Early supported discharge for people after stroke; evidence to inform implementation and scale-up in Ireland

Background

Early Supported Discharge (ESD) has broadly been defined as a model of health service delivery for people after stroke that facilitates an early discharge from the hospital with continued rehabilitation in the home environment from a multidisciplinary team at the same intensity as would be received in the inpatient setting.

Aim

The aim of this thesis is to gain a comprehensive understanding of stakeholders’ experiences of ESD and the characteristics of those accessing ESD to inform future service delivery and scale-up of ESD in Ireland.

Methods

First, a qualitative evidence synthesis was completed to synthesise the totality of evidence of the experiences of ESD for people after stroke, family members, carers and healthcare professionals (HCPs). Second, a qualitative descriptive study using one-to-one semi-structured interviews with HCPs explored their experiences of the development and delivery of ESD in Ireland. Finally, secondary analysis of the Irish National Audit of Stroke (INAS) data over a three-year period profiled the clinical characteristics and rehabilitation needs of people after stroke discharged home with and without ESD.

Findings

The qualitative evidence synthesis of 14 studies found that ESD was experienced as a goal focused and collaborative process that eased the transition home but not to community services. Organisational, and interprofessional factors were reported to be critical to the success of ESD but a number of unmet needs persisted for people after stroke and their families despite ESD. The qualitative descriptive study with 16 HCPs identified staffing and funding challenges in the delivery and scale-up of ESD in Ireland. HCPs highlighted the important contribution of family members to the success of ESD and the need for HCPs to support people after stroke and family members and provide them with sufficient information. HCPs had varied views on the use of telerehabilitation within ESD. The secondary analysis noted an increase in the proportion of people after stroke being discharged home with ESD from 3.8% in 2018 to 6.6% in 2020. Those aged 65–79 years represented the largest proportion of those discharged home with and without ESD. For those discharged with ESD, the mean length of stay (LOS) reduced each year from 17 days (SD=20) in 2018 to 13 days (SD=13) in 2020. Those with a modified Rankin Scale score of 1 or 2 at discharge represented the highest proportion of those returning home with ESD (59.3%) and without ESD (40.8%).

Conclusions

This thesis contributes to addressing a knowledge gap in relation to the delivery and scale-up of ESD in Ireland by focusing on stakeholders experiences of ESD as well as characterising the clinical profile and rehabilitation needs to those accessing ESD in Ireland. While ESD is broadly experienced as a positive process, the transition from ESD to community services is deemed to be problematic and unmet needs such as information needs, and carer support require further consideration. There is a need for significant scale-up of ESD to meet National Stroke Strategy targets. Consensus on ESD eligibility criteria nationally needs to be established and staff recruitment and retention issues need to be urgently addressed to prevent service shortages and ensure consistent access to key services.