1 Introduction

The pressure for acute hospital beds increases year on year as the numbers of older people grow [5, 6]. During COVID-19, this was exacerbated further through the reduction of beds due to staff illness and the increase in bed demand by patients with COVID-19. Optimising bed capacity is critical during these times to ensure the right patient is in the right bed. This article critically evaluates health leader’s opinions before the implementation of a facility-based rehabilitation initiative, entitled Transition to Home (T2H), as an alternative to inpatient rehabilitation in the acute hospital setting [7,8,9,10].

Acute hospitalisation is necessary and appropriate, however optimising the time an individual spends in hospital has been gaining currency for many years [11], whilst the desire to achieve the most appropriate hospital stay for all continues to dominate clinical practice and research [9]. Additionally, hospital stays are associated with significantly higher risks for older people; including deterioration in function and strength [5, 7, 12, 13] and increased infection risk [14]. Achieving safe discharge as soon as the patient is medically stable is important to the patient, their family/whānau and the hospital. This requires appropriate community based services [11], continuity of care between hospital and community, and well-developed care coordination [6, 9, 15, 16]. Despite the need for early discharge, research has shown that 27 percent of hospital discharges are delayed in patients aged over 75 years [17].

The importance of the role of community care in facilitating early hospital discharge has been recognised for some time in Aotearoa New Zealand [15, 16] and internationally [9]. The integration between hospital and home and continuation of active rehabilitation across the hospital / community interface [7,8,9] is well-developed and the success of early supported discharge models such as ‘START’ has been demonstrated via two randomised controlled trials [9, 10]. However, although community-based services are available for patients when considered ‘safe’ to be discharged home, for those patients with complex comorbidities, there is invariably a delay between being determined ‘medically stable’ and ‘safe for discharge,’ as illustrated in Fig. 1.

Fig. 1
figure 1

Image illustrating delay between being determined ‘medically stable’ and ‘safe for discharge

Full size image

Figure created by authors within the Visio software [18] to illustrate the delay between being determined ‘medically stable’ and ‘safe for discharge’.

Consequently, patients who are already vulnerable experience a longer stay in hospital and are placed at increased risk [5, 19]. Many centres internationally have utilised aged care to provide an intermediary solution. However, aged care facilities have not been designed to provide specialist rehabilitation and as a result, individuals with complex conditions are discharged to facilities where rehabilitative services are not well developed. Nurse-led models of intermediate care have been widely utilised internationally since the 1980s [20] with varying degrees of success. The T2H initiative provides an alternative solution; it utilises off-site aged care facilities working in partnership with the supported discharge team (START) to deliver facility-based rehabilitation. However, T2H can only be successful if referrals are made in a timely fashion. Therefore, understanding the views and attitudes of potential referrers and care providers prior to implementing such an initiative is important.

This study aimed to answer the question ‘what is the role of rehabilitation in post-acute care, from the perspective of clinical staff (medical, nursing and allied health) and managers?’.

2 Methods

This study aims to explore the implementation of a facility-based rehabilitation programme for older patients (Māori 55 + , non-Māori 65 +), of both genders, that are determined, by clinically based health professionals, as being unsafe to be home. The researchers interviewed key stakeholders from nursing, medicine, allied health, management, and the aged care sector.

A purposive approach (n = 14) to participant selection was utilised in this study, whereby participants were stratified by position within the tertiary hospital, community or aged care facilities that have an association with the Waikato region tertiary Hospital. Potential participants were identified by the researcher, then contacted via email by an administrator. Consenting participants were interviewed over a two-week period through videotelephony during a Covid-19 lockdown in 2021. Additionally, interviewees were asked to suggest further participants, and none were identified.

2.1 Data collection

The interview schedule was developed by the researchers and piloted with two senior nurses. Feedback given during the pilot interviews was used to create the final interview schedule. The interview schedule was not provided to the participants, however verbal prompts were provided, and clarification was offered by the researchers during the interview, at the participant’s request. Repeat interviews were not undertaken. The interviews’ duration was 45 –60 min. These were audio and visually recorded using an online videotelephony service, then transcribed using the otter.ai software [21]. The transcripts were checked independently by the researchers, comparing the AI generated transcripts to the original recordings to ensure accuracy. Following this, the final transcript versions were sent to participants for comment, correction and approval, to ensure participants' voices were accurately represented in the research findings. The participant-approved transcripts were utilised by the researchers for data analysis, which involved identifying themes, relevant to the research question. Field notes were not made during or after the interviews.

