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A self-management program increases the dosage of inpatient rehabilitation by 26 minutes per day: a process evaluation
Abstract
Purpose
To evaluate the implementation of a self-management program, My Therapy, designed to increase inpatient rehabilitation therapy dosage via independent practice.
Materials and methods
A process evaluation of My Therapy for adult patients admitted for rehabilitation for any condition supervised by physiotherapists and occupational therapists across eight rehabilitation wards compared usual care. Outcomes included reach, dosage, fidelity and adaptation.
Results
The mean (SD) age of the process evaluation sample (n = 123) was 73 (11) years with a mean (SD) length of stay of 14.0 (6.6) days. The My Therapy program reached 68% of participants (n = 632/928), and resulted in an average increase in therapy dosage of 26 (95% CI 12 to 40) minutes/day of independent practice. All My Therapy audited programs (n = 28) included body function/structure impairment-based exercises, and half (n = 13/28) included activity/participation-based exercises. On average, participants completed programs 1.8 (SD 1.2) times/day, which were prescribed in accordance with the My Therapy criteria, demonstrating fidelity. There were no between-group differences in daily steps or standing time, however, My Therapy participants spent more time sitting (p ≤ 0.05). Implementation adaptations were minimal.
Conclusion
A self-management rehabilitation program was implemented with fidelity for two in three rehabilitation patients, resulting in increased therapy dosage with minimal adaptations.
IMPLICATIONS FOR REHABILITATION
The My Therapy self-management program was implemented with good reach (68% of participants received My Therapy) across four public and private inpatient rehabilitation services.
Under My Therapy conditions, the dosage of inpatient rehabilitation therapy participation increased by an average of 26 minutes per day, which will help close the evidence-practice gap between the current rehabilitation dosage of about 1-hour per day, and the recommended rehabilitation dosage of 3-hours per day.
My Therapy programs most frequently included impairment-based exercises that were completed in sitting, and did not increase time spent standing and walking.
Consideration should be given to prescribing My Therapy (content and dosage) at an optimal level to promote patient functional independence, while maintaining safety.
Introduction
Adult physical rehabilitation encompasses a range of services delivered through multidisciplinary teams, aiming to deliver person centred care using evidence based interventions and evaluating progression towards meaningful goals [Citation1]. Rehabilitation can be delivered within traditional bed-based settings in a hospital, as well as home-based services, whereby rehabilitation is delivered to patients within the community environment [Citation1–3]. There is evidence that rehabilitation outcomes are influenced by the amount of therapy the person receives [Citation4] and one way to increase dosage is to increase therapy staffing levels [Citation5]. However budgetary constraints often limit additional staffing resources, despite the known benefits and the ever increasing complexity of the inpatient rehabilitation cohort [Citation6]. Clinicians, health service managers, and policy makers need to think creatively of ways to increase the dosage of evidence-based therapy interventions to promote functional recovery during rehabilitation. One solution to the problem of providing a sufficient dosage of therapy is through patient therapy self-management, that is, re-directing some of the idle time rehabilitation patients have between supervised therapy sessions into meaningful self-directed therapy activities [Citation7].
An example of this is My Therapy, a consumer driven self-management program, that focuses on occupational therapy and physiotherapy exercises and tasks that can be completed outside of supervised therapy sessions [Citation8]. Pilot work has shown that My Therapy can increase rehabilitation therapy participation by up to 14 min per day [Citation8]. In 2021-22, the My Therapy intervention was evaluated via a multi-site stepped wedge cluster randomised control trial conducted over eight wards at four health services (two public and two private). The trial included 2550 (control conditions, n = 1458; My Therapy conditions n = 1092) rehabilitation participants admitted to a rehabilitation ward, as well as, 788 geriatric evaluation and management participants (control conditions, n = 388; My Therapy conditions n = 400) admitted to a rehabilitation ward giving a total of 3,338 participants (unpublished data).
Process evaluations are increasingly being used alongside clinical and economic evaluations, to help understand the factors that may positively or negatively influence trial results [Citation9,Citation10]. Guided by the Medical Research Council (MRC) framework, process evaluations aim to: capture reach and determine the extent the intended population came into contact with the intervention; determine the dosage and quantity of intervention delivery; determine fidelity by understanding if the intervention was delivered as intended and how it was delivered; and determine if any adaptations were required to the intervention from what was planned [Citation10]. Process evaluations, can provide valuable insights into unexpected or unanticipated results (clinical or economic), and can provide a clear description of intervention implementation to allow the intervention to be scaled up or replicated elsewhere should desired results be achieved [Citation10]. The aim of this study was to evaluate the reach, dosage, fidelity and adaptations of the implementation of My Therapy into inpatient rehabilitation, as part of a larger stepped wedge cluster randomised trial.
Methods
Context: My Therapy intervention
My Therapy is a “consumer driven, self-management program designed to increase the dosage of therapy participation during physical rehabilitation, through independent practice of exercise and activity, in addition to usual care” [Citation11]. Implementation was intended to be additional to usual care, and not as a substitution of supervised therapy. My Therapy was delivered by occupational therapists and physiotherapists on the ward through provision of a subset of therapy activities to be practised independently where safe and appropriate using an online exercise prescription program PTX (www.physiotherapyexercises.com). Discussion and input from the participants, alongside occupational therapy and physiotherapy collaboration, were key to developing the individualised My Therapy programs delivered in paper format. While a recommended goal of exercise/additional therapy dosage was set by prescribing therapists, the quantity and frequency to complete activities were at the participant’s discretion [Citation11]. My Therapy is based on four criteria/pillars: i) the provision of a written self-management program (delivered electronically or in paper format); (ii) ensuring programs are documented by the therapist in the medical record; (iii) providing a feedback mechanism between the patient and the therapist (such as an activity/exercise completion tick sheet); and (iv) ensuring programs are actively monitored and progressed, as clinically indicated [Citation12]. At a practical level, My Therapy was designed to be provided to all participants on the ward where deemed safe and appropriate by the treating occupational therapist or physiotherapist. Any additional items (such as weights) that were required for the participant to complete their program were provided for use on provision of the My Therapy program by the therapist. Recommendations were made to the participant by their treating therapist to complete the My Therapy program outside of structured therapy sessions with health professionals (e.g. occupational therapists and physiotherapists).
In the six weeks prior to cross over to My Therapy conditions, implementation preparation occurred. This allowed for education of the My Therapy intervention through formal verbal education to clinical staff, interactive group discussions to co-design local implementation strategies and provision of written explanatory materials for occupational therapy and physiotherapy staff. Other members of the rehabilitation team were engaged in the pre-implementation phase by raising awareness with their role when under My Therapy conditions, but this was limited to encouraging participants to complete their My Therapy programs and not to supervise the program. To support implementation at each of the four health services, there was regular collaboration between site co-ordinators at each of the sites through online meetings and email correspondence. This provided an opportunity for shared resources between participating sites and tailoring to meet local needs.
Study design and setting
This observational process evaluation study, completed alongside a stepped wedge cluster randomised trial, has been reported in accordance with the STROBE checklist [Citation13]. The process evaluation was conducted from April 2021 to April 2022. The protocol for the main clinical trial and the process evaluation have been previously published [Citation11,Citation12]. For this process evaluation, a quantitative dominant design was used. The evaluation was undertaken in eight rehabilitation wards across two public and two private Victorian health networks in Australia, with two of the public health wards located in the community (i.e., home-based wards). Multi-site ethics approval was received from Alfred Hospital Human Research Ethics Committee (HREC) (ID: 69610), followed by site specific approvals at each of the participating health services (Alfred Hospital, ID 758/20; Eastern Health, ID S21-004-69610; Cabrini Health, ID 11-04-03-21; Healthscope via La Trobe HREC, ID 758/20).
The four study components aligned with the study aims are: i) capture reach and determine the extent the intended population came into contact with the intervention; ii) determine the dosage and quantity of intervention delivery, including the amount of supervised therapy participation as part of usual care, and My Therapy program content, mapped to the International Classification of Function (ICF) [Citation14]; iii) determine fidelity (patient adherence as well as therapist engagement) by understanding if the intervention was delivered as intended, how it was delivered and physical activity levels in sitting, standing and stepping; and iv) determine if any adaptations were required to the intervention from what was planned (Appendix A, Supplementary Material) [Citation11,Citation12].
All participants included in this process evaluation were subgroups of the participants included in the stepped wedge cluster randomised trial (
). The first group (group 1), recruited to evaluate program reach, included a subgroup of participants admitted in each block of the main trial (n = 3,338). The second group (group 2) recruited for the evaluation of dosage and fidelity were recruited over three time points (month 1/block 1 (April 2021), 6/block 5 (September 2021) and 12/block 9 (March 2022) of the 12-month/block 9 clinical trial), and were a subgroup of group 1. The third group (group 3) recruited for a detailed evaluation of dosage were a subgroup of participants from group 2. The fourth group (group 4) recruited for a detailed evaluation of fidelity were a subgroup of participants from group 2.
Figure 1. Participant flow.
Group 1 (reach) included all eight participating rehabilitation wards in the clinical trial, capturing all admitted participants including but not limited to diagnoses, such as orthopaedic, neurological, reconditioning, and respiratory, with and without a cognitive impairment. For group 2 (dosage and fidelity), the aim was to recruit a consecutive sample of 120 participants already consented to the main clinical trial, meeting the eligibility criteria of being over 18 years, admitted for rehabilitation for any reason and having access to Medicare (Australian universal health care program). Participants in group 2 (dosage and fidelity), met the additional eligibility criteria of not having a cognitive impairment (limiting ability to complete data collection tools) and being English speaking. Participants were approached by a member of the research team, their involvement in the study explained and written consent was gained. For groups 3 (dosage) and 4 (fidelity), convenience sampling was used from participants already recruited in group 2 with group 3 only including participants with a My Therapy program. Participants under control conditions receiving usual care only were included in groups 1 (reach), 2 (dosage and fidelity) and 4 (fidelity).
Outcomes
Data were collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools, that were hosted at Monash University and managed by Helix [Citation15,Citation16].
For this process evaluation, independent groups of participants were classified as receiving usual care (during control blocks of the stepped wedge cluster randomised trial, termed control conditions) or receiving My Therapy plus usual care (during intervention blocks of the stepped wedge cluster randomised trial, termed intervention conditions). If participants completed a self-management program under the control conditions this has been called a “self-management program”; if participants completed a self-management program under the intervention conditions this has been called a “My Therapy program” with both self-management and My Therapy programs needing to meet the four My Therapy criteria/pillars [Citation12]. It was recognised that some participants may not agree to participate in a My Therapy program or be unable to be provided a program, for example, due to safety considerations. However, the intention was that every patient on the ward would be assessed for a My Therapy program during the intervention blocks, and if appropriate, be provided with a program.
Reach: Data collection was completed on eight participating wards across the four health services over nine time points (once every six-weeks midway through each block during the 12-month clinical trial by site co-ordinators/associate investigators). To understand the reach of a self-management program under control and intervention conditions, medical files were audited to determine whether a self-management program had been prescribed, supplemented with discussion with treating therapists (group 1 (reach)). My Therapy was only considered to have been implemented when all four My Therapy criteria/pillars were fulfilled. On a single day, the ward audit was completed for the participating ward, capturing all admitted participants. Within the ward audit, there were no exclusion criteria applied, thereby capturing all participants on the ward. Individual participants were not able to be identified within the ward audit. Data were uploaded by the site co-ordinator to a customised form on REDCap that was blinded to the researcher. An apriori target for reach was not set. While a 100% reach would be ideal considering the whole of ward approach, researchers recognised this may not always be achievable, and note that the My Therapy feasibility study achieved a 72% reach [Citation8].
Dosage and fidelity were measured over three time points (month 1/Block 1 (April 2021), 6/Block 5 (September 2021) and 12/Block 9 (March 2022) of the 12-month clinical trial). Participants were classified as receiving usual care (control conditions) or receiving My Therapy plus usual care (intervention conditions).
Dosage: Group 2 (dosage and fidelity) participants, were audited using the therapy timetable by capturing the scheduled and completed duration of occupational therapy and physiotherapy sessions and delivery mode. The audit of the therapy timetable was completed by a researcher. If provided a My Therapy program, participants completed a daily written activity log capturing time spent and the number of times and the number of activities/exercises completed, as well as the recommended amounts from the therapist. The audit was completed midway through each block.
Fidelity: Group 2 (dosage and fidelity) participants with a My Therapy program, the activity log described above captured My Therapy patient adherence to the prescribed program by recording the recommended amount and the number of activities and amounts actually completed. For participants with a My Therapy program, all My Therapy programs provided across the seven-day data collection period were audited to capture therapist My Therapy engagement (occupational therapy and physiotherapy prescription and frequency of review of the program). The audit was completed midway through each block.
Dosage: The My Therapy programs of group 3 (dosage) participants was audited capturing the focus of the exercise/activities recommended (classified as an exercise) to address: i) body function/structure impairment tasks (e.g. strengthening exercises); or ii) activity/participation based tasks which were considered the practice of functional activities repetitively (e.g. task specific training [Citation17] such as walking or dressing practice) according to the ICF [Citation14]; who recommended the activities/exercises (i.e. occupational therapy or physiotherapy) and the position in which the activities were to be completed (i.e. standing, sitting, lying). The audit was completed midway through each block.
Fidelity: Group 4 (fidelity) participants under control and intervention conditions, wore activity monitors capturing physical activity levels in sitting, standing and stepping. Participants were asked to wear an accelerometer-based activity monitor (activPAL, PAL Technologies Limited). Participants were asked to wear monitors for 24 hours per day over seven consecutive days. Monitors were placed on the anterior middle thigh in a zip lock bag, placed on a small piece of gauze to protect the skin and covered by a waterproof dressing
Evaluation of adaptations: The adaptations log was based on the service profile audit completed on each of the participating wards which captured any major deviations to planned implementation (once every six-weeks at the start of each block, capturing information for the previous block, Appendix A, Supplementary Material).
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