting group with small-to-medium (d = 0.28) and small (d = 0.17) effect sizes, respectively. The study found a modest improvement for the wellbeing of ABI community dwellers when their goals were embedded in values, while memory of goals and goal achievement was similar across both groups. Study limitations and future recommendations are discussed, and replication is required.

Current use of therapeutic groups by Australian occupational therapists servicing community-dwellers with acquired brain injury: a qualitative interpretive descriptive study

PURPOSE

Therapeutic groups are recognised as an effective intervention modality to support community-dwellers with acquired brain injury (ABI), but little is known about their current use by occupational therapists. This study aimed to understand the use of groupwork by Australian occupational therapists servicing community-dwellers with ABI. Barriers and facilitators for using groups were also explored.

METHODS

A qualitative interpretative descriptive approach was used. Participants were private practice occupational therapists who provided services to community-dwellers with ABI. Data were collected using semi-structured paired and individual interviews, then thematically analysed.

RESULTS

Therapist perspectives about groupwork were revealed. Themes of power, potential and promise; stepping stones; feasibility challenges; and embracing groups were generated from the data. Therapists confirmed that groupwork is a valuable therapeutic modality that can improve clients' performance and participation in meaningful life roles. Concerns related to funding and feasibility were identified as barriers. Successful therapeutic groups required buy-in from participants, a workplace supportive of groups, and personal investment from therapists.

CONCLUSION

Insights gained from occupational therapists suggest greater flexibility in funding is required to allow therapists to run therapeutic groups for community dwellers with ABI.

"Everyone's brains are different…you can't just have one therapy plan to suit everyone" - A qualitative investigation of community-based rehabilitation services following traumatic brain injury

PURPOSE

To examine the lived experiences of adults who have received community-based rehabilitation (CBR) services in Australia or New Zealand for cognitive-communication disorders (CCDs) following traumatic brain injury (TBI) and their support people. Participants' recommendations for future models of care were also explored to enhance rehabilitation services for people with TBI.

METHOD

A qualitative descriptive approach grounded in phenomenology was used, whereby semi-structured interviews were conducted with each participant. A total of 28 interviews were completed, four in-person and 24 via video conferencing. Two participant groups were recruited: Adults with TBI; and their support people. Sixteen adults with a self-reported diagnosis of cognitive-communication disorder (CCD) following TBI who had received CBR and 12 support people were included. Interviews were analysed using reflexive thematic analysis.

RESULT

Four themes were identified by the participant groups indicating the core pillars of CBR models of care. They included the importance of: (a) accessible and inclusive CBR services; (b) specialised clinical skills and treatment approaches; the acknowledgment that (c) knowledge is power; and the significance of (d) peer networks and support.

CONCLUSION

This study further advances the evidence base of how services can be optimised to meet the complex needs of adults with CCDs following a TBI. Clinicians, researchers, and service providers should endeavour to incorporate the four core pillars outlined to enhance future CBR models of care for this clinical population.

Reclaiming Agency in Care Decisions and Barriers From the Perspectives of Individuals With Acquired Brain Injury and Their Family Members

BACKGROUND

The ability to self-advocate or have a say in one's care is integral to personalised care after acquired brain injury (ABI). This study aimed to understand what constitutes self-advocacy and associated barriers and facilitators throughout hospital transitions and into the community.

METHOD

Qualitative methodology was employed with semistructured interviews conducted with 12 people with ABI and 13 family members. Interviews were conducted at predischarge (in-person or via telephone) and 4 months postdischarge (via telephone) from the brain injury rehabilitation unit of a tertiary hospital. Data were thematically analysed using a hybrid deductive-inductive approach.

RESULTS

Self-advocacy reflects the process of reclaiming agency or people's efforts to exert influence over care decisions after ABI. Agency varies along a continuum, often beginning with impaired processing of the self or environment (loss of agency) before individuals start to understand and question their care (emerging agency) and ultimately plan and direct their ongoing and future care (striving for agency). This process may vary across individuals and contexts. Barriers to self-advocacy for individuals with ABI include neurocognitive deficits that limit capacity and desire for control over decisions, unfamiliar and highly structured environments and lack of family support. Facilitators include neurocognitive recovery, growing desire to self-advocate and scaffolded support from family and clinicians.

CONCLUSION

Self-advocacy after ABI entails a process of reclaiming agency whereby individuals seek to understand, question and direct their ongoing care. This is facilitated by neurocognitive recovery, growing capacity and desire and scaffolded supports. Research evaluating approaches for embedding self-advocacy skills early in brain injury rehabilitation is recommended.

PATIENT OR PUBLIC CONTRIBUTION

Two caregivers with lived experience of supporting a family member with ABI were involved in the design and conduct of this study and contributed to and provided feedback on the manuscript.

Methodologies to measure access to care post-discharge in adults with serious injury-related disability: a scoping review

PURPOSE

This scoping review examined the methodologies used to measure access to care in serious injury-related disability populations, for whom access to care post-discharge has significant implications for patient outcomes and rehabilitation trajectories.

METHODS

Four electronic databases were searched for literature published between 1 January 2000 and 15 February 2022. Relevant articles needed to relate to access to care in adult community-dwelling trauma and rehabilitation populations.

