Delivery of a quality improvement program in team-based rehabilitation for patients with rheumatic and musculoskeletal diseases: a mixed methods study

Figures & data

Table

Objective: To evaluate the effectiveness of a structured goal setting and tailored follow-up rehabilitation program (the BRIDGE program) compared to existing rehabilitation programs for patients with RMDs. Intervention: The BRIDGE program, developed by the research team, was designed to improve the quality in rehabilitation processes, with emphasize on high degree of patient involvement, continuity and coordination across levels of healthcare. The program included five interacting elements, presented in the table, meant to facilitate the health professionals’ guidance and support to each patient’s rehabilitation process over time.
Elements in the BRIDGE program:	Available tools to support each phase in the rehabilitation process:
	Guidance booklets, developed for the intervention phase in this trial, were available for providers and patients, respectively.
Motivational interviewing (MI)	The provider booklet included highlights from MI theory, an MI conversation guide related goal setting and follow-up, and a template for the provider’s MI self-evaluation. MI rating scales were available for the providers, to guide the patients’ reflections on their levels of willingness, confidence, and readiness for actions.
Patient-specific and structured goal setting	A brief introductory film about rehabilitation goals, developed for this trial, was available for patients, at YouTube. The booklets included written information about goals and goal setting, and a reflection task called “The shoe” (additional file 7) designed to stimulate the development of goals for each patient.
Written plans for rehabilitation	The booklets contained brief educational material, examples and templates for goal-directed action- and coping plans, including strategies for overcoming potential barriers. The plans addressed both strategies for self-management and support from others.
Personalized feedback on progress on goals/outcomes	Digital graphs, based on electronic questionnaires, were meant to be used as feedback on progress on goal attainment and other outcomes throughout the follow-up period. The patients could choose to use the graphs in dialogues with important others and external services. They could also use pre-existing smartphone applications for self-management, feedback and maintenance of health-related behavior changes over time. Names of relevant applications were recorded on a list developed for this trial.
Tailored follow-up after discharge	One month after discharge, patients received an MI-based follow-up call designed to facilitate the further rehabilitation process. The booklets contained templates for written plans for patients’ self-management and follow-up, including assessment of necessary support and available resources (e.g., next of kin or external services).
Design: The figure presents the stepped-wedge cluster-randomized design, with number of patients included from each center. A total of 8 Norwegian rehabilitation centers (clusters) in secondary care started in the control phase simultaneously (T1, delivering their traditional programs). They switched to the intervention phase (T2, adding the BRIDGE program) in a randomized order based on pre-defined time points. There was an educational outreach visit at each centre shortly before their timepoint for crossover, directed at the local coordinator, the multidisciplinary team, and their leader(s). At the end of the trial, all centers delivered the BRIDGE program. A total of 374 adults with RMDs were included: n = 206 in the control group (recruited in the T1 phase, light grey in the figure) and n = 168 in the intervention group (recruited in the T2 phase, dark grey in the figure).
Outcomes: Data on standardized, patient-reported outcomes were collected at admission and discharge, and at 2, 7, and 12 months after admission. Primary outcome was patients’ goal achievement measured by the Patient Specific Functional Scale. Secondary outcomes were physical function (30-seconds Sit-To-Stand test) and health-related quality of life (EuroQoL 5D-5L). [20–21]

Figure 1. Procedural diagram for the convergent approach: the quantitative and qualitative data were collected separately in the intervention-phase of the trial, before they were analysed separately, and then integrated and discussed for the purpose of a mixed, complementary investigation of the delivery of the BRIDGE program. QI: quality indicators.

Horizontal time base from control to intervention phase. Up from intervention phase rise three parallel processes vertically, the quality indicator questionnaire, the fidelity checklist, the focus groups.

Table 1. Fidelity checklist for optimal delivery of the BRIDGE program.

