The design elements of outpatient geriatric rehabilitation from patient, healthcare professional, and organizational perspective; a qualitative study

Abstract

Purpose

To gain a rich understanding of the experiences and opinions of patients, healthcare professionals, and policymakers regarding the design of OGR with structure, process, environment, and outcome components.

Methods

Qualitative research based on the constructive grounded theory approach is performed. Semi-structured interviews were conducted with patients who received OGR (n = 13), two focus groups with healthcare professionals (n = 13), and one focus group with policymakers (n = 4). The Post-acute Care Rehabilitation quality framework was used as a theoretical background in all research steps.

Results

The data analysis of all perspectives resulted in seven themes: the outcome of OGR focuses on the patient’s independence and regaining control over their functioning at home. Essential process elements are a patient-oriented network, a well-coordinated dedicated team at home, and blended eHealth applications. Additionally, closer cooperation in integrated care and refinement regarding financial, time-management, and technological challenges is needed with implementation into a permanent structure. All steps should be influenced by the stimulating aspect of the physical and social rehabilitation environment.

Conclusion

The three perspectives generally complement each other to regain patients’ quality of life and autonomy. This study demonstrates an overview of the building blocks that can be used in developing and designing an OGR trajectory.

IMPLICATIONS FOR REHABILITATION

• There’s a growing preference for providing geriatric rehabilitation in an outpatient setting at the patients’ home (called outpatient geriatric rehabilitation), but little is known about the content, efficiency, and quality assurance of outpatient geriatric rehabilitation.

• The key elements for the outpatient geriatric rehabilitation framework consist of a specialized geriatric rehabilitation dedicated multidisciplinary team, patient-centered blended eHealth applications, collaboration with integrated care, especially in community care nursing, and physical and social rehabilitation environments.

• The outpatient geriatric rehabilitation design framework, which emerged from the thematic analysis, offers valuable insights, and can support healthcare professionals and policymakers to establish an effective rehabilitation pathway.

Keywords:

• Geriatric rehabilitation at home
• patients’ quality of life
• integrated care
• qualitative research
• older adult perspective
• policymaker perspective
• healthcare professional perspective

Introduction

How are we going to make geriatric rehabilitation (GR) future-proof? The demand for GR will increase. An important driver of this is the aging of society and the associated loss of physical function. Acute and subacute functional decline as a result of hospitalization, exacerbations of chronic conditions, and injuries and falls will also increase [1,2]. At present, there is a growing shortage of healthcare professionals, leading to a limited capacity for inpatient GR (IGR) [3–5]. Driven by these expectations and the knowledge that older adults experience a need for rehabilitation support at home after IGR [6] and wish to stay at home for longer [7], the tendency is to deliver GR at home with a specialized multidisciplinary team led by an elderly care physician. This is called ambulatory or outpatient geriatric rehabilitation (OGR) [8,9].

Since 2014, the Netherlands has introduced Geriatric Rehabilitation (GR) into its healthcare system, shifting reimbursement from a long-term care government-guided system to a market-guided payment system [10]. This change has led to the professionalization of GR, involving the design of various care pathways [11] and a focus on the rehabilitation climate [12]. More recent developments have concentrated on the OGR trajectory [13], driven by the added value demonstrated in several studies that show positive outcomes associated with rehabilitation at home, for example, on functional outcomes, self-employment, risk of falling, caregiver burden, and cost-effectiveness [11,12,14–16]. Ramsey et al. [17] demonstrated that patients at home spent 2.5 less time lying down than those undergoing inpatient care. Furthermore, a recent systematic review [18] shows that OGR is as effective as usual care and possibly cost-effective. This review also highlighted several frequently used structure, process, and environment elements that may influence the outcomes of OGR.

Despite the professionalization within GR in the Netherlands and the evidenced positive outcomes of OGR, little is known about the perspectives of patients, healthcare professionals, and policymakers on the components that are needed in designing OGR. Examples of these could be the contents of OGR and inclusion criteria for receiving OGR instead of IGR [8,19]. Moreover, many barriers and facilitators exist. For example, external factors, such as financial and practical feasibility might play a role in how traveling, time management, and costs become barriers to providing rehabilitation at home [14,20]. Several studies have stated that more research is needed to finalize the contents, efficiency, and quality assurance of OGR for patients, healthcare professionals, and policymakers [15,21,22].

