Organising health care services for people with an acquired brain injury: an overview of systematic reviews and randomised controlled trials

Leisure Engagement Among People Living With Acquired Brain Injury: A Scoping Review

Return to previously valued occupations is a common goal of individuals following acquired brain injury (ABI). However, the focus of rehabilitation is often on self-care and productivity occupations. Return to leisure should be a priority of rehabilitation to support a person's physical, cognitive, social, and emotional well-being. Consequently, the aim of this article was to review the research evidence on engagement in leisure occupations among community-dwelling adults living with ABI. A six-step scoping review was conducted searching five databases. Articles were included if they focused on leisure engagement post-stroke or traumatic brain injury. Seventeen studies were included. Leisure engagement decreased post-ABI with engagement primarily in solitary, sedentary, cognitively inactive, home-based leisure. Leisure engagement was impacted by personal and contextual factors. The findings identify a need to focus on and address changes to leisure following ABI, with exploration of why these changes have occurred beyond personal factors.

Rehabilitation models that support transitions from hospital to home for people with acquired brain injury (ABI): a scoping review

BACKGROUND

Research shows a lack of continuity in service provision during the transition from hospital to home for people with acquired brain injuries (ABI). There is a need to gather and synthesize knowledge about services that can support strategies for more standardized referral and services supporting this critical transition phase for patients with ABI. We aimed to identify how rehabilitation models that support the transition phase from hospital to home for these patients are described in the research literature and to discuss the content of these models.

METHODS

We based our review on the "Arksey and O`Malley framework" for scoping reviews. The review considered all study designs, including qualitative and quantitative methodologies. We extracted data of service model descriptions and presented the results in a narrative summary.

RESULTS

A total of 3975 studies were reviewed, and 73 were included. Five categories were identified: (1) multidisciplinary home-based teams, (2) key coordinators, (3) trained family caregivers or lay health workers, (4) predischarge planning, and (5) self-management programs. In general, the studies lack in-depth professional and contextual descriptions.

CONCLUSIONS

There is a wide variety of rehabilitation models that support the transition phase from hospital to home for people with ABI. The variety may indicate a lack of consensus of best practices. However, it may also reflect contextual adaptations. This study indicates that health care service research lacks robust and thorough descriptions of contextual features, which may limit the feasibility and transferability to diverse contexts.

"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.

Challenges to Systems of Long-Term Care: Mapping of the Central Concepts from an Umbrella Review

The ageing of the population poses urgent challenges to the health and social protection sectors, including the need for greater adequacy and integration of health care services provided to older people. It is considered necessary and urgent to understand the state-of-the-art of community-based models of care for older people in institutional care and at home. This study aims to map the concepts that politicians and providers need to address through an umbrella review as a review method. Articles describing the structuring aspects of care models appropriate to the needs in long-term care and systematic reviews or meta-analyses targeting people aged 65 years or more were considered. A total of 350 studies met the inclusion criteria and were included in the review. The results identified the need to contribute to effective and more efficient integration and articulation of all the stakeholders, based essentially on professional care at the patient's homes, focused on their needs using the available technologies, empowering patients and families. Eight categories emerged that addressed factors and variables involved in care models for the long-term care needs of institutionalised and home-based older people as a guarantee of accessibility to healthcare and to enhance the well-being and quality of life of patients and family caregivers.

Critical Characteristics of Housing and Housing Supports for Individuals with Concurrent Traumatic Brain Injury and Mental Health and/or Substance Use Challenges: A Qualitative Study

Traumatic brain injury (TBI) and mental health and/or substance use challenges (MHSU) are commonly co-occurring and prevalent in individuals experiencing homelessness; however, evidence suggests that systems of care are siloed and organized around clinical diagnoses. Research is needed to understand how housing and housing supports are provided to this complex and understudied group in the context of siloed service systems. This study aimed to describe critical characteristics of housing and housing supports for individuals with concurrent TBI and MHSU from the perspectives of service users with TBI and MHSU and housing service providers. Using basic qualitative description, in-depth interviews were conducted with 16 service users and 15 service providers. Data were analyzed using thematic analysis techniques. Themes capture core processes in finding and maintaining housing and the critical housing supports that enabled them: (1) overcoming structural barriers through service coordination, education and awareness raising, and partnerships and collaborations; and (2) enabling engagement in meaningful activity and social connection through creating opportunities, training and skills development, and design of home and neighborhood environments. Implications for practice, including the urgent need for formalized TBI and MHSU education, support for service providers, and potential interventions to further enable core housing processes are discussed.