2.2 Data analysis

The researchers utilised NVivo 12 [4] to manually code the interview transcripts. A descriptive, general inductive coding method was used by the researcher to assigns codes that summarised passages of qualitative data. Analysis also followed grounded theory in that themes emerged from the qualitative data collected from participants [2]. This analysis approach supported the researchers to allow the narrative to emerge from the raw data without any preconceived notion of what the codes should be [1, 22].

2.3 Coding consistency checks

Coding occurred independently in parallel by two researchers, codes were then checked and merged. Additionally, stakeholders were asked to check and comment on the developed categories [1].

2.4 Ethical considerations

Ethical approval was sought through the researchers’ institutional ethics research committee and the research ethics committee of the healthcare site (Reference Number UAHPEC3423, 23/09/2021).

3 Results

To ensure confidentiality, participants were assigned pseudonyms; H1 to H11 for hospital participants and A1 to A3 for aged care participants.

Participants pseudonyms and associated roles

H1

Geriatrician and head of department—older persons and rehabilitation service

H2

Medical director of medical services

H3

Senior medical officer (emergency department)

H4

Community gerontology Clinical Nurse Specialist

H5

Nurse manager for older persons and rehabilitation service

H6

Operations director for older persons, medicine and emergency department

H7

Operations manager for rehabilitation support (community)

H8

Charge nurse manager (emergency department)

H9

Associate charge nurse manager (emergency department)

H10

Nurse director for older persons, medicine and emergency department

H11

Operations manager for allied health

A1

Aged care village manager

A2

Aged care centre manager

A3

Aged care unit manager

3.1 Themes

Three central themes emerged following data analysis. The first relating to the current model of rehabilitation; the second regarding person centred care and what matters most to the patient; and the third highlighting the need for a multidisciplinary team that work as integrated partners in care. Accounts of participant discussion are included to enhance presentation of these findings.

“Rehabilitation: Not just Monday to Friday, eight to five” (H8, Charge Nurse Manager (emergency department)

The prevailing opinion regarding how a facility-based rehabilitation initiative could be successfully implemented reflected participants' thoughts towards the current inpatient rehabilitation model and the way patients and their family/whānau were expected to ‘fit’ into the hospital environment. One participant commented.

“…the longer [patients] are in the hospital, the more it potentially disables them, it is not an environment that meets patient needs. It is an environment that meets the needs of the medical team...”. (H1, Geriatrician and Head of Department)

H2 (Medical Director of medical services) reinforced this sentiment stating.

“…one of the things I have learned is that… older patients sometimes do worse in the hospital where they may be placed in a bed isolated in the corner. Even simple tasks such as timing of medication becomes disrupted when an elderly patient is hospitalised”.

Social isolation was also identified by participants as an issue associated with the current inpatient rehabilitation model, concerns such as.

“…[patients] being physically located away from loved ones is hard, people cannot visit [during lockdowns], which makes the situation worse…” (H3, Senior Medical Officer (emergency department)) and “…family, friends and elderly partners often have difficulties finding parking which is a huge barrier… they cannot come and visit as often as they want” (H4, Community gerontology Clinical Nurse Specialist).

All aged care participants highlighted the role the sector could play in supporting hospitals to discharge patients earlier. A1 (Aged Care village manager) felt that aged care was able to.

“…. bridge the gap between hospital and home for vulnerable patients…”, while easing hospital bed pressures.

A2 (Aged Care centre manager) agreed, suggesting that aged care should be seen as a.

“…bridge, making sure there’s a clear walkway for patients returning to the community, without any stumbling blocks”.

Additionally, the aged care sector has long understood the need to minimise social isolation, which is achieved in several ways such as scheduling activities that maintain connection between residents and the community [23].

“Person centred care: What matters most?” (H5, Nurse Manager for older persons and rehabilitation service)

The need for healthcare professionals to work in partnership, not only with each other, but with the patient and their family/whānau was highlighted. Participant H5 (Nurse Manager for older persons and rehabilitation service) explained that.

“…good coordination of individual healthcare professionals coming together to make plans that include the patient and their families’” is essential.

Participant H7 (Operations Manager for rehabilitation support (community) agreed, stating a positive patient journey that.

“…considers [patient] needs and what they see as a priority. Being involved in setting goals that are real and meaningful, not what we have decided, it should be in an environment of their choice where they feel comfortable, where they don't have that loss of dignity… [and feel] disabled by the environment”.

