An evidence-informed approach to discharge planning from specialist brain injury rehabilitation: a mixed method study using the PRECEDE–PROCEED model

This phase focused on ‘asking and answering’ (Crosby and Noar 2011) key questions related to discharge planning and understanding the social determinants of an optimal discharge for individuals with ABI. This was achieved through (1) an informal review of research evidence for best-practice discharge planning from an inpatient ABI rehabilitation service (conducted by LSC and NAL) and (2) informal panel interviews with multi-disciplinary staff and managers to clearly understand the characteristics of an optimal, timely and coordinated discharge for patients. Informal approaches in this stage of the PRECEDE–PROCEED process are common and can promote flexible engagement and trust-building (Cereda et al. 2020; Del Mundo et al. 2023). An expert panel was assembled, consisting of senior representatives working on the ABI unit. The expert panel was comprised of two rehabilitation physicians, one nurse unit manager, two senior occupational therapists, one senior physiotherapist and two senior social workers. Panel discussions were facilitated by LSC and NAL and minutes kept of each meeting. The panel met online six times, on a monthly basis, from June to November 2021, to discuss what an optimum discharge ‘looked like’ and what implementation of best-evidence would deliver as an outcome for patients, families and staff on the ABI unit.

This phase explored the current discharge pathway for individuals with ABI and identified ideal outcomes from proposed implementation efforts. A retrospective file audit was conducted by an external researcher (LSC) of select patient discharges that were nominated by expert panel members that lacked coordination, were delayed or ultimately rushed. The file audit was undertaken between August and December 2021 of patient discharges between December 2019 and June 2021. An audit checklist (see Supplementary File S1) was designed a priori to ensure consistency in data extraction. In addition, mapping discussions with clinical staff on the ABI unit expert panel were undertaken to understand usual processes, actions, meetings and timelines for discharge planning activities that occur during a patient’s inpatient rehabilitation. An external stakeholders survey was designed to capture the perspectives of those not employed within the ABI unit yet involved in the discharge plan through assuming care of a patient in the community. The survey included questions about external stakeholders’ demographic characteristics, current discharge planning processes and perceived barriers, and enablers to timely and coordinated discharge planning. Survey questions were developed based on expert panel discussions (in phase 1), and incorporated barriers and enablers were identified through a review of discharge literature. The 28-item survey was piloted by two healthcare professionals from the expert panel described in phase 1 and minor adjustments were made; surveys were designed to take 15–20 min to complete. Ratings of agreement were measured on a five-point Likert scale or on a visual analogue scale (VAS) from 0 to 100. Free-text boxes were used for any comments related to these perspectives. External stakeholders who consented to participate were provided a link to an online survey in Research Electronic Data Capture (REDCap) (Harris et al. 2009). Please see Supplementary File S2 for examples of survey questions.

This phase investigated the behaviours and environmental factors that influenced existing discharge processes. A survey was conducted for multi-disciplinary staff working on the ABI unit. The survey included the same questions from the external stakeholder survey in phase 2, with the addition of a question regarding the role of an existing team contact person for patients on the ABI unit. The survey was made available to staff online via REDCap and in paper on the ABI unit to provide flexibility and increase completion rates (see Supplementary File S2). ABI unit staff who were members of the expert panel were eligible to complete the survey. Question types (e.g. agreement/disagreement/neutrality via Likert scales, VAS and free-text boxes) were the same as external stakeholder surveys. Focus groups were also conducted with ABI unit staff who self-nominated; focus groups were guided by an interview schedule (Supplementary File S3) and conducted in discipline groups where possible. One medical representative participated in an individual interview due to an inability to attend a focus group. Interviews were conducted by an external researcher (LSC): an occupational therapist with a PhD and 10 years of research experience who had previously conducted focus groups. Interviews were audio-recorded and transcribed verbatim by LSC prior to analysis. Fieldnotes were taken after each focus group interview for reference during analysis.

This phase involved categorising the pre-disposing, enabling and reinforcing factors that affected the behaviours, attitudes and environmental factors (see Fig. 1) identified during phase 3. This phase also explored administrative and policy factors that could influence implementation. To aid this, a review of existing discharge documentation used on the ABI unit was completed. Members of the ABI expert panel sent external researchers (LSC, LJC) documents used to plan and record discharge-related activities. These documents included a Housing Needs and Preferences Form, a Social Work Referral Checklist, and a Discharge Recommendations Template. Discharge documentation were reviewed and compiled for analysis.

As a final pre-implementation action, a list of recommendations developed through phases 1–4 of the PRECEDE–PROCEED model for evidence-based discharge planning processes was presented in an online ABI Service Improvement Meeting. Attendees of this meeting were not formal participants in the study. The attendees were clinical staff, many who held ward leadership positions, including allied health professionals and medical and nursing staff who were linked through their work role to the ABI unit. Individual attendees ranked their priorities for implementation through an online audience response system (Mentimeter© 2023; https://www.mentimeter.com).

Please refer to Fig. 2 for a flowchart of study phases and the components and participants in each phase.

Fig. 2.

