Re/connecting with “home”: a mixed methods study of service provider and patient perspectives to facilitate implementing rehabilitation in the home for reconditioning

Abstract

Purpose

To explore the views of healthcare professionals and patients about the advantages and disadvantages of rehabilitation in the home (RITH) for reconditioning, and identify factors that should contribute to the successful implementation of a consensus-based RITH model for reconditioning.

Materials and methods

Interviews with 24 healthcare professionals and 21 surveys (comprising Likert scale and free text responses) of inpatients undergoing rehabilitation for reconditioning provided study data. Interpretive thematic analysis was used to analyse interview data; descriptive statistics analysed Likert scale responses; patient written responses assisted with the interpretation of themes developed from the interview data.

Results

Two major themes were elicited in this study: the home is a physical setting and the home is a lived space. Advantages and disadvantages of RITH for patients, carers and healthcare professionals were identified within these themes. Appropriate patient selection; effective communication with patients and carers, and within RITH teams; adequate patient and carer support; ensuring the safety of patients and staff; and education of patients, carers and healthcare professionals are essential for the satisfactory implementation of RITH.

Conclusion

The concept of home shapes the delivery of RITH. Recognising the advantages and disadvantages of RITH highlights important considerations needed to successfully implement RITH for reconditioning.

IMPLICATIONS FOR REHABILITATION

• The home setting facilitates a person-centred approach to care, especially when staff consider patients to be equal partners in their care.

• Home offers an opportunity to negotiate contextually relevant rehabilitation goals with patients.

• Effective communication between patients, their local doctor, family, and rehabilitation staff is essential for the successful delivery of rehabilitation in the home.

• Safety concerns (for patients and staff) and the shift in the burden of care from hospital staff to family must be adequately addressed prior to the commencement of rehabilitation in the home.

Keywords:

• Rehabilitation
• home
• rehabilitation in the home
• home-based rehabilitation
• qualitative research
• reconditioning
• deconditioning

Introduction

Healthcare capacity to provide inpatient rehabilitation services is challenged by increasing demand in Australia [1,2], with research suggesting patients spend an average of 12% of their acute hospital admission waiting for a rehabilitation bed [3]. According to the Australasian Rehabilitation Outcomes Centre (AROC), reconditioning is the largest inpatient impairment category, making up 26% of all inpatient rehabilitation episodes in Australia [4]. It comprises patients who require rehabilitation for generalised deconditioning following medical illness, surgery, or treatment for cancer, not attributable to any of the other impairment groups including stroke, cardiac disorders, orthopaedic disorders, pain disorders, and neurologic conditions.

The provision of rehabilitation in the home (RITH) by a multidisciplinary team offers an alternative to inpatient rehabilitation services [1,5]. With appropriate patient selection, home-based rehabilitation has been found to be effective for specific conditions such as uncomplicated total knee arthroplasty and early supported discharge for stroke [6,7]. Moreover, the acute care burden of the COVID-19 pandemic has demonstrated the need for a greater focus on opportunities for in-home care in the subacute sector as hospital substitution [8,9].

Patient and/or carer perspectives about participating in RITH (for mostly orthopaedic, stroke or neurologic conditions) or early supported discharge services (ESD) have been explored (see for example [6,10–14]). While evidence suggests satisfaction with home-based rehabilitation programs for these conditions there are also areas of concern [13–15]. Issues faced by patients include: the challenges of returning home with altered functional capacities; changes in personal autonomy and dependency on others; trust in the level of support provided by the health service [13]. Being “at home” can also take on new meaning arising from feelings of insecurity and ambivalence despite its familiarity and comfort [13]. Nevertheless, older people and their families mostly perceive the home as the best place for recovery [15]. At home, patients experience social support from family and friends, improved well-being, all while undertaking individualised rehabilitation plans; the hospital, however, does provide benefits in terms of sharing the rehabilitation experience with others, the availability of certain equipment, or when a patient is unwell or lacks confidence to return home [16]. These various perspectives suggest that more qualitative research is needed to better understand the views and opinions of patients and carers [15], as well as healthcare professionals about home-based rehabilitation as hospital substitution.

RITH for reconditioning as hospital substitution is not widely established in Australia, and there is limited relevant published research relating to this diverse patient group. Thus, in 2021/2022, we undertook a cross-sectional, mixed methods study with the aim of developing and costing a consensus-based model for RITH as hospital substitution for patients requiring reconditioning, and of understanding issues relevant to the implementation of RITH for this patient population. The research team consisted of academics (n = 4), rehabilitation physicians (n = 6), an allied health professional (n = 1), and a health financing consultant (n = 1). The study comprised a rapid review of the literature on home-based rehabilitation, a three-round on-line Delphi survey of Australian health professionals working in the rehabilitation field, interviews with service providers (medical and allied health professionals), and a paper-based survey of a sample of rehabilitation inpatients. The rapid review of the literature was undertaken to inform the research, and was prior to the other parts of the study which were conducted concurrently. The Delphi survey [17] (published in detail elsewhere) produced a consensus-based model comprising five key steps across the patient journey from the acute hospital to RITH: initial patient identification; determination of patient eligibility and acceptance onto RITH; care plan development; program delivery; and discharge from RITH. Consensus items also addressed clinical governance and budgetary considerations [17]. An estimate of the costing of the consensus-based RITH model in the Australian context was undertaken and is presented in a second publication [18]. This current paper reports on qualitative and quantitative data drawn from interviews with 24 healthcare professionals and survey responses from 21 rehabilitation inpatients, focusing on the advantages and disadvantages of RITH for reconditioning as hospital substitution, and discusses the implications for the implementation of RITH.