Health professionals should be encouraged to view the older person in the context of their daily lives, as part of a family and a community [16, 24, 25]. Therefore, locating health services closer to a person’s home is especially important. When patient care is integrated into the person’s community, higher patient and family/whānau satisfaction, reduced deaths and reduced readmission rates can be seen when compared with a traditional inpatient admission [16, 24, 25]. Patterson [26] suggests that the majority of rehabilitation services can be safely delivered outside acute hospital settings, either in the community or at home. By engaging communities, innate resources such as the patient’s family/whānau, friends, religious and community organisations can be harnessed, decreasing the likelihood of readmission.

“Multidisciplinary team: Integrated partners in care” (H5, Nurse Manager for older persons and rehabilitation service)

The World Health Organization [27] states that a successful community-based rehabilitation model must utilise a genuine multidisciplinary approach to care, which includes integration at the level of clinical care. To ensure success a comprehensive assessment, individualised goals and a unique plan of care need to be developed and shared across all care providers. One participant commented that there were.

“…real gaps about how staff come together to plan care” which was exacerbated by “…staff not fully understanding each other’s role in the patient’s plan of care” (H7, Operations Manager for rehabilitation support (community).

Another participant (A1, Aged Care village manager) gave an example highlighting the importance of hospital staff having a clear understanding of the aged sector and its role,

“…when a patient comes to my facility for rehab, they get to the point where they are ready to go home. However, the husband at home isn’t ready to have the patient back because he is exhausted. If the rehab team does not fully understand the role the aged care facility has in the community, a situation could occur whereby the rehab team wants to discharge the patient home, while the facility sees the patient as a future resident, in their community…”.

Victor et al., [17] have similar views, suggesting that a dysfunctional multidisciplinary team (MDT) can contribute to discharge delays and missed or late referrals to community social services, thus being detrimental to a patient’s post-hospital journey. In order to succeed, MDTs’ need to share responsibility and accountability for patient care outcomes by meeting regularly to share information which ensures their functions remain coordinated [6, 17, 27]. Participant H9 (Associate Charge Nurse Manager (emergency department) shared that when MDT’s work well together it is.

“…through our connectedness as an entity and as people that we can make things happen and achieve a desired goal for the individual that we are caring for…”

4 Discussion

Although this study had a relatively low number of participants, themes were saturated, and no other new material was arising. Data saturation was achieved when no new codes or themes were identified and interviewees were asked to suggest further participants, and none were identified [28]. Clear themes emerged which are important to address prior to implementation of new services such as this proposed facility-based rehabilitation initiative, as the success of these must be measured through improved outcomes for older people and critically a lower length-of-stay and reduced healthcare costs. All interviewed Aotearoa New Zealand health leader’s were supportive of a facility-based rehabilitation initiative and identified key aspects that would need to be considered to ensure successful patient outcomes.

However, safety remains a crucial consideration when implementing a significant change in model of care. This was identified by a number of participants, who highlighted the need for medical support and oversight. Participant H2 (Medical Director of medical services) suggested the importance of considering.

“…that most doctors are worried about not if the patient gets better, but what happens if they get worse, am I going to be blamed? And is there a safety net for these patients?” The level of medical support available in the community was also highlighted as a potential issue by another participant, Leonel who identified “…in terms of medical support, the day-to-day medical support depends on the family doctor attached to the facility. I think we have to select facilities where the General Practice support is reliable…”

In his interview, participant H1 (Geriatrician and Head of Department) commented that.

“…medical support in the Aged Care sector is only ad hoc so they will not be there all the time...”

Nursing resource was also identified as a consideration, and in her interview, participant H8 (Charge Nurse Manager (emergency department) shared that it is important to.

“…recognise what some of the challenges are, in both efficiency of staffing resource, equipment and rehab needs of the client, when you move it from a very controlled environment within the hospital, where you have got a number of staff.”

These concerns were also identified from an Aged Care perspective, where in her interview participant A2 (Aged Care centre manager) identified medication management and medical support as a potential issue.

“…in Aged Care, we are contracted to our own General Practitioners (GP). They [facility-based rehabilitation patients] would be contracted to their own GP. If that patient needed to see their GP, and they couldn't go out of the facility. Not all GPs want to come in. So that's a consideration that needs to be taken into account. Because if there were any medication changes, or they became acutely unwell to the point that they require a GP, that would be a challenge.”