Supporting government policies to embed and expand rehabilitation in health systems in Europe: A framework for action

Investment in action is vital to confront the challenges associated with chronic diseases and disability facing European health systems. Although relevant policy responses are being increasingly developed, most of them fail to recognize the role of rehabilitation services in achieving public health and social goals. Comprehensive guidance is thus urgently needed to support rehabilitation policy development and expand access to rehabilitation care to meet population needs effectively. This paper describes a framework to guide policy action for rehabilitation in Europe. The framework was developed in collaboration with the European Academy of Rehabilitation Medicine based on a focused literature review and expert consultations. A review in PubMed and grey literature sources identified 458 references and resulted in 135 relevant documents published between 2006 and 2019. Thematic analysis of extracted information helped summarize the findings and develop the draft policy action framework. This was circulated to a wider group of experts and discussed in three workshops in 2018-2019. The framework was revised according to their feedback. The proposed framework contains 48 options for policy action organized in six domains and twelve subdomains that address several areas of health programming. The proposed framework provides a structure to understand the policy terrain related to rehabilitation in Europe and the measures required for translating aspirational political pronouncements into targeted programmatic action and tangible health and social outcomes.

Caregivers' engagement during in-hospital care of sABI's patients: Evaluation of informal co-production from the health providers' perspective

One of the challenges of providing healthcare services is to enhance its value (for patients, staff and the service) by integrating the informal caregivers into the care process, both concretely managing their patient's health conditions and treatment (co-executing) and participating in the whole healthcare process (co-planning). This study aims at exploring the co-production contribution to the healthcare process, analysing whether and how it is related to higher caregivers' satisfaction with service care and reduced staff burnout, in the eyes of the staff. It also investigated two possible factors supporting caregivers in their role of co-producers, namely relationship among staff and informal caregivers related to knowledge sharing (i.e. an ability determinant supporting co-production) and related to role social conflict (i.e. a willingness determinant reducing co-production). Results of a structural equation model on a sample of 119 healthcare providers employed by neurorehabilitation centers in Italy with severe acquired brain injury confirmed that knowledge sharing positively related with caregivers' co-executing and co-planning. Also, social role conflict was negatively related with co-executing but positively with co-planning. Furthermore, co-planning resulted in being unrelated to both outcomes, whereas co-executing was associated with caregivers' satisfaction, as measured by staff perceptions. Overall, our data provided initial empirical evidence supporting the ability of the determinant's contribution in allowing informal caregivers to assume an active role in both co-production domains. Furthermore, as expected, the role of conflict willingness determinant was found to be a hindering factor for co-executing but, conversely, a trigger for co-planning. This result should be considered more carefully in future studies.

Measures for the integration of health and social care services for long-term health conditions: a systematic review of reviews

Background

As people are living longer with higher incidences of long-term health conditions, there is a move towards greater integration of care, including integration of health and social care services. Integrated care needs to be comprehensively and systematically evaluated if it is to be implemented widely. We performed a systematic review of reviews to identify measures which have been used to assess integrated care across health and social care services for people living with long-term health conditions.

Methods

Four electronic databases (PUBMED; MEDLINE; EMBASE; Cochrane library of systematic reviews) were searched in August 2018 for relevant reviews evaluating the integration of health and social care between 1998 and 2018. Articles were assessed according to apriori eligibility criteria. A data extraction form was utilised to collate the identified measures into five categories.

Results

Of the 18 articles included, system outcomes and process measures were most frequently identified (15 articles each). Patient or carer reported outcomes were identified in 13 articles while health outcomes were reported in 12 articles. Structural measures were reported in nine articles. Challenges to measuring integration included the identification of a wide range of potential impacts of integration, difficulties in comparing findings due to differences in study design and heterogeneity of types of outcomes, and a need for appropriate, robust measurement tools.

Conclusions

Our review revealed no shortage of measures for assessing the structures, processes and outcomes of integrated care. The very large number of available measures and infrequent use of any common set make comparisons between schemes more difficult. The promotion of core measurement sets and stakeholder consultation would advance measurement in this area.