Methods

Healthcare professional interviews and patient surveys were conducted during a period of COVID hospital lockdowns, in Sydney, New South Wales in 2020–2021.

Interviews with healthcare professionals

A convenience sample of healthcare professionals, who were currently working in rehabilitation (and variously experienced in RITH/community and/or hospital-based rehabilitation), was identified from different settings: two public hospitals and one private hospital, and a community rehabilitation service. These settings were places of work for the rehabilitation physician investigators from the project team. They shared information about the study at their rehabilitation team staff meetings, explained the voluntary nature of participation, and provided staff with a written study information flyer. 

A convenience sample of six general practitioners (GPs) was also assembled. These GPs were known to project team investigators as those who had some understanding of the primary care issues around community-based rehabilitation. They were approached either directly or via email to inform them of the study and to provide them with the written study information flyer.

The study information flyer invited staff with medical, nursing or allied health backgrounds who were currently working in either hospital or community-based rehabilitation or general practice to share their knowledge at an interview to help the study investigators develop an understanding of issues surrounding RITH. Healthcare professionals interested in participating were asked to contact the research fellow, using the details provided. Twenty-four participants gave written informed consent to take part in an interview: 18 rehabilitation professionals (see Table 1) – eight physiotherapists (PT), six occupational therapists (OT), four doctors working in the field of rehabilitation medicine (RDr), and six GPs. No participants were paid to take part in any interviews, and only the research fellow (KW), who undertook all the interviews, was aware of the identity of the study participants. The research fellow is an experienced qualitative researcher in health care services and had no research or working experience in the field of rehabilitation prior to undertaking this study.

Table 1. Work experience of interviewed rehabilitation professionals in RITH and/or community rehabilitation practice.

Professional field	Experience in RITH/ community rehabilitation practice*
	6 months- 2 years	2-4 years	>4 years
Physiotherapy (n = 8)	1	4	3
Occupational therapy (n = 6)	3	2	1
Rehabilitation medicine (n = 4)	1	1	2

* These years of experience are in addition to any hospital-based rehabilitation experience.

Table 2. Demographics of inpatient respondents* to survey.

Age in years (n = 21)		Gender (n = 20)**		Living arrangements prior to current admission (n = 21)
Age subtotal		Male (n = 7)	Female (n = 13)	Lives alone (n = 7)	Lives with someone (n = 14)
18-59	1	0	1	0	1
60-69	3	2	1	1	2
70-79	5	1	4	1	4
80-89	11	4	6	4	7
≥ 90	1	0	1	1	0

* All respondents were rehabilitation inpatients, undergoing rehabilitation for reconditioning, following medical illness, surgery, or treatment for cancer (that is, not due to any of the other impairment groups including stroke, cardiac disorders, orthopaedic disorders, pain disorders, and neurologic conditions) [19]. All respondents had been assigned an AN-SNAP reconditioning class of 4AR1 or 4AR2 (which are the two highest functioning reconditioning case-mix classes) on admission to rehabilitation. Classes are as follows: 4AR1 Reconditioning, weighted Functional Independence Measure (FIM) motor 67-91; 4AR2 Reconditioning, weighted FIM motor 50-66, FIM cognition 26-35.

** All respondents were asked to nominate whether they identified their gender as male, female or other. One respondent did not provide their gender. No respondents chose the “other” category.

Semi-structured interviews were employed to gather the views of individual healthcare professionals about RITH for reconditioning as hospital substitution. These interviews were undertaken via online video or audio calls. All interviews with rehabilitation professionals were between 50 to 60 min duration, and of 20 to 30 min duration with GPs; all interviews were recorded, transcribed and de-identified prior to their analysis. Interviews with rehabilitation professionals (RPs) focused on their practical experience of delivering rehabilitation in the home, including the advantages they noted and how disadvantages may be overcome. Interviews with GPs focused on their experiences of caring for patients undergoing home rehabilitation, and practical issues around clinical governance and RITH. The interview protocols were not informed by the results of the patient surveys, as both service provider interviews and the patient surveys were conducted concurrently.

Patient surveys

A written survey was undertaken with inpatients who were undergoing inpatient rehabilitation for reconditioning in two public hospitals and one private hospital. Surveys were utilised because during the COVID-19 pandemic, hospitals restricted the entry of staff to those supporting direct patient care, thus precluding the possibility of research interviews.

Given that RITH for reconditioning as hospital substitution is not widely established in Australia, the aim of the survey was to explore matters likely to concern patients about RITH that might not be captured by interviews with healthcare professionals, such as patient perceptions of costs, benefits, risks, and care needs in relation to hospital versus home based rehabilitation. The survey questions were informed by the experience of the research team, and the rapid review of the literature. The survey included statements seeking responses based on a 5-point Likert scale (from strongly disagree to strongly agree, see Appendix 1, supplementary material) and open text boxes for free written comments.

It was decided, a priori, that patients most likely to be eligible for RITH for reconditioning would be classified in the two highest functioning reconditioning case-mix classes of the Australian National Subacute and Non-Acute Patient classification Version 4 (i.e., AN-SNAP Reconditioning Classes 4AR1 and 4AR2), used to determine activity-based funding for admitted subacute services in public hospitals [19]. These AN-SNAP classes are based on patient level of function, as determined by the Functional Independence Measure (FIM^TM) [20]. The general code 4AR refers to patients requiring reconditioning, with patients being assigned to an AN-SNAP reconditioning class on admission to rehabilitation programs. Patients assigned 4AR1 have weighted FIM motor scores of 67–91; and patients assigned 4AR2 have weighted FIM motor scores of 50–66 and FIM cognition scores of 26–35 [19].

