Assessment of rehabilitation potential in frail older people in the acute healthcare setting: a mixed methods study

Background Hospital admissions in frail older people are associated with a greater risk of disability, cognitive decline and adverse outcomes. Rehabilitation interventions are frequently cited as key in supporting frail older people’s recovery following periods of decompensation and ill health. Healthcare practitioners are required to make decisions, in the face of growing complexity of service provision, patient needs and expectations, about a patient’s potential to respond to rehabilitation interventions. The clinical currency in which these decisions are transacted is through the use of the term rehabilitation potential. Decisions about rehabilitation potential can determine what rehabilitation services a patient can access. There is no universally agreed, systematically assessed or explicitly operationalised model or clinical guideline that helps therapists to make consistent, transparent, patient-centred and evidence-based decisions about rehabilitation potential. This PhD study addresses this gap through the development of the Rehabilitation Potential Assessment Tool (RePAT) to be used with frail older people. Methods An exploratory sequential mixed-methods approach was used to develop and test the RePAT intervention following the Medical Research Councils framework for Developing and Evaluating Complex Interventions. A mapping review identified relevant evidence to inform the development of the RePAT intervention. Focus groups explored the opinions, experiences and understanding of rehabilitation potential from multiple perspectives. Results from these components were synthesised and subjected to a two-step Delphi consensus which informed the RePAT intervention and training programme. A non-randomised feasibility study with nested semi-structured interviews was completed, where the RePAT intervention was delivered in an acute hospital setting, to explore whether the intervention was deliverable and acceptable to staff and patient participants. Intervention fidelity was tested. Patient and public involvement was integrated into every step of the research process, including qualitative data analysis and intervention design. Results Evidence from 49 articles included in the mapping review and five focus groups with 28 participants identified that rehabilitation potential was complex, poorly understood and judged by different people at different times. In the absence of predictive variables for rehabilitation, practitioners made complex decisions based on rehabilitation response, performance and outcomes. These were then considered against ethical considerations, patient choice and resource availability. The RePAT intervention was modelled and a two-step Delphi consensus with 46 participants was completed. A 15 item rehabilitation potential assessment tool and training package were developed. Six staff participants were recruited and trained to use the RePAT on a total of 26 patients who were identified as frail using validated frailty measures. RePAT was found to be acceptable and tolerated in the hospital setting and provided a structured, transparent, evidence-based approach to support decision-making into rehabilitation potential. Its content allowed clinicians to embrace the complex and dynamic forces at play in frailty rehabilitation and recovery from acute ill health to aid decision-making in an effort to select the most appropriate treatment. A structured approach allowed practitioners to make explicit their reasons behind rehabilitation decision-making and rehabilitation potential and encouraged them to become cognoscente of ethical dilemmas and biases. Conclusion The RePAT was developed and tested in a clinical environment. There was evidence that it provided structure to clinical reasoning which had not been evident and encouraged practitioners to become cognoscente of ethical dilemmas and biases. This study lays the groundwork for further research into rehabilitation decision-making amongst clinicians working with older people living with frailty. The research process detailed within this thesis was feasible and the RePAT intervention is now ready for further clinical and cost-effectiveness evaluation