From hospital to municipality

The role of physiotherapists' and occupational therapists' discharge summaries in seamless stroke rehabilitation

Abstract

Background: Stroke rehabilitation occurs both in hospitals and within primary healthcare services. The transition between hospital and municipality can be a vulnerable time for patients, and effective communication is crucial for ensuring continuity in rehabilitation. Health policy documents and guidelines set expectations and recommendations to ensure cohesive rehabilitation. Occupational therapists (OTs) and physiotherapists (PTs) play crucial roles in stroke rehabilitation, and their communication and collaboration are therefore the focus of this thesis. Aim: The overall aim of the PhD project was to explore the communication between hospital and municipal PTs and OTs and its influence on continuity in stroke rehabilitation for patients discharged home. Methods: The four papers in the thesis have a qualitative design. Paper I use an adapted priority setting process, where patients, caregivers, and healthcare professionals contributed. The three subsequent studies are built upon these research needs. In paper II, patients' physiotherapy and multidisciplinary discharge summaries are analyzed using qualitative content analysis to explore the content and the extent to which they adhere to recommendations from the stroke care pathway. Papers III and IV consist of semi-structured interviews with patients and municipal OTs and PTs, analyzed using thematic analysis. Paper III explores patients' experiences of follow-up by OTs and PTs, while paper IV explores municipal OTs’ and PTs’ perspectives on hospital-provided information. Results: Paper I outlines a pragmatic priority setting approach and presents a top-10 list of users' research needs. Paper II reveals that PTs more frequently report to the municipalities than OTs, either through discipline specific or multidisciplinary discharge summaries. There are also variations in PTs’ and OTs’ adherence to the pathway recommendations for discharge summary content. Discharge summaries from both PTs and multidisciplinary teams frequently omit descriptions of patients' ability to follow instructions, learn, their motivation, and the intensity of interventions. Both OTs and PTs describe patients' neurological impairments and their impact on daily activities. However, they often overlook patient participation, and PT summaries typically omit goal descriptions. The absence of separate OT summaries from the stroke unit results in a lack of information for the municipal therapists regarding patients' cognitive functions at discharge, as this is seldom referenced in the PT summaries. In paper III patients share a wide range of experiences related to continuity and satisfaction with PTs and OTs. Three themes were evident i) their expectations for municipal follow-up were created during interaction with the hospital's therapists, ii) the experience of involvement affected their experience of continuity and satisfaction with the rehabilitation process both in hospital and in municipalities, and that iii) they faced challenges after hospital discharge related to finding and receiving appropriate level of rehabilitation. Paper IV reveals that many municipal PTs and OTs read and utilize all available information. However, they find that the quality and timeliness of discharge summaries vary, and they call for more detailed descriptions and reflections on impairments, functions, and interventions. The discharge information is used to prepare and plan rehabilitation, and is actively used in interactions with patients, to create trust and manage patients’ expectations. Conclusion: This thesis emphasizes the need for improved communication practices, both across healthcare settings and directly with patients. It uncovers variations in adherence to the guidelines’ recommendations, leading to a lack of information, particularly concerning cognitive function and patient involvement. Municipal therapists, who rely on this information to plan rehabilitation, request more detailed descriptions. Patients, on the other hand, experience a lack of individualized follow-up, which affects their perception of cohesive rehabilitation. By placing greater emphasis on collaborative practices and addressing patients’ individual needs, therapists may help close gaps during transitions between hospital and municipal care, fostering a sense of continuity despite the challenges posed by fragmented healthcare systems.