While not measured for activity-based funding purposes, data on frailty are collected by inpatient rehabilitation services on patients in the Reconditioning Classes. National AROC data for the 2019 calendar year (obtained via a Data Access Application to AROC by the Project Team in 2020) found that 37.3% (22.9% mild; 13.4% moderate; 1.1% severe) of patients classified as 4AR1, and 50.4% (24.8% mild, 23.1% moderate, 2.5% severe) of patients classified as 4AR2 were frail (mild, moderate or severe) according to the Clinical Frailty Scale [21]. Patients within AN-SNAP classes 4AR1 and 4AR2 were identified by rehabilitation physician investigators and invited to participate in the study.

Each person was informed of the voluntary nature of the survey; that the rehabilitation physician would remain unaware of their choice about participating; and that their decision would not influence their treatment or care in any way. Potential participants received a participant information sheet and survey in an unsealed envelope marked only with the hospital name. Proffering the anonymous questionnaire in a sealed envelope for collection by ward staff was taken to represent consent to be a study participant. Twenty-one inpatients completed surveys (Table 2).

Ethics

The research was approved by the St Vincent’s Hospital Human Research Ethics Committee (2021/ETH01105).

Analysis

Analysis of the interview data was completed by the research fellow (KW), following the six-part process of reflexive thematic analysis outlined by Braun and Clarke [22]. Analysis commenced with data familiarisation and coding of the interview transcripts using NVivo 12. Reflexive thematic analysis offers the researcher a blend of both inductive and deductive coding approaches [23,24]. Both approaches were used for developing a codebook in this study. The deductive codes, informed by the rapid review of the literature, provided a basic framework pertinent to this research. By remaining open to new ideas for coding in response to careful, repeated reading of the transcripts, inductive codes were generated while searching for differences and similarities in the content of each interview. This permitted a nuanced interpretation of the interview transcripts. Rather than viewing the codes as fixed forms corresponding to the real world, we considered that meaningful descriptions of data were assembled through a researcher’s ongoing, interpretive engagement with transcripts or recordings, with other people during interviews, and as part of the research team [25,26]. Thus, the researcher’s subjectivity is an inescapable resource for analytical outputs through engagement with the data [23]. Following coding, a first round of interpretive analysis (KW) was undertaken to elicit common themes amongst participant responses. The full data set was checked iteratively as themes were further developed, refined and named, with subsequent readings and analysis of the transcripts undertaken with other researchers to discuss, pose questions, and finally come to agreement and report on the research findings (RP, CP, AC).

Descriptive statistical analysis using SPSS V27 was undertaken to summarize patient survey responses on the Likert scales (see Appendix 1, supplementary material). In reporting results, “agreement” with a statement combines the categories of “agree” and “strongly agree,” and “disagreement” combines the categories of “disagree” and “strongly disagree”; neutral responses are reported separately. Nineteen respondents, out of twenty-one, provided written responses in free text boxes. Most written responses (17/19) were specific and were utilised to identify matters of importance to survey respondents; notably, patient free text comments have provided useful insights to guide quality improvements in health care [27]. Thus, Likert scale and free text responses from the patient surveys were aligned to the identified qualitative themes in order to compare and contrast patient and healthcare professional views about RITH. This assisted with discerning the advantages and disadvantages of RITH and implications for implementing RITH for reconditioning as a model of care.

Results

Thematic analysis of interviews with healthcare professionals

The shaping of the home environment was the common concept linking all the interview transcripts. Two major themes were developed with our interpretation of this concept: firstly, the home is a physical setting in which work is performed, and secondly, the home is a lived space shaped in, and by, the healthcare practices and social practices performed in everyday life. In this paper, the word “space” is used to denote something that arises from dynamic, social interactions when considering the home environment [28–30]. By understanding the home environment as a physical setting, our analysis identified two sub-themes: the home is a location for rehabilitation to take place, and the home is a place for substituting the care provided in hospital. By identifying the home as a lived space, it may be viewed as a restorative space shaped by health care practices, and also as a familiar, social space. Advantages and disadvantages of RITH arose from within each of these perspectives configuring the home environment.

Theme 1: the home is a physical setting in which work is performed

The home is a location for rehabilitation

In this sub-theme, the home is a specific place where a patient lives that has a particular physical layout in which rehabilitation activities occur. The home is assessed to ensure it is a safe place for the patient, and prepared for their return. The safety of staff must also be assured in this working environment.

Interview participants highlighted the importance of their own knowledge of the home as an advantage, “knowing exactly what house layouts [are] like … what obstacles are in the way” (PT-3) rather than relying on descriptions from patients or others. This enabled them to select appropriate assistance aids where needed, and to choose an area as a location for therapy. A virtual home visit was sometimes a useful alternative to an actual home visit, when a family member or carer carrying a smart phone or tablet about the home provided therapists with pictures of the home set up.