RESULTS

The initial search identified 679 articles. Following de-duplication, the title/abstract screening was completed on 533 articles, and 56 full-text articles were reviewed. Thirty-eight articles met the eligibility criteria and were included in this review. Of the 38 studies included, there was large heterogeneity in the methodologies used to measure access to care. Two articles used multidimensional measures of access to care.

CONCLUSIONS

There is an urgent need to establish the use of multidimensional measures as standard practice in access-to-care research. Failure to account for the multidimensional nature of access to care limits the full realisation of access for people with serious injury-related disability and prevents the implementation of processes that could improve access to health, rehabilitation, and support services and enhance the quality of care for individuals with a serious injury-related disability.

Perceived service adequacy and unmet need after discharge from brain injury rehabilitation

PURPOSE

The present study aimed to quantify the perceived needs and adequacy of realised access to post-acute services in a sample of people with acquired brain injury in the first 6-months after discharge from inpatient rehabilitation. A secondary focus was the influence of access to funding and specialist transitional rehabilitation on unmet needs.

MATERIALS AND METHODS

Participants were 51 adults with a median age of 50 (IQR 35-57) recruited from an inpatient rehabilitation unit in an Australian tertiary hospital. The sample was those who had an acquired brain injury, including 23 who sustained a traumatic injury and 28 who sustained a non-traumatic injury. Measures were collected via telephone at 3- and 6-months, in a prospective observational cohort design using the Needs and Provisions Complexity Scale. A series of logistic regression models were used to determine the effects of participation in a transitional rehabilitation program and funding pathway on adequacy and unmet needs.

RESULTS

Unmet needs for rehabilitation were most commonly reported (60%), followed by unmet needs in relation to health care (40%), social care (35%), personal care (32%) and environment-related (14%). Participants who attended transitional rehabilitation were more likely to indicate unmet health care needs (OR = 6.40, 95% CI = 1.40-29.24, p = 0.02).

CONCLUSIONS

The study highlights the need to look beyond functional impairment when conceptualising appropriate access. Additionally, the present research highlighted the need for greater work into an expectation of services.IMPLICATIONS FOR REHABILITATIONThe majority of people with an acquired brain injury report unmet needs at 6 months post discharge.Present findings support the utility of patient reported measures when considering treatment evaluation with people with ABI, where assessing the personal appraisal of individuals needs may prove to be a key indicator to facilitate optimal service access.There are specific services that needed and not provided including psychological, speech pathology, family carer needs and vocational rehabilitation, and therefore are a key target for ensuring appropriate support is provided.

"It gave her that soft landing": Consumer perspectives on a transitional rehabilitation service for adults with acquired brain injury

Transitional rehabilitation service models for people with acquired brain injury (ABI) may address sub-optimal support for individuals returning home after hospitalization for ABI. This study investigated perspectives of people with ABI and close others who received transitional rehabilitation. A qualitative study involving semi-structured interviews with 10 individuals with ABI and 12 associated close others was conducted as part of a mixed-method evaluation of an Australian transitional rehabilitation service (TRS) pilot project. Thematic analysis based on the Framework method was conducted independently by two researchers. Three broad themes illustrated participants' experience of the TRS: (1) structure after hospital discharge; (2) a "soft landing"; and (3) equipped for community living. Findings suggest that home-based, interdisciplinary transitional rehabilitation after hospital discharge was perceived as an important stage of rehabilitation by participants. Valued features relate to post-hospital rehabilitation structure: a single point of contact to facilitate organization and information exchange, a known discharge destination, and consistent communication; support and therapy within a familiar home environment; and being equipped with relevant knowledge and strategies to manage ongoing challenges. Further research exploring the experiences of individuals with ABI without close family or social support, and research capturing longitudinal outcomes from transitional rehabilitation is recommended.

Factors that support and hinder recovery and adjustment after traumatic brain injury: a qualitative multiple case study

Background/Aims

The numbers of individuals acquiring brain injuries in childhood is increasing. The deficits caused by brain injury can often have long-term implications that require support from caregivers, friends and the community. This study was conducted to gain an understanding of the shared perspectives of parental caregivers and their adolescent children as to what factors supported and hindered recovery and adjustment after traumatic brain injury.

Methods

In this qualitative multiple case study, semi-structured interviews were conducted with a purposive sample of four individuals with traumatic brain injury and their five parental caregivers. A thematic, cross-case analysis was used to identify factors that support and hinder recovery and adjustment.

Results

Seven themes were identified from the interviews: lack of educational resources about traumatic brain injury; poor consistency of care; caregiver stress and guilt; disconnection and isolation; connection, empathy and social support; being high achieving and resourceful; and authentic relationships between adolescents with traumatic brain injury and their parents.

Conclusions

The findings highlight the need for improved access to follow-up or community-based services for adolescents with traumatic brain injury who do not experience a hospital or inpatient rehabilitation stay. Additionally, healthcare providers should capitalise on the relationships between adolescents with traumatic brain injury and their parents to support recovery. The information gained from this study can be used to inform allied health professionals when developing and implementing interventions to support recovery in adolescents with traumatic brain injury and their parental caregivers.