Therefore, this study aims to gain a better understanding of the experiences and opinions of patients, healthcare professionals, and policymakers regarding the design of OGR on components related to the structure, process, environment, and outcome.

Research design and methods

Design and theoretical background

A qualitative research approach, which consisted of interviews and focus groups based on the constructive grounded theory approach according to Charmaz [23,24] was used to evaluate experiences and opinions regarding the design of OGR in (1) older adults who have been admitted to an OGR setting (patients), (2) healthcare professionals involved with OGR (professionals), and (3) members of the board of directors responsible for the policies associated with (O)GR within a healthcare organization (policymakers).

The Post-acute Care Rehabilitation (PAC-Rehab) quality framework by Jesus et al. [25] was applied as a theoretical background. This model distinguishes four components of a patient-centered approach, namely that the processes (patient care and interprofessional) and immediate outcomes (ICF) have an iterative and integrative connection which is influenced by the structure (organizational requirements), and environmental (patient and systematic) context. All of the elements are related to the rehabilitation’s end goals (macro-outcomes), such as functional performance, patients’ and caregivers’ quality of life, consumer experience, and healthcare utilization [25].

Setting

All participants were approached between March and October 2022 through the four organizations affiliated with the GR “Development Practice.” The Development Practice is a collaboration between The University Network for Elderly Care Amsterdam University Medical Center location VUmc and four Skilled Nursing Facilities (SNF) focused on GR in the Netherlands.

The GR trajectory in the Netherlands involves several steps based on internationally agreed-upon basic elements [10,19,26]. It begins with hospital admission after an acute event, followed by transfer to a GR ward in a skilled nursing facility if the patient is medically stable. A specialized multidisciplinary team led by an elderly care physician focuses on rehabilitation, aiming to achieve independence in daily activities. Rehabilitation may continue through OGR with the specialized clinical team and community care nursing involvement. The elderly care physician leads the outpatient rehabilitation process, while the general practitioner handles other medical issues.

Recruitment and data collection

During the multidisciplinary discharge meeting, patient eligibility for the study was determined. A member of the multidisciplinary team provided an information letter and discussed the study with the eligible patients. If interested, the professional notified the researcher (AP). The researcher followed up with the patient within a week to give oral and written information. If the patient agreed to participate, written informed consent was obtained before inclusion.

Professionals and policymakers were recruited by e-mail via internal contacts within the organization. We adopted a purposive sampling strategy [23,24]. Written informed consent was obtained before inclusion.

Patients

We included patients who were able to communicate, were legally competent (assessed by a physician), and had recently completed the OGR trajectory after being admitted to a skilled nursing facility. The interviews were scheduled to occur within four weeks after finishing the OGR trajectory to minimize the risk of recall bias. We aimed to recruit participants with a wide variety of OGR trajectories (e.g., stroke, hip fracture, and chronic conditions). The interviewer (AP) conducted face-to-face semi-structured interviews (n = 13), using a pilot-tested interview guide (Supplementary Material 1) [27]. The interviews took place at the patient’s home, where occasionally a caregiver was present (n = 5). The purpose of this interview was to understand a patient’s GR trajectory and experiences at home.

Professionals and policymakers

Two focus groups were held with professionals that contained five to eight respondents. Respondents were selected based on whether they worked in one of the four organizations involved and had experience with OGR. We included a variety of professionals, such as physiotherapists, occupational therapists, speech therapists, elderly care physicians, (IGR/community care) nurses, and psychologists. We also held one focus group that included four policymakers from each of the four organizations involved who were familiar with the content and organization of OGR.

To facilitate attendance, we arranged a hybrid setting (a combination of an in-person meeting and online) for the professionals and online video conferencing using Microsoft Teams [28] for the policymakers. A topic guide was used with questions, prompts, and exercises to encourage a focused and rich discussion (Supplementary Materials 2 and 3). The focus groups were moderated by two facilitators each with a clearly defined role: a discussion leader (AP) and an observer responsible for timekeeping, maintaining structure, and taking notes (MH/MP). This setup ensured that all predetermined topics were thoroughly discussed and explored, and besides identified unexpected, yet relevant, themes [24,29]. To increase the credibility of the study results, we performed a member check by emailing the summary of the focus group results to the participants for verification, with the opportunity to give additions and feedback [24,29]. To improve the study’s thoroughness, we made field notes during and immediately after the interviews and focus groups. These notes contain our observations (who, where, what, when) and critical reflective notes, which will contribute to the empirical evidence in the analysis [24,29].