Participants stated patient selection must be informed by an assessment of the safety of the home as a location for therapy. Disadvantages included potential risks arising from how the home is set up or functions, and may preclude some people from being part of a RITH program, “… say they’ve got a flight of stairs and this client isn’t able to do stairs … I would not say it’s safe for them … to receive therapy at home” (OT-10). Staff, however, also perceived risks for themselves simply by working at a location outside of the hospital. “There’s always risk that goes with providing rehab in someone’s home” (OT-20).

The home is a substitute for the hospital

The home setting is used as a comparison for hospital-based care in this subtheme. What is considered as an advantage (or disadvantage) is based upon the benefits (or deficits) in care for the patient or the hospital system arising from the transfer of care between locations, and how care may be delivered by therapists as a consequence of the transition from the hospital to home.

Rehabilitation professionals perceived the advantages of rehabilitation at home to be a reduction in costs for patients and the hospital system, and patients having a reduction in potential risks associated with a hospital stay, “from my perspective, low cost and decreased length of stay in hospital” (RDr-13). When patients did not need specialised equipment provided in hospital, earlier discharge home advantageously freed up hospital beds for acute care needs. There was increased incidental activity for people in their homes, compared to having greater reliance on others when in hospital, “Also I think it helps with that incidental activity throughout the day. Even being in an inpatient rehab setting, lots of things are done for patients you know their meals are brought to them, the nurse changing their sheets, those things. All of those things change as soon as they’re put in their own environment” (PT-18).

Rehabilitation professionals perceived disadvantages of home care arose from patients having unmet needs, such as being unable to share the rehabilitation experience or peer support gained from mixing with other patients, “it’s good to share their own experience while they’re an inpatient, … at home, they cannot share their own experience” (RDr-13). At home, some rehabilitation professionals assessed there may be unfulfilled needs for nursing care or other services provided in hospitals, “access to nursing, having access to dietetics, or the myriad that you do get in a hospital that sometimes we do lack” (PT-8), and also that therapists may be unable to provide the same intensity of treatment in the home.

Disadvantages for RITH team members when working in isolation in the home were noted, such as lacking appropriate therapy equipment or additional staff members to call upon if needed. “When you’ve got somebody who needs at least two people in a hoist …, it’s probably going to be too hard for us to at home [to] provide enough care unless you’ve got really committed family to do that” (PT-3). While some carers or family members may be able to assist RITH team members, rehabilitation professionals suggested this should not be relied upon and another member of the RITH team may need to be scheduled to work at the same time. They noted a potential for a lack of communication between staff members when sharing the care of a patient in the community, “working in isolation of other clinicians … could possibly be detrimental if we are not on the same page” (OT-11); thus effective team communication was needed to help patients achieve their goals. The necessity to travel to treat patients reduced the time available for the overall provision of care, and driving between different locations carried its own risks.

General Practitioner comments centred on the transfer of care from the hospital to home and issues concerning clinical governance with the medical care of the patient, “And then there’s clinical governance, who’s responsible, who’s supervising? So when you say, how would a GP work with it [RITH], there’s all those sorts of considerations” (GP3), and “if patients do develop any problems, it’s sometimes very difficult to get them reconnected to the team” (GP1). GPs highlighted the importance of overcoming poor communication between different teams, and establishing routines and care pathways within the RITH program. Ideally, GPs suggested this should be through a central care co-ordinator or case manager, who has responsibility for ensuring that contact is made with the appropriate person in the RITH team when issues arose, “Communication. I think people would expect and appreciate it to know what’s going on. No surprises and have good access if things go wrong” (GP2). This included facilitating prompt contact between the GP and rehabilitation physician. Problems that were not part of the usual, holistic care a GP provides were perceived to belong to the province of the rehabilitation physician or allied health professionals. Responses indicated GPs were willing to provide usual follow-up care that ensues when a patient leaves hospital.

Theme 2: the home is a lived space

By identifying the home as a lived space, it may be viewed as a restorative space shaped by health care practices, and also as a familiar, social space.

The home is a restorative space

In this subtheme, considering the home as a restorative space required rehabilitation professionals learning to know the patient well in order to individualise their treatment program and utilise the opportunities the specific home environment offered. Rehabilitation professionals perceived the patient as an individual rather than as an object of care.

[When] people get home, when you see somebody in their environment, it’s a totally different understanding … [seeing] roles that are hidden often when they’re in a hospital bed … as carers, or as leaders in their community… so you understand the motivating forces when you see somebody in their own home environment compared to … a generic label [when] you don’t see the person. (PT-15)

The home environment facilitated the development of the therapeutic relationship, in which a patient’s personal goals are negotiated in ways best suited to their home setting and lifestyle.

I think just because you’re including their home environment, you get a real holistic perspective of how patients live and manage their day-to-day tasks, so their rehab can actually be tailored to things that are important to them and things that they actually have to do. (PT-18)

There were several advantages in understanding the home as a restorative space. An individualised program for a patient was developed and monitored in ways that are context specific and person centred. The assessment of the patient was made richer by doing this in their home environment. A patient’s confidence was gained enabling them to speak up about what matters to them about their therapy and their desired goals with the rehabilitation professional being able to respond and adjust to the patient’s needs and requirements.

… [It’s] not just therapy. It’s like knowing that person as a whole … there might be things that they don’t want to share but it comes, … [they] start telling you … ‘I’m not doing this because I’m scared that I’m going to fall’, and I think that’s important as a therapist to know because you can come up with strategies. (PT-8)

The importance of engaging the patient and their family in the rehabilitation program was highlighted in this notion of how the home environment is shaped. Accountability for participation in therapy was encouraged by promoting how a patient may readily adhere to their exercise program. At the same time, family members and carers were also educated about how they might best help the patient, “you can say to the family, they need to do it like this or do it like that” (PT-11) and the engagement of both patients and their carers in the RITH program was a priority, “I generally find that people do a lot better when family are involved” (OT-10).

