Inequities in access to rehabilitation: exploring how acute stroke unit clinicians decide who to refer to rehabilitation

Abstract

Purpose: Less than half of the patients with stroke in Australian hospitals are assessed by rehabilitation specialists. We sought to explore how clinicians working in acute stroke units (ASUs) determine which patients to refer to rehabilitation services. Method: Qualitative descriptive study. Team meetings were observed and medical records were reviewed over four weeks at two ASUs. Focus groups were conducted with staff from eight ASUs in two states of Australia. Results: Rehabilitation was mentioned in team meetings for 50/64 patients (78%) during the observation period. Rehabilitation referrals were organised for 47 patients (94%) for whom rehabilitation was discussed (74% of the sample); and for no patients when rehabilitation was not discussed. Factors identified that influenced whether referrals were organised included the anticipated discharge destination; severity of stroke; staff expectations of the patient’s recovery; and if there was advocacy by families about rehabilitation. Clinicians tended to refer the patients they considered would be accepted by the rehabilitation service. Staff at two ASUs expressed concern that referring all patients with stroke-related deficits to rehabilitation would be unfavourable with rehabilitation providers. Conclusions: Decisions made by ASU staff regarding who to refer to stroke rehabilitation are often not solely based on patients’ rehabilitation requirements.

Implications for Rehabilitation

• Not all patients on acute stroke units (ASUs) who may have benefited from rehabilitation were offered rehabilitation referrals.

• Criteria for rehabilitation referrals need to be made explicit and discussed openly with consumers, ASU clinicians and rehabilitation specialists.

• A change in rehabilitation assessment practices is required to provide data regarding the unmet rehabilitation needs of patients with stroke.

• New models of rehabilitation service delivery or increased rehabilitation services may be required to meet the rehabilitation needs of all patients with stroke.

Keywords:

• Patient selection
• referral
• rehabilitation
• stroke
• stroke unit
• team meetings