The interviews (duration = 60 m) and focus groups (duration = 90 m) were recorded on tape and transcribed verbatim. The research data was stored in a safe place in a secure folder within Amsterdam UMC, along with any personal data. Any names of individuals and institutions are pseudonymized in the transcripts. Data collection and data analysis was an iterative process, which continued until saturation occurred.

Data analysis

The data analysis for the three groups was executed by AP and AL based on constructive grounded theory [23]. We applied open coding techniques during two consecutive phases. First, a line-by-line analysis of the manuscripts was conducted (initial coding) with constant comparison between the data of each interview and between the interviews. Second, the focused selective coding phase took place in which we merged the most useful initial codes into categories. These categories were distributed across subthemes. The analysis per perspective is presented sequentially in Supplementary Materials 4–6. Subsequently, we conducted an in-depth analysis to assess the similarities and differences between the three perspectives, based on the PAC-Rehab quality framework [25], which resulted in overarching themes. Whenever there were dissimilarities during the data analysis process, discussion with the research team resolved this. MAXQDA version 2020 was used for the analysis process. We used the consolidated criteria for reporting qualitative research (COREQ) as a reporting guideline [30].

Ethical consideration

This study was approved by the Medical Ethics Committee of the University of Amsterdam in The Netherlands (protocol ID 2021.0786).

Results

Tables 1 and 2 show the characteristics of the participating patients (n = 13), professionals (n = 13), and policymakers (n = 4).

Table 1. Participant characteristics; interview patients.

Participant; care organization	Gender	Age	Marital status	Diagnosis (multi-morbidity)	Length of IGR (weeks)	Length of OGR (weeks)	Personal perception of functioning at the start of OGR
1 A	Female	85	Widow, living alone	Stroke	4	2	Walks independently indoors with walker and small distances outdoors with walker; ADL independent with effort; receives domestic help 1× a week.
2 A	Female	80	Widow, living alone	Stroke	2	3	Walks independently indoors and outdoors with walker; has family caregivers; does not want home care.
3 B	Male	75	Living with partner^a	Lithium intoxication (COPD)	4	2	Walks independently indoors with walker with effort, cannot walk outdoors; homecare 2× a week to shower; partner is caregiver.
4 A	Male	76	Living with partner^a	Spinal stenosis (Parkinson’s disease)	2	2	Walks independently indoors with walker; ADL independent except for showering; partner is caregiver.
5 A	Female	82	Widow, living alone	Stroke	8	4	Walks independently indoors with walker, walks small distances outdoors with help; receives home care for showering and domestic help; has family caregivers.
6 C	Female	72	Widow, living alone	Stroke	3	3	Walks independently indoors with walker and small distances outdoors; ADL independent with effort; receives domestic help; has family caregivers.
7 C	Female	64	Living alone	Bacterial hip arthritis (stroke)	12	4	Walks independently indoors with walker, outdoors with help; ADL independent with effort; receives domestic help 1× a week; has family caregivers.
8 B	Male	76	Living with partner^a	Pneumonia (COPD, kidney failure)	3	2	Walks independently indoors with walker, outdoors with help; receives a lot of help from partner who is caregiver.
9 A	Male	71	Living with partner^a	COVID-19 (COPD)	6	8	Walks little distance with effort indoors with walker and outdoors a few meters with help; ADL dependent on partner who is caregiver.
10 A	Male	82	Living alone	Stroke (delirium)	4	5	Walks independently indoors and outdoors; receives home care to dress and shower 2× a week, domestic help 1× a week; has family caregivers
11 A	Female	75	Widow, living alone	Stroke	12	6	Walks indoors with walking stick with effort and insecure or uses the triple chair; receives homecare for washing, clothing, and showering; receives a lot of help from family caregivers
12 B	Male	74	Living with partner^a	COVID-19 (COPD)	1	4	Is dependent on partner who is caregiver for walking, and all ADL activities
13 C	Male	84	Widow, living alone	COVID-19, stroke	5	12	Walks independently indoors, outdoors with help because of visual spatial neglect.

ADL: activities in daily life.

^a Partner was present during the interview.

Table 2. Participant characteristics; focus groups healthcare professionals and organizational perspective.