Potential disadvantages arose from a lack of commitment by the patient to actively participate in the RITH program, despite negotiating goals at the outset of the program, or from the rehabilitation professional being unable to rely on the patient to perform their program as instructed.

I can fulfill my role. Can you fulfil your part of the bargain? … If you are seeing them once in a while, you do need to be able to know that you can actually trust them … so you know they are going to take that stuff on board and actually follow through with it. (PT-9)

Trying to achieve all the patient’s goals to the maximum extent within the duration of the RITH program was seen as not always being the most efficient way of operating a RITH program, and hence was a potential disadvantage. A RITH team could also expect that a patient, who was progressing well, would continue to do so to maximise their own performance by taking responsibility for their recovery, without needing more care from their rehabilitation professionals. One interview participant stated RITH programs often select patients with a pre-existing high level of function, thus disadvantaging other patients who have higher therapy needs but are committed to engaging in therapy in their home. “… it [RITH] has to be custom built, but it has to be delivered bang for buck. It has to have purpose … Revisit around the strategic focus rather than just delivering packages – a package is fairly generic – it has to be very focused on this partnership, a strong partnership” (PT-15).

Home is a familiar, social space

This subtheme describes how the concept of being at home for RITH engenders a social space that restructures the relational dynamics of care as a consequence of social and healthcare practices.

In this subtheme, the home was seen as being comfortable, familiar, and to provide increased wellbeing and a sense of achievement for the patient by having returned home from hospital – “getting people back home tends to lift their spirits” (PT-18), with “… a positive effect on patients’ mental health, psychosocial well-being, with an earlier discharge to home” (PT-15). The familiar environment of home empowered the patient with the transfer of care to the home. The home thus belongs to the patient who has a strong sense of “ownership” and also control of their situation, strengthening their position when considering the power dynamics of their relationship with RITH team members.

… you’re coming into their world, they’re inviting you in, … you know as a therapist in a hospital you very much it’s your space, when you go into someone else’s space the whole dynamics, sort of the power relationships … very much changes. (PT-9)

The social negotiation of managing expectations, deciding on goals and encouraging participation was seen as important for a RITH program. Rehabilitation professionals noted as a disadvantage that some patients felt just being in their own home, rather than in hospital, was a satisfactory result. These people would do whatever it took to achieve this outcome without necessarily being committed to participating in rehabilitation, which some rehabilitation professionals found challenging.

… there’s some people who are just desperate to go home. They’ll sign on any line, say anything you want, but when you get there, they don’t want it. They don’t want to participate; they don’t want you in their house. (PT-8)

The home was perceived as a complex situation for family members to manage while the patient is participating in RITH. Tensions arose on occasion when rehabilitation professionals negotiated roles and responsibilities with patients and their families or carers regarding if, and how caring should be managed.

… the family can be a bit overly involved … when you’re in somebody else’s home, you can’t really tell them to go away. (PT-9)

…if you think that somebody is going to provide an awful lot of care and, and it turns out to be a lot more than they expect it to be giving. … Yeah, sometimes it can be quite hard to involve families. (OT-4)

Many interview participants stressed the important role of education in the rehabilitation process for both patients and their families and/or carers from the outset before entering a program to its completion and follow-up after therapy in the home has ceased. “That person who’s taking the person home has to understand the full responsibilities of how to care for that person” (PT-8).

Patient survey results

The Likert scale survey responses are available in full in Appendix 1, supplementary material. A selection of survey responses, as aligned to the identified qualitative themes from the healthcare professional interviews are reported here as the percent of patients agreeing or disagreeing with, or being neutral about, various statements. Patient free text survey responses (FTR) are provided in italics. Individual responses are identified according to patient survey number (PID-No).

Theme 1 – the home is a physical setting in which work is performed

The home is a location for rehabilitation

Around half of patients agreed with the statements, “It will be easy for me to move around my home if I have rehabilitation in the home” (50%) and “I will feel safer having rehabilitation in hospital rather than at home” (52%). Hence, while receiving rehabilitation at home was viewed positively, safety remained an issue of concern. “Until I get home, I am not sure about what I will need above what is available. The provision of a physio visiting will be of enormous help to overcome any barriers I may experience in doing regular exercise” (FTR PID-2). The importance of addressing patients’ physical needs was also highlighted by PID-2, “I would need a modification to my bed at home so that I could raise the head of my bed to sleep comfortably. I would also need an aid to enable me to pick items from the floor.” Many patients (76%) agreed they expect to have enough information about rehabilitation in the home before deciding if it would be right for them, with 80% of patients also expecting to have the opportunity to ask questions before making such a decision.