Vitamin D serum level in subjects with critical illness polyneuropathy and myopathy

BACKGROUND

Critical illness polyneuropathy and myopathy (CIPNM) is a disabling neuropathy that occurs in intensive care unit (ICU) subjects. It was hypothesized that a low serum level or deficiency of 25(OH)D might be associated with CIPNM. The aim of the present study was to ascertain the 25(OH)D serum level in subjects with CIPNM.

METHOD

Consecutive ICU patients admitted to neuro-rehabilitation were prospectively enrolled. At admission, vitamin D serum levels were measured and EMG examination was performed to ascertain those with CIPNM. 25(OH)D was stratified as sufficient (≥30 ng/mL) insufficient (20-29.9 ng/mL), and deficient (<20 ng/mL).

RESULTS

Eighty-four patients (31 F, 53 M; mean age 51.7±12.6) were identified and 63 (21 F, 42 M) enrolled. CIPNM was detected in 38 (9 F, 29 M) patients. A deficient mean serum level of vitamin D was observed in the whole population: 18.1 ± 9.2 ng/mL. No difference of vitamin D serum levels was detected in subjects with and without CIPNM: 17.5 ± 8.4 and 19.0 ± 10.5 ng/mL (p=0.58), respectively.

CONCLUSION

Almost all subjects showed Vitamin D deficiency. No difference was detected between those with and without CIPNM. The condition might represent a secondary phenomenon resulting from the inflammatory process as well as from conditions that could interfere with vitamin D metabolism.

Randomized Controlled Trials of Rehabilitation Services in the Post-acute Phase of Moderate and Severe Traumatic Brain Injury - A Systematic Review

Background and aims: There is a gap in knowledge regarding effective rehabilitation service delivery in the post-acute phase after traumatic brain injury (TBI). Recently, Gutenbrunner et al. proposed a classification system for health-related rehabilitation services (International Classification System for Service Organization in Health-related Rehabilitation, ICSO-R) that could be useful for contrasting and comparing rehabilitation services. The ICSO-R describes the dimensions of Provision (i.e., context of delivered services), Funding (i.e., sources of income and refunding), and Delivery (i.e., mode, structure and intensity) at the meso-level of services.

We aim to:

-Provide an overview of randomized, controlled trials (RCTs) with rehabilitation service relevance provided to patients with moderate and severe TBI in the post-acute phase using the ICSO-R as a framework; and

-Evaluate the extent to which the provision, funding and delivery dimensions of rehabilitation services were addressed and differed between the intervention arms in these studies.

Materials and methods: A systematic literature search was performed in OVID MEDLINE, EMBASE, CINHAL, PsychINFO, and CENTRAL, including multidisciplinary rehabilitation interventions with RCT designs and service relevance targeting moderate and severe TBI in the post-acute phase.

Results: 23 studies with 4,644 TBI patients were included. More than two-thirds of the studies were conducted in a hospital-based rehabilitation setting. The contrast in Context between the intervention arms often co-varied with Resources. The funding of the services was explicitly described in only one study. Aspects of the Delivery dimension were described in all of the studies, and the Mode of Production, Intensity, Aspects of Time and Peer Support were contrasted in the intervention arms in several of the studies. A wide variety of outcome measures were applied often covering Body function, as well as the Activities and Participation domains of the International Classification of Functioning, Disability, and Health (ICF).

Conclusion: Aspects of service organization and resources as well as delivery may clearly influence outcome of rehabilitation. Presently, lack of uniformity of data and collection methods, the heterogeneity of structures and processes of rehabilitation services, and a lack of common outcome measurements make comparisons between the studies difficult. Standardized descriptions of services by ICSO-R, offer the possibility to improve comparability in the future and thus enhance the relevance of rehabilitation studies.

Effect of verticalization with Erigo® in the acute rehabilitation of severe acquired brain injury

