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Home-Based Rehabilitation Evaluation

The National Ageing Research Institute is conducting a project for the Department of Human Services that focuses on the evaluation of Home-Based Rehabilitation Services in Victoria. As part of this project a literature review has been completed. A brief summary of the project (below) and the Draft Literature Review - May 2003 (PDF file 140KB) are now available for your reference.

Project Summary

Introduction

Home rehabilitation has evolved in recent years as a viable alternative to in-patient rehabilitation for suitable patients. The aim of home rehabilitation is to provide an in-home alternative to in-hospital rehabilitation. The potential benefits associated with home rehabilitation include those related to:

• patients and families (eg improved empowerment, earlier return to home and family), and
• the community, as home rehabilitation program costs have been shown in some studies to be lower than hospital based in-patient rehabilitation (eg von Koch, 2001 – stroke patients).

Home based rehabilitation programs are based on some common underlying concepts. However, in practice, there have been a number of different models applied.

Aim

(1) To evaluate the outcomes for similar patient groups in meeting their rehabilitation goals when involved with two models of rehabilitation care:
a) where the intensive period of rehabilitation occurs within the in-patient setting;
b) where part of the intensive period of rehabilitation occurs in the in-patient setting and part in the patient's home whether this be in-patient substitution or an ambulatory home-based service.
(2) To ascertain when and why people are referred to centred-based rehabilitation from either inpatient rehabilitation or from home-based rehabilitation and what is intended to be achieved by the referral.

Objectives

• to review the research literature comparing the effectiveness of home-based rehabilitation for patients, including older people, relative to inpatient rehabilitation;
• to profile the main patient groups in inpatient substitution and home-based programs;
• to compare the two current models of care and investigate:
  • referral and assessment practices and tools;
  • goal-setting and review practices;
  • continuity of care/pathways for patients from in-patient rehabilitation setting to leaving rehabilitation;
  • role of inter-disciplinary teamwork in the above;
  • frequency of interventions and the disciplines involved;
  • current outcome measures currently used and identify others that may be of use;
  • patient and carer satisfaction with samples from the three service configurations;
  • comparative LOS in inpatient rehabilitation with the three service configurations using comparable groups (eg, orthopaedic and neurological patients);
  • comparative length of “episode of care” with the three service configurations using comparable groups; and
  • outcomes achieved by the three models at completion of in-patient or home rehabilitation (bed substitution or ambulatory) using comparable groups, and at 3 months following completion of rehabilitation (in-patient or home rehabilitation);
• to recommend a framework for “best practice” in home-based inpatient substitution and ambulatory rehabilitation.

Method

A research review of the international research literature will be undertaken. The review will focus on randomised controlled trials or systematic reviews that evaluate effectiveness of aspects of home rehabilitation programs, including patient outcomes, carer outcomes, and cost comparisons. Information about models of service delivery will also be included in the review. The literature review will include papers comparing outcomes of home-based rehabilitation relative to in-patient rehabilitation.

A survey will be conducted of home rehabilitation services in Victoria. A summary of the planned activities will be provided to home rehabilitation agencies with the survey, so they are informed of the series of planned activities. The survey will investigate current outcome measures used, with the aim of identifying a small set of measures that could be used as part of the evaluation process. The recently completed Outcome Measures in Rehabilitation project by NARI will also be considered as part of decision making regarding potential measures for the home rehabilitation program evaluation, with the goal of achieving a degree of common measurement between in-patient and out-patient care. In addition, the survey, together with the structured interviews (below) will explore issues associated with best practice and models of care.

In developing a framework for best practice, staff from selected home rehabilitation programs will complete a structured interview, identifying key elements considered to be associated with successful home rehabilitation, including model of care, and issues associated with practice implementation. Selection of programs for this component of the project will be done with input from DHS staff, and will include centre/s using an in-patient substitution model and centre/s using an ambulatory home-based model. Centre/s without a home rehabilitation program, but with an in-patient rehabilitation program will also be involved.

Two home rehabilitation programs based on a bed substitution model, two programs using an ambulatory care model, and two in-patient rehabilitation programs with no home based rehabilitation program will be recruited. Programs will preferably be recruited from both metropolitan and regional settings. Services recruited will be invited to participate in:

1. Providing admission data for a sub-set of new patients admitted to the service, including demographic, and functional measures. This will provide a profile of patients;
2. A survey of patients and carers discharged from the home rehabilitation services in (a); and
3. A longitudinal evaluation of outcomes for these patients, using a series of standardised outcome measures. This will include measures of patient and carer outcomes, at commencement of home rehabilitation and at discharge from the program, and at 3 months post-discharge from the service. Where available, data from commencement of the in-patient rehabilitation program will also be obtained. This process will only be commenced late in the 2002-2003 financial year.

Ethics applications will need to be made for several components of this work program. Early decision making as to which programs will participate in the project will identify which Ethics Committees submissions need to be made to. Generally, Ethics Committees do not meet in January.

Reference:

1. von Koch, L., J. de Pedro-Cuesta, et al. (2001). "Randomized controlled trial of rehabilitation at home after stroke: one-year follow-up of patient outcome, resource use and cost." Cerebrovasc Dis 12(2): 131-8.

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