The home is a substitute for the hospital

Most patients (67%) agreed it would be more convenient to be treated in their home, however, patients’ preferences to be treated either at home (29%) or in hospital (29%) were outweighed by feeling neutral on location (43%). Some patients also expressed uncertainty about the cost of care at home, with 43% agreeing with the statement, “I will worry I might have more out of pocket expenses if I have rehabilitation at home.” The majority of patients (76%) agreed they would miss the motivation of the hospital gym by having rehabilitation at home. “Group physio does inspire one to work harder” (FTR PID-11). Most patients (65%) agreed they would receive more therapy at home compared to in hospital, but patients did not agree or were unsure as to whether this would translate to a better outcome; one third (33%) agreed with, and 52% were neutral about, the statement that they would receive a better outcome from their rehabilitation by staying in hospital). In a free text response, however, PID-17 noted “I have had rehab at home two years ago. The visits are fast and not as comprehensive as hospital rehab.” Survey responses highlighted the potential for unmet needs at home, with 60% of patients believing they would need help at home with their daily care needs from care assistants; 35% of patients agreed they did not have anyone at home to help with tasks like shopping or transport; and 40% disagreed that family and friends will help them at home with daily care needs. PID-8 commented about their need for “Reliable and punctual assistance if I have to be independent, then I would need to prepare meals myself and would need someone to do shopping.” Most patients (60%) agreed they could easily call for help if something went wrong at home. Less than one third (29%) of patients believed they would feel more pain or discomfort doing rehabilitation in the home compared to hospital.

Theme 2 – the home is a lived space

The home is a restorative space

The survey respondents were uncertain about whether their therapists would better understand the goals of rehabilitation when they were treated at home: 43% were neutral, and 24% disagreed with the statement. This highlights how communicating the value of goal setting in the home environment is an important part of any RITH program. Participants commented on the necessity for the continuity of care provision e.g., “The same, well-qualified therapists rather than a roster of therapists where you do not feel as though there is progress being made … daily as an ideal” (FTR PID-3) and expressed how the therapeutic relationship with their rehabilitation professionals should address their needs as a part of the restorative process, e.g., “I will need consistency, adequate time and understanding of my own needs” (FTR PID-18) and “I would need the reassurance of a phone number to contact the rehabilitation providers should I need to between their visits. Likewise with pain medication in case that needed changing any time” (FTR PID-2).

2.2 Home is a familiar, social space

The majority (81%) of patients agreed that “rehabilitation will teach me to look after myself again”, and 71% agreed they had “important things to do at home they couldn’t do in hospital.” These findings emphasised that RITH has value to patients, and highlighted the importance of being at home e.g., “Have access to clothing of my own. Being able to see friends and socialise more. Not receiving mail [in hospital] which may contain something which needs immediate attention.” (FTR PID-15). Being at home reinforced the expectations that patients have of their therapists while participating in a RITH program, “It is very important the homeowner and the visiting therapist are at ease with one another” (FTR PID- 10), and the importance of controlling their own time by expecting therapists to come to their home at a particular time and to be punctual e.g., “Scheduled time rather than fitted in” (FTR PID-3). In addition, patients recognised the burden placed on families by their return home, “The expectation on family is great. One daughter lives 5 h away. The other works fulltime 9–5 Monday to Friday” (FTR PIF-18).

Discussion

This study aimed to gather the views of healthcare professionals and patients about rehabilitation in the home for reconditioning and to identify how a consensus-based model for RITH for reconditioning should be delivered. The notion of “home” is fundamental to our qualitative interpretation of the interview data and has provided key insights into the advantages and disadvantages of RITH, aligned to the central themes of the home being a physical setting in which work is performed, and the home as a lived space. Our qualitative findings are supported and strengthened by drawing on the findings of the patient surveys.

The general concept of “home” has been considered within both social theory and rehabilitation research [31–37]. The notion of home is considered to carry multiple meanings, such as those concerned with the home as a site of therapy [33–35] and the tensions thereby engendered during its transformation into a therapeutic context while still carrying the home’s meaningful dimensions of lived experience – physical, social, personal, temporal, occupational and societal [36,37]. Our study supports the notion of home being multilayered. We find the home environment figures as a material, existential, and meaningful setting, and necessarily includes the relations connecting both people and their environment in the performance of working and social practices. This is evident in our research findings identifying how the home environment is shaped in our interpretation of participants’ views and suggests important practice considerations to implement RITH. Many of these practice considerations extend across the different thematic expressions of “home” rather than acting at a single juncture, and cover patient selection, family and carer support, safety, communication, and education. These considerations are important to ensure care is delivered holistically in synergy with the shaping of the home environment. Table 3 provides a summary of the advantages and disadvantages of RITH and associated practice considerations identified within our various themes drawn from responses of both interview and survey participants.

Table 3. Themes shaping the home environment: an outline of advantages, disadvantages, and practice considerations for the implementation of RITH.