Healthcare professional
Participant; focus group	Care organization	Gender	Discipline	Work setting and experience with OGR^a
1; 1	A	Female	Geriatric rehabilitation nurse	Geriatric rehabilitation ward in skilled nursing home; is responsible for clinical rehabilitation (general); average experience.
2; 1	A	Female	Physiotherapist	Geriatric rehabilitation ward in skilled nursing home; responsible for clinical and ambulatory rehabilitation (general), coordinator for geriatric rehabilitation in skilled nursing home; average experience.
3; 1	C	Female	Psychologist	Geriatric rehabilitation ward in skilled nursing home; responsible for clinical and ambulatory rehabilitation (stroke and general), chair of the psychology department; some experience.
4; 1	B	Female	Physiotherapist	Geriatric rehabilitation ward in skilled nursing home; is responsible for clinical and ambulatory rehabilitation (lung and orthopedics); average experience.
5; 1	A	Female	Psychologist	Skilled nursing home, little experience with AGR, in training to become a GRZ psychologist; little experience.
6; 2	A	Female	Occupational therapist	Geriatric rehabilitation ward in skilled nursing home; responsible for clinical and ambulatory rehabilitation (general); average experience.
7; 2	C	Female	Occupational therapist	Geriatric rehabilitation ward in skilled nursing home; responsible for clinical and ambulatory rehabilitation (general); much experience.
8; 2	A	Female	Physiotherapist	Geriatric rehabilitation ward in skilled nursing home; responsible for clinical and ambulatory rehabilitation (general); average experience.
9; 2	A	Female	Physiotherapist	Geriatric rehabilitation ward in skilled nursing home; responsible for clinical and ambulatory rehabilitation (general); average experience.
10; 2	C	Female	Elderly care physician	Geriatric rehabilitation ward in skilled nursing home; responsible for management and performance of ambulatory rehabilitation (general); much experience.
11; 2	A	Female	Community care nurse	Community care; responsible for the care at home of (outpatient/ambulatory rehabilitation) patients; average experience.
12; 2	D	Female	Speech therapist	Geriatric rehabilitation ward in skilled nursing home; responsible for clinical and ambulatory rehabilitation (stroke and general), chair of the psychology department; little experience.
13; 2	B	Female	Occupational therapist	Geriatric rehabilitation ward in skilled nursing home; responsible for clinical and ambulatory rehabilitation (stroke); average experience.
Organizational policymakers
Participant	Care organization	Gender	Experience with OGR	Position in the organization/company
1	C	Female	Average	Director of geriatric rehabilitation
2	B	Female	Average	Specialist elderly care and strategic project leader
3	A	Female	Average	Director of home and recovery, responsible for geriatric rehabilitation and community care nursing
4	D	Male	Some	Director of home and recovery, responsible for geriatric rehabilitation and community care nursing

^a Little experience <2 years; average experience 2-10 years; much experience >10 years

In-depth analysis of three perspectives

The in-depth and integrated analysis resulted in overarching themes that concerned the experiences and opinions of all three groups regarding the design of OGR. In some instances during the analysis, the field notes proved valuable in interpreting the results. Figure 1 presents the resulting overarching themes which are subdivided into the components of structure, process, environmental context, and outcome [25].

Figure 1. The overarching themes from the in-depth analysis of the patient, healthcare professional and organisation perspectives based on the PAC-rehab quality framework.

Seven main themes should be considered when designing an outpatient geriatric rehabilitation trajectory based on patients’, professionals’, and policymakers’ experiences and opinions. These seven themes are organized into a framework with four building blocks: structure, process, environment, and outcome, all centered around the patient. This framework is based on the Post-acute Care Rehabilitation quality framework.

Outcome

The outcome component relates to the goals of OGR [19], with an emphasis on “Regaining quality of life.” Patients “want control over their functioning in daily life at home, and autonomy.” They are generally satisfied with the outcomes of OGR. Professionals strive for autonomy and independence for the patients. They see that patients often desire to be back at home. Moreover, they observe that patients experience loneliness, that they must learn to deal with a new situation, and do not like to organize everything themselves due to reduced self-confidence or fatigue. This is also experienced by many patients. In particular, the transition back home is often experienced as strange and tiring. Once at home, almost all of the patients became aware of the advantages as they now could be in charge of their daily schedule and take control of their lives:

“The idea that you still matter because you do your things. You can do anything you want, go into town with your girlfriends, I decide." (Patient 6)

Most patients experience asking for help and support as difficult:

“I tried by myself for as long as I could until my self-esteem came back. So that I could shower myself, and that I decide for myself, that I’m not tied to someone else.” (Patient 1)

Policymakers wish to develop further and strive to use OGR as a way to enable people to live at home for longer, shorten the inpatient period, prevent readmissions, and promote self-management.