The recovery of the orthostatism after a severe acquired brain injury (sABI) is an essential objective to pursue in order to avoid the occurrence of secondary complications resulting from prolonged immobilization to which the patient is subjected during the acute phase. This randomized controlled trial aims to evaluate the effect of verticalization with the lower limb robot-assisted training system Erigo® versus conventional neurorehabilitation in 44 adult subjects affected by sequelae of sABI in the acute rehabilitation phase, related to cardiorespiratory signs and measures of impairment and activity. At the end of the study (20 treatment sessions, 5 sessions per week), in both groups of patients, there were no dropouts nor adverse events. In subject verticalized with Erigo®, there were no episodes of (pre)syncope from orthostatic hypotension nor postural orthostatic tachycardia and cardiorespiratory signs remained stable; moreover, there were no increase in muscle tone nor reduction in range of motion at lower limbs. Results obtained show improved outcomes on the whole and in a similar way in both groups; however, the improvement in scores of the National Institutes of Health Stroke Scale, the Tinetti scale, and the Functional Independence Measure from the enrollment to the end of the treatment cycle being equal, the evaluation performed at the 10th session allows to establish that the improvement appears earlier in the intervention group and later in the control group. The more rapid recovery of impairments and some activities in subjects treated with Erigo® could allow a "time-saver" to devote to the rehabilitation of sensory-motor functions which are more complex and subordinated to the preliminary reacquisition of elementary postures and motor strategies.

Communicating information and professional knowledge in acquired brain injury rehabilitation trajectories - a qualitative study of physiotherapy practice

Purpose: The communication of information and professional knowledge is paramount during patient transitions, and conveying practice knowledge is an important part of the health professional's role. Physiotherapy interventions in both specialist and primary health care are often necessary to aid persons in rehabilitation following an acquired brain injury (ABI). The aim of this study was to investigate how physiotherapists experience the way patient information is communicated across health care levels in ABI rehabilitation.Methods: We performed interviews with a total of 19 physiotherapists related to the rehabilitation trajectories of 10 people with acquired brain injuries. We performed a systematic text condensation analysis informed by constructionist and interactionist perspectives and theories of learning.Results: The physiotherapists in this study considered the patients to be complex and resource intensive. Written information upon hospital discharge was necessary but not sufficient, and they emphasized the need for verbal communication and closer collaboration across health care levels and clinical settings.Conclusions: The findings in this study indicate the need to improve routines for the communication of information and to clarify issues related to economy and responsibilities. Collaboration across health care levels require reciprocal understanding of the contextual differences in rehabilitation trajectories.Implications for rehabilitationThe discharge process is an important arena for continuous development of collaborative practices in the neurological rehabilitation context.Rehabilitation trajectories should be customized for the specific patient in a manner that is closely connected to contextual limitations and affordances.Communication between health care professionals in the transitional phase of rehabilitation trajectories is important to identify altered prerequisites for providing rehabilitation services in the primary care context.

Organisation of health services for preventing and treating pressure ulcers

BACKGROUND

Pressure ulcers, which are a localised injury to the skin, or underlying tissue, or both, occur when people are unable to reposition themselves to relieve pressure on bony prominences. Pressure ulcers are often difficult to heal, painful, expensive to manage and have a negative impact on quality of life. While individual patient safety and quality care stem largely from direct healthcare practitioner-patient interactions, each practitioner-patient wound-care contact may be constrained or enhanced by healthcare organisation of services. Research is needed to demonstrate clearly the effect of different provider-orientated approaches to pressure ulcer prevention and treatment.

OBJECTIVES

To assess the effects of different provider-orientated interventions targeted at the organisation of health services, on the prevention and treatment of pressure ulcers.

SEARCH METHODS

In April 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched three clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs, non-RCTs, controlled before-and-after studies and interrupted time series, which enrolled people at risk of, or people with existing pressure ulcers, were eligible for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment, data extraction and GRADE assessment of the certainty of evidence.