Shaping the home environment	Perceived Advantages	Perceived Disadvantages	Practice considerations for implementation of RITH
A location for therapy or activities A specific place where a patient lives that has a particular physical layout in which rehabilitation activities occur.	Therapists can familiarise themselves with the home setup. Therapists can select appropriate aids. Therapists can choose appropriate areas of the home as location for therapy and practice.	Patients may not be safe at home. Therapists may not be safe working in the home.	Patient selection based on an assessment of physical safety. Home assessment. Risk assessment for safety of therapist. The setting up of the home for patient safety (e.g., provision of aids).
A substitute for the hospital The home setting is used as a comparison for hospital-based care.	Fewer costs for the health system and patients/families. Fewer risks of iatrogenic harm caused by hospitalisation. Opportunities for increased incidental activity for patients.	Unmet patient or carer needs. Decreasing patient motivation. Inadequate equipment for efficacious therapy. Poor communication between RITH team and, or with GPs. Unclear clinical governance arrangements.	Patient selection based on assessment of medical fitness to return home. Provision of community support services (e.g., personal care, meals, shopping) as needed. Identify and address any other specific needs of patients, carers, and staff. Ensure clear clinical governance responsibilities. Ensure RITH can be delivered within established cost parameters. Ensure patients and carers understand cost implications.
A restorative space Requires rehabilitation professionals to know their patient to individualise their treatment program and utilise the opportunities offered by the specific home environment	Goal setting and patient assessment can be more contextually relevant in their home environment. An individualised program for a patient is developed and monitored in ways that are context specific and patient centred. Family members and carers are educated about how they might best help the patient. Patients and their carers are engaged in the RITH program.	A possible lack of motivation to actively participate in RITH. The therapist being unable to place reliance on the patient to perform their program as instructed. Balancing the need for general reconditioning against the achievement of all specific patient goals within the program timeframe. RITH may be limited to patients with pre-existing higher levels of function.	Patient selection based on patient motivation and engagement. Patient selection based on levels of function compatible with RITH. Develop and maintain a social connection with patients and their families/carers. Negotiate therapy: goal setting duration of therapy intensity of therapy Patient and carer education. Effective communication practices.
Familiar, social space The concept of being at home for RITH engenders a social space that restructures the relational dynamics of care as a consequence of social and healthcare practices.	Patients experience the home as a familiar, social space e.g., comfort, food, amenity of friends and family. “Ownership” of home. Home empowers patients to maintain autonomy and negotiate health care.	The home is a complex situation for family members to manage while the patient is doing RITH. There may be undue carer burden. Tensions between family members acting as carers, the patient and RITH team members.	Education of patient, carers and GPs about RITH. Educate RITH team members about how patients are empowered in their home environment and its impact on care provision. The negotiation of carers’ roles and responsibilities is essential. Social negotiation of roles and responsibilities of all parties in the RITH program. Effective communication practices.

Understanding the patient’s needs in the home environment is a key factor in the delivery of care for RITH [16,38,39] with patient selection for home-based services performed in the acute setting by teams familiar with providing home-based care in collaboration with ward clinicians [40]. When the home is perceived as a location for therapy, we have identified safety as the primary driver used by rehabilitation professionals to identify suitable patients, and to assess and prepare their home environment with any necessary aids [16,41]. Moreover, ensuring the safety of RITH team members within the home environment is mandated by institutional work, health and safety perspectives and legal requirements, and RITH team members must be educated about maintaining their personal safety when delivering RITH.

Patients, too, regard safety as an issue of concern; hence an important implication for RITH is the necessity to educate rehabilitation professionals about appropriate patient selection to ensure patients are safe to return home, and to assess and modify the home to address patient needs. Patients stress the importance of communication to provide them with information and to answer their questions to assist them to make informed decisions about RITH. Kimmel et al. (2021) emphasise similarly the need for increased patient involvement in decision-making about transferring to rehabilitation outside of the hospital setting [11]. The benefits of good communication highlight the potential to enhance the recruitment of patients for RITH since our study demonstrates that many patients (42%) feel neutral about going home for RITH despite most people (71%) having important things to do at home, and importantly, the necessity to address the concerns patients hold about their safety during rehabilitation at home.

When the home is regarded as a substitute for hospital care, patient selection is shaped by assessing medical fitness to be discharged from hospital, and by how well a patient’s personal care needs may be met by family or carers [42,43]. Thus, obtaining the agreement of a patient’s carer or family is another important factor of a RITH program [5,43,44]; failing to do this may render a patient ineligible for RITH. Often, the handover of care provided by staff in the hospital to the carer involves little or no recognition of the personal costs and impacts on the time, finances, and family and working life of the carer [5,45]. A realistic assessment of the “costs” associated with a RITH program needs to be relayed to patients, their carers, and staff members. Further, the provision of paid in-home support services (such as personal care, meal or shopping services) should be available to patients on RITH whenever needed. Our research published previously [17,18] suggests that potential cost savings exist compared to inpatient rehabilitation care, even when patients require addition community support services to enable their rehabilitation at home.

Discharging a patient from acute care to their home for rehabilitation requires communication and consultation with carers, as it is the carer who shoulders much of the burden arising from inadequate discharge planning. This is an important implication arising from our study. This highlights the need for team members in a RITH program to communicate well and provide support for the patient’s carer in addition to the patient [5,38,45–47]. Clear communication between the hospital team, the RITH team and the GP at the time of discharge is also required to avoid confusion around care, or unexpected, additional tasks for all team members caring for the patient. Team planning to schedule the appropriate numbers of staff and to ensure the availability of equipment during a home visit is also important. Ultimately, the patient may suffer from poor planning processes.

The question of who takes responsibility for the medical care of the RITH patient underscores the importance of medical governance and how to resolve issues about care in the best interests of the patient [17]. This study has pointed to the need for both GPs and rehabilitation physicians to agree on their roles in how patient care is provided in a RITH program and the necessity to clearly delineate care pathways and communication links.

When the home is a restorative space, the rehabilitation professional comes to know the patient as an individual person within their own environment. This may be considered as a dynamic and reciprocal process of engagement connecting both professional and patient, during which collaboration and active participation facilitate care [48,49]. The home, in this theme, facilitates the development of a relationship in which a patient’s personal goals are negotiated in ways best suited to their home setting and lifestyle. This is an important outcome of this study. Individualising goals in the home environment improves the patient’s confidence in their ability to live at home [50–52]. Håkansson Eklund et al. [53] clarify how person-centred goals, based on personal preference and needs, focus on living a life that has meaning as well as achieving particular functional capabilities they associate with patient-centred care. Such functional goals are commonly regarded as realistic, short term and measurable treatment goals, relevant to a patient’s everyday life [16,50,54]. This study has found tension exists for staff between selecting patients who will most likely attain goals within the timeframe of the RITH program compared to those patients, perhaps less functionally capable at the outset, who will persevere after a program has finished in order to achieve their goals.