“The view of the patients on their own recovery and daily functioning” is divided into two groups. The first group is patients who experience independence in their daily functioning and indicate that they can do a lot by themselves, such as daily activities and making day trips. This has a positive impact on their quality of life and is similarly reflected in confidence surrounding their recovery and satisfaction concerning their progress. The second group, which was the majority of patients, experienced obstacles in their daily functioning, such as walking (outside) and a fear of falling. This resulted in a negative attitude toward recovery and feelings of frustration and doubt about the future:

“You think, like, damn, you can manage, there is no way you can’t do it by yourself and then you get mad at yourself.” (Patient 4)

Process

To regain a better quality of life for the patient, several patient care and interprofessional process elements are essential. A “Smooth start and finish of OGR by deploying a patient-oriented multidisciplinary network” is essential. All three groups discussed the “preparation for and smooth start of OGR.” The policymakers indicated that triage before OGR is important to determine the division of tasks. During this stage, further admission options for OGR are explored:

“So, the outpatient rehabilitation does not necessarily have to start from a clinical admission but can also start directly from home or hospital.” (Policymaker 3)

Professionals prepare the patients for discharge home during IGR and strive to make the transition home as smooth as possible. Patient-centeredness is important here, for example, in drawing up the treatment plan. Other essential topics are earlier identification of the discharge conditions and social support possibilities, arranging a trial discharge, and providing better information about OGR. This matches the patients’ experiences and wishes. Additionally, patients stated that knowing the discharge date in advance is beneficial and the moment of discharge is experienced as mainly positive:

“Yes, there’s no place like home. But now and then, I think, like, those 14 days would have been nice, but you won’t find out until you get home” (Patient 1)

Nevertheless, some patients experienced uncertainty about the discharge and their functioning.

“Finishing of OGR and coordination of aftercare” is organized differently in the participating care organizations. Professionals indicated that arranging a meeting at the end of OGR with the entire multidisciplinary team and the patient is desirable. In addition, professionals emphasized wanting to be able to follow the patient and guide them with a specialized team for longer to increase the effect of rehabilitation:

“I would like to keep someone within the organization to, like, say, prevent readmission…that you always have the same therapists throughout the process so that you no longer have crises either." (Professional 10)

In contrast, policymakers indicated that long-term chronic treatments must be supported by working well with Primary Care (PC). Coordination of aftercare can be improved through better cooperation and communication with PC. For example, this can help prevent patients from feeling uncertain about arranging appointments with PC therapists.

Besides a smooth start and finish of OGR, a “well-coordinated, specialized dedicated team at home” is a second main theme. Both policymakers and professionals highlighted “the added value of a dedicated, specialized team” in which the clinical professionals follow the patient home. Patients also indicated that they preferred to be treated by the same professional at home as they had in IGR. They expressed a lot of confidence in the professionals and often left choices about the content and interpretation of rehabilitation to the therapists:

“I liked everything they did. I said yes to everything, that’s good. Being agreeable achieves more than opposing, at least that’s how I see it.” (Patient 13)

The professionals noted that physiotherapy and occupational therapy were mainly used. However, expertise from other disciplines, such as psychology, speech therapy, social work, and dietitian are missed. Policymakers and professionals emphasized their wish that community care (CC) nurses, as well as IGR nurses, become an integral part of the multidisciplinary team, whereby CC nursing has to be involved earlier during OGR. However, collaboration with CC nursing is currently not effective and needs improvement:

“…that we just have better communication, like, well, what did they manage at home and what should they be able to do to be allowed to return home.” (Professional 1)

Finally, professionals and patients indicated that communication during OGR with, but also between, the treatment team is important, but also more challenging than during IGR.