MAIN RESULTS

The search yielded a total of 3172 citations and, following screening and application of the inclusion and exclusion criteria, we deemed four studies eligible for inclusion. These studies reported the primary outcome of pressure ulcer incidence or pressure ulcer healing, or both.One controlled before-and-after study explored the impact of transmural care (a care model that provided activities to support patients and their family/partners and activities to promote continuity of care), among 62 participants with spinal cord injury. It is unclear whether transmural care leads to a difference in pressure ulcer incidence compared with usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.53 to 1.64; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).One RCT explored the impact of hospital-in-the-home care, among 100 older adults. It is unclear whether hospital-in-the-home care leads to a difference in pressure ulcer incidence risk compared with hospital admission (RR 0.32, 95% CI 0.03 to 2.98; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).A third study (cluster-randomised stepped-wedge trial), explored the impact of being cared for by enhanced multidisciplinary teams (EMDT), among 161 long-term-care residents. The analyses of the primary outcome used measurements of 201 pressure ulcers from 119 residents. It is unclear if EMDT reduces the pressure ulcer incidence rate compared with usual care (hazard ratio (HR) 1.12, 95% CI 0.74 to 1.68; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the number of wounds healed (RR 1.69, 95% CI 1.00 to 2.87; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the reduction in surface area, with and without EMDT, (healing rate 1.006; 95% CI 0.99 to 1.03; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if EMDT leads to a difference in time to complete healing (HR 1.48, 95% CI 0.79 to 2.78, very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision).The final study (quasi-experimental cluster trial), explored the impact of multidisciplinary wound care among 176 nursing home residents. It is unclear whether there is a difference in the number of pressure ulcers healed between multidisciplinary care, or usual care (RR 1.18, 95% CI 0.98 to 1.42; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if this type of care leads to a difference in time to complete healing compared with usual care (HR 1.73, 95% CI 1.20 to 2.50; very low-certainty evidence; downgraded twice for very serious study limitations and twice for very serious imprecision).In all studies the certainty of the evidence is very low due to high risk of bias and imprecision. We downgraded the evidence due to study limitations, which included selection and attrition bias, and sample size. Secondary outcomes, such as adverse events were not reported in all studies. Where they were reported it was unclear if there was a difference as the certainty of evidence was very low.

AUTHORS' CONCLUSIONS

Evidence for the impact of organisation of health services for preventing and treating pressure ulcers remains unclear. Overall, GRADE assessments of the evidence resulted in judgements of very low-certainty evidence. The studies were at high risk of bias, and outcome measures were imprecise due to wide confidence intervals and small sample sizes, meaning that additional research is required to confirm these results. The secondary outcomes reported varied across the studies and some were not reported. We judged the evidence from those that were reported (including adverse events), to be of very low certainty.

Serum vitamin D deficiency in subjects with severe acquired brain injury and relationship with functional severity

BACKGROUND

Vitamin D may be important for the development and function of the nervous system. Low serum vitamin D levels have been detected in several neurological diseases.

OBJECTIVE

To ascertain the relationship between 25(OH)D serum level and disability in subjects with severe acquired brain injury (sABI).

DESIGN

Prospective cross-sectional study Methods: Consecutive subjects with sABI admitted to neuro-rehabilitation were enrolled. A sample of subjects from the neurological ward was considered the control group. Vitamin D serum levels and blood parameters were measured at admission. Disability Rating Scale (DRS), Glasgow Outcome Scale (GOS), and Level of Cognitive Functioning (LCF) were used in assessing disability.

RESULTS

A total of 104 subjects (34 F, 70 M; mean age 53.9 ± 15.2 years) were enrolled: 54 (19 F, 35 M) with sABI and 50 (15 F, 35 M) subjects as control group. Deficient mean serum levels of vitamin D (19.2 ± 9.4 ng/mL) were detected in the subjects with sABI and a significant inverse correlation between vitamin D serum levels and DRS score was detected (p = 0.04).

CONCLUSION

Subjects with sABI showed vitamin D deficiency that might correlate to disability severity. The reason is unclear and might represent a secondary phenomenon resulting from the inflammatory process.

Understanding new models of integrated care in developed countries: a systematic review

Background

The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.

Objectives

The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.

Design

The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.

Setting

Any setting.

Participants

Patients receiving a health-care service and/or staff delivering services.

Interventions

Changes to service delivery that increase integration and co-ordination of health and health-related services.

Main outcome measures

Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.

Study design

Empirical work of a quantitative or qualitative design.

Data sources

We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.

Review methods

The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.

Results

We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.

Limitations

Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.

Conclusions

There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.

Future work

Links between elements of new models and outcomes require further study, together with research in a wider variety of populations.

Study registration

This study is registered as PROSPERO CRD37725.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The effects of integrated care: a systematic review of UK and international evidence

BACKGROUND

Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context.

METHODS

The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence.

RESULTS

One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users.

CONCLUSIONS

Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand.

TRIAL REGISTRATION

Prospero registration number: 42016037725 .

Benefits of Centralized Scheduling in a Postacute Residential Rehabilitation Program for People With Acquired Brain Lesions: A Pilot Study

OBJECTIVE

To determine whether the use of a designated staff person to coordinate and schedule therapy services in a postacute residential rehabilitation program for people with acquired brain lesions results in (1) a higher-intensity treatment and a reduced length of stay; (2) reduced rehabilitation costs; and (3) increased patient and staff satisfaction.