Element in the BRIDGE program	Single items in the providers’ checklist for program fidelity (no. 1–18)	Yes	No	n.a
Structured goal setting	During the first days of the rehabilitation stay: 1 Deliver the P booklet, and invite P to prepare to goal setting using the booklet, the video and the reflection task.
	2 Together with P, develop 3–5 written rehabilitation goals, and ask P to write the goals in his/her booklet.
Written rehabilitation plan	3 Together with P, develop a written rehabilitation plan related to the stay, including strategies for potential barriers.
Monitoring the goal progress/individual  feedback  along the rehabilitation process	At admission: 4 Introduce the digital solution for data collection, and guide P to secure identification online.
	5 Guide P to record the agreed goals digitally (in the PSFS), and to complete the other outcome measures in the online solution.
	During the stay: 6 Provide positive feedback to P on goal-directed actions and tasks performed in the process
	7 Together with P, adjust goals and actions when necessary, to gain sufficient self-efficacy (related to goals and goal-directed activities), and sufficient outcome expectations.
	At discharge: 13 Ensure that P know when and how to use the online solution for further evaluation at home.
	14 Inform P how to use the graphs for clinical outcomes for feedback on their own progress; alone or in dialogue with next of kin or important caregivers across levels of care.
Tailored follow-up, across levels of care.	Before discharge: 8^a Together with P, identify 3-5 goals for the time after discharge (written both in the P’s booklet and in the online solution for data collection).
	9^a Together with P, develop a written plan for follow-up, including strategies to overcome potential barriers.
	10 Ensure that P’s plan for self-management (support from others not required) is completed and documented in the online solution for data collection
	11 Together with P, discuss and plan follow-up from externals (documented in the online solution for data collection)
	12 Make an appointment regarding appropriate time for the mandatory phone call about 4 weeks out in the follow-up period
	After discharge: 15 Conduct the agreed follow-up conversation (phone call) with P
	16 If appropriate for the rehabilitation process: conduct further phone calls (up to four during the follow-up period)
	During the follow-up phone conversations: 17 Together with P, evaluate goals and interventions, consider the need for adjusted or new interventions, or additional support from externals in primary care or local community.
	18 If appropriate for the rehabilitation process: support P in getting in contact with services relevant for the P’s further rehabilitation process in the follow-up period.

n.a: not appropriate (a third response alternative applicable for only item 16 and 18); P: the patient; PSFS: Patient-specific functional scale.

^aPatient-specific goals and rehabilitation plans for the follow-up period may be identical to initial goals and plans, if appropriate for the context at home.

Figure 2. Fidelity scores for single items in the providers’ checklist for fidelity in the BRIDGE trial. HP: health professionals; rehab: rehabilitation; P: patient; PR: pass rate; FU: follow-up.

A three section bar chart presenting fidelity scores between 88 and 100 for the first section, initial goal setting. Lower and between 80 and 95 in next section reflecting planning for continued process after discharge. Lowest and between 29 and 85 in third section, follow-up.

Table 2. Characteristics of the participants and composition of the focus groups.

Group no.	Partici-pants	Age (years) (min–max)	Rehabilitation site	Profession	Postgraduated studies (completed or current)	Work experience in somatic rehabilitation (years)	Focus group duration (minutes)
					MI (courses or education)
1	5	31–51	1 hospital 4 rehabilitation institutions	2 OT 2 PhT 1 SE	1 master 1 master (c) 1 postgrad.st	6–26	118
					1 postgrad.st MI 3 1-day seminars MI
2	5	36–60	2 hospitals 2 rehabilitation institutions	2 OT 2 PhT 1 SW	1 master 3 postgrad.st 1 postgrad.st(c)	7.5–34	132
					1 postgrad.st MI 4 1-day seminars MI
3	5	28–61	1 hospital 3 rehabilitation institutions	1 N 3 PhT 1 SW	1 postgrad.st	3–30	105^a
					1 basic course MI 4 1-day seminars MI
In total	15	median 41 (28–61)	3 hospitals 5 rehabilitation institutions	1 N 4 OT 7 PhT 2 SW 1 SE	2 master 1 master (c) 5 postgrad.st 1 postgrad.st (c)	median 12 (3–34)	355

c: current; OT: occupational therapist; PhT: physiotherapist; SE: sport educator; N: nurse; SW: social worker; postgrad.st: postgratuate studies comprising participants with master’s (completed) in public health science (1) and physiotherapy (1); a participant with a master’s (current) in health science; participants with postgraduate studies (completed) in multidisciplinary rehabilitation (1), rehabilitation and integrated health (1), evidence-based practice in health (1), cognitive therapy (1), vitality training (1), and motivational interviewing (MI) (2); and 1 participant with postgraduate study (current) in cognitive therapy.

^aGroup 3: duration 105 min, +15 min not audiotaped, due to technical problems with one dictation machine.

Figure 3. Joint display of intended program delivery confirmed by quantitative and qualitative results, and potentials for improvements suggested by the results from at least one database. FU: follow-up; P: patient; MI: motivational interviewing.

Three parallel piles of boxes in six levels. First level, program-delivery as intended, confirmed in all three boxes, but nuanced in focus groups. Second, improvement-potential for involving externals, confirmed in all boxes. Level 3–5, improvement-potentials regarding follow-up, rehabilitation plans and digital graphs, confirmed by fidelity checklist and focus groups. Level 6: improvement-potentials regarding rating scales, only confirmed in focus groups.