“Coordination of the OGR trajectory” needs attention according to both the policymakers and professionals. Some professionals experienced a loss of control and oversight during OGR. All three groups indicated that a central guide for the patient, for example, distributed by a case manager, is important for keeping an overview during (O)GR:

“And we must not forget the client … who no longer understands anything about the situation anymore and is just aware that they now have an occupational therapist or a physiotherapist or a social worker. So that guide for the client is extremely important in that sense. Because a lot of this is about vulnerable older people.” (Policymaker 4)

Furthermore, professionals noted that providing therapy across different regions is challenging and inefficient. Consequently, this inefficiency affects time management and creates reluctance around implementing OGR, according to the professionals. For example, the planning of an agenda is a challenge because professionals are responsible for both clinical and outpatient patients. The respondents suggested that central planning may be a viable solution to this.

The third essential process theme is “The added value of integrating patient-oriented eHealth applications with existing treatment.” Both professionals and policymakers believed that eHealth applications can make a positive contribution to “organizing the processes within rehabilitation more efficiently and effectively.” Earlier integration into (O)GR and interaction with existing treatments are desirable features:

“I wouldn’t have it be completely digital, but I do think it could be a nice addition, even if it’s only to make a video call about, like, how you’re doing. Sometimes you don’t have to travel all the way there and you can just briefly give some advice or…videos explaining your exercises that people can also do by themselves…" (Professional 2)

An automatic medication dispenser or assistive robot are things you would want to deploy clinically. You could integrate it much earlier in your pathway. (Policymaker 1)

Professionals think that the patient’s age is a limitation in the feasible use of eHealth. Meanwhile, policymakers think these are unjustified assumptions, noting that during COVID and the lockdowns, more technology was used.

Moreover, policymakers emphasized that “technology is meant to help the patient.” Technology can enable greater control for the patients over their care trajectory and encourage self-management. Policymakers also believed that a shift is needed to support the notion that technology is for the patient and not for the professional. In this way, the development of blended care pathways is needed:

Convert the rehabilitation trajectories or recovery trajectories to digital tools and really give control to the patient. Because right now, we still often see that the professionals are in control and determine what steps the patient goes through. And if we don’t change that, it’s almost impossible to succeed during rehabilitation at home. And if we can say here is your tablet, it says precisely what steps you must go through for the best possible rehabilitation or recovery. I think the patient will be more in control. The technology helps with that exceptionally well. (Policymaker 4)

Structure

The organizational requirements within the structure component will additionally influence the process elements and the outcomes of OGR. The first theme identified that “Refinement of OGR’s organization is needed with financial, time-management and technological challenges.” all three groups have a “view on the development of OGR’s organization.” Patients discussed how satisfied they are with the structure of OGR as it is now, noting that they had good experiences. However, they do provide further suggestions, such as wanting to be called by a team member a few days after discharge and having more therapy at home. The professionals and policymakers see the need and added value of OGR and support further development. The policymakers advised taking into account shortages in the labor market when developing OGR:

“Linking up with current infrastructure is really important to me. Especially given the scarcity we are experiencing in the labor market now and perhaps also financially in the future.” (Policymaker 4)

Unfortunately, according to both professionals and policymakers, the development of OGR has so far been unsatisfactory, partly because organizational preconditions are not clear. Policymakers stated that attention is needed on how to keep professionals involved during the development. Professionals similarly highlighted feelings that development was going too fast. Additionally, professionals and policymakers both indicated that OGR is difficult to finance with the current working method and that they wanted the financing process to be less complicated:

“Yes, more attention is paid to the hours than to the people.” (Professional 6)

Regarding the “required facilities for the proper execution of OGR,” both patients and professionals indicated that access to training equipment at clinical locations is desired:

“No matter how good the physiotherapist is, my options are very limited here, but in the building, there is a leg press for your legs and weights." (Patient 3)

Besides, they indicated that transport is a challenge. It takes time, money, and energy to travel to the clinic for therapy sessions. Finally, professionals and policymakers highlighted that eHealth is both promising and challenging in terms of development, finances, and incorporating eHealth in care processes (blended care).

