Stroke has a major impact on survivors and their social environment. Care delivery is advocated to become more client-centered and home-based because of their positive impact on client outcomes. The objective of this study was to explore professionals’ perspectives on the provision of Home-Based Stroke Rehabilitation (HBSR) in the Netherlands and on the barriers and facilitators influencing the implementation of HBSR in daily practice.
Semi-structured focus groups were conducted to explore the perspectives of health and social care professionals involved in stroke rehabilitation. Directed content analysis was performed to analyze the transcripts of recorded conversations.
Fourteen professionals participated in focus groups (n = 12) or, if unable to attend, an interview (n = 2). Participants varied in professional backgrounds and roles in treating Dutch clients post stroke. Barriers and facilitators influencing the implementation of HBSR in daily practice were identified in relation to: the innovation, the user, the organization and the socio-political context. Participants reported that HBSR can be efficient and effective to most clients because it facilitates client- and caregiver-centered rehabilitation within the clients’ own environment. However, barriers in implementing HBSR were perceived in a lack of (structured) inter-professional collaboration and the transparency of expertise of primary care professionals. Also, the current financial structures for HBSR in the Netherlands are viewed as inappropriate.
In line with previous studies, we found that HBSR is recognized by professionals as a promising alternative to institution-based rehabilitation for clients with sufficient capabilities (e.g. their own health and informal support).
Multiple factors influencing the implementation of HBSR were identified. Our study suggests that, in order to implement HBSR in daily practice, region specific implementation strategies need to be developed. We recommend developing strategies concerning: organized and coordinated inter-professional collaboration, transparency of the expertise of primary care professionals, and the financial structures of HBSR.
Stroke is one of the major causes of mortality, loss of independence, and lower quality of life of stroke survivors and has a great impact on the social environment . Between 2010 and 2030 the absolute number of people with a stroke is expected to increase by 56% in men and 37% in women . Also, stroke is known to have major socio-economic consequences. The financial burden placed on European countries by stroke is huge. For 2010, the estimated cost of stroke in Europe was €64 billion .
Stroke rehabilitation in the Netherlands
Firstly, stroke rehabilitation can be offered as institution-based rehabilitation: organized within hospitals, rehabilitation centers and nursing homes. Within institution-based rehabilitation, care is centered around a diagnosis. Professionals are specialized in treating clients with this specific diagnosis. Also, within the institution, regular (formal and informal) inter-professional meetings take place .
Secondly, stroke rehabilitation can be offered on outpatient basis. After their transfer home (from the stroke unit or institution-based rehabilitation), stroke survivors can consult outpatient rehabilitation professionals. Stroke survivors receiving outpatient rehabilitation live at home and visit the institution to receive therapy.
Thirdly, stroke rehabilitation can be offered as Home-Based Stroke Rehabilitation (HBSR). During HBSR (Home-Based Stroke Rehabilitation) rehabilitation is offered within the home environment of the client. It includes community-based rehabilitation delivered by primary care professionals, such as occupational therapists, physical therapists, speech therapists, dieticians, social workers, nurses and general practitioners . A broad range of professionals can be involved during HBSR, because the impact of stroke is multifaceted, affecting a broad range of body functions, activities and participation patterns . In the Netherlands primary care is not nationally organized: professionals deliver care from independent private practices and from a variety of institutions. General health insurances cover a certain (predefined) amount of treatment hours for selected disciplines only. The variety in financial legislations between these selected disciplines is large. Sometimes additional treatment hours and/or disciplines are financed, depending on the severity of symptoms, personal circumstances and insurance coverage. Insurance coverage differs per person and depends on the selection of optional insurances.
Home-Based Stroke Rehabilitation (HBSR)
Healthcare professionals and organizations are challenged to provide high quality health and social care, in a client centered and cost-efficient manner. To improve the quality and efficiency of care, the location of care delivery is shifting from institution-based settings to home-based services such as HBSR.
HBSR is known for its positive impact on client outcomes. HBSR resulted in more independent clients [7, 8] who are better at performing daily activities [8, 9] and who are more satisfied with their treatment compared to clients who receive conventional (institution-based) rehabilitation [8–12]. Also, HBSR is shown to reduce the length of hospital stay and to decrease the likelihood of admittance in a long-term stay facility . Furthermore, HBSR has the benefit of treating clients within a familiar environment. According to prior studies this tends to stimulate mental and physical activity, provides more meaning to tasks [13, 14] and prevents potential problems with the transfer of learned skills from the training setting to executing daily activities .
In the Netherlands a number of reforms and new policies have been implemented over the last years to facilitate client-centered and cost-effective care. These changes include policies increasing the responsibility of the municipalities for care and welfare on the municipality and transferring more responsibilities from professional carers to civilians and local communities themselves . Despite these efforts, the client-centered and cost-effective provision of high quality care remains a challenge because guidelines, practical suggestions and organisational support seems to be missing . Consequently, both researchers as well as healthcare professionals initiate new regional projects [17–19]. According to the literature, this does not only take place in the Netherlands. Many clients do not receive appropriate care, or receive unnecessary or even harmful care .
Major difficulties can arise when implementing innovations, like HBSR, into routine practice. Even though previous studies have shown positive effects of HBSR [7–15], innovations are not always provided to those clients for whom it could be beneficial . Prior studies show that clients and caregivers experience a gap after institution-based rehabilitation (e.g. delays and discontinuity of therapy and feeling abandoned and unsupported) and poor accessibility of community services [22, 23]. In order to further implement an innovation like HBSR, context specific implementation strategies are needed at different levels [24–26].
This Dutch study explores and describes professionals’ perspectives on determinants that could influence the further implementation of HBSR. These insights can guide the selection of context specific implementation strategies. This study will not only provide insight into region specific factors influencing implementation, but also general issues playing a role in the implementation of HBSR.
- How do professionals characterize stroke rehabilitation services that are currently provided in the Netherlands?
- What are the current and potential barriers and facilitators influencing the implementation of HBSR in their daily practice, according to professionals?