What are the characteristics of patients with a stroke who are believed to need a pre-discharge home visit by occupational therapists?

Abstract

Pre-discharge home visits are commonly completed by occupational therapists as part of the stroke rehabilitation care pathway. However, wide variations have been reported between stroke units in the number of home visits completed (Drummond et al 2012a; Royal College of Physicians 2006). This research aimed to identify the characteristics of those patients who are believed to need a visit by occupational therapists. Such a study is important as there is currently limited guidance to indicate when a home visit should be completed, or which particular patients should have a home visit. This has implications in terms of standardising practices between occupational therapists and provision of equitable services to patients. The research for this study combined qualitative and quantitative approaches. The qualitative research consisted of twenty interviews with senior occupational therapists working in in-patient stroke care across the United Kingdom. The interviews explored their views as to the types of patients who would and would not require a pre-discharge home visit. For the quantitative component, a comparative analysis was conducted on the characteristics of two groups of patients from a larger feasibility randomised controlled trial of Home Visits after Stroke (HOVIS). This analysis compared the characteristics of those patients whom the occupational therapists believed a home visit was ‘essential’ (n=33) and those for whom they did not (n=93). It also analysed the occupational therapists reasons for stating that a home visit was essential for each patient. Four key patient characteristics were identified as being particularly influential in the occupational therapists’ decision making process. These were: moderately severe physical disabilities, mild to moderate cognitive impairments, cortical strokes and living alone. Occupational therapists sought to balance characteristics relating to the patient’s level of ability to manage activities with details of the patient’s home environment, including the availability of support within the home environment. Although the presence of physical and cognitive impairments were important factors in the occupational therapists’ decision making, the findings suggest that they did not believe that the most physically and cognitively impaired patients were the most likely to need a visit. The main conclusion from this programme of work was that the home visit is multifaceted and individually reasoned for each patient, but that the four key characteristics outlined above are considered to be major factors in the decision making process by occupational therapists. It is suggested that future research on home visits for patients with a stroke should focus on those with moderately severe physical disabilities and on the role and importance of a patient’s cognition in occupational therapists’ reasoning process. A focus on the interactive relationship between these components would be fruitful. It is also recommended that future clinical guidelines should incorporate consideration of environmental and cognitive factors