Flowchart of study phases.

Eight patient files were audited; the patient characteristics, lengths of stay and discharge destinations are illustrated in Table 1. Content analysis revealed three themes: (1) systemic delays and institutional hurdles, (2) interpersonal and family dynamics, and (3) psychological and emotional challenges. Representative statements from content analysis of written entries are illustrated in Table 1.

Fourteen external stakeholders from the community completed the survey. Table 2 provides details of participant characteristics.

Results from external stakeholders revealed a division of opinion; a similar proportion agreed (35%) and disagreed (36%) that discharges occurred in a timely way. The majority agreed that discharge occurred in a coordinated manner (64%) and that patients and families were involved in discharge using a family-centred approach (57%). See Fig. 3 and Table 3 for additional survey results. Content analysis of external stakeholder responses revealed a similar divergence of themes, one of ‘lack of preparation and communication’, with a representative statement:

More lead time and consistency in communication needed regarding discharge timeframes and patient needs (External Stakeholder 9).

Fig. 3.

Diverging bar graph indicating responses from external stakeholders (n = 14).

Somewhat conversely, another theme was ‘family were involved’, with multiple respondents noting occasions where family of patients were invited to participate in activities, such as meetings or carer training. A representative statement of this is:

All family members…were given the opportunity to be involved in regular care team meetings (External Stakeholder 13).

Forty-seven healthcare professionals working on the ABI unit participated in the staff survey, representing a 41% response rate. See Table 2 for characteristics of healthcare professionals. Regarding timely discharge for patients, 39% of healthcare professionals agreed this usually happened, whereas 32% disagreed, demonstrating a division of opinion in parallel with external stakeholder surveys. The majority of ABI unit staff (76%) agreed patients and families were involved in their discharge planning using a family-centred care approach. The same proportion (76%) agreed patients and families receive the information and education they require related to discharge from the ABI unit. See Fig. 4 for an overview of results.

Fig. 4.

Diverging bar graph indicating responses from healthcare professionals on ABI unit (n = 47).

Content analysis of ABI staff surveys revealed themes of ‘inconsistencies impact on patients’ and ‘there’s more we could do’. Multi-disciplinary staff noted that the composition of team members involved in an individual’s discharge planning could influence the patient’s overall experience, for example: ‘…[discharge outcomes] can be inconsistent depending on the treating team’ (ABI Staff Member 12). Responses also suggested staff acknowledgement that more could be done to support timely and coordinated discharge for patients, with a representative statement: ‘We could do more systematic education to support discharge for all patients and families’ (ABI Staff Member 9). This theme also included areas for suggested improvement in communication processes, with this representative quote:

‘Sometimes [I] feel like communication from team members coordinating specifics of discharge planning could be better’ (ABI Staff Member 24).

The PRECEDE–PROCEED model was used to classify barriers and facilitators for timely and coordinated discharge. Pre-disposing factors included inconsistent planning processes and limited staff knowledge of discharge goals. Enabling factors included accommodation options and access to funding. Reinforcing factors were communication and family and nursing involvement. The most important perceived barriers were 'lack of appropriate accommodation options' and 'lack of access to funding schemes'. The most important perceived facilitators for discharge were 'communication between [multi-disciplinary team] MDT members and the patient/family' as well as 'communication between MDT members'. See Table 4 for full results.

Twenty-five healthcare professionals from the ABI unit participated in focus groups. See Table 5 for discipline composition and numbers within focus groups.

Deductive analysis revealed the ACSQHC standards most commonly coded to were comprehensive care, partnering with consumers and clinical governance. See Table 6 for representative quotes from these standards. Communication processes were frequently mentioned in focus group data; these data were often coded to subthemes of ACSQHC standards (e.g. subtheme 2.06 of partnering with consumers: partner with patients and families to plan, communicate, set goals and make decisions about their current and future care) rather than standard 6: communicating for safety. The impact of the COVID-19 pandemic was also often noted by ABI unit staff, with comments such as: ‘that ability to educate and support families has been seriously compromised by all the limitations COVID has presented’ (Participant 1, Focus Group 5).

A review of documents used by staff to plan and record discharge activities found existing forms for discipline-specific discharge processes (e.g. checklists), forms for hire or purchase of equipment, forms to prompt referrals and documents to note discharge recommendations. The review compared mapping outcomes of an optimal discharge (identified in phase 1) with existing documentation. Potential gaps in documentation were found in areas of documenting expected timeframes for action and expected discharge date, processes for carer training and trial of community transition, and communicating recommendations for those with lower health literacy.

From results described in phases 1–4 above, a list of recommendations for discharge process change were presented to healthcare professionals at an ABI Service Improvement Meeting. Meeting attendees (n = 29) ranked their priorities; the three highest rated actions were (1) establishment of a discharge pathway and multi-disciplinary checklist, (2) review of meetings for clearer objectives for discharge discussions and (3) increase in family involvement on the ward. See Fig. 5 for all ranked results.

Fig. 5.

Ranked recommendations for change from healthcare professionals (n = 29) NDIS = National Disability Insurance Scheme.