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

Chouliara, N., Cameron, T., Byrne, A., Lewis, S., Langhorne, P. , Robinson, T., Waring, J., Walker, M. and Fisher, R. (2023) How do stroke early supported discharge services achieve intensive and responsive service provision? Findings from a realist evaluation study (WISE). BMC Health Services Research, 23, 299. (doi: 10.1186/s12913-023-09290-1) (PMID:36978068) (PMCID:PMC10052830)

Abstract

Background: Stroke Early Supported Discharge (ESD) involves provision of responsive and intensive rehabilitation to stroke survivors at home and it is recommended as part of the stroke care pathway. Core components have been identified to guide the delivery of evidence-based ESD, however, service provision in England is of variable quality. The study sought to understand how and in what conditions the adoption of these components drives the delivery of responsive and intensive ESD services in real world settings. Methods: This qualitative study was part of a wider multimethod realist evaluation project (WISE) conducted to inform large-scale ESD implementation. Overarching programme theories and related context–mechanism–outcome configurations were used as a framework to guide data collection and analysis. Six case study sites were purposively selected; interviews and focus groups with ESD staff members were conducted and analysed iteratively. Results: We interviewed 117 ESD staff members including clinicians and service managers. Staff highlighted the role of certain core components including eligibility criteria, capacity, team composition and multidisciplinary team (MDT) coordination in achieving responsive and intensive ESD. Regardless of the geographical setting, adhering to evidence-based selection criteria, promoting an interdisciplinary skillset and supporting the role of rehabilitation assistants, allowed teams to manage capacity issues and maximise therapy time. Gaps in the stroke care pathway, however, meant that teams had to problem solve beyond their remit to cater for the complex needs of patients with severe disabilities. Adjusting MDT structures and processes was seen as key in addressing challenges posed by travel times and rural geography. Conclusions: Despite variations in the wider service model of operation and geographical location, the adoption of core components of ESD helped teams manage the pressures and deliver services that met evidence-based standards. Findings point to a well-recognised gap in service provision in England for stroke survivors who do not meet the ESD criteria and emphasise the need for a more integrated and comprehensive stroke service provision. Transferable lessons could be drawn to inform improvement interventions aimed at promoting evidence-based service delivery in different settings. Trial registration ISRCTN: 15,568,163, registration date: 26 October 2018.

• Item Type: Articles
• Additional Information: This study was funded by a National Institute of Health Research (NIHR) Health Services & Delivery Research (HS&DR) project grant (NIHR HS&DR Project: 16/01/17).
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: Langhorne, Professor Peter
• Authors: Chouliara, N., Cameron, T., Byrne, A., Lewis, S., Langhorne, P., Robinson, T., Waring, J., Walker, M., and Fisher, R.
• College/School: College of Medical Veterinary and Life Sciences > School of Cardiovascular & Metabolic Health
• Journal Name: BMC Health Services Research
• Publisher: BioMed Central
• ISSN: 1472-6963
• ISSN (Online): 1472-6963
• Copyright Holders: Copyright © 2023 The Authors
• First Published: First published in BMC Health Services Research 23: 299
• Publisher Policy: Reproduced under a Creative Commons license