As well as refinement of OGR’s organization “Building closer cooperation and integrated care (with primary, secondary, and tertiary care)” is a main theme on the structure level. Integrated care is an essential topic for policymakers. They highlighted that “building relationships takes time and energy.” For cooperation with general rehabilitation specialists and hospitals to be effective, gaining trust is key. This is especially the case concerning triage. Further, policymakers noted that cooperation in the social domain falls short and that timely collaboration could improve discharge possibilities (for example, due to completed adjustments to housing) and prevent readmissions:

“There is also quite a lot to organize when someone is going home and has few informal caregivers or no support structure around them. However, we do not know enough about this, and I have found that it also takes a lot of time and energy to build and maintain relationships.” (Policymaker 1)

Policymakers also see “advantages and opportunities in building networks.” They stated that an informal network can improve compliance with therapy, with greater possibilities to communicate more easily and increase visibility for chain partners. Care chains are organized differently depending on the region or city. As such, examples of effective organizational procedures cannot always be copied. Both policymakers and professionals indicated that integral cooperation with greater communication between OGR, PC, and the region is currently ineffective, and therefore needs attention. They identify two aims concerning this. First, to continue treatment properly, and second, to have an overview of what services are offered in the region. Additionally, they stated that the knowledge and skill levels of PC professionals are essential, and improvement is necessary.

Environment

The structure, process, and outcome components are all influenced by “Stimulating rehabilitation aspects of the physical and social environment.” At the start of OGR, both patients and professionals feel that rehabilitating at “home is different from IGR,” yet they do recognize the advantage:

“That they learn it the correct way right from the start because if we ask where they always hang the towel, they can’t tell you that at that moment.” (Professional 1)

However, professionals do mention not always being able to implement the rehabilitation climate at home. They indicated that CC nursing needs more knowledge of the rehabilitation climate, and further training is desired.

All three groups indicated that “the rehabilitation location must be tailor-made for the patient.” Policymakers see the advantages of therapy at home. However, they advise providing therapy on location as soon as the patient is ready, partly because of the possibilities for group treatment. Patients who preferred therapy on the location indicated reasons, such as the presence of training equipment, advice from the therapist, and their own choice. In contrast, patients who preferred therapy at home cited reasons, such as fatigue, transport problems, not wanting to leave the house, and the practicality:

“There’s more at home, and you come across more things that are difficult and you haven’t thought about.” (Patient 7)

The majority of professionals preferred rehabilitation at home because it is functional and corresponds well to the patient’s needs. Furthermore, the possibility of intermediate forms of outpatient care is also discussed by all three groups and generally viewed as a good option:

“That you can be partly at home in your environment, but in an exercise room you have other things that you can practice at a different level, which can make it challenging again, so to speak.” (Professional 4)

Both patients and professionals mentioned experiencing “the importance of social support.” The professionals emphasized that social vulnerability deserves attention:

“…that there is a clear social map, with volunteers and buddies. I believe that social vulnerability in particular is an issue where we as therapists have our backs against the wall. It would be nice if you had shorter lines of communication with the regional organization there.” (Professional 13)

Further, they indicated that caregivers must be involved from the moment of admission in IGR and that if no caregiver is present, appointing a volunteer could be one solution. Patients stated that they did receive help to different degrees from informal caregivers. They also indicated that support and external motivation in doing the exercises are needed:

“If it has to come from yourself, you’ll do it, but it’s more non-committal.” (Patient 3)

Factors that were mentioned as motivations were therapists, family, equipment, homework programs, and weather conditions.

Discussion

This qualitative study presents a better understanding of how to design OGR from the perspective of the patient, healthcare professional, and organization. An in-depth analysis of all three perspectives identified seven main themes. The findings suggest that the outcome of OGR is focused on regaining patients’ quality of life and autonomy. Essential process elements to attain this are a patient-oriented multidisciplinary network, a well-coordinated multidisciplinary dedicated team at home, and patient-oriented blended eHealth applications. Additionally, refinement of the organization of OGR and incorporating closer links with integrated care is needed at the structure level. The stimulating aspects of the physical and social rehabilitation environment influence all of these steps.

This present study has explored several important elements that are associated with the organization and content of OGR, which corroborates previous findings [18], such as a case manager, a dedicated specialized team that provides inpatient and outpatient GR, integration of patient-oriented technology, caregiver involvement, and integrated care [9,10,20,31]. This knowledge about the potentially valuable elements for the OGR trajectory could be applied in the design of OGR. Overall, the three groups exhibited similarities in their experiences and wishes concerning OGR and complemented each other in many areas. The engagement and alignment of different stakeholders, including healthcare professionals and policymakers, can positively impact the implementation of a newly designed OGR intervention in the future [32].