In 2017 the WHO [29] recommended that “…rehabilitation should be provided in both hospitals and communities to ensure timely intervention and access to services …. as close as possible to people’s communities, including in rural areas” (p. 17). Providing rehabilitation during the acute phase of care remains important; however, for many people, undertaking rehabilitation in the community is appropriate. This is particularly important for people with certain conditions such as hearing loss or vision impairment, where interventions should be provided in settings close to where a person lives, works or studies [29].

With this in mind it may be time to reconsider how inpatient rehabilitation is delivered and to change our mind-set regarding the setting in which rehabilitation can be delivered. In her interview, participant A3 (Aged Care unit manager) identified that Aged Care facilities were the ideal location for patients requiring an extended period of rehabilitation. She discussed a situation where a had experienced a dense stroke and was admitted to her facility following a period of inpatient rehabilitation in a hospital setting. The resident’s goal remained to go home, however,

“…. obviously, the rehab that she had at the hospital wasn't sufficient enough to achieve this goal, they have to free up the bed. So that long term plan, they can’t manage that. So, she has to come here, really, and we're trying to meet that goal currently.”

Additionally, participant H9 (Associate Charge Nurse Manager (emergency department), identified a potential benefit of facility-based rehabilitation being that patients could receive rehabilitation in a setting closer to where they live. This could allow the rehabilitation staff to take the patient on home visits to assess their ability in their own environment, instead of.

“…rehabbing them in an acute area that actually is not their home... you would be quite surprised how much more they do in their own environment”.

Additionally, participant H7 (Operations Manager for rehabilitation support (community) shared that.

“…the relationship between Aged Care facility staff and hospital staff will benefit both the short-term facility-based rehabilitation patients as well as the long-term residents, so let’s give it a go.”

5 Limitations

This study was conducted in a one region of Aotearoa New Zealand (Waikato) with a relatively small sample size (n = 14). cultural influences and organisational variables may have influenced results, additionally, broad generalisation of the findings may not be possible. The Waikato region (Aotearoa New Zealand) consists of one tertiary hospital that provides services to a population of approximately 425,000 people and covers a geographical area of 21,000km2 [30]. Within the Waikato region (Aotearoa New Zealand), 59% of the population reside in urban areas, and 41% in rural areas [30]. Additionally, 23% of the Waikato region (Aotearoa New Zealand) population identify as Māori (the indigenous people of New Zealand), compared to the Aotearoa New Zealand national average of 16% [30]. Participant responses may have been influenced by both the cultural and rural mix of the region and therefore, undertaking this study in a different location, organisation or cultural mix may produce different findings.

6 Conclusion

Aged care bolstered through rehabilitation undertaken by a proven early supported discharge team as an alternative to rehabilitation being undertaken in an acute hospital is sensible on many levels. However, its success is dependent on when and indeed if a patient is referred in a timely fashion and to achieve such, requires careful consideration and indeed confidence of the referrers in the process. This research utilised a general inductive method of enquiry to develop key themes from the transcripts, which has uncovered key areas for development when implementing such initiatives. This approach followed grounded theory, where themes emerged from qualitative data collected from participants [2]. Such a methodological approach is applicable in a variety of healthcare settings.

All interview participants were supportive of the approach, with three central themes identified to ensure successful patient outcomes. The first involved recognising that the current model of rehabilitation may not be ‘fit for purpose’ for every older patient requiring inpatient rehabilitation. The second emphasised that person-centred care is central to a facility-based inpatient rehabilitation model, achieved through individualised and unique rehabilitation goals and plans of care that consider “what matters most”. The third theme highlighted the importance of a coordinated and united multidisciplinary team that meet regularly to share information and plan patient care, working as “integrated partners in care”. A final consideration was the need for medical support and oversight. All interview participants accepted that it was time to reconsider how inpatient rehabilitation is delivered, which will challenge us to change our mind-set regarding the location in which rehabilitation can safely be delivered.

7 Implication of findings

  • All interview participants were supportive of the implementation of facility-based rehabilitation (Transition to Home) as an alternative to the current inpatient rehabilitation model.

  • Interview participants identified key aspects that would need to be considered to ensure successful patient outcomes in such a model.

  • However, safety remains a crucial consideration when implementing a significant change in model of care. This was identified by a number of participants, who highlighted the need for medical support and oversight.