DESIGN

This nonrandomized retrospective study from 2009 through 2012 uses data collected relative to 2 different methods of scheduling: (1) self-planning, in which each single team member makes appointments that are then displayed on a shared board; and (2) managed planning, in which appointments are made by a designated staff person.

SETTING

A residential center for people with postacute acquired brain lesions.

PARTICIPANTS

Patients (N=20) with acquired brain lesions who had similar clinical and demographic characteristics comprised the managed planning group (n=10) and the self-planning group (n=10).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Organizational measures (length of stay in rehabilitation, number of treatment hours, total cost of rehabilitation), clinical outcome scales (Disability Rating Scale, FIM, and Barthel Index), perceived quality of treatment by patients (questionnaire), and perceived satisfaction of team members (Job Descriptive Index).

RESULTS

All patients improved on all clinical rating scales at the time of discharge (all effect sizes are large). In the managed planning group, the number of treatment hours increased (Cohen's d=2.15), resulting in reduced length of stay (Cohen's d=.95) and cost of rehabilitation (Cohen's d=1.22). In addition, the quality of treatment perceived by the patients and their families increased, while team member satisfaction did not change.

CONCLUSIONS

The use of a designated staff person to manage therapy services improves efficiency and efficacy of a patient-centered health care system. The proposed scheduling system results in a remarkable cost saving for the National Health System.

Experiences of patients with traumatic brain injury and their carers during transition from in-patient rehabilitation to the community: a qualitative study

PURPOSE

To explore the experiences of individuals who have had a severe traumatic brain injury (TBI) and their carers in the first month post-discharge from in-patient rehabilitation into living in the community.

METHOD

Using a qualitative approach underpinned by critical realism, we explored the narratives of 10 patients and nine carers using semi-structured interviews approximately one month post-discharge. Thematic analysis was carried out independently by two researchers.

RESULTS

Firstly, perceptions of support were mixed but many patients and carers felt unsupported in the inpatient phase, during transitions between units and when preparing for discharge. Secondly, they struggled to accept a new reality of changed abilities, loss of roles and loss of autonomy. Thirdly, early experiences post-discharge exacerbated fears for the future.

CONCLUSIONS

Most patients and carers struggled to identify a cohesive plan that supported their transition to living in the community. Access to services required much persistence on the part of carers and tended to be short-term, and therefore did not meet their long-term needs. We propose the need for a case manager to be involved at an early stage of their rehabilitation and act as a key point for information and access to on-going rehabilitation and other support services. Implications for Rehabilitation Traumatic Brain Injury (TBI) is a major cause of long-term disability. It can affect all areas of daily life and significantly reduce quality of life for both patient and carer. Professionals appear to underestimate the change in abilities and impact on daily life once patients return home. Community services maintain a short-term focus, whereas patients and carers want to look further ahead - this dissonance adds to anxiety. The study's findings on service fragmentation indicate an urgent need for better integration within health services and across health, social care and voluntary sectors. A link person/case manager who oversees the patient journey from admission onwards would help improve integrated care and ensure the patient, and carer, are at the center of service provision.

Effectiveness of a Very Early Stepping Verticalization Protocol in Severe Acquired Brain Injured Patients: A Randomized Pilot Study in ICU

BACKGROUND AND OBJECTIVE

Verticalization was reported to improve the level of arousal and awareness in patients with severe acquired brain injury (ABI) and to be safe in ICU. We evaluated the effectiveness of a very early stepping verticalization protocol on their functional and neurological outcome.

METHODS

Consecutive patients with Vegetative State or Minimally Conscious State were enrolled in ICU on the third day after an ABI. They were randomized to undergo conventional physiotherapy alone or associated to fifteen 30-minute sessions of verticalization, using a tilt table with robotic stepping device. Once stabilized, patients were transferred to our Neurorehabilitation unit for an individualized treatment. Outcome measures (Glasgow Coma Scale, Coma Recovery Scale revised -CRSr-, Disability Rating Scale-DRS- and Levels of Cognitive Functioning) were assessed on the third day from the injury (T0), at ICU discharge (T1) and at Rehab discharge (T2). Between- and within-group comparisons were performed by the Mann-Whitney U test and Wilcoxon signed-rank test, respectively.

RESULTS

Of the 40 patients enrolled, 31 completed the study without adverse events (15 in the verticalization group and 16 in the conventional physiotherapy). Early verticalization started 12.4±7.3 (mean±SD) days after ABI. The length of stay in ICU was longer for the verticalization group (38.8 ± 15.7 vs 25.1 ± 11.2 days, p = 0.01), while the total length of stay (ICU+Neurorehabilitation) was not significantly different (153.2 ± 59.6 vs 134.0 ± 61.0 days, p = 0.41). All outcome measures significantly improved in both groups after the overall period (T2 vs T0, p<0.001 all), as well as after ICU stay (T1 vs T0, p<0.004 all) and after Neurorehabilitation (T2 vs T1, p<0.004 all). The improvement was significantly better in the experimental group for CRSr (T2-T0 p = 0.033, T1-T0 p = 0.006) and (borderline) for DRS (T2-T0 p = 0.040, T1-T0 p = 0.058).

CONCLUSIONS

A stepping verticalization protocol, started since the acute stages, improves the short-term and long-term functional and neurological outcome of ABI patients.

TRIAL REGISTRATION

clinicaltrials.gov NCT02828371.

Is the practice of goal-setting for patients in acute stroke care patient-centred and what factors influence this? A qualitative study

Objective:

To explore whether goal-setting for rehabilitation with acute stroke survivors is patient-centred and identify factors which influence the adoption of patient-centredness in goal-setting practice.

Setting:

Acute stroke unit in a large teaching hospital in England.

Participants:

Patients with stroke who had no cognitive or significant communication problems and health care professionals who had a significant engagement with an individual patient were approached for participation.

Method:

Multiple qualitative methods were used. Perceptions and beliefs about patient-centredness, within the context of goal-setting, were collected from patients and corresponding professionals using qualitative semi-structured interviews. Adoption of patient-centred behaviour was triangulated using analysis of patient records and observation of team meetings related to participating patients.

Data analysis:

Interview transcripts and field notes were coded, clustered under categories and descriptively summarised. Additionally, data from patients’ documents were summarised. These summaries were then mapped on to an a-priori frame work of patient-centredness from which further interpretative themes were derived.

Results:

Seven patients and seven health-care professionals participated. Goal-setting was not consistently patient-centred as evidenced by a) incongruities between patients and professionals in setting, communicating and prioritising of goals and b) dysfunctional therapeutic relationships. The factors that influenced patient-centred goal-setting were both professional and patient beliefs and attributes, work-culture, practice model, limitations in knowledge and systems that disempowered both professionals and patients.

Conclusion:

It may be possible to infer that current local practice of goal-setting was inadequately patient-centred. Further research is required to identify strategies to overcome these challenges and to develop patient-centred goal-setting methods.

Organising health care services for people with an acquired brain injury: an overview of systematic reviews and randomised controlled trials

BACKGROUND

Acquired brain injury (ABI) is the leading cause of disability worldwide yet there is little information regarding the most effective way to organise ABI health care services. The aim of this review was to identify the most up-to-date high quality evidence to answer specific questions regarding the organisation of health care services for people with an ABI.

METHODS

We conducted a systematic review of English papers using MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Library. We included the most recently published high quality systematic reviews and any randomised controlled trials, non-randomised controlled trials, controlled before after studies or interrupted time series studies published subsequent to the systematic review. We searched for papers that evaluated pre-defined organisational interventions for adults with an ABI. Organisational interventions of interest included fee-for-service care, integrated care, integrated care pathways, continuity of care, consumer engagement in governance and quality monitoring interventions. Data extraction and appraisal of included reviews and studies was completed independently by two reviewers.

RESULTS

A total of five systematic reviews and 21 studies were included in the review; eight of the papers (31%) included people with a traumatic brain injury (TBI) or ABI and the remaining papers (69%) included only participants with a diagnosis of stroke. We found evidence supporting the use of integrated care to improve functional outcome and reduce length of stay and evidence supporting early supported discharge teams for reducing morbidity and mortality and reducing length of stay for stroke survivors. There was little evidence to support case management or the use of integrated care pathways for people with ABI. We found evidence that a quality monitoring intervention can lead to improvements in process outcomes in acute and rehabilitation settings. We were unable to find any studies meeting our inclusion criteria regarding fee-for-service care or engaging consumers in the governance of the health care organisation.

CONCLUSIONS

The review found evidence to support integrated care, early supported discharge and quality monitoring interventions however, this evidence was based on studies conducted with people following stroke and may not be appropriate for all people with an ABI.