It was striking but not surprising that patients mainly expressed experiences and wishes regarding the outcomes, professionals were primarily focused on the process, and policymakers highlighted structural aspects. Being in control and having autonomy are essential topics for the patients and are related to their experienced quality of life [33]. While patients indicated that being independent is essential for a better quality of life, they noted that external motivation to perform exercises and training is also necessary. Meanwhile, policymakers discussed how technology could effectively promote a patient’s autonomy. This aligns with earlier research [3,34–36] which demonstrated that blended eHealth applications can improve rehabilitation outcomes, such as in performing daily activities. Although our study did not indicate how to implement blended care in the OGR trajectory, the place of rehabilitation was extensively discussed. All three groups noted the advantage of providing therapy at home and on location, which aligns with the study of Prins et al. [20]. A rehabilitation environment that fits the patient’s needs will improve functional outcomes and reduce negative feelings [31]. Tijssen [12,37] demonstrated that an enriching rehabilitation environment can improve patients’ autonomy and ability to engage in daily activities and exercises, although this research primarily focuses on IGR. All three groups experienced home rehabilitation differently from IGR. Patients have to relearn behaviors at home and get used to new situations. They also typically have more ambitious goals than those put forward during IGR [38]. The policymakers and professionals also felt the rehabilitation climate was missing at home. To improve this, transferring GR knowledge to PC professionals and CC nurses would be beneficial [19,39]. However, there is still much uncertainty about improving the rehabilitation environment at home and effectively encouraging the patient to exercise in this situation. More research is needed on the rehabilitation climate during OGR and how to promote the patient’s autonomy.

Finally, the organization and deployment of a dedicated team with specialized professionals throughout the rehabilitation process with a warm transfer to the CC nursing teams and PC was emphasized. The advantage of a dedicated team could be that patients can benefit from the specialist knowledge of the GR professionals for a more extended period [31]. This is in line with research into transitional care after hospitalization [38,40], which shows that coordination of the transition home by a nurse and communication with integrated care are successful elements in preventing readmissions [40]. Moreover, to increase the quality of care, it is necessary to strengthen collaboration and implement a person-oriented, integrated care model among providers and settings [5]. It is also important to involve the patients’ social network from the beginning of the rehabilitation trajectory, which can influence the quality of GR [33,41].

The results of our study provide insights for structuring OGR and can be utilized by policymakers to develop the rehabilitation pathway. Further research on the effectiveness and efficiency of the elements is recommended.

Strengths and limitations

The strength of this research is that a team of researchers reflected the design of OGR in the broadest way possible by exploring three specific perspectives and comparing them [42–44]. Furthermore, through purposive sampling, we included a heterogeneous group of participants per perspective [43,44]. These points also increase the generalizability of the results to other healthcare organizations that offer OGR [24,42]. Although the perspectives have been collected in the Netherlands, they are in line with previous international research which demonstrated consensus that GR should preferably be offered in an outpatient setting [8] and further development of OGR is needed [19]. Finally, as the participants participated voluntarily, patients who felt weak and had little energy were less likely to participate, and people who had a positive experience and affinity with OGR were most willing to participate, which may have presented a distorted image and bias [24,44]. Nevertheless, a group of vulnerable people who are often excluded from research did participate in this study.

Conclusion

The findings of the present study provide an overview of the structure, process, and environmental components that may have an influence on the outcome of OGR with a clear focus on regaining patients’ quality of life. Essential elements are a well-coordinated dedicated team at home, patient-oriented blended eHealth applications, closer cooperation with integrated care, and the physical, and social rehabilitation environments. This provides a good foundation for further international consensus, development, and testing of blended OGR in clinical practice. It is crucial to emphasize the need for ongoing research and development in the OGR field, as the number of older people is expected to increase enormously, alongside a shortage in the workforce [3–5].

Ethical approval

This study was approved by the Medical Ethics Committee of the University of Amsterdam in The Netherlands (protocol ID 2021.0786).

Acknowledgments

We thank all the participants for their cooperation and their willingness to share their experiences and opinions. We also want to thank the organizations affiliated with the GR Development Practice; GRZPLUS (Omring and Zorgcirkel), Vivium Care Group, Zonnehuisgroup Amstelland), and the University Network for Elderly Care VUmc.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data will be made available, from the corresponding author on reasonable request.

Additional information

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.