RITH team members should also consult carers to learn the extent to which they would like and are able to be involved in making plans and goals for the patient in a RITH program [5,45]; doing so acknowledges carers as key stakeholders in a RITH program [38], especially as caregiving may involve the carer in trying to ensure the patient completes activities set by multidisciplinary team members. Developing and maintaining effective communication with patients, their families and carers has an important role in educating patients and families about RITH and promoting the therapeutic relationship experienced when the home is considered as a restorative space. Kimmel et al. (2021) highlight how communication with patients is crucial when delivering a flexible and goal oriented service model for rehabilitation in the home [11]. Furthermore, a collaborative approach between the patient, their family and rehabilitation team members has been found to be a determinant of implementing successful home-based stroke rehabilitation [49].

Regarding the home as a familiar, social space highlights how patients are empowered by their return home. Not only is it important to negotiate person-centred goals for rehabilitation within the home environment, but the social relations between people are also emphasised in ways that impact on issues affecting personal choice, autonomy, and control in the home environment. The familiar space of home generates a setting for therapy that includes acknowledging how choices may change once patients are discharged from hospital; encouraging participation in therapy by establishing rapport between patients, families, and therapists; acknowledging the burden of care for carers and friends, who wish to support the patient, and providing ongoing communication with carers how to best to proceed; ensuring rehabilitation staff, known to the patient, continue throughout the duration of a RITH program; and agreement that timing for therapy must fit with the patient’s lifestyle and preferences. The home setting permits patients to decide how to organise rehabilitation to best fit in with their everyday life [55]; having family and friends close at home gives confidence to patients as they regain their abilities to participate in everyday life [11].

Educating rehabilitation professionals about how patients are empowered through regaining “ownership” of their personal context is very important. The patient’s power to control both participation and decision-making during a RITH program is strengthened, and may well subvert a health professional’s perception of controlling an episode of health care. It is useful to note Johansson et al. [51] emphasise how the home setting facilitates a person-centred approach to care, especially when staff consider patients to be equal partners in their care – thus permitting power sharing and decision-making in the attainment of personally meaningful goals for patients. Vik et al. [56] use the concept of agency to explain the importance of being in control of everyday life (by autonomously making decisions, choosing, and doing) during rehabilitation for the participants in their study of participation and engagement during home-based rehabilitation. Rehabilitation professionals, by accepting control lies in the hands of the patient who has the power to say “no” or to select when or how therapy best fits with their lifestyle, engender a feeling of authority for patients to be motivated and participate in rehabilitation [51]. Kimmel et al. [11] report also how there is a need for flexibility for disciplinary involvement, convenience of timing for patients, and the number of interventions provided by home-based rehabilitation services. Some patients perceive some services do not meet their needs or deliver too many visits on any one day [11]. We found that patients want effective, efficient communication by healthcare professionals about the timing and purpose of visits. Vik et al. [56] also recommend professionals adapt their services during a rehabilitation program to how their patients wish to participate in daily life rather than focusing on functional goals set at the outset of therapy. This allows for a dynamic understanding of the social environment and everyday activities, within which people manage their daily lives. The notion of home as a familiar, social space supports such recommendations outlined above to deliver a RITH program.

Limitations

We were unable to gather the views of carers and families in this study, as families and friends were excluded from visiting patients in hospital during the COVID pandemic when this study was undertaken. The number of potential RITH patients was much lower than usual in rehabilitation wards during the pandemic, thus limiting sample size, and the pandemic negated the possibility of the research team directly interviewing patients in the wards. We chose not to burden ward staff with keeping an accurate measure of response rates to survey invitations because the rehabilitation units were under unusual pressure due to the pandemic. Anecdotally, most patients invited to participate in the survey did so, with about 10% choosing not to participate. While we gathered a range of interview participants from multidisciplinary teams working in rehabilitation, no nurses volunteered for this study, which we regard as a limitation. Convenience sampling of healthcare professionals, while common in clinical and qualitative research, also introduces the potential for response bias, which must be acknowledged. This study was conducted in metropolitan Sydney, which also limits its generalisability, however, we suggest the results offer useful insights to those considering how to implement RITH elsewhere.

Conclusion

RITH for reconditioning following surgery, medical illness, or cancer has the potential to offer expanded opportunities for people to undertake rehabilitation in their home. In this study, recognising the advantages (such as greater opportunity to set contextually relevant goals) and disadvantages (such as safety concerns and shifting the burden of care) that may be encountered with the delivery of RITH is based upon the multiple ways the concept of home is shaped. This affords a broad appreciation of the requirements and benefits arising from home-based care for both patients and health care professionals and highlights important practices for facilitating RITH.

Disclosure statement

HammondCare is a not‐for‐profit provider of rehabilitation, palliative care and aged care services. The authors have no competing interests to declare.

Data availability statement

The data generated and analysed during the current study are available from the corresponding author on reasonable request and pending ethics committee approval.

Additional information

Funding

This study was funded by the Medibank Better Health Foundation. The funding body had no role in the design of the study; collection, analysis, interpretation of data; or in the writing of the manuscript.