Implementing high intensity home-based rehabilitation for patients following stroke: a mixed methods study

Facility-based rehabilitation following stroke is costly and yields inconsistent outcomes. A high intensity home-based rehabilitation (HIHR) model may improve value and support patient-centered care. Studies are needed to assess contextual factors influencing adoption of HIHR models. The purpose of this study was to examine how clinical adoption of HIHR influenced its reach, maintenance, and fidelity, as well as therapists' perceptions of its acceptability, appropriateness, and feasibility.

HIHR was implemented as a standard-of-care pathway for patients with stroke at one academic hospital and its integrated home health agency. Data were examined for its first two years of implementation guided by the RE-AIM QuEST mixed methods approach. Quantitative data included retrospective clinical data for patients who met HIHR eligibility criteria at hospital discharge (used to measure reach, maintenance, and fidelity) and clinicians' ratings on the Acceptability of Intervention, Intervention Appropriateness, and Feasibility of Intervention Measures. Qualitative data were collected in three focus groups with medical, rehabilitation, and case management clinicians who were potential adopters of HIHR. These qualitative data were analyzed for adoption, fidelity, acceptability, appropriateness, and feasibility. We used a triangulation mixed methods analytic approach, collecting quantitative and qualitative data concurrently, and integrating the data at the interpretation phase.

Clinicians rated acceptability, appropriateness, and feasibility of HIHR highly, with mean (SD) scores of 4.35 (0.64), 4.24 (0.56), and 4.00 (0.58), out of 5, respectively. HIHR's reach was 15.0% (49 of 327 eligible patients discharged to HIHR). Maintenance (reach over time) diminished in year 2 compared to year 1 (8.8% vs. 19.4%). Fidelity was poor (only 1 of 49 [2.0%] patients received all HIHR services). Four barriers related to adoption emerged to explain the quantitative findings: clinician education, in-hospital communication, patient eligibility, and service shortfalls.

While the HIHR model implemented in one health system was viewed as acceptable, appropriate, and feasible by clinicians, several barriers limited its adoption, undermining reach, maintenance, and fidelity. Key challenges included inconsistent education and in-hospital communication, overly restrictive eligibility criteria, and service delivery gaps. The findings offer valuable insight into how clinical contextual factors influence HIHR adoption, which can inform the model's